Personal care services provided to children with special health care needs (CSHCN) and their subsequent use of physician services

Examining outpatient occupational therapy utilization among children and youth with special health care needs in South Carolina: A structural equation model of individual- and community-level factors

BACKGROUND

Children and youth with special health care needs (CYSHCN) comprise 23 % of the pediatric population in South Carolina (SC), compared to state prevalences of 13.6 %-24 % nationwide. While occupational therapy (OT) is critical to maximizing CYSHCN's participation in daily activities, there are significant disparities in rehabilitation access in the Southeast region.

OBJECTIVE

This study examines associations between patient-and community-level factors and outpatient OT utilization.

METHODS

This study analyzes OT utilization data among CYSHCN (N = 1913) in a health system in SC from 07/01/2022-06/31/2023, merged with Child Opportunity Index 2.0 zip-code level social drivers of health (SDOH) data. SDOH are non-medical factors that affect individual's long-term health, with estimates ranging from "very low" to "very high" opportunity. Structural equation modeling was conducted to understand complex associations between observed and latent variables in a real-world context.

RESULTS

CYSHCN were diagnosed with congenital (40.77 %), developmental (37.87 %), and neurological/neuromuscular conditions (21.36 %). CYSHCN who were non-Hispanic Black or Hispanic and were hospitalized were associated with living in lower opportunity areas. CYSHCN with private or military/other insurance/self-pay were associated with living in higher opportunity areas than Medicaid-insured CYSHCN. CYSHCN who were female and ≥12 years demonstrated lower OT utilization. CYSHCN who participated in speech and/or physical therapy demonstrated higher OT utilization. OT utilization increased with each increase in SDOH.

CONCLUSION

With these findings, healthcare providers may consider accessibility barriers, including transportation, when referring CYSHCN to OT services. Further research is needed to examine the impact of household-level SDOH on OT access across SC.

Physician and informal care use explained by the Pediatric Quality of Life Inventory (PedsQL) in children with suspected genetic disorders

PURPOSE

To examine associations between Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scales and PedsQL Infant Scales with formal health care resource utilization (HCRU) and informal caregiver burden.

METHODS

We studied a pediatric cohort of 837 patients (median age: 8.4 years) with suspected genetic disorders enrolled January 2019 through July 2021 in the NYCKidSeq program for diagnostic sequencing. Using linked ~ nine-month longitudinal survey and physician claims data collected through May 2022, we modeled the association between baseline PedsQL scores and post-baseline HCRU (median follow-up: 21.1 months) and informal care. We also assessed the longitudinal change in PedsQL scores with physician services using linear mixed-effects models.

RESULTS

Lower PedsQL total and physical health scores were independently associated with increases in 18-month physician services, encounters, and weekly informal care. Comparing low vs. median total scores, increases were 10.6 services (95% CI: 1.0-24.6), 3.3 encounters (95% CI: 0.5-6.8), and $668 (95% CI: $350-965), respectively. For the psychosocial domain, higher scores were associated with decreased informal care. Based on adjusted linear mixed-effects modeling, every additional ten physician services was associated with diminished improvement in longitudinal PedsQL total score trajectories by 1.1 point (95% confidence interval: 0.6-1.6) on average. Similar trends were observed in the physical and psychosocial domains.

CONCLUSION

PedsQL scores were independently associated with higher utilization of physician services and informal care. Moreover, longitudinal trajectories of PedsQL scores became less favorable with increased physician services. Adding PedsQL survey instruments to conventional measures for improved risk stratification should be evaluated in further research.

Home Health Care Utilization in Children With Medicaid

BACKGROUND

Although many children with medical complexity (CMC) use home health care (HHC), little is known about all pediatric HHC utilizers. Our objective was to assess characteristics of pediatric HHC recipients, providers, and payments.

METHODS

We conducted a retrospective analysis of 5 209 525 children age 0-to-17 years enrolled Medicaid in the 2016 IBM Watson MarketScan Medicaid Database. HHC utilizers had ≥ 1 HHC claim. Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes were reviewed to codify provider types when possible: registered nurse (RN), licensed practical nurse (LPN), home health aide (HHA), certified nursing assistant (CNA), or companion/personal attendant. Enrollee clinical characteristics, HHC provider type, and payments were assessed. Chronic conditions were evaluated with Agency for Healthcare Research and Quality's Chronic Condition Indicators and Feudtner's Complex Chronic Conditions.

RESULTS

Of the 0.8% of children who used HHC, 43.8% were age <1 year, 25% had no chronic condition, 38.6% had a noncomplex chronic condition, 21.5% had a complex chronic condition without technology assistance, and 15.5% had technology assistance (eg, tracheostomy). HHC for children with technology assistance accounted for 72.6% of all HHC spending. Forty-five percent of HHC utilizers received RN/LPN-level care, 7.9% companion/personal attendant care, 5.9% HHA/CNA-level care, and 36% received care from an unspecified provider. For children with technology assistance, the majority (77.2%) received RN/LPN care, 17.5% companion/personal assistant care, and 13.8% HHA/CNA care.

CONCLUSIONS

Children using HHC are a heterogeneous population who receive it from a variety of providers. Future investigations should explore the role of nonnurse caregivers, particularly with CMC.

The Effects of Chronic Disease on Ambulatory Care-Sensitive Hospitalizations for Children or Youth

Considerable research has focused on hospitalizations for ambulatory care–sensitive conditions (ACSHs), but little of that research has focused on the role played by chronic disease in ACSHs involving children or youth (C/Y). This research investigates, for C/Y, the effects of chronic disease on the likelihood of an ACSH. The database included 699 473 hospital discharges for individuals under 18 in Texas between 2011 and 2015. Effects of chronic disease, individual, and contextual factors on the likelihood of a discharge involving an ACSH were estimated using logistic regression. Contrary to the results for adults, the presence of chronic diseases or a complex chronic disease among children or youth was protective, reducing the likelihood of an ACSH for a nonchronic condition. Results indicate that heightened ambulatory care received by C/Y with chronic diseases is largely protective. Two of more chronic conditions or at least one complex chronic condition significantly reduced the likelihood of an ACSH.

The Pediatric Personal Care Allocation Model for Home Care (PCAM): A Personal Care Case-Mix Model for Children Facing Special Health Care Challenges

Background:

State Medicaid programs in the United States provide services to children with special health care challenges through the Early Prevention, Screening, Diagnostic, and Treatment program. One element of the services provided is Medicaid Personal Care Services (PCS), which are intended to correct or ameliorate any functional impairments faced by a child or youth (C/Y) in the community. Previous research indicates that considerable variation in the allocation of PCS depends on the assessor. A case-mix model is developed that might make the distribution of such services more uniform and equitable.

Data:

The sample in this research includes 2708 C/Y aged 4 to 20 who were receiving PCS in Texas in 2008.

Results:

A case-mix model was developed that groups sample members into 33 categories based on the number of hours of PCS authorized by an assessor. The Pediatric Personal Care Allocation Model (PCAM) explains 27% of the variance in the allocation of PCS hours.

Discussion:

The implementation of the PCAM should provide guidance to assist in ensuring that C/Y facing similar functional challenges receive similar levels of PCS. However, implementation of any case-mix model is only a first step in moving to a prospective payment system for PCS.

Post-acute care for children with special health care needs

BACKGROUND

Almost all studies of post-acute care (PAC) focus on older persons, frequently those suffering from chronic health problems. Some research is available on PAC for the pediatric population in general. However, very few studies focus on PAC services for children with special health care needs (SHCN).

OBJECTIVE

To investigate factors affecting the provision of PAC to children with SHCN.

METHODS

Pooled cross-sectional data from Texas Department of State Health Services hospital discharge database from 2011-2014 were analyzed. Publicly available algorithms identified chronic conditions, complex chronic conditions, and the principal problem leading to hospitalization. Analysis involved estimating two logistic regressions, with clustered robust standard errors, concerning the likelihood of receiving PAC and where that PAC was delivered. Models included patient characteristics and conditions, as well as hospital characteristics and location.

RESULTS

Only 5.8 percent of discharges for children with SHCN resulted in the provision of PAC. Two-thirds of PAC was provided in a health care facility (HCF). Severity of illness and the number of complex chronic conditions, though not the number of chronic problems, made PAC more likely. Patient demographics had no effect on PAC decisions. Hospital type and location also affected PAC decision-making.

CONCLUSIONS

PAC was provided to relatively few children with SHCN, which raises questions concerning the potential underutilization of PAC for children with SHCN. Also, the provision of most PAC in a HCF (66%) seems at odds with professional judgment and family preferences indicating that health care for children with SHCN is best provided in the home.

The Pediatric Home Care/Expenditure Classification Model (P/ECM): A Home Care Case-Mix Model for Children Facing Special Health Care Challenges

Case-mix classification and payment systems help assure that persons with similar needs receive similar amounts of care resources, which is a major equity concern for consumers, providers, and programs. Although health service programs for adults regularly use case-mix payment systems, programs providing health services to children and youth rarely use such models. This research utilized Medicaid home care expenditures and assessment data on 2,578 children receiving home care in one large state in the USA. Using classification and regression tree analyses, a case-mix model for long-term pediatric home care was developed. The Pediatric Home Care/Expenditure Classification Model (P/ECM) grouped children and youth in the study sample into 24 groups, explaining 41% of the variance in annual home care expenditures. The P/ECM creates the possibility of a more equitable, and potentially more effective, allocation of home care resources among children and youth facing serious health care challenges.

The interRAI Pediatric Home Care (PEDS HC) Assessment: Evaluating the Long-term Community-Based Service and Support Needs of Children Facing Special Healthcare Challenges

The vast majority of assessment instruments developed to assess children facing special healthcare challenges were constructed to assess children within a limited age range or children who face specific conditions or impairments. In contrast, the interRAI Pediatric Home Care (PEDS HC) Assessment Form was specifically designed to assess the long-term community-based service and support needs of children and youth aged from four to 20 years who face a wide range of chronic physical or behavioral health challenges. Initial research indicates that PEDS HC items exhibit good predictive validity—explaining significant proportions of the variance in parents’ perceptions of needs, case managers’ service authorizations, and Medicaid program expenditures for long-term community-based services and supports. In addition, PEDS HC items have been used to construct scales that summarize the strengths and needs of children facing special healthcare challenges. Versions of the PEDS HC are now being used in Medicaid programs in three states in the United States.