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Peds program reduces ED visits by 55%
'Medical home' includes parent education
A program designed to find a "medical home" for complex pediatric patients can reduce the number of ED visits by 55%, according to a study published in the March 11, 2010, online edition of the Journal of Pediatrics.1
Study data was collected between 2004 and 2007 from the Pediatric Medical Home Project at UCLA for Children with Special Healthcare Needs, which was founded at Mattel Children's Hospital at UCLA in Los Angeles in 2003. Researchers examined emergency department, urgent care, and inpatient encounters for 30 medical home patients for one year prior to enrollment in the program and for one year after enrollment. The average number of ED visits per patient decreased from 1.1 + 1.7 before enrollment to 0.5 + 0.9 after enrollment.
The program has several key components, says Thomas S. Klitzner, MD, PhD, chief of the UCLA Division of Pediatric Cardiology, executive director of the medical home project and lead author of the study. Klitzner also notes that this pilot program looked at significantly complex children; they had to have had visits with at least two pediatric subspecialists to participate in the program. "Any child seeing more than one specialist is likely to require that," Klitzner says. "Once you are dealing with such a patient, if they can have a medical home program to help co-manage their conditions through coordination of visits and family support, you will improve the quality of health for that child."
The researchers conducted an initial one-hour visit with the patient to develop lists of problems and introduce them into the program," Klitzner says. "We also developed an 'all about me' binder." This binder includes not only the initial problem list, but a medication list, a list of physicians, notes, and lab results. "The physician gives it to the patient to carry with them on future visits," says Klitzner. "There's also a place to put business cards and family information."
One of the most important elements was the hiring of an administrative assistant to be the family liaison, Klitzner says. "We have two of them, both of whom speak English and Spanish, and they become the primary contact for the families," he explains. Most of their work involved providing administrative services such as access to scheduling; record retrieval and distribution; and maintenance of lists of potential providers, community schools, regional health centers, and other resources, Klitzner says.
Why ED visits dropped
Why does such a program reduce ED visits?
"We interviewed the parents and they gave us a number of answers, most important of which was that they felt empowered and more comfortable with their child's condition and had a centralized person they could go to," says Klitzner. "Parents would start the week with up to 10 visits and by the liaison putting more than one on the same day at the same location, they were able to reduce the need for outpatient visits."
This population was entirely Medicaid, he adds. Often the father had the family car at work during the day, and the only available place to go when the child needed medical care was the ED. "By using this 'telephone triage' program, we found they could get scheduled," says Klitzner.
Leslie Hamilton, MD, medical director of the medical home program, says, "The families can also call the care coordinator with simple things like meds refills. Also, since they get to know us very well, they're able to talk through certain situations and find more appropriate triage to determine what needs be seen urgently, what requires subspecialty follow-up, and so on."
Carlos Lerner, MD, medical director of the UCLA Children's Health Center in Los Angeles, says, "We also provide better health maintenance so the children are less likely to get sicker. We're not just dealing with putting out fires, but global care of a child, making sure that their prescriptions are always filled, nutrition is addressed, and the community support structure is also addressed."
Klitzner says, "I don't believe a program like this will ever eliminate ED visits for these kids. They're way too sick. But it will limit their visits to those that are appropriate."
For more information about medical homes for complex pediatric patients, contact:
Program, concepts can help EDs
While a program that found medical homes for pediatric patients with complex illnesses reduced their ED visits by 55%, is this a model that is translatable to a large number of EDs? Absolutely, says Thomas S. Klitzner, MD, PhD, chief of the Division of Pediatric Cardiology at the David Geffen School of Medicine at the University of California Los Angeles, and executive director of the Pediatric Medical Home Project at UCLA for Children with Special Healthcare Needs.
"I think this model of intense care coordination for complex children can reduce utilization of the ED and allow for easier discharges," Klitzner says. "Our goal is to disseminate this program widely."
For the ED to ensure the community is prepared to implement the program, "the most important first steps are for us to develop a cadre of primary care providers to go into the community and provide this kind of care," he says.
Even without such a formal program, there are steps ED managers can take to minimize unnecessary peds visits, says Leslie Hamilton, MD, medical director of the medical home program. "Communicating with outside pediatricians is very important," Hamilton says. "So is parent empowerment." So, for example, the ED provider should make sure the parents know the phone number of their child's pediatrician, as well as those of their subspecialists.
"This way the ED physician can contact the subspecialist and create a plan, say, for seizure medicine, so if they start a new prescription they won't run out" and have to return to the ED, says Hamilton. The ED provider also should educate the parents and child about the medications, she says. "So, for example, if the child sees seven doctors and is on 14 different meds, you must empower them to know that this particular medicine, for example, is for breathing for a refill you should call the pulmonologist, and here is their number. They want to see you in one week."