P2D121: Virtual-first Comprehensive Care for Children with Medical Complexity Under Population-based Payment Model

Background: Children with medical complexity (CMC) represent fewer than 1 percent of children and more than 30 percent of pediatric health care costs. CMC experience fragmented, uncoordinated, or unavailable outpatient health care; inadequate home health services; high admission and readmission rates; and large health care costs. Several comprehensive care pilot programs for CMC have been shown to reduce ED visits, hospitalizations, mortality rates, and patient/family satisfaction measures. However, no program within the US has scaled beyond a few hundred patients nor used a population-based payment model to finance the program.

Methods: We established a multidisciplinary virtual-first comprehensive care program for CMC which provided care coordination, education, parental support, behavioral health care, and acute medical care virtually. Eligibility is based on a patient’s Medicaid status and an adapted version of the pediatric complex chronic condition classification system. Comprehensive care is provided by a pediatrician led multi-disciplinary care team that includes nurse practitioners, nurses, licensed clinical social workers, and care team assistants. Patients undergo a 12-week onboarding process, after which they graduate to daily digital touchpoints and quarterly provider visits. Care gaps are identified through the daily digital touchpoints, or through direct digital outreach to the provider team, are triaged to the appropriate care-team member based on the content of the care gap – e.g., medical, behavioral, or acute social need. If a patient requires in-person assessment, a mobile-integrated care team consisting of paramedics, community health workers, and nurse practitioners is deployed into the patient’s home in geographically dense regions (Figure 1). Enrollment, diagnosis, and healthcare utilization diversion have been tracked. The program is financed through a population-based payment model arranged with UnitedHealthcare.

Results: Over 6,000 patients were assigned to our program under the population-based payment model. Since enrollment began on 1/1/2023, over 681 patients have been formally engaged and enrolled in the program. The program is projected to obtain a 40% enrollment rate (2,400 patients) by the end of the calendar year. Patients assigned to the program have an average of 4 complex chronic conditions with a standard deviation of 2.6 chronic conditions. The most common complex chronic conditions include behavioral health disorders (47.5%), respiratory diseases (46.0%), neurologic diseases (27.6%), cardiovascular diseases (25.9%), technology dependence (20.0%), gastrointestinal diseases (21.5%), developmental delay (19.0%), and genetic/congenital disorders (15.4%) (Figure 2). Since utilization diversion tracking was established in late January, a total of 35 urgent care, 15 emergency department visits, and 2 inpatient admissions have been avoided by patients within the program.

Conclusion: While early in its operations, this novel virtual care-coordination program financed by a population-based payment model shows promising engagement and utilization prevention for children with medical complexity. Further enrollment and evaluation will be completed prior to the conference.