Reduction in Hospitalization for CYSHCN

Introduction: The CT Medical Home Initiative SW provides care coordination for children and youth with special health care needs, linking them to medical and other community-based services and resources. Southwest Connecticut has a diverse population including an affluent community as well as large immigrant and minority communities with great socio-economic disparities. The initiative targets those in need through FQHCs and practices serving the Medicaid population. Method: Title V funds were used to provide assistance to a team serving Southwest CT comprised of a lead Physician Champion, a Nurse Coordinator and a Social Worker. The Nurse Coordinator and Social Worker were trained to provide comprehensive care coordination. The team provided technical assistance and support to participating medical homes. A Physician Champion and care coordination facilitator (a point of contact) were identified in each practice. Resource lists were developed and distributed. Technical assistance to medical homes included strategies to improve patient flow. Results: A Cohort consisting of 567 CYSHCN enrolled continuously in the initiative from 2006 through 2009 who had experienced hospital admissions in 2006 and in subsequent years was identified. CYSHCN in the cohort experienced fewer hospitalizations (from an annual average of 2.3 in 2006 to 2.0 in 2009) and shorter lengths of stay when they were hospitalized (a reduction in average length of stay from 7.89 days in 2006 to 3.97 in 2009). Conclusion: Efficiencies gained through medical home implementation yield both quality of life and cost savings benefits as evidenced by a reduction in hospital utilization for CYSHCN.