P0664 - A Whole Child Model of Care Addresses Disparities and Closes Care Gaps for Medicaid Patients with Complex Medical Conditions

Background:
Rady Children’s Hospital – San Diego was awarded a demonstration pilot, California Kids Care (CKC), from the California Department of Health Care Services (DHCS) to provide whole-child care for Medicaid eligible children with certain California Children Services (CCS) eligible conditions. CKC is a patient-centered pilot and since 2018 has provided comprehensive, coordinated care to children with the following conditions: Acute Lymphoid Leukemia, Cystic Fibrosis, Diabetes, Hemophilia and Sickle Cell Disease. The program serves a high percentage of Hispanic/Latino (53.3%) and African American (16.1%) members (Figure 1). Given the complex nature of these conditions and the health disparities seen in Medicaid populations combined with inequities traditionally seen in the Hispanic and African American populations, CKC offered innovative care navigation and better assess for clinical teams to monitor and meet patients’ needs to close care gaps and improve overall health outcomes.

Program Design

Methods:
CKC’s model of care includes highly skilled Nurse Care Navigators (CNs) and Patient Care Coordinators (PCCs) with backgrounds in each specified CKC condition. Utilizing this knowledge base CNs are able to strongly reinforce pertinent education and provide support that is specific to a member’s condition and individual needs. The Care Team is integrated into RCHSD and has a direct line of communication with specialists that serve our patients. CNs attend Comprehensive Clinic visits and CCS Case Conferences to support member needs, while also meeting regularly with clinical teams. This offers a unique opportunity to facilitate more efficient care of chronic medical conditions and avoid delays in care.

Additionally, RCHSD is a part of an established integrated delivery system (IDS) with partnerships between primary care providers (PCPs) and specialty physicians throughout the region. Through this established relationship, CKC was well positioned to work with specialists and PCPs to optimize care, re-establish medical homes and provide navigation to assist families with coordinating complex care needs.

Outcomes

Results:
A Quality Management Plan was deployed to monitor comprehensive and data driven outcomes. We provided framework, structure, and methodology to support the provision of care, information flow, performance improvement, and accountability for goal attainment. Results showed the holistic approach is benefiting patients. When comparing Baseline measures in December 2018 to one year of post-implementation data we measured the following improvements: Annual Well Child Checks (28% to 54.9%), Dental Screening (9% to 79.1%), Annual Vision Screening (23.7% to 43.8%), Food Security Screening (3% to 15.8%), Transportation Screening (1.8% to 20.9%) and MyChart Enrollment (53.8% to 61.8%).

Conclusion:
Our results demonstrate the positive impact the CKC care model had in bridging the gap and addressing disparities for Medicaid patients with complex medical conditions. This model of care can easily be scaled to other vulnerable populations with a patient-focused, whole-child approach and comprehensive care management.