The current strategy to caring for children with complex medical conditions and social vulnerabilities is best illustrated using the What, How, Why Paradigm. The health care system delivers information and resources (the what), while delivering some of behavioral interventions and support (the how). But it inconsistently offers interventions that target a patient’s social challenges (the why).
Research shows social challenges are the most impactful on patients’ health, but because these challenges are not medical, the health care system is often not equipped to intervene. It can be difficult for families to manage a child’s complex medical condition due to social determinants of health (SDoH), such as economic instability, poor education, food insecurity, social isolation and low health literacy.
To target the social factors that drive health outcomes in socially vulnerable youth with complex and chronic medical conditions, Drs. Michael A. Harris and Kim Spiro at Doernbecher Children’s Hospital and Oregon Health & Science University in Portland, Oregon, developed the Novel Interventions in Children’s Healthcare (NICH) program.
NICH serves to address the circumstances outside of health that impair health and health care and result in avoidable medical costs for youth with complex and chronic medical conditions. NICH matches the intensity of the intervention with the complexity of the social challenges that patients and their families face.
To participate in NICH, children must have a complex or chronic health condition, experience avoidable health complications, evidence social vulnerability, such as food insecurity or homelessness, and demonstrate poor response to current care models.
NICH is everywhere—in the home, in the hospital, in the school and in the community. Barriers to health and well-being do not disappear once a patient leaves the hospital. NICH interventionists are available to assist families 24/7. They provide real-time access for patients and families so that problems can be addressed prior to them becoming unmanageable outside of a clinical setting.
The NICH intervention integrates three components:
- Strategic family and systems interventions.
- Health systems integration and patient needs alignment.
- Resource access for family and patient optimization.
Of the children enrolled in NICH:
- 35% have a mental health condition and 40% have a trauma history.
- 57% are not regularly attending school.
- 42% have a caregiver with a drug or alcohol problem, and 35% have a caregiver with a mental health condition.
- 40% have a caregiver with a medical condition.
- 50% have caregivers who are underemployed or unemployed.
- 83% of the families have been involved with child protective services.
- 51% have food insecurity.
- 57% have unreliable transportation.
- 51% have housing insecurity.
- 73% have limited support from family and friends.
Finding cost savings
Electronic health record and cost-of-care data suggest health and care improved while participating in NICH. Participation is associated with reductions in avoidable utilization and related costs, even after participation ends. For example, in the year following NICH initiation, children in the program experienced approximately 30% fewer ED visits, 42% fewer inpatient admissions, and 51% fewer days in the hospital, with greater improvements in the second year of participation.
When examining average length of stay (LOS) during inpatient admissions, NICH program involvement was associated with 2.5 to 4.5 fewer days per admission during the first year and 3.2 to 5.7 fewer days for the second year following program initiation, with ranges signifying variability in data access.
The reductions in LOS reflect considerable costs savings, depending on the reason for admission and contractual agreements among other variables. Further, the reduced frequency of admissions for youth on Medicaid reflect additional costs avoided when the hospital is at capacity.
When examining savings for payers, NICH program involvement was associated with a 43.7% average reduction in paid physical costs for members on Medicaid, with approximately $2,490 less in per-member per-month costs, or $29,880 annually. The cost of care paid out by the plan continues to decrease by another $15,000 to $20,000 annually a year after patients have left the program.
Notably, in the year following graduation from NICH, the program continues to reduce costs for the payer and the hospital system without incurring any costs for the program itself.
While most of the interest in the program has centered on its cost-savings, the improvements to health and care should not be overlooked. For example, among youth with type 1 diabetes (T1D)—accounting for about 40% of NICH enrollees—the outcomes for health and care surpass most other medical and psychosocial interventions. Youth in NICH with T1D evidence significant improvements in their glycemic control (>1%).
Data also show that 5% of youth with T1D come into the program with diabetes technology (continuous glucose monitors and/or insulin pumps), and 15% leave the program with diabetes technology.
Furthermore, targeted outreach and interventions for ethnic and racial minority youth resulted in significant increases in routine outpatient diabetes care, coupled with fewer no-shows and cancellations. These outcomes are also found across disease conditions, such as cystic fibrosis, kidney disease, epilepsy, inflammatory bowel disease and sickle cell disease.
NICH participation is associated with a significant reduction in likelihood of hospital admission, as well as the number of admissions per year. The data also showed trends pointing to fewer days admitted per patient and fewer overall costs.
Given the current focus in health care on social factors and spending of the highest utilizing patients, it’s critical to expand and implement interventions that address SDoH in youth who are high risk, high need and high cost. NICH is a means to improve health, quality of life, and health care dollar allocation.
NICH during COVID-19
NICH has always leveraged technology to stay in contact with youth and their families, and this approach has continued throughout the COVID-19 pandemic. NICH-enrolled families are some of the most vulnerable to the effects of COVID-19—from loss of employment to loss of housing, and limited access to PPE and cleaning supplies.
Many NICH families are also struggling with the burden of being essential workers and the associated risk of exposing their children or other family members to COVID-19—many of whom may be socially or medically vulnerable themselves.
Fortunately, the NICH team has a decade of experience with securing affordable housing and advocating for families with children who have complex or chronic medical conditions. NICH secured masks, sanitizing wipes, cleaning supplies, hand sanitizer and toilet paper through charitable donations so families have what they need to stay safe and healthy through the pandemic.
And finally, NICH continues to serve a role in keeping children out of the hospital so as many beds as possible are available for adults and children dealing with COVID-19.
Implementing this program was not without challenges. On the payer side, NICH is paid through an alternative payment method (APM), and while the Department of Health and Human Services has indicated that Medicare and Medicaid are both moving in the direction of APMs and bundled payment models, state Medicare and Medicaid providers have been slow to adopt either of these payment methods.
In addition, payers that have their own programs for SDoH tend to be housed in the medical setting, requiring patients to come in for services. The level of service tends to be relatively low intensity for patients’ SDoH challenges. On the hospital side, challenges include balancing the need to fill beds with not having the same patients bounce right back to the hospital after being discharged. Hospitals are also staffed to take care of medical needs not social challenges.
A path for success
NICH’s success is the result of several factors, including an intervention that directly targets the factors that drive health outcomes, innovative thinking of the C-suite and leaders at Doernbecher Children’s Hospital and Oregon Health & Science University, generosity of donors who have contributed to the program, and the compassion and social sophistication of the frontline staff who deliver these services. NICH is funded in part by The Leona M. and Harry B. Helmsley Charitable Trust.
Eight years after the NICH program was created, over 400 youth have been served, and conservatively, a combined $14 million has been saved for payers and millions saved for the children’s hospital.
While these numbers seem impressive, they don’t describe the value of avoided hospitalizations and medical emergencies to children and their families in terms of the indirect costs. These indirect costs include lost wages due to needing to be with their children when hospitalized, childcare expenses for other children in the family, and transportation and food costs. NICH improves care and improves health.