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Digital Home-Monitoring of Patients after Kidney Transplantation: The MACCS Platform

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A Multidisciplinary Home Visiting Program for Children With Medical Complexity.

Elaine Lin¹, Kathryn Scharbach², Bian Liu^3,4

¹Division of General Pediatrics, Department of Pediatrics and elaine.lin@mountsinai.org.

Hospital Pediatrics

|October 3, 2020

Summary

This summary is machine-generated.

A new home-based primary care program for children with medical complexity (CMC) reduced hospital stays and healthcare costs. Increased home visits correlated with fewer emergency department visits and hospitalizations, showing potential for improved outcomes and financial sustainability.

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Area of Science:

Pediatric healthcare innovation
Complex care management
Home-based medical services

Background:

Children with medical complexity (CMC) have high care needs and costs.
Existing literature lacks home-visiting models for CMC.
Innovative care delivery is essential for this population.

Purpose of the Study:

To describe the development of a multidisciplinary, home-based primary care program for CMC.
To evaluate the outcomes of this novel care model.

Main Methods:

Retrospective review of medical records for 121 CMC patients (July 2013-March 2019).
Comparison of pre- and post-program healthcare utilization (length of stay, ED visits, hospitalizations).
Analysis of cost data and correlation between home visits and healthcare use.

Main Results:

Program enrollment associated with reduced average length of stay.
Increased home visits linked to decreased emergency department visits and hospitalizations.
Total costs of care decreased post-enrollment for patients with available data.

Conclusions:

The home-based primary care model shows potential for improving health outcomes in CMC.
This model may offer financial sustainability for managing complex pediatric care.
Home-visiting programs represent a viable strategy for CMC.