How one hospital is combatting neighborhood-specific problems.
Andrew F. Beck
Cincinnati Children’s Hospital Medical Center has called Avondale, Ohio, home since 1926. The hospital has been on a decades-long mission to lead, advocate, and collaborate in order to improve the health of local children and reduce health disparities in targeted populations.
Two such population groups were the focus of a health initiative aimed at reducing the inpatient bed-day rate by at least 10% by mid-2020 for children from two nearby neighborhoods, and to narrow the gap between those neighborhoods and healthier ones.
“This was not a simple or straightforward program,” says the initiative’s lead researcher Andrew F. Beck, MD, attending physician, Division of General & Community Pediatrics and Division of Hospital Medicine at the health system. “Rather, it was complex, involving active collaboration with community partners.”
Beck and fellow researchers explored common elements that underpin morbidity across conditions and serve as key contributors to hospital days and disparities. This focus allowed them to bring the right hospital resources and community partners to the table to tackle the most problematic conditions.
The multi-level approach involved analyzing real-time EHRs to identify neighborhood “hot spots” in need of additional support for children living within those neighborhoods; optimizing chronic disease management by closing care gaps during hospitalizations and after discharge; mitigating social risks such as housing instability and limited access to medications and personal hygiene supplies; and helping children transition out of the hospital. The researchers hoped to develop, test, and refine a theory for how to narrow equity gaps across broader geographic areas.
There were exact improvements within each of these domains. First, we engineered the EHR to send us alerts every morning if any child from the target neighborhoods was admitted. This prompted a multi-disciplinary huddle for learning purposes to explore what could have prevented, care gap closure to look into preventive solutions during the hospitalization, like immunizations, and consideration of transition needs (e.g., follow up appointments, medications). Second, we placed focus on common chronic conditions that were disproportionately contributing to bed-days. For instance, we have pursued work with our asthma patients to ensure that they have controller medications prior to exacerbation seasons. We also looked at the distribution of RN and social work care managers to ensure that they were connected with our most at-risk patients. Third, we have worked with community partners to assess for patterns in social risks. For instance, we have actively sought to identify building complexes that need broader advocacy and not just patient-level work. When we identified resource limitations, we actively worked with the local food bank to start an in-clinic food pantry to deliver food into the neighborhood and bolster access to hygiene supplies.
Societal factors influence health outcomes
In many neighborhoods like Avondale and Price Hill, access to pharmacies, grocery stores, green spaces, and adequate transportation can be limited. Housing may have exposures known to adversely affect health (e.g., pests, mold). This constellation of social, economic, and environmental factors influences short- and long-term health outcomes at the patient level, researchers say.
“We manage about 95% of all pediatric hospitalizations for children living in the county and nearly 100% of children in those neighborhoods,” Beck says. “Child hospitalization rates are high in those neighborhoods and are likely driven by a combination of social, economic, and environmental factors, so we set out to foster healthier communities where it was most urgently needed.”
Beck and his team defined a goal in spring 2015: to reduce the inpatient bed-day rate for children from Avondale and Price Hill by at least 10% by June 30, 2020. Meeting this goal required being accountable for an entire population and focusing on the root causes of place-based inequities, he says.
Improvement efforts began in July of that year, with the assembly of a multidisciplinary team that included inpatient and outpatient medical providers, social workers, community partners (such as legal aid), and parents of neighborhood children.
This initiative focused on roughly 8,000 children living in the high-morbidity, high-poverty Avondale and Price Hill neighborhoods. Children from these communities disproportionately experienced morbidity across nearly every condition and pediatric subspecialty.
The study period was between July 2012 and June 2018, with July 2012–June 2015 as the baseline phase and July 2015–June 2018 as the improvement phase.
Across the entirety of the study period there were a total of 38,583 hospitalizations for in-county children, of which 37,337 (97%) lasted less than 14 days. Hospitalizations that met diagnostic and length-of-stay inclusion criteria contributed 76,759 inpatient bed-days. The county’s inpatient bed-day rate was 5.6 days per 1,000 children per month.
The baseline rate for Avondale and Price Hill was 8.4 days per 1,000 children per month. This equated to neighborhood children collectively spending about 75 days each month and 900 days each year on inpatient units in Cincinnati Children’s Hospital Medical Center before improvement efforts began in the summer of 2015.
By the end of the study period in 2018, the average monthly inpatient bed-day rate decreased to 6.9 per 1,000 children, or 18% fewer in-hospital days than at baseline (July 2012–June 2015). There was no similar decrease in the rate for control neighborhoods, . where the rate remained at 7.6 inpatient bed-days per 1,000 children per month throughout the study period.
The rate reduction in Avondale and Price Hill was likely driven by fewer hospitalizations instead of shorter lengths-of-stay. The hospitalization rate dropped 20%-from 4.1 events per 1,000 children per month to 3.3 events-again beginning during the summer of 2015.
Finally, researchers assessed the degree to which the efforts narrowed equity gaps relative to the rest of the county. For the baseline period, Avondale had the fourth-highest and Price Hill the 11th-highest inpatient bed-day rates out of 80 county neighborhoods. In that period, Avondale and Price Hill children spent 2,720 days in the hospital, compared to 2,145 in the improvement period (July 2015–June 2018). The number of hospitalizations decreased from 1,344 to 1,041. Indicative of a move toward equity, Avondale improved to the ninth-highest and Price Hill to the 15-highest inpatient bed-day rates.
Expanding population health initiatives
Beck says he and his team have been encouraged by the marked, statistically significant improvements in Avondale and Price Hill when comparing two key metrics from the 2012-2015 benchmark to their results in 2015-2018: the inpatient bed-day rate and hospitalizations.
“This meant children spend hundreds of additional days at school and at home instead of in the hospital,” Beck says.
While they are pleased with the results, there is still progress to be made, Beck says. “We are taking what we have learned from our efforts in Avondale and Price Hill into account as we plan for scale and spread across additional local neighborhoods. We believe that the theories and methods used to decrease bed-day rates and hospitalizations could serve as a relevant example to other pediatric population health improvement projects-locally as well as nationally.”
These findings were recently published in Health Affairs.
Tricia Krizner is a Cleveland-based writer.