Needs-Driven Pediatric Population Segmentation Informing Child & Family Centered Care Management

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Primary Author:</td>
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Julie Harris, BSIE, MBA</td>
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Co-Principal Investigators/Collaborators:</td>
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<p>Jay Rosenbloom MD, PhD, Albert Chaffin, MD, Resa Bradeen, MD</p>
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Organization:</td>
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Children's Health Foundation</td>
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Abstract</h2>
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Purpose</h3>
<p>Develop meaningful and actionable measures and a practical health information solution to improve pediatric practices’ effective support of the child/family in achieving optimal management of their chronic conditions and overall health.</p>
<h3>
Background</h3>
<p>100+ pediatricians work through the Children’s Health Foundation to understand and systematically document child/family needs for support from their pediatric-medical-home team. This includes assessing medical complexity, patient functioning, family factors, and identifying the overall level of support the child/family needs in order to optimally manage their chronic condition and/or overall health.</p>
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Materials & Methods</h3>
<p>1) Advisory group of leading pediatric providers, sub-specialists, hospitalists, health plan advisors, and foster parent completed literature reviews, interviews, and investigations to evaluate office-based-pediatric-care-management. 2) Learning collaborative to develop office-based care management competencies. 3) Developed a common language, assessment tool/form, and approach for assessing patient support needs at the point-of-care considering factors beyond traditional claims-based medical risk modeling. 4) Implemented patient support level needs assessment/segmentation across 100+ pediatricians with data tracked through a registry. 5) Developed pediatric population management, office-based-pediatric-care-management measures, and improvement programs.</p>
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Results</h3>
<p>In one year, 60,102 children/families had their self-management-needs assessed by their Primary-Care-Pediatrician at the point-of-care. By April, 2014 the sample= 66,157 children/families. 1% have the highest level of support needs (Care Management Tier 1), 4%=CM Tier2, 22%= CM Tier3, 73%= CM Tier4. Strongest correlation driving support needs level was number of chronic medical/mental health conditions paired with additional patient functioning factors. </p>
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Conclusion</h3>
<p>Pediatrician-led improvement programs designed to be meaningful for patient care and with actionable measures can be successfully and broadly implemented in the private-practice-primary-care-pediatrics setting. Patient and family factors contribute to the amount of care coordination support the child/family can benefit from through their pediatric medical home, particularly when multiple chronic conditions are present. Systematic assessment and tracking of child/family support needs across the medical, patient-functioning, and family-factors domains is meaningful and actionable in pediatric care and is expected to improve patient experience and outcomes.</p>
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<p>© Improvement Science Research Network, 2012</p>
<p>The ISRN published this as received and with permission from the author(s).</p>