Child Health Planning Research Articles

Value-Based Proposition of an Adapted Integrated Care Telehealth Service for Accountable Care Organization Members.

The authors describe a real-world application of virtually integrated primary and behavioral health care implemented within an accountable care organization (ACO) system. Cost-of-care data from before and after a 6-month intervention were analyzed for 121 Medicaid and Child Health Plan Plus ACO members. The intervention was associated with a significant shift in the distribution of health care costs, from inpatient and emergency care to outpatient and preventive care. The program demonstrates a flexible and replicable approach to integration that can help expand effective primary care.

An assessment of the predictive value of low risk criteria for children with intermittent asthma.

Current asthma guidelines recommend short acting beta agonist medication (SABA) be used in combination with an inhaled corticosteroid to reduce risk for severe asthma exacerbations. This may not be appropriate for patients at low risk for severe exacerbations. This study is a cohort study using computerized claims data from Texas Children's Health Plan. Inclusion criteria were members 1 to <18 years with a diagnosis of asthma in a baseline year between 2016 and 2018 and who had ≤2 SABA canisters or equivalent dispensed, no oral corticosteroid or inhaled corticosteroid dispensing, no asthma hospitalizations, and no asthma emergency department visits in the baseline year. Follow up year outcomes of asthma hospitalizations and emergency department visits were determined for the year following the baseline year. Forty-five thousand two hundred and thiry health plan members 1 to <18 years met inclusion criteria. The rate of follow up year asthma hospitalization was 1.1 per thousand for those with no baseline SABA dispensing and 1.5 per thousand for those with >0 and ≤2 SABA canister dispensings (p = 0.3). Follow up year Emergency Department visits rates were 14 per thousand and 17 per thousand, respectively (p = 0.08). In analyses adjusted for age group, the follow up year asthma hospitalization rate was not different comparing the 0 SABA to the >0 and ≤2 SABA canister dispensings group (odds ratio: 0.99, 95% confidence interval: 0.54-1.81). Asthma patients at low risk for severe exacerbations can be identified. This information can be useful to guide treatment decisions.

Evaluation of a pediatric asthma high-risk scoring algorithm.

Identification of patients with asthma at increased risk for hospitalization and emergency department (ED) visits presents opportunity for intervention. Retrospective analysis of computerized health plan claims data. Texas Children's Health Plan, a large Medicaid managed care program, developed an asthma risk scoring algorithm using the clinically relevant parameters of hospitalization for asthma, ED visits for asthma, short-acting β agonist medication dispensing, inhaled corticosteroid medication dispensing, number of prescribing providers, loss to follow-up, and oral corticosteroid dispensing. The risk score performance was evaluated using 2016-2018 risk scores to predict 2017-2019 asthma hospitalizations and ED visits. We identified 107,811 unique members aged 1 to less than 18 years with an asthma diagnosis. For those aged 3 to less than 18 years, the area under the receiver operating characteristic curve (AUC) for risk score predicting hospitalization ranged from 0.72 to 0.79. For those aged 1 to less than 3 years, the AUC ranged from 0.65 to 0.69. Those with a risk score of 1 or greater accounted for 20% to 23% of pediatric members 3 to less than 18 years with asthma but 53% to 56% of asthma hospitalizations in the follow-up year. Sixteen to eighteen percent of those aged 3 to less than 18 years with a risk score of 9 or greater were hospitalized in the follow-up year. Texas Children's Health Plan asthma risk score stratifies risk of asthma hospitalization and ED visits for Medicaid-insured children. The risk score performs better for children aged 3 to less than 18 years than for those aged 1 to less than 3 years.

Behavioral health service utilization: Trends in utilization within a patient-centered medical home for low-income children and women.

Background:Behavioral health (BH) problems frequently present in primary care settings. Despite high intervention needs, the majority of low-income, racially/ethnically diverse children and women do not receive necessary care. The current study examined utilization of BH care among low-income, racially/ethnically diverse pediatric and obstetric patients receiving services in an integrated patient-centered medical home (the Center) compared to patients receiving services in traditional settings.Methods:A retrospective review was performed on all consecutive Texas Children's Health Plan (TCHP) patients who received outpatient BH services between 2015 and 2017. Children and woman who utilized BH services at the Center were compared against those who utilized BH services via a traditional sitting outside the Center.Results:A total of 54,612 were identified. Of those, 3,559 (6.5%) patients were seen at the Center and 51,053 (93.5%) patients were seen in the traditional setting. A larger proportion of pregnant/postpartum women and African American and Hispanic/Latino children and women utilized BH services in the PCMH compared to the traditional setting. Results also indicated higher levels of BH service use for patients with behavior problems or anxiety disorders, and increased use of services provided by doctoral level psychologists in the PCMH.Conclusion:Findings support the benefit of integrated BH services in PCMH models for engaging traditionally marginalized populations in BH care.

Physician Care Coordination and the Use of Psychotropic Polypharmacy in the Management of Pediatric Mental Disorders.

Psychotropic polypharmacy is a concern in the management of pediatric mental disorders due to the lack of pediatric data to support the practice. Although seeing multiple providers has been identified as an important predictor of polypharmacy, no study has yet assessed the effect of care coordination between providers on receipt of psychotropic polypharmacy. To examine the association between the intensity of care coordination within a patient's care team and the likelihood of the patient receiving multiclass psychotropic polypharmacy. A retrospective study was conducted using the 2013-2015 administrative claims data from a Medicaid managed care organization (Texas Children's Health Plan). Children and adolescents aged 18 years or younger with a diagnosis of a mental/behavioral disorder and receipt of psychotropic prescriptions from multiple prescribers were included in the study. Psychotropic polypharmacy was defined as the receipt of 2 or more psychotropic medications from different drug classes concurrently for 60 days or more. Care coordination was measured using social network analysis (SNA), a new technique included in the Agency for Healthcare Research and Quality Care Coordination Measures Atlas. Care density, an SNA surrogate for care coordination, was calculated as the ratio of the sum of patients shared by physician pairs within a patient's care team to the total number of physician pairs. The Andersen behavioral model was used to guide multivariate logistic regression analyses conducted to assess the association between care density and the likelihood of patients receiving psychotropic polypharmacy after controlling for predisposing and need factors. A total of 24,147 children and adolescents diagnosed with a mental/behavioral disorder were identified. About 34.0% (n = 8,092) of these individuals received psychotropic medications from multiple prescribers who were either primary care physicians (PCPs) or specialists. Logistic regression analysis showed a significant association between care density and the use of psychotropic polypharmacy. However, the direction of this relationship varied depending on the composition of the patient's care team. Among patients with only PCPs involved in their care team, patients in the higher care-density group were 28% less likely to receive psychotropic polypharmacy (OR = 0.72; 95% CI = 0.62-0.96) than those in the lower care-density group. In contrast, among patients who had both PCPs and specialists involved in their care team, those in the higher care-density group were 2 times more likely to experience psychotropic polypharmacy (OR = 2.01; 95% CI = 1.68-2.40). Care density was not significantly associated with the receipt of psychotropic polypharmacy in the specialist-only group. This study found significant associations between care density and prescription of psychotropic polypharmacy. This relationship varied depending on the patient's diagnosis, disease complexity, and composition of the patient's care team. No outside funding supported this study. The authors do not have any financial relationships or potential conflicts of interest relevant to this article to disclose. The abstract for part of this study, titled "Association Between Physician Care Coordination and the Use of Psychotropic Polypharmacy in the Management of Pediatric Mental Disorders," was selected as a silver medal abstract and was presented at the AMCP Managed Care & Specialty Pharmacy Annual Meeting 2017; March 27-30, 2017; Denver, CO.

Effectiveness of a Comprehensive Case Management Service for Children With Medical Complexity.

To assess whether children with medical complexity (CMC) exposed to a hospital-based comprehensive case management service (CCMS) experience improved health care quality, improved functional status, reduced hospital-based utilization, and/or reduced overall health care costs. Eligible CMC at Seattle Children's Hospital were enrolled in a cluster randomized controlled trial between December 1, 2010, and September 29, 2014. Participating primary care providers (PCPs) were randomly assigned, and CMC either had access to an outpatient hospital-based CCMS or usual care directed by their PCP. The CCMS included visits to a multidisciplinary clinic ≥ every 6 months for 1.5 years, an individualized shared care plan, and access to CCMS providers. Differences between control and intervention groups in change from baseline to 12 months and baseline to 18 months (difference of differences) were tested. Two hundred PCPs caring for 331 CMC were randomly assigned. Intervention group (n = 181) parents reported more improvement in the Consumer Assessment of Healthcare Providers and Systems version 4.0 Child Health Plan Survey global health care quality ratings than control group parents (6.7 [95% confidence interval (CI): 3.5-9.8] vs 1.3 [95% CI: 1.9-4.6] at 12 months). We did not detect significant differences in child functional status and most hospital-based utilization between groups. The difference in change of overall health care costs was higher in the intervention group (+$8233 [95% CI: $1701-$16 937]) at 18 months). CCMS clinic costs averaged $3847 per child-year. Access to a CCMS generally improved health care quality, but was not associated with changes in child functional status or hospital-based utilization, and increased overall health care costs among CMC.

'Doing Better Together': Developing a cross-agency regional child health and wellbeing plan

In 2013, the alignment of the geographic boundaries of the regional Local Health District, Family and Community Services and the Medicare Local/Primary Health Network presented a strategic opportunity to form a high-level strategic partnership and planning group. This group provided an ideal platform for collaboration. The Local Health District had already identified the need for a five-year child health plan and proposed that this was completed collaboratively and that it covered both health and broader wellbeing. The emergence of integrated care as a focus area for the New South Wales (NSW) Ministry of Health was an additional driver for developing a shared plan. Membership of the Senior Partnership and Planning Group was expanded to include representatives from the child and family non-government sector and the Department of Education. Whilst each organisation involved are working towards child health and wellbeing in many ways every day, the Plan focuses on the ‘additionality’ that comes from cross-agency collaboration and integration. A stakeholder consultation workshop with over one hundred service providers informed the determination of strategic priorities and related actions for inclusion in the Plan. The Plan provides a framework for shared governance, collaboration and a common vision for child health and wellbeing outcomes over a five year period. The mission for the Child Health and Wellbeing Plan is for the children of Inner West Sydney region to be healthy, safe, respected, valued and happy, living in supportive families, and nurtured in strong inclusive communities. The Plan is based on the important idea that agencies working together, in collaboration with communities, can do more and can achieve meaningful change, particularly when vulnerable children and families are involved. Vulnerable children include those living in poverty, at risk of violence, abuse and neglect, newly arrived refugees and migrants, living with parents or carers who have mental health and/or substance abuse issues, and whose chances of reaching their potential are reduced or at risk. The ‘Inner-West Child Health and Wellbeing Plan: Doing Better Together’ was launched by the NSW Minister for Health in November 2015. 'Healthy Homes and Neighbourhoods' is a three-year integrated care initiative funded through a NSW Ministry of Health Integrated Care Planning and Innovation Fund. 'Healthy Homes and Neighbourhoods' is a demonstration project of the Child Health and Wellbeing Plan and provided an immediate and significant opportunity to extend and test the collaborative partnership. The program addresses the complex health and social needs of the most vulnerable families in our community who may be disconnected from key services and who require multi-agency assistance. Approximately 170 individuals have enrolled for care coordination since program implementation in June 2015. All the needs of identified families are in scope for the intervention, including housing, employment, income support and legal advice. Geospatial mapping identified clusters of extreme family disadvantage, where additional community projects are being implemented. Scoping papers have been completed for the Child Health and Wellbeing Plan high priority initiatives with oversight, support and quality assurance from an Implementation Sub-Committee with cross-agency representation.

Disease prevalence among nursery school children after the Great East Japan earthquake

ObjectiveTo investigate the relationship between personal experience of the Great East Japan Earthquake and various disease types among nursery school children.DesignWe conducted a nationwide survey of nursery school children born...

The Impact of Tobacco Smoke Exposure on Childhood Asthma in a Medicaid Managed Care Plan.

Tobacco smoke exposure increases breathing problems of children. Texas Children's Health Plan is a Managed Medicaid and Children's Health Insurance Program (CHIP) managed care provider. The aim of this study is to determine associations among tobacco smoke exposure, asthma prevalence, and asthma health-care utilization. Texas Children's Health Plan conducts an annual survey of members who have a physician visit. Questions were added to the survey in March 2010 about asthma and tobacco smoke exposure. Survey results for children < 18 years of age were matched to health plan claims data for the 12 months following the date of the physician visit. A total of 22,470 parents of unique members/patients from birth to < 18 years of age participated in the survey. More whites than African Americans or Hispanics report that the child's mother is a smoker (19.5% vs 9.1% and vs 2.3%, respectively; P < .001). Compared with children whose mother does not smoke, parent report of asthma diagnosis and claims for dispensing of short-acting beta agonist medication are greater if the mother is a smoker (adjusted OR, 1.20 [95% CI, 1.03-1.40] and 1.24 [95% CI, 1.08-1.42], respectively). In contrast to Medicaid, in which there are no out-of-pocket costs, the CHIP line of business requires copays for ED visits. ED visits are influenced by maternal smoking only in the CHIP line of business (adjusted OR, 4.40; 95% CI, 1.69-11.44). Maternal smoking increases risk for asthma diagnosis and prescription of asthma quick relief medication. Maternal smoking predicted asthma-related ED visits only for the CHIP line of business.

Maternal confidence of Fukushima mothers before and after the nuclear power plant disaster in Northeast Japan: Analyses of municipal health records

The Fukushima nuclear power plant accident created many challenges, including those for families with small children who sought to assess and address the health risks of radiation exposure. Mothers' worries about their young children have been described in prior studies, but none has examined the impact of a nuclear power accident on their self-confidence as mothers. The present study focused on levels and associated factors of maternal confidence (one of the indicators used to evaluate Japan's national Maternal and Child Health Plan) before and after the accident. Comparing three samples of mothers with 18-month-old children in Fukushima City (218 in 2010; 300 in 2011, the year of the accident; and 188 in 2012) indicated that maternal confidence was lower in 2011 compared to 2010 and 2012. Interpersonal problems at home were significantly associated with lower maternal confidence in 2011, as well as increased depression in 2012. Other factors associated with lower maternal confidence across these 3 years were poorer perceived health and first-time motherhood. Suggested strategies include giving special attention to maternal confidence after nuclear disasters, as well as continuous monitoring of maternal confidence and a focus on mothers' interpersonal issues. Improving access to health information is one key to supporting maternal confidence after a disaster occurs.

Genomic imprinting

Genomic imprinting is an epigenetically-driven phenomenon that responds to environmental stimuli to determine the fetal growth trajectory. This review aims at describing the transgenerational meaning of genomic imprinting while supporting the study of genomic imprinting in placenta for the determination of an important biomarker of chronic and developmental disorders in children as driven by the environment. Recent work has shown that genomic imprinting reaches beyond the basic significance of an epigenetic mark regulating gene expression. Genomic imprinting has been theorized as the main determinant of epigenetic inheritance. Concomitantly, new studies in the field of molecular epidemiology became available that tie the fetal growth trajectory to genomic imprinting in response to environmental stimuli, making of genomic imprinting the driving force of the fetal growth. When carried out in placenta, the effector of the intrauterine environment as conveyed by the maternal exposure to the general life environment, the study of genomic imprinting may reveal critical information on alterations of the fetal growth trajectory. The study of genomic imprinting profiles in placentas from birth cohorts of individuals exposed to different environmental stimuli can provide a new, much needed, tool for the elaboration of effective public health intervention plans for child health.

Child maltreatment: Is the glass half full yet?

1Medical Director, Texas Children's Health Plan, and Clinical Associate Professor, Pediatrics, Baylor college of Medicine, Houston, TX Received: December 5, 2008; accepted: December 5, 2008 Correspondence[email protected]

Extended child health plan offers greater support

Extended child health plan offers greater support

The painful face of poverty

The painful face of poverty

Using Bright Futures to Improve Community Child Health

&lt;P&gt;Just as &lt;cite&gt;Bright Futures Guidelines for the Health Supervision of Infants, Children, and Adolescents&lt;/cite&gt;, third edition, leads us to consider “a new approach to health supervision for children,” its publication prompts a reexamination of the opportunities to strengthen collaboration between the public and private entities that make up the children’s healthcare delivery system. Historically, public health agencies and assistance programs have functioned as a safety net for children’s healthcare. The Medicaid program was established in 1965 to provide essential medical services to low-income children and families. Medicaid’s Early Periodic Screening Diagnosis and Treatment (EPSDT) program supports access to a comprehensive array of health screenings and services; states must provide certain mandatory benefits and may elect to cover additional optional benefits. Efforts to promote high-quality child healthcare to the Medicaid population are therefore easily justified. However, within many states or regions, numerous health-related services are available but may not be connected — nor broadly applied — and poor reimbursement to primary care clinicians under the Medicaid program may further limit its impact on child health outcomes. When this occurs, the public health system must provide the necessary services.&lt;/P&gt;&lt;H4&gt;ABOUT THE AUTHORS&lt;/H4&gt;&lt;P&gt;Wendy S. Davis, MD, is Director, Division of Maternal and Child Health, Vermont Department of Health. Patricia Berry, MPH, and Judith S. Shaw EdD, MPH, are with the Department of Pediatrics, College of Medicine, University of Vermont. &lt;/P&gt; &lt;P&gt;Address correspondence to: Wendy S. Davis, MD, Director, Division of Maternal and Child Health, Vermont Department of Health, 108 Cherry Street, P.O. Box 70, Burlington, VT 05402-0070; fax: 802-863-7229; e-mail &lt;a href="mailto:wdavis@vdh.state.vt.us"&gt;wdavis@vdh.state.vt.us&lt;/a&gt;. &lt;/P&gt;&lt;P&gt;Dr. Davis and Dr. Shaw have participated in the writing of &lt;cite&gt;Bright Futures Guidelines for the Health Supervision of Infants, Children, and Adolescents&lt;/cite&gt;, third Edition, published by the American Academy of Pediatrics. Ms. Berry has disclosed no relevant financial relationships.&lt;/P&gt;&lt;H4&gt;EDUCATIONAL OBJECTIVES&lt;/H4&gt;&lt;OL&gt;&lt;LI&gt;Describe available state and federal public health agencies with which healthcare professionals may partner in child health improvement activities.&lt;/LI&lt;LI&gt;Assess one’s ability to utilize the revised &lt;cite&gt;Bright Futures Guidelines for Health Supervision&lt;/cite&gt; in guiding community child health planning.&lt;/LI&gt;&lt;LI&gt;Identify opportunities for collaboration in implementing activities related to the Bright Futures theme “Promoting Community Relationships and Resources.”&lt;/LI&gt;&lt;/OL&gt;

ECONOMIC IMPACT OF THE COMMUNITY-ACQUIRED METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS EPIDEMIC ON THE DRISCOLL CHILDREN'S HEALTH PLAN

Cellulitis and abscess accounted for increasing percentages of inpatient (4.6-11.1%), outpatient (0.6-1.2%) and total (1.7-3.3%) expenses from 2001 through 2004. The per member per month expenses attributed to cellulitis and abscess increased from $0.74 in 2001 to $1.19 in 2004. The epidemic of community-acquired methicillin-resistant Staphylococcus aureus infections in children has had a significant economic impact on the Driscoll Children's Health Plan.

Changes in Access, Utilization, and Quality of Care After Enrollment Into a State Child Health Insurance Plan

There currently are few published data evaluating the effect of State Children's Health Insurance Programs on health care outcome measures in children. Colorado's Child Health Plan Plus (CHP+) is a non-Medicaid State Children's Health Insurance Program that began enrollment in April 1998. The objectives of this study were to compare reported (1) access to care, (2) utilization of health care, and (3) quality of care during the year before and the first year after enrollment into CHP+. We interviewed 480 randomly selected families by telephone 2 months after their first enrollment into CHP+ (September 1999 to January 2000) and, again, 1 year later. We used generalized linear models to examine the effect of enrollment on health care access, utilization, and quality while controlling for type of previous insurance, length of time uninsured before enrollment, race/ethnicity, and age. Regarding access to care, the percentage of families who reported a usual site of preventive care did not change significantly, but families reported more often being able to see providers as soon as desired for routine care (incidence ratio [IR]: 2.03; 95% confidence interval [CI]: 1.37-3.02]), for care when sick or injured (IR: 2.77; 95% CI: 1.85-4.16), for specialty care (IR: 1.96; 95% CI: 1.16-3.32), and for all health care (IR: 2.35; 95% CI: 1.81-3.07). Unmet medical needs decreased after versus before enrollment for prescription medications (IR: 0.38; 95% CI: 0.26-0.55), mental health care (IR: 0.63; 95% CI: 0.40-0.97), prescription glasses (IR: 0.44; 95% CI: 0.29-0.65), and dental care (IR: 0.59; 95% CI: 0.47-0.76). Regarding utilization, the proportion who saw a provider for routine care in the past year increased (IR: 1.39; 95% CI: 1.06-1.83), but reported visits for sick, specialty, and emergency department care and hospitalizations did not increase. Regarding quality of care, the proportion who rated their health care as "best" increased (RI: 1.31; 95% CI: 1.04-1.66) after versus before enrollment. Families who were newly enrolled into CHP+ perceived dramatic increases in access to all types of care and decreases in unmet medical needs, no increase in utilization of emergency department or hospitalization services, and improved overall quality of care in the year after enrollment into CHP+.

Planning the Next Wave of SCHIP Research

Was the State Children's Health Insurance Program (SCHIP) a flash in the pan or is it the future of children's health insurance? Your answer may depend on the news you read. As states have grappled with tight budgets in the recession economy and the long-ago planned “dip” in federal funding for SCHIP for fiscal years 2002–2004, several states made decisions to limit their SCHIPs through restricting enrollment, increasing premiums, limiting benefits, and decreasing outreach activities. As a consequence, July through December 2003 marked the first period since SCHIP was enacted in 1997 that program enrollment decreased nationally, attributable to marked declines in 11 states and the District of Columbia.1 On the other hand, during the latter half of 2003, a handful of states expanded SCHIP eligibility and enhanced program benefits, and the majority of states continued to report modest increases in SCHIP enrollment.1 Despite the national recession beginning in 2001 that led to increased unemployment and associated decreases in employer-sponsored insurance coverage for children, increased child enrollment in SCHIP and Medicaid more than offset the reduction in employer-sponsored coverage.2 As a result, the rate of uninsurance among US children declined from 15% in 19973 (at SCHIP inception) to 11.4% in 2003,4 a decline attributable in large part to SCHIP enrollment that was particularly robust among children living in households with annual incomes 2 to 3 times the poverty level, beyond the eligibility limits of most Medicaid programs. The findings of Kempe et al5 in this issue of Pediatrics regarding the Colorado version of SCHIP, Child Health Plan Plus, offer good news about SCHIP beyond enrollment statistics. Families reported higher rates of being able to see providers for a variety of routine and acute care needs and also reported a significant decline … Reprint requests to (M.M.D.) University of Michigan, 300 NIB, 6C23, Ann Arbor, MI 48109-0456. E-mail: mattdav{at}med.umich.edu

The Beat

The Beat

Disenrollment From a State Child Health Insurance Plan: Are Families Jumping S(c)HIP?

Colorado's Child Health Plan Plus (CHP+) is a non-Medicaid state child health plan that began enrollment in April 1998. Families are disenrolled 12 months after enrollment if they fail to re-enroll. To assess insurance coverage before and 1 year after initial enrollment in CHP+; reasons for disenrollment; and factors associated with re-enrollment. We interviewed 480 randomly selected families 2 months after initial enrollment into CHP+ (September 1999 through January 2000) and 1 year later. Prior to CHP+, 38% of families had Medicaid (MK), 35% were privately insured (PI), 6% were uninsured (UI), and 20% had other/unknown insurance. After the 12 months, 34% were re-enrolled, 16% got other insurance (6% MK, 10% PI/other), 4% had children older than 18 years, and 46% were UI (9% had intentionally and 37% had unintentionally disenrolled from CHP+). All unintentionally disenrolled families were planning to re-enroll and 90% still appeared eligible. In multivariate analysis, having a primary care provider prior to enrollment was associated with re-enrollment (odds ratio [OR] 1.7, 95% confidence interval [CI] 1.1 to 2.6), but having problems with the application process impeded re-enrollment (OR 0.7, 95% CI 0.6 to 0.9). Only about a third of families eligible for State Children's Health Insurance Program successfully re-enrolled before their termination date. Institution of a passive renewal process would decrease unnecessary disenrollment in eligible families.