Redesigning Care Management for Medically Complex Children

By Christopher Cheney

A new medical group has taken an innovative approach to care redesign to serve Medicaid-eligible children with medical complexity and special healthcare needs.

Children with medical complexity make up less than 1% of children in the United States, but they represent 56% of hospitalized pediatric patients and 82% of hospital days in children’s hospitals. Children with medical complexity represent just 5% to 6% of children covered under Medicaid, but they account for approximately one third of Medicaid expenditures on pediatric patients.

Imagine Pediatrics launched nearly a year ago with a virtual-first care model that provides care and support services to Medicaid-eligible children with medical complexity and special healthcare needs on a 24/7 basis. The medical group, which features a pediatrician-led multidisciplinary approach, does not replace a pediatric patient’s primary care providers or specialists, but is geared to filling care gaps with a high level of access.

“We work in collaboration with their existing doctors and medical homes, so we are not replicating or duplicating care,” says Patricia Hayes, MD, chief clinical officer of Imagine Pediatrics. “We bring an extra layer of support for these children.”

In addition to its virtual-first care model, Imagine Pediatrics can dispatch paramedics with pediatrics training to the homes of patients. These paramedics offer a range of services, including IV antibiotics, IV fluids, testing for common illnesses, lab draws, and helping with hospital transitions of care.

The medical group is serving 20,000 patients in Florida and Texas, and has full-risk, value-based contracts with three health plans: UnitedHealthcare Community Plan of Texas, UnitedHealthcare Community Plan of Florida, and Superior HealthPlan, which is based in Florida.

“We are unique because we provide 24/7, integrated care delivered to Medicaid-eligible children with medical complexity and special healthcare needs,” Hayes says. “Although they are a small percentage of the pediatric patient population, they account for an outsized share of healthcare spending. We are providing them with unprecedented access, when they have historically had limited access to primary care or specialty care.”

These patients are frequent healthcare users, often requiring multiple hospitalizations or trips to the emergency room or urgent care clinic. As a result, their care is often fragmented and uncoordinated, leading to care gaps and unnecessary expenses.

Imagine Pediatrics aims to improve that care platform, coordinating care and reducing stress on hospitals and PCPs.

Imagine Pediatrics provides virtual care through multiple channels, including an app and telemedicine platform. The medical group’s care team includes pediatricians, nurses, social workers, therapists, care team assistants, pharmacists, and dietitians, along with virtual care support for home health nurses at these children’s bedsides, providing an extra layer of support for consultation services.

Providing care coordination

In working with health plans and their networks, the medical group’s leadership team says they can work faster than primary and specialty care teams to make sure these families get what they need when they need it.  This takes the burden off of PCPs, as well as health system CMOs who are called on to manage care for these patients when they end up in the hospital.

“We do a lot of the legwork and paperwork that it takes to get things done for these families,” Hayes says. “We set up appointments for them. We expedite prior authorizations by working closely with their health plans to get them medications, procedures, or equipment.”

In many cases, Hayes says, Imagine Pediatrics is in daily contact with patients and their families.

“The idea is to identify gaps and fill them before an emergency situation arises,” she says. “We also make sure that everything we do gets communicated back to the primary care teams, so we are all on the same page.”

Generating results

Over the past 10 months, the medical group has measured a 15% reduction in inpatient admissions and 20% reduction in total cost of care among engaged pediatric patients.

Patient and family engagement is crucial in reducing inpatient admissions, Hayes says.

“Just in the 11 months that we have been live, we have conducted more than 50,000 care interactions,” she says. “That includes virtual visits, in-person visits, and digital messaging through our app. We get ahead of the curve for these families. We are proactive. We are making sure these children stay healthy at home.”

Hayes says this strategy helps the medical group reduce total cost of care.

“We try to stay ahead of things, try to prevent unnecessary utilization of emergency care, and try to improve the healthcare experience of these families,” she says. “We also try to improve the experience of these patients’ primary care team.”

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.