Enhancing Clinical Networks & Community Collaboration

Children’s hospitals serve as a safety net for many children from lower socio-economic backgrounds. That is where parents turn to when their children get sick and unfortunately, this often happens when the condition has deteriorated to a point where they will need to hospitalize their child.

Research on some common conditions – asthma, diabetes, bronchiolitis and respiratory syncytial virus, pneumonia, and kidney and urinary tract infections – from children’s hospitals have shown that there is a definite difference in resource utilization between income groups. The lowest income groups end up having to bear the highest costs. The individual hospitalization level cost differences across income groups ranged from $187 (4.1%) to $404 (6.4%). Patient-level cost differences ranged from $310 to $1087 or 6.5% to 15% higher for the lowest-income patients.

The cost differences are due to 2 main drivers. One is due to the higher number of hospitalizations per child as these children do not receive adequate on-going care, sometimes even no care, in the community and thereby end up in the hospital repeatedly. The other cost driver is that these children end up staying in hospital longer for non-medical reasons. The decision to discharge them may relate to psychosocial issues such as food insecurity, housing etc. which need to be sorted out first.

These cost drivers point to the need for both policy level and health system level interventions to reduce these costs. Policy is needed for better support in the community and while there are continuous efforts in this direction, there are strategic interventions that health systems can implement to serve these families better.

Let us explore 2 of these strategies

Increasing touchpoints in community care

For a variety of reasons these children do not show up as much in ambulatory care and a lot of preventive interventions are being missed. As an example, most kids with asthma can be appropriately managed in primary care. When they do not have the adequate medication, clinical events that could be managed with inhalers deteriorate to the point that they need to rush to the ER. This happens repeatedly, putting an avoidable strain on the families and on emergency room resources. Children’s hospitals can prevent these incidents by intervening at the community level with proactive outreach. The hospital’s data and purpose-built algorithms can be used to identify those children that need to be treated for these chronic issues. These data pipelines can be designed to periodically generate cohorts of children who need proactive care. Powered by this data, affiliated ambulatory care clinics can be turned into the frontline where early interventions through proactive care plans can mitigate the impact of these common diseases. These clinics can reach out to these families, ensure they are taken care of as per best practice, educate parents and follow up at appropriate intervals.

Increased coordination with non-clinical community resources

Often the challenges for these families are outside the realm of clinical care. It may be the lack of nutrition or it may be that living conditions are poor. As an example, poor housing conditions – mold, bugs- can aggravate asthma in susceptible children. Identifying these risk factors and acting on them requires a team effort. This involves collaborating with the community, social workers and supportive legal services. UMass Medical Center in Worcester MA has one such program. Identification of psychosocial factors is again a data driven effort that will need to be tied into such programs involving workers from organizations outside of the hospital.

Role of CRM

Customer relationship management platforms such as the Health Cloud are designed specifically for organizations to manage their interactions with patients and with partner organizations. They serve as the platform for better outreach and access programs. Powered by robust integrations with enterprise data in the EMR and from other patient data repositories, comprehensive solutions can be set up where different departments can launch outreach programs to reach out and close the loop on many of the most needy children out in the community. Affiliated practices and organizations can have their staff collaborate and work toward common objectives like improving access, timelines of interventions and socio-economic support.

Persistent’s Digital Front Door empowers healthcare organizations to provide these capabilities and more. Learn about this Salesforce, Vonage and MuleSoft powered solution here.