Cooling The Hot Spots Where Child Hospitalization Rates Are High: A Neighborhood Approach To Population Health

Abstract

Improving population health requires a focus on neighborhoods with high rates of illness. We aimed to reduce hospital days for children from two high-morbidity, high-poverty neighborhoods in Cincinnati, Ohio, to narrow the gap between their neighborhoods and healthier ones. We also sought to use this population health improvement initiative to develop and refine a theory for how to narrow equity gaps across broader geographic areas. We relied upon quality improvement methods and a learning health system approach. Interventions included the optimization of chronic disease management; transitions in care; mitigation of social risk; and use of actionable, real-time data. The inpatient bed-day rate for the two target neighborhoods decreased by 18 % from baseline (July 2012–June 2015) to the improvement phase (July 2015–June 2018). Hospitalizations decreased by 20 %. There was no similar decrease in demographically comparable neighborhoods. We see the neighborhood as a relevant frame for achieving equity and building a multisector culture of health.

Insights Results

Overview of article/program

This article assesses the Cincinnati Children’s Hospital Medical Center’s initiative to reduce hospital days for children with 2 high-morbidity, high-poverty neighborhoods, aiming to narrow the gap between their neighborhoods and healthier ones

As a part of the Cincinnati Children’s Hospital Medical Center’s commitment to ensure that the city’s children are the healthiest in the nation through strong community partnership, this initiative’s goal was to reduce the rate at which children from high-morbidity, high-poverty neighborhoods spend days in the hospital. Meeting this goal required being accountable for an entire population and focusing on the root causes of place-based inequities. Specifically, this initiative has employed the Model for Improvement and a learning health system approach to spur cross-sector collaboration and a move toward scale

This quality improvement imitative was in collaboration with the All Children Thrive (ACT) Learning network, which connects teams across sectors to navigate complex, multi-dimensional problems. ACT pushes toward action using 4 strategies: 1) Network members focus on equity-oriented outcomes via a strong measurement framework and analytic core; 2) Strategic multi-sector partnerships are pursued, fostering collaboration in and outside of healthcare; 3) Network build capability by teaching quality improvement methods; and 4) Everyone involved keeps children and families at the center of the work

4 focus areas guided the development of the initiative: 1) Chronic conditions (e.g., proactive care, integrated services/personnel); 2) Transitions of care (e.g., multidisciplinary huddles, care gap closure during hospitalization, connections back to home and school); 3) Mitigation of social risk (e.g., balanced approach to medical and social needs, partnerships with community agencies and schools around key barriers); and 4) Actionable, real-time data (e.g., transparent data on disparities across conditions or clinical divisions within healthcare systems, parents or family members and partnered agencies seeing data and recognizing patterns)

Methods of article

The specific improvement aim was to reduce inpatient bed-day rate for children from Avondale and Price Hill by at least 10% in 5 years through the assembly of a multi-disciplinary team composed of inpatient and outpatient medical providers, social workers, community partners, parents of neighborhood children and more
The team identified 8 key drivers for the initiative: 1) Families are partners in co-creating improvement strategies; 2) Families receive the right care in the right place at the right time; 3) Families trust that they are receiving the right care for them; 4) Clinical decision making is standardized but can be adapted to patient and family needs; 5) Proactive supports assist families in removing barriers to health; 6) The healthcare system is accountable to the population and able and willing to address disparities in care settings; 7) Families and the community are activated in support of achieving health equity; and 8) Families are well equipped to self-manage acute and chronic disease symptoms
The primary outcome was the neighborhood inpatient bed-day rate

Results

Over the 5 years, there was a rate reduction (18%) in inpatient bed-day rate, which was likely driven by fewer hospitalizations rather than shorter lengths of stay. In the meantime, the control group rates remained the same
Additionally, emergency department visit rates increased in the 2 regions and the control group, suggesting a relationship to background trends, not the improvement initiative
The number of hospitalizations decreased from 1,344 to 1,041
Study results indicate a move towards equity as both regions improved in their ranking of inpatient bed-day rates among other counties
The study found value in commitment to working with an entire population and not one subdivided to be convenient to the healthcare system
The study found power in the use of electronic health records to specify population health outcomes and link them to contextual factors (e.g., neighborhood housing quality)

Key takeaways/implications

It must be considered that these efforts were largely mission driven and may be viewed differently had the medical center been operating in a pay-for-value model. As such, researchers believe that collaborative efforts would be supported by an amended view of fee-for-service
Research efforts and programs that align with ACT’s 4 main strategies should be considered. The 4 strategies are: 1) Network members focus on equity-oriented outcomes via a strong measurement framework and analytic core; 2) Strategic multisector partnerships are pursued, fostering collaboration inside and outside of healthcare; 3) Network build capability by teaching quality improvement methods. Accrued skills are then deployed to integrate initially siloed sectors; and 4) Everyone involved keeps children and families at the center of the work
Limitations to the study include potential lack of generalizability to there regions, difficulty in determining which of the multilevel interventions made the most difference, use of a priori exclusion decisions, change in neighborhood over time, inability to measure the cost of the program’s efforts, and children could have been hospitalized at another center