Project Name: Improving Regional Pediatric Care Management

Project Overview: Hudson Headwaters Health Network (HHHN) is a rural, multi-site community health network, with each primary care practice maintaining a robust and well established patient-centered medical home certification, incorporating comprehensive care management. Building on this model, and successful participation in regional collaboratives, HHHN developed and began implementing a pediatric health home model. with the objectives of preventing episodic, crisis-based care, improving appropriate interventions, and enhancing comprehensive care management for children in the community. The first year of the program focused on high utilizers of the emergency department, including children with asthma and adolescents and teens presenting for behavioral health services, emphasizing care coordination and education. In year two, HHHN moved beyond strictly clinical services, using a multifaceted, population health framework to address systems barriers. HHHN intends to replicate the system with other partners across the region.

The goals of the project were to systematically identify and target social determinants of health, expand resource networks to address barriers to access, and improve health outcomes for the community’s children.

Project objectives were to:

1. Implement a comprehensive pediatric health home model;
2. Encourage appropriate utilization of primary care services and support both integration of and improved access to behavioral health and other services
3. Expand the care management program to incorporate enhanced social services that address barriers to health and wellness for children and their families
4. Improve organizational performance on child health quality measures; and
5. Enhance the knowledge base for evidence-based pediatric care.

• 2015-2016 Key Grant Activities
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  • Added Emergency Department (ED) pediatric care manager to the health center team;
  • Offered education for providers and members of the patient care team about the project and new interventions;
  • Provided education for patients on appropriate use of ED services, as well as availability of primary care services, same day access, and urgent care;
  • Assisted patients with timely follow-up to primary and behavioral providers, and connecting to social services and community resources; and
  • Established a data tracking system.
• 2015-2016 Key Project Outcomes
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  • HHHN staff gained insight into the drivers of ED utilization by children and their families, allowing the Network to identify, develop and tailor interventions appropriate to the needs of the community.
  • Pediatric emergency department use decreased by 15%. ED utilization for breathing difficulties was reduced by 27.2% and by 12.5% for behavioral health evaluations. The Network also saw a 19.5% decrease of patients who utilized the ED more than three times in six months.
• 2016-2017 Key Grant Activities
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  • Identified, monitored and tracked high-risk pediatric patients and children at risk for poor health outcomes;
  • Trained staff on identification and engagement of at-risk children and families, patient self-management skills, resource availability, and follow up processes;
  • Integrated pediatric Community Resource Advocate into the primary care team;
  • Provided comprehensive care management to identify socio-economic and other barriers to care and link children and families to community resources; and
  • Expanded community partnerships to include Child Protective Services, the foster care system, school systems, public health departments and local and state providers.

• 2016-2017 Project Outcomes:

  • HHHN provided outreach to 177 pediatric patients through phone calls and letters to advise families of the pediatric care management program; 109 children (62%) were enrolled.
  • Program interventions resulted in improvements in pediatric care outcomes for key measures:
    • Two -year olds receiving immunizations increased from 74.3% in 2016 to 83.2% in 2017;
    • Children using appropriate medications for asthma increased from 76.3% in 2016 to 82.6% in 2017;
    • Children 3 – 17 years old receiving physical activity counseling increased from 83% in 2016 to 85% in 2017;
    • Children aged 3-17 who received Body Mass Index (BMI) measurement increased from 83% in 2016 to 86% in 2017; and
    • Pediatric screening for depression decreased slightly from 82.5% in 2016 to 81.9% in 2017.
  • The center provided 26 training opportunities for staff. Subjects included Trauma Informed Care, Neonatal Abstinence Syndrome, complex trauma and exposure screening, mental health, and domestic violence.
  • HHHN met with school leaders and guidance counselors in 16 school districts, and created partnerships with schools and after school programs, which resulted in identification and referral of 14 high-need children to the pediatric care management program.
  • In addition, HHHN provided program education to 25 community-based organizations, including public health departments, youth centers, and family courts increasing the number of CBO partners. This bi-directional referral process resulted in 24 referrals to the pediatric program.
  • HHHN successfully expanded its pediatric team to include an additional Care Manager and expanded services to five additional sites.

Project partners: Glen Falls Hospital and the Adirondack Health Institute.

About the Grantee:

Hudson Headwaters Health Network is a not-for-profit, community-based network of 17 health centers serving the Lake George/Adirondack and Glens Falls Region since 1981. Its services include comprehensive primary care, obstetrics and gynecology, behavioral health, dentistry, lab and imaging.

Website at https://www.hhhn.org/