Pediatric Specialty Care Model for Management of Chronic Respiratory Failure: Cost and Savings Implications and Misalignment With Payment Models

Objective: To describe program design, costs, and savings implications of a critical care–based care coordination model for medically complex children with chronic respiratory failure. Design: All program activities and resultant clinical outcomes were tracked over 4 years using an adapted version of the Care Coordination Measurement Tool. Patient characteristics, program activity, and acute care resource utilization were prospectively documented in the adapted version of the Care Coordination Measurement Tool and retrospectively cross-validated with hospital billing data. Impact on total costs of care was then estimated based on program outcomes and nationally representative administrative data. Setting: Tertiary children’s hospital. Subjects: Critical Care, Anesthesia, Perioperative Extension and Home Ventilation Program enrollees. Interventions: None. Measurements and Main Results: The program provided care for 346 patients and families over the study period. Median age at enrollment was 6 years with more than half deriving secondary respiratory failure from a primary neuromuscular disease. There were 11,960 encounters over the study period, including 1,202 home visits, 673 clinic visits, and 4,970 telephone or telemedicine encounters. Half (n = 5,853) of all encounters involved a physician and 45% included at least one care coordination activity. Overall, we estimated that program interventions were responsible for averting 556 emergency department visits and 107 hospitalizations. Conservative monetization of these alone accounted for annual savings of $1.2–2 million or $407/pt/mo net of program costs. Conclusions: Innovative models, such as extension of critical care services, for high-risk, high-cost patients can result in immediate cost savings. Evaluation of financial implications of comprehensive care for high-risk patients is necessary to complement clinical and patient-centered outcomes for alternative care models. When year-to-year cost variability is high and cost persistence is low, these savings can be estimated from documentation within care coordination management tools. Means of financial sustainability, scalability, and equal access of such care models need to be established. Dr. Graham conceptualized and designed the study, reviewed all data analysis for interpretation, drafted the initial article, and approved the final article as submitted. Dr. McManus conceptualized and designed the study, reviewed all data analysis for interpretation, critically reviewed the article, and approved the final article as submitted. Dr. Rodday was engaged in the initial study design, carried out the initial analyses, reviewed and revised the article, and approved the final article as submitted. Ms. Weidner was engaged in the initial study design, coordinated the data collection and initial analysis, reviewed and revised the article, and approved the final article as submitted. Dr. Parsons conceptualized and designed the study, coordinated and supervised data collection, reviewed all data analysis for interpretation, critically reviewed the article, and approved the final article as submitted. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://ift.tt/2gIrZ5Y). Supported, in part, by internal grant funding from Boston Children’s Hospital through the Payer-Provider Quality Initiative. Program and research support were provided as an internal grant at Boston Children’s Hospital through the Children’s Hospital Collaborative Clinical Effectiveness Fund. Drs. Rodday and Weidner’s institution received funding from Boston Children’s Hospital (internal grant). Dr. Rodday received support for article research from Boston Children’s Hospital (internal grant). The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: Robert.Graham@childrens.harvard.edu ©2018The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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