Adolescents with Special Health Care Needs in Patient-Centered Medical Homes: Utilization and Transition Outcomes in All-Payer Claims Data

 近20%的青少年因持续的医疗、行为或其他健康状况而产生健康后果，存活至成年的有特殊医疗保健需求的青少年（ASHCN）数量持续增加。有证据表明，以患者为中心的医疗之家（PCMH）的医疗保健提供模式为儿童提供了更有效，更高效，更及时的护理，成本更低，特别是在最高的利用者：有特殊医疗保健需求的儿童。我们不知道的是，当他们长大成人时，PCMH如何使ASHCN受益。也不知道卫生保健系统如何最好地为ASHCN提供服务，ASHCN的病情在严重程度和持续时间上各不相同。对PCMH的投资很高，因此，我们需要了解它是否能提高预防保健的利用率，而不是更昂贵的医院服务，儿科PCMH提供者是否正在帮助ASHCN过渡到成人提供者，以及利用率和过渡如何取决于医疗复杂性。我们研究的长期目标是提高ASHCN的初级保健质量。本R03提案的总体目标是量化儿科PCMH对ASHCN医疗保健利用和向成人护理过渡的影响，利用我们将佛蒙特州的所有付款人医疗索赔数据库与国家质量保证中心（NCQA）的PCMH认可的实践级别详细信息联系起来的能力。拟议的研究的理由是，低估的影响PCMH ASHCN的医疗复杂性，将允许开发或修改基于实践的质量改进方法，以支持健康和过渡目标的ASHCN，量身定制的ASHCN医疗复杂性。假设PCMH中的ASHCN将有更多的初级保健就诊，更少的急诊室就诊，更少的住院时间，30天内更少的再入院，并且比不在PCMH中的ASHCN更有可能成功过渡到成人提供者。这两项旨在检验这些假设的研究旨在（1）通过医疗复杂性水平测量PCMH识别对ASHCN中医疗服务利用的影响，（2）通过ASHCN医疗复杂性水平评估ASHCN从儿科PCMH向成人提供者的成功过渡。这种方法是创新的，因为它将推动ASHCN研究的现状过去的自我报告的措施，并强调医疗复杂性在医疗资源使用问题的重要性。拟议的研究是重要的，因为它将测试PCMH对ASHCN过渡到成人提供者和接受预防和健康初级保健的目标的影响。了解这种影响将为未来推广PCMH模型以支持ASHCN健康的努力提供信息，并通过考虑医疗复杂性，为采取以患者为导向的方法提供支持提供信息。

 DESCRIPTION (provided by applicant): Nearly twenty percent of adolescents have health consequences attributable to persistent medical, behavioral, or other health conditions, and the number of adolescents with special health care needs (ASHCN) that survive into adulthood continues to increase. There is evidence that patient-centered medical home (PCMH) health care delivery model provides children more effective, efficient, and timely care at lower cost, particularly among the highest utilizers: children with special health care needs. What we do not know is how PCMH may benefit ASHCN as they grow into adulthood. It is also not known how the health care system best serves ASHCN whose conditions differ in severity and duration. The investment in PCMH is high and therefore, we need to learn whether it improves utilization of preventive care over more expensive hospital-based services, whether pediatric PCMH providers are helping ASHCN transition to adult providers, and how utilization and transition depend on medical complexity. The long-term goal of our research is to improve the quality of primary care for ASHCN. The overall objective of this R03 proposal is to quantify the impact of pediatric PCMH on ASHCN health care utilization and transition to adult care capitalizing on our ability to link Vermont's all-payer medical claims database with practice-level details of PCMH recognition from the National Center for Quality Assurance (NCQA). The rationale for the proposed research is that understating the impact of PCMH on ASHCN by medical complexity will allow for the development or modification of practice-based quality improvement approaches to support the health and transition goals of ASHCN, tailored to ASHCN medical complexity. The hypotheses are that ASHCN in PCMH will have more primary care visits, fewer emergency room visits, fewer inpatient stays, fewer hospital readmissions within 30 days, and will be more likely to successfully transition to adult providers than ASHCN not in PCMH. The two studies proposed to test these hypotheses are designed to (1) measure the impact of PCMH recognition on health care service utilization among ASHCN by level of medical complexity and (2) assess the successful transition of ASHCN from a pediatric PCMH to an adult provider by ASHCN level of medical complexity. The approach is innovative because it will move the current state of ASHCN research past self-report measures and highlight the emerging importance of medical complexity in questions about health care resource use. The proposed research is significant because it will test the impact of PCMH on the goals of ASHCN to transition to adult providers and to receive primary care for prevention and wellness. Understanding this impact will inform future efforts to spread the PCMH model to support the health of ASHCN and inform efforts to take a patient-oriented approach to this support by considering medical complexity.