Association between Practice Participation in a Pediatric-focused Medical Home Learning Collaborative and Reduction of Preventable Emergency Department Visits by Publicly-Insured Children in Massachusetts

Abstract

INTRODUCTION:
This study evaluates the impact of practice participation in a pediatric patient-centered medical home learning collaborative on preventable emergency department (ED) visits among children in MassHealth (Massachusetts Medicaid/Children’s Health Insurance Program).

METHODS:
Claims and enrollment data were extracted for child MassHealth members (aged 3–18) comprising 2 groups: members enrolled in a group of 13 child-serving practices that participated in an intensive, 29-month long patient-centered medical home learning collaborative (intervention group), and members enrolled in a group of 12 comparison practices with roughly similar panel size, type, and geographic location (comparison group). Preventable ED visits were identified using a modified version of the New York University ED algorithm. Two analyses were then conducted: (1) a repeat cross-sectional analysis among children enrolled in intervention or comparison group practices during baseline (first half of 2011) and follow-up (second half of 2013) periods; and (2) a longitudinal analysis among a subset of children enrolled for the full study period (2011–2013). Both analyses tested whether the effect of the intervention differed for children with versus without chronic conditions (effect modification).

RESULTS:
Preventable ED visits declined from baseline to follow-up among children in both intervention and comparison practices. In the cross-sectional analysis, the decrease was the same in both practice groups, and for children with versus without chronic conditions. The longitudinal analysis shows a statistically significantly greater decrease among children with chronic conditions enrolled in the intervention practices (P = 0.02).

CONCLUSION:
Children with chronic conditions might receive the greatest benefit from receiving care in a medical home setting.

Insights Results

Overview of model

Using Children’s Health Insurance Program Reauthorizations Act of 2009 (CHIPRA) Quality Demonstration funding, the Massachusetts Medicaid Agency (MassHealth) implemented a learning collaborative to support PCMH transformation at 13 practices

healthcare utilization data on publicly-insured children with chronic illnesses in participating practices (experimental groups) and comparable practices (control group) was analyzed using: 1) a cross-sectional analysis comparing the beginning to the end of collaborative; and 2) a longitudinal analysis tracking a subset of children throughout the intervention

Key takeaways/implications

The proportion of children having preventable ED visits fell over the course of the study period for both the control and the experimental groups; however, the decrease was greater among children with chronic conditions who received care in the intervention practices for the full duration of the PCMH collaborative
The study suggests potential benefits to children of interventions designed to develop PCMH characteristics at practice sites; however, does not confirm a casual relationship
Study Limitations: 1) Does not correlate measures of medical homeness with preventable ED visits because MHI data could not be completed for the comparison group; 2) Selection bias and uncontrollable differences between control and experimental groups; 3) Because both groups saw a decline in ED visits, there might be other systematic efforts that need to be considered; and 4) Unable to examine the issue of cost reduction
Suggested area for future research: studies that connect the specific content of PCMH interventions to measurable improvements in medical homeness and patient outcomes, and that clarify the role of continuous enrollment in supporting improved outcomes, would help advance the case for the medical home model as a driver of healthcare quality improvement