O2070: Reduced readmissions among Medically Complex Children enrolled in a care-coordination program

Background: 30-day readmission rates are linked to hospital payments and are indicators of a healthcare system’s performance as well as patient health outcomes2. The Cleveland Clinic uses a readmission risk score calculator to predict readmission risk for each patient. Readmission risk scores are based on a patient’s history of healthcare utilization, morbidities, medication lists, among other predictive indicators2. Implementing readmission risk scores as identifiers of patient morbidity and complexity allows for medical providers to proactively address barriers to safe and equitable care.
It is intuitive that children with medical complexity (CMC) carry higher than average readmission risk scores. Increased medical complexity comes with increased interaction with the healthcare system, longer medication lists, and higher levels of fragility.
CMC account for 6% of children, but 40% of Medicaid spending, 41% of hospital days, and >40% of hospital deaths4.
Care coordination programs for medically complex children have been shown to reduce overall costs of care1. The most distinguishing feature of complex care clinics is the employment of care coordination models.
Cleveland Clinic’s (CC) Pediatric Complex Care Clinic is a patient and family-centered medical home providing comprehensive, coordinated care across a variety of settings (outpatient, virtual, and inpatient consultative) for CMC. The clinic assigns patients a PCP, nurse care coordinator, social worker, dietician, and psychologist. The team performs frequent check-ins to assist families in navigating the healthcare system, promptly touch base with families after ER visits and inpatient visits and communicate with a team of multidisciplinary providers to improve consistency of care.

Methods: CC developed an internally validated, 30-day readmission risk score, which is embedded into the EMR. Primary care physicians’ readmission rates for all CCF Ohio locations were compared over one year. The physicians’ performance was calculated based on observed to expected readmissions -- ((Readmissions/Admissions)*100)/Risk of Readmission)2

Results: In 2023 the average risk of readmission score for CCF Pediatric Complex Care Clinic patients was 37.7% (expected % of readmissions for this group of patients)3. Actual observed readmissions were 17.7%, for a difference of 20 % points3. This was the best readmission performance among OH-based primary care physicians, as reported by the CC Readmission Reduction Continuous Improvement Team3.

Conclusion: CMC account for a disproportionate share of hospital stays, inpatient mortality, insurance use, and hospital costs4. CMC carried higher average readmission risk scores but conversely demonstrated the strongest risk reduction in this study. Care coordination models are the defining feature of complex care clinics. It can be surmised, therefore, that employing such models will reduce cost and improve healthcare utilization; providing strong evidence for investing in such programs. This data should inspire attention to performance indicators, such as relative risk reduction, to drive unbiased, regimented management of this special population of patients.