MCOs Partner with Hospital to Help Sickle Cell Patients
MCOs Partner with Hospital to Help Sickle Cell Patients
New hematology unit funded by grant from two health plans aims to reduce inpatient admissions, improve quality of care for children with sickle cell disease
A $400,000 grant from two local Medicaid managed care plans has enabled Children’s Hospital of Philadelphia to try a new approach to treating sickle cell disease complications in children.
Prior to the opening of the Hematology Acute Care Unit (HACU) last year, children with sickle cell pain crisis or fever waited for treatment in the hospital’s ED, then were admitted to the hospital for observation, says Charles Adams, MSW, social worker in the department of hematology at Children’s.
"They would come to the emergency room, be seen, cultured in the emergency room, automatically admitted, stay in two to three days," says Adams. "If the cultures came back negative they would be sent home. If they came back positive, they would be here another 10-14 days for antibiotics."
The frequent, lengthy hospital stays and long waits in the ED were quite a burden to the families of sickle cell patients and were also a problem for insurance plans covering these children, says Adams.
Staffed by an attending hematologist and two pediatric nurse practitoners, and using specially developed treatment protocols, the HACU was designed to provide a place outside the ED where pediatric sickle cell patients could be evaluated rapidly and then possibly managed on an outpatient basis, eliminating the automatic 3-14 day hospital stay, he says.
"It’s really worked well, the families love it," says Adams. "For example, if a child [with sickle cell] came in with a fever, pretty much it was an automatic 24-48 hour stay. Now, we are talking between 6-15 hours."
Moving sickle cell patients out of the ED
Patients with sickle cell disease are frequent visitors to emergency rooms, but, for many reasons, the ED is not the best place for them, says Kwaku Ohene-Frempong, MD, Professor of Pediatrics at the University of Pennsylvania and Director of the Comprehensive Sickle Cell Center at Children’s.
Because sickle cell complications are unpreventable, strike without warning, and are very painful, patients need treatment quickly, says Frempong. However, though the sickle cell pain crisis might be acute, it is not often life-threatening, meaning the child is seen by ED physicians after patients with more emergent conditions are treated.
"We have one of the busiest EDs in the country," says Frempong, who is also the Chief Medical Officer for the Sickle Cell Disease Association of America. "If someone brings a sickle cell child there late at night, like 10 o’clock, because the child is in severe pain, we know that the pain of sickle cell disease is severe but not life-threatening, but the child is sick and needs care anyway."
"But, if, at the same time, someone came in with a severe asthma attack or was in an accident, which we know is life-threatening, they would be seen first," continues Frempong.
Two hospitals in other parts of the country, Montefiore Medical Center in New York and Grady Memorial Hospital in Atlanta, developed acute care hematology units for management of sickle cell complications in adults, he says, He thought it would be a good idea to determine whether the same model would work for children.
"A setting where they could come, get a very quick evaluation to make sure there is nothing complicating their sickle cell attack, and where they could be given pain medicine quickly is ideal," he says.
How it works
The HACU is located on one of the inpatient units upstairs that gets most of the admissions from the ED, says Frempong. Four 23-hour beds are dedicated to the unit, which is now open 14 hours each day.
When a patient has a complication, they call the hematologist on duty, who evaluates the situation over the phone. If he determines the patient should come in, the triage nurse in the ED is told to expect the patient and send them directly to the unit, says Adams.
The patients are evaluated, given pain medication, and have blood drawn for cultures. Depending on the patient’s condition, they may then be discharged for outpatient management or observed in the unit. (See related story on protocols for managing fever in sickle cell patients.)
"With a child in sickle cell crisis, it can last anywhere from four to five days," says Frempong. "But, about 80% of the time they don’t need to be hospitalized. They can be given medication that they can take at home. If the home treatment is not working, they can come back in and get some stronger medication and IV fluids for several hours and go back home and continue."
The staff continuously monitors the cultures taken from the patients. If a patient is sent home, but the cultures turn positive, the family is telephoned to bring the patient back to the hospital for admission.
"So far, we haven’t had anybody we’ve sent home whose cultures were positive," notes Frempong. "So, it appears that with the criteria we use, we are able to determine who should go and who should stay."
Patient satisfaction is up, admissions are down
The unit has already reduced the admission rate for children with sickle cell disease and fever from 92% to 30% at Children’s, notes Frempong.
"In the regular ED, you can only hold [the patients] for a couple of hours," he says. "Because our ED is so busy, we cannot hold patients for any length of time. At the end of three hours, you have to make a decision whether to admit the child to the inpatient unit and continue the care or discharge the child. In a busy place, you end up admitting many more children because they aren’t given the full chance to see if they will improve to the point where they could go home."
The families of the patients treated in the HACU are probably the most satisfied with the unit, says Adams.
Their children are seen quickly, by physicians who are familiar with their condition and their case history, and they are often allowed to be treated at home.
Getting help from managed care
When developing the unit, Frempong negotiated with the hospital administration and nursing staff to determine the best location for the program, but needed to find the funding from outside sources.
After hearing a proposal from Frempong, two local Medicaid managed care plans, HMA Health Plan and Keystone-Mercy Health Plan, agreed to a grant of $400,000 over a three-year period. Keystone-Mercy will give $300,000 over three years and HMA will give $100,000 over the same period.
Frempong emphasizes that he did not approach the health plans with a business venture.
"I made that very clear to them, I didn’t want them to say, Tell me how much money we will save, then we’ll give you the [grant],’" he says. "I came to them with a request for a community service grant that, if they wanted to do something in the community, this was something they could do to say that they are putting some of the money they are making back in the communities."
Keystone-Mercy has more than one hundred patients treated at the Sickle Cell Center at Children’s and the plan was interested in investing in a program that would lower the hospital admission rates for those patients, says Stanley Lynch, MD, Chief Medical Officer and Senior Vice President of Medical Affairs.
"Obviously that represents significant cost savings to us because outpatient care is much cheaper than inpatient care," he says. "Also, [we were concerned] that it improve the quality of care as well as the utilization of services."
With several patients already under the care of Dr. Frempong at Children’s Hospital, it only made sense for the health plan to make a proactive investment in a program that had the dual purpose of improving patient care and, possibly, reducing the number of inpatient days, says Denise Ross, CEO of HMA Health Plan of Philadelphia.
"Ultimately, the children would receive more personalized care in this unit as well as hopefully reduce repeated emergency room visits and hospitalization," she says. "I think that that’s why we invested in this type of unit, we felt that those patients could receive better quality of care and have it be more cost-efficient. Since it’s been in existence, going on a year now, we would like to see how the evaluation of the unit pans out."
Both the hospital and the health plans are in the process of collecting data on the unit’s cost efficiency and the effectiveness of its delivery of care. If the unit lives up to their expectations, both Ross and Lynch say they plan to extend the funding past three years.
Though it is still too early for an analysis, Frempong says he hopes the unit will be a model for sickle cell centers across the country.
"I think this is something we are going to recommend for every large sickle cell center in the country," he says. "I think it makes a huge difference in the way patients receive their care."
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