• Article
  • October 4, 2017

Integrating Medical and Behavioral Care Helps Children With Medical Complexity

This is the final installment in a series on the CARE Award: "Coordinating All Resources Effectively." CARE is the basis of a national hallmark study aimed at improving quality outcomes and reducing costs of care for children with complex medical conditions enrolled in Medicaid. Children's Hospital Association partners with 10 of the nation's leading children’s hospitals on the CARE program, which encompasses more than 8,000 patients, as well as their caregivers and health care payers.

Here, we check in with one of CARE's participating institutions, Cook Children's Health Care System in Fort Worth, Texas.

Prior to the introduction of the CARE Award program in September 2014, Cook Children's Health Care System (CCHCS) had no primary care medical home—something Jose Gonzalez says was a priority to develop. "It was something we had been struggling with for a while as an institution," says Gonzalez, M.D., vice president, Clinical Affairs of the Cook Children's Health Plan (CCHP) and Center for Children's Health.

Though each of the CCHCS primary care Neighborhood Health Clinics were already operating with most elements of a primary medical home, each did so largely independent of the other clinical practice facilities within the system. "There was a hodgepodge of how these kids' care was managed," Gonzalez says. "One primary care clinic did not necessarily communicate with the others."

But fast forward three years, and the landscape has changed dramatically.

An integrated approach 

Today, CCHP cares for more than 8500 medically complex children within the STAR Kids program, nearly 500 of whom were already CARE enrollees. STAR Kids is a Medicaid managed care program introduced by the state of Texas last November, designed to meet the needs of children with medical complexity by providing coordinated benefits for all aspects of their care. 

Within the STAR Kids program, CCHCS employs an integrated case management model. Its focus is patient-centered, evidence-based care with an emphasis on quality outcomes. An important aspect of this approach is the integration of both medical and behavioral care.

"We thought this piece was key for us," Gonzalez says. "When we looked at the baseline data on these children, about 60 percent to 70 percent had some kind of behavioral diagnosis, as well as a medical diagnosis."

CARE Award 'a prelude' to STAR Kids

While CARE Award results are in process and pending, CCHCS continues to see improvement across multiple key metrics, including hospital and emergency department (ED) usage among its medically complex patients. Gonzalez says the similarities between the CARE Award program and STAR Kids helped to make the integration successful, including

  • Family collaboration — Patients are assigned a care service coordinator who helps families work with the health care team to follow up on referrals, coordinate community resources and medical supplies and set up PCP visits.
  • Needs assessment —The care team conducts a needs assessment for each patient to develop the appropriate care and access plans to align with the family and patient goals, as well as streamlining communication of this information among all specialists involved in the patient’s care.
  • Care integration — The program coordinates behavioral health and community-based service providers into the patient's care and access plans, which Gonzalez says is "essential" to the quality of ongoing care.

Moving forward

CCHCS continues to improve its complex care program. According to Stephanie Weikel, M.H.A., project facilitator with Cook Children's Health Care System, several initiatives are in the works:

  • Widespread primary medical home development— CCHCS is working to finalize its NCQA certification, which Weikel says will help more closely align the objectives of the CARE Award with those of the Star Kids program.
  • Dedicated home — Discussions are underway to establish a dedicated complex care center for its patients, which may come in the form of a separate brick-and-mortar facility or a "virtual clinic" concept rotating among its current facilities with assigned dedicated providers.
  • Payment methodology — CCHCS is re-evaluating the effectiveness of its payment model, to ensure all parties are on the same page regarding payment documentation.

In addition, Weikel says focused feedback from the care teams have helped effect a change coming in early 2018—the consolidation of the entire CCHCS system onto the same EMR platform. "We've been able to bring to light what a lot of other physicians and staff members have been saying about not being able to see each other’s information," Weikel says. "We were able to come as a unified front, so everyone will be able to see everyone else’s records."

About CARE

In partnership with 10 of the nation's leading children's hospitals, the Children's Hospital Association received a three-year, $23 million Health Care Innovation Award from the Center for Medicare and Medicaid Innovation. Of the roughly 3 million children with medical complexities nationwide, two-thirds are covered by Medicaid. These 2 million children represent nearly 40 percent of costs. They are clinically fragile and have intense medical and care coordination needs that are not always met by existing care delivery and payment models.

Read other CARE hospital case studies.

Send questions or comments to magazine@childrenshospitals.org.

This publication was made possible by Grant Number 1C1CMS331335 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. Pub# 3224, Approved 9/29/2017