Population Health Strategies Benefit Kids on Medicaid


Integrated care teams and care management tools led to 3,600 fewer bed days in a year.

Child healthcare

In the largest-ever study to measure the impact of population health strategies and tools on hospital outcomes among Medicaid-enrolled children, researchers at a children’s hospital in Southeastern Pennsylvania found targeted interventions can deliver better patient experience, improved health outcomes, and value to the Medicaid system.

In the study, published in JAMA Network Open, of a population health management program, targeted at 93,000 Medicaid-enrolled children seen at Children’s Hospital of Philadelphia (CHOP), researchers found that targeted interventions for children with chronic medical health issues who were at higher risk for sustained hospitalizations over time reduced in aggregate about 50 admissions monthly and 3,600 bed days annually.

The CHOP intervention, implemented over two years, sought to identify high-risk, Medicaid-enrolled children with special health care needs and provide solutions that would keep them out of the hospital or reduce their stays if they were admitted.

There has been limited data on the potential impacts of population health management initiatives to reduce overall hospitalization rates among children and adults, according to David Rubin, MD, MSCE, director of Population Health Innovation and PolicyLab at CHOP and lead author on the study. 

Of note the bed day reduction was nearly a 10% reduction in daily bed census for the Medicaid-enrolled primary care patients across the organization. Effects were concentrated in children with multiple complex chronic conditions and children with moderate or severe persistent asthma.

A set of reporting tools in patients’ electronic medical record notified clinicians and staff if their patients visited the emergency department or were admitted into the hospital. Then, an integrated care team would connect with these families to help them schedule and prepare for follow-up appointments, assist with locating needed services and answer questions they had about their care. These clinical teams also utilized technological tools to improve coordination and communication between them.

Related: Population Health Initiative Reduces Pediatric Hospitalization Rate

The researchers designed the integrated care teams to meet the needs of medically complex children who frequented the hospital and might benefit from increased care coordination, as well as frequently hospitalized children and teens with asthma-one of most common chronic pediatric conditions. The teams included physicians, nurses, social workers, and community health workers, who connected with patients in their homes; they were more proactive in their engagement with families because they were notified promptly of high-risk events like hospitalizations. For healthy children included in the study, population health reports through the electronic health record in their primary care practice helped ensure timely follow-up from emergency department visits and better compliance with recommended well-child visits and vaccinations. Finally, given that children with multiple prior asthma-related hospitalizations are at highest risk of future asthma-related hospitalizations and emergency department visits, their intervention was customized with a bundle of integrated services. This included personalized bedside education in the hospital, facilitated filling of discharge medications, connection to community health workers/asthma navigators who can facilitate enhanced coordination between inpatient and outpatient care teams, and expedited follow-up with an allergist or pulmonologist.

 “This is one of the largest studies to examine the impact of a system-wide implementation of highly targeted programs that emphasized delivering point-in-time population health management reports within the electronic health record to integrated care teams of physicians, nurses, social workers, and community health workers,” Rubin says.

“Healthcare executives may be weighing the pros and cons of making investments in population health management,” he says. “This paper, even though focused on children, provides a roadmap and evidence on how to be more precise in developing a population health management strategy within health systems that emphasizes quality improvement and financial stewardship.”

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