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

 描述(由申请人提供)：近20%的青少年由于持续的医疗、行为或其他健康状况而产生健康后果，有特殊健康护理需求(ASHCN)的青少年存活到成年的人数持续增加。有证据表明，以患者为中心的医疗之家(PCMH)卫生保健提供模式以较低的成本为儿童提供更有效、更高效和更及时的护理，特别是在利用率最高的儿童中：有特殊卫生保健需求的儿童。我们不知道的是，随着ASHCN成长为成年期，PCMH可能会如何使他们受益。也不知道卫生保健系统如何最好地为ASHCN提供服务，因为ASHCN的病情严重程度和持续时间各不相同。PCMH的投资很高，因此，我们需要了解它是否提高了预防性护理的利用率，而不是更昂贵的基于医院的服务，儿科PCMH提供者是否正在帮助ASHCN向成人提供者过渡，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。这份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认可的实践级细节联系起来的能力。拟议研究的理由是，通过医疗复杂性低估PCMH对ASHCN的影响，将允许开发或修改以实践为基础的质量改进方法，以支持ASHCN的健康和过渡目标，以适应ASHCN的医疗复杂性。假设是，与不在PCMH的ASHCN相比，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，30天内再次住院的人数更少，并且更有可能成功过渡到成人提供者。这两项旨在验证这些假设的研究旨在(1)通过医疗复杂性水平来衡量卫生保健服务认可对ASHCN中医疗保健服务利用的影响；(2)通过ASHCN医疗复杂性水平来评估ASHCN从儿科PCMH向成人服务提供者的成功过渡。这种方法是创新的，因为它将使ASHCN研究的现状超越自我报告措施，并突出医疗复杂性在卫生保健资源使用问题上的新出现的重要性。这项拟议的研究具有重要意义，因为它将测试PCMH对ASHCN过渡到成人提供者和接受初级保健以预防和健康的目标的影响。了解这一影响将有助于今后推广PCMH模式以支持ASHCN健康的努力，并通过考虑医疗复杂性来采取以患者为中心的方法来支持这种支持的努力。

 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.