The Intersection of Complex Care and Hospital Medicine: Opportunities to Advance Health for Chronically Ill Populations

Abstract

Children with medical complexity (CMC) are a high-need, high-cost population representing 1% of all children yet accounting for nearly one-third of all child health-related costs. 1 Nearly half of health costs for CMC are attributable to hospital care 2 ; 30-day readmission rates for CMC are 4 times higher than that for non-CMC, 3 and 26% of hospital days and 43% of in-hospital deaths are attributable to CMC. 4 High hospital use by CMC is a consequence of multiple chronic conditions, severe functional limitations, reliance on long-term medical technology for daily living (eg, feeding tube in a child with severe neurologic impairment), and high-intensity care needs supported by multispecialty care and home-based services (eg, home nursing) that are typical for this patient population. 1 Parents of CMC take responsibility for the vast majority of caregiving and face many challenges, including inadequate insurance, lack of a patient-centered medical home, and insufficient hours of coverage for home health care workers. 5 As a result of intense financial and emotional stress, caregivers themselves experience physical and mental health problems that can compromise their ability to effectively perform caregiving tasks. 6 Additionally, direct clinical encounters for CMC in health care settings are often inefficient and poorly coordinated. 5 Because the traditional health care delivery system often fails to meet the needs of CMC and their families, because CMC frequently receive acute hospital care, and because care of CMC is a core competency of pediatric hospital medicine (PHM), pediatric hospitalists have an essential role to play in the development of innovative solutions to improve care for CMC. 7 In response, hospitalists have been integral in refining and studying structured complex care programs for CMC. 8,9 These programs are frequently focused on comprehensive care coordination, interdisciplinary collaboration, improved access to care, facilitated communication between providers and parents, and enhanced support during transitions of care. Early evaluations of complex care programs have demonstrated reductions in health care use, lower costs for many participants, and a better patient and family experience. 8,10 Complex care program efforts to improve care for CMC are well aligned with broader shifts toward high-value care at the population level (ie, better health outcomes and a better experience for children and families and providers at lower cost). As health systems face increasing pressure to shift care to lower-cost settings and strengthen transitions between sites of care, hospitalists have a key role in the ambitious aim to deliver value-based care and advance health for the most complex and challenging pediatric patient populations.