State Variation in Posthospital Home Nursing for Commercially Insured Medically Complex Children

Abstract

BACKGROUND AND OBJECTIVES: Home nursing is essential for children with medical complexity (CMC), but provision varies substantially across states. Our objectives were to quantify state-to-state variability in distribution of posthospitalization home nursing to commercially insured CMC and to rank-order states.METHODS: Retrospective cohort study of hospitalized commercially insured children with $1 complex chronic condition from birth to 18 years of age in the Truven MarketScan database. Cohort eligibility criteria were hospital discharge between January 2013 and November 2016 and at least 30 days of follow-up after discharge. Two primary outcome measures were used: receipt of any home nursing within 30 days of hospital discharge (yes or no) and number of days of posthospitalization home nursing (1-30 days). A composite metric encompassing both receipt and quantity was created by evaluating the 95th percentile of days of home nursing (0-30 days).RESULTS: Overall, 9.9% of the sample received home nursing. After we adjusted for patient characteristics, the probability of receiving home nursing varied across states, ranging from 3.4% to 19.2%. Among home nursing recipients, the adjusted median home nursing days across states ranged from 6.6 to 24.5 days. The adjusted 95th percentile of days of home nursing (across the entire of sample, including recipients and nonrecipients of home nursing) ranged from 6.8 to 22.6 days. CONCLUSIONS:We observed striking state-to-state variability in receipt of home nursing and mean number of days of posthospitalization home nursing among commercially insured CMC after adjustment for demographic and clinical differences. This suggests opportunities for state-level improvement.WHAT'S KNOWN ON THIS SUBJECT: Home nursing is an essential service for children with medical complexity. Estimates of posthospital home nursing prevalence vary widely, and state differences have been suggested.WHAT THIS STUDY ADDS: In a commercial insurance claims database, substantial state-to-state variability in provision of posthospitalization home nursing to children with medical complexity was quantified. Using a novel reproducible composite metric, states were ranked on the basis of their provision of home nursing services.

Access and Quality of Pediatric Home Healthcare: A Systematic Review

“…48 Another retrospective cohort evaluation of 88,139 commercially insured children, found that the adjusted probability of receiving post-hospitalization home nursing within 30 days varied substantially across states (3.4%-19.2%). 53 Studies also evaluated home healthcare access through the lens of hospital discharge delays. 23,25,27,34,38,47,50,[54][55][56][57] The most methodologically rigorous study was a multi-site prospective cohort study of 185 patients found that inadequate home healthcare nursing accounted for an average excess stay in the hospital of 53.9 days (range: 4-204) and 35.7 days (3-6) for new and existing patients, respectively.…”

Allocation of Pediatric Home Care Nursing Hours

“…Standardizing the allotment of nursing hours optimizes availability of this scarce resource. Variations across state lines impact access to pediatric home care nursing, home care nursing hours, and contributes to healthcare disparities (Rasooly et al, 2020). Proposals suggest there should be federal standards for Medicaid home-based services (Ollove, 2021).…”

“…care nursing, which may contribute to healthcare disparity (Rasooly et al, 2020). Currently no standard exists for prescribing pediatric nursing hours based on the medical complexity of the patient (Sobotka et al, 2020).…”

“…Home care services are received by 5% to 7% of pediatric hospital discharges (Berry et al, 2016; Feudnter et al, 2005). There are significant state variations in use of posthospital pediatric home care nursing, which may contribute to healthcare disparity (Rasooly et al, 2020). Currently no standard exists for prescribing pediatric nursing hours based on the medical complexity of the patient (Sobotka et al, 2020).…”

For Medically Complex Children, There Really Is “No Place Like Home”

“…Such studies can be used to provide an important beginning but reveal little about the actual quantity of HNC use. An approach to filling that knowledge gap is provided in this month's issue of Pediatrics by Rasooly et al, 5 who assessed the use of HNC among CMC. Using a 4-year commercial data set that included actual payments for services, the team looked at whether patients received any home nursing services within 30 days of a hospital discharge and the number of days of nursing services for those receiving them.…”