Cooling The Hot Spots Where Child Hospitalization Rates Are High: A Neighborhood Approach To Population Health

Abstract

Improving population health requires a focus on neighborhoods with high rates of illness. We aimed to reduce hospital days for children from two high-morbidity, high-poverty neighborhoods in Cincinnati, Ohio, to narrow the gap between their neighborhoods and healthier ones. We also sought to use this population health improvement initiative to develop and refine a theory for how to narrow equity gaps across broader geographic areas. We relied upon quality improvement methods and a learning health system approach. Interventions included the optimization of chronic disease management; transitions in care; mitigation of social risk; and use of actionable, realtime data. The inpatient bed-day rate for the two target neighborhoods decreased by 18 percent from baseline (July 2012-June 2015) to the improvement phase (July 2015-June 2018). Hospitalizations decreased by 20 percent. There was no similar decrease in demographically comparable neighborhoods. We see the neighborhood as a relevant frame for achieving equity and building a multisector culture of health. Inequities "entail a failure to avoid or overcome inequalities that infringe on fairness and human rights norms." 1 Equity gaps are ever present in pediatrics, with neighborhood-to-neighborhood variation in child morbidity paralleling differences in underlying rates of poverty. 2-6 Such gaps have persisted for generations, driven at least in part by upstream social, environmental, and economic challenges (for example, racial discrimination, substandard housing, limited access to health-promoting resources, and socioeconomic deprivation). 7-10 These challenges affect one's ability to access preventive services, adhere to care recommendations, and trust that the health care system has one's interests at heart. [11][12][13] They also trigger morbidity directly via adverse exposures (such as in-home cockroaches and asthma exacerbations) or indirectly via "toxic" stress responses (for example, repetitive stress that alters immunologic functioning). 14,15 With an evolution toward value-based payments, health care systems are focusing more attention on population health outcomes for lower-income patients. Whether driven by mission or margin, health care systems increasingly see themselves as accountable to more than just the people who walk through their doors. [16][17][18][19][20] They recognize that achieving equitable outcomes requires different-often multilevelapproaches, but little has been published about how to do this for, and with, populations.Population health is defined as "the health outcomes of a group of individuals, including the distribution of outcomes within that group." 21(p381) Cincinnati Children's Hospital Medical Center recently committed "to help[ing] ensure Cincinnati's 66,000 children are the healthiest in the nation through strong community partnerships," as part of its strategic plan for 2020. 22(p610)

Neighborhood socioeconomic deprivation is associated with worse patient and graft survival following pediatric liver transplantation

“…These data might provide a more comprehensive understanding of the socioeconomic milieu in which a patient experiences and manages his or her chronic disease . Such geographic, place‐based data are associated with adverse health outcomes across diseases, and this knowledge has been used to improve other medical outcomes for children of low SES . Using a validated index of neighborhood socioeconomic deprivation in a cohort of pediatric liver transplant recipients, we previously demonstrated that children from the most deprived neighborhoods have twice the rates of nonadherence .…”

Association of a Targeted Population Health Management Intervention with Hospital Admissions and Bed-Days for Medicaid-Enrolled Children

“…As pediatric health systems seek to integrate population health programs, few robust evaluations of such initiatives exist, particularly among children enrolled in Medicaid. 16,24 Prior studies [25][26][27] revealed a potential benefit of targeted care management programs for medically complex children and multicomponent improvement collaborative for children with asthma, while Although our results are promising, important conditions promoting success may not be present in all health systems. The health system in this study had advantages in managing its patients with the highest risk through a primary care model, given its employed physician staffing model and unified EHR platform across its network practices, emergency department, and hospital.…”

“…The number of children with medical complexity who received in-network care increased by 44.1%, from 1131 children in January 2014 to 1632 children in June 2017, surpassing the After program launch, mean admission rates for the out-of-network patients remained largely stable, while admission rates for in-network patients decreased (in-network, 4.37 [95% CI, 4.10 to 4.63] monthly admissions per 1000 beneficiaries; difference, −0.43 [95% CI, −0.63 to −0.22] monthly admissions per 1000 beneficiaries; out-of-network, 3.40 [95% CI, 3.16 to 3.67] monthly admissions per 1000 beneficiaries; difference, −0.04 [95% CI, −0.24 to 0.17] monthly admissions per 1000 beneficiaries) (Table 2).Figure 3shows mean monthly number of bed-days for in-network and out-of-network patients, before and after program implementation. Although there was greater variation in bed-days compared with counts of admissions, overall there was a modest decrease in mean monthly bed-days among in-network patients compared with an increase in mean bed-days among out-ofnetwork patients (in-network,16.12 [95% CI, 14.93 to 17.32] vs 15.20 [14.03 to 16.37] monthly…”

Resident-sensitive quality measures

“…64 However, traditional quality metrics do not align well with the work that residents perform. 65 Paradoxically, quality measures sometimes attributed to supervising physicians may actually be attributable to residents. 66 Once quality measures relevant to the work that residents perform are clearly delineated, scholars have advocated the use of electronic health records (EHRs) to produce such measures.…”

“…This outcome will be determined by a plethora of variables arising from the patient, multiple members of the health care team, aspects of the health care system, and even the neighborhood community of the patient. 65 The portions of the continuum between these extremes will be important to learn more about. Sebok-Syer and colleagues are currently beginning to explore this area, seeking to determine the spectrum of interdependence in emergency medicine performance metrics for residents.…”