6 Considerations Unique to Children's Hospitals in the Drive to Greater Healthcare Value

While discussion of healthcare challenges and strategies generally focuses on Medicare patients, a segment of the population on the opposite end of the spectrum — children — also deserves attention. Children's hospitals, whether freestanding or part of a healthcare system, play an important role in the healthcare delivery system. Although many aspects of children's hospitals are similar to general acute-care hospitals, there are some considerations unique to pediatric care.

Shared goals, vision

"Fundamentally, [children's hospitals and general acute-care hospitals] are not different," says Martha Whitecotton, president of Levine Children's Hospital in Charlotte, N.C. The hospital is part of Charlotte-based Carolinas HealthCare System and is located on the campus of Carolinas Medical Center. "We're accomplishing the same end, just with a different size and age of patients."

Both kinds of hospitals are working to increase the value of healthcare services by improving quality and lowering costs. However, some of the strategies used to reach these goals differ between general and pediatric hospitals. Ms. Whitecotton shares six aspects of care that may be unique to children's hospitals as all hospitals respond to healthcare reform measures.

1. Intersections of pediatric and adult services. In general, strategic planning for children's hospitals affiliated with health systems is nearly identical to planning for general acute-care hospitals, as they both have service lines such as cardiology, neuroscience, oncology and orthopedics, according to Ms. Whitecotton.

However, children's hospitals need to consider intersections of pediatric and adult care when developing strategies for reaching quality and cost goals. For example, caring for newborns with congenital heart disease also involves the care of the mother. In a children's hospital affiliated with a health system, like Levine Children's Hospital, treating both mother and child is less challenging and perhaps lower cost because of the easy access to adult services. In contrast, many freestanding hospitals have needed to add a maternal program to their offerings to provide coordinated care for the mother and newborn, according to Ms. Whitecotton.

Similarly, advances in surgery mean more people with congenital heart disease are living to adulthood and require follow-up care. "At a certain point, [these patients] typically need additional surgical evaluation for the disease," Ms. Whitecotton says. "The best person to do that is a congenital heart surgeon." She says many freestanding children's hospitals are building adult cardiac wings to care for adults with congenital heart disease.

2. Family-centered care. In recent years, hospitals have shifted their focus from provider-centric care to patient-centered care as part of the move toward a pay-for-performance model. Many hospitals are also encouraging the involvement of family in patients' care to ensure patients will have support after discharge and will not get readmitted.

In children's hospitals, family-centered care has been a necessity from the beginning. "You're compelled in a children's hospital to approach care from a family-centered perspective," Ms. Whitecotton says. "If the family is not emotionally, psychologically, intellectually and physically able to care for the child, you can't discharge the child. You have to bring the family along at the same time you bring the patient along." Families are essential partners in the care of their children.

3. Philanthropy. Philanthropy is a significant part of hospitals' financing, and may have more importance as reimbursements decline. "It plays a huge role on the development side with the application of philanthropy — finding creative uses to advance our programs," Ms. Whitecotton says.

4. Accountable care organizations. Children's hospitals also differ from general acute-care hospitals in their strategies around ACOs. One of the benefits of being a children's hospital is being able to learn how to best coordinate care for populations from general acute-care hospitals' experiences with ACOs, as CMS' program focuses on Medicare patients. "Much in the [healthcare reform] law is driven by change in the Medicare population," Ms. Whitecotton says. "The children's hospital world has an opportunity to watch how it goes and respond accordingly, so there is more time to model and respond."

On the other hand, the focus on the Medicare population means children's hospitals' role in ACOs is more ambiguous. "One of the things we're struggling with tremendously is how to look at accountable care organizations from a children's population standpoint," says Ms. Whitecotton. "What does it include? Who should be in it?"

5. Supply and demand. Children's hospitals' patient volumes are increasing, creating capacity challenges, according to Ms. Whitecotton. Demand is high at a time when hospitals may see an influx of newly insured patients under the healthcare reform law's Medicaid expansion. In addition, the supply of pediatric specialists may be threatened if children's hospitals' graduate medical education funds are cut in states' quest to reduce costs.

While children's hospitals that are part of a larger health system have greater access to funds, freestanding children's hospitals' graduate education funds are often under scrutiny as legislators look for ways to cut costs, according to Ms. Whitecotton. "Freestanding children's hospitals are where the largest number of pediatric specialists are trained," she says. "They're already in incredibly small numbers. If those programs shrink because they lose funding, it could create a true manpower crisis."

To maintain access to pediatric care, children's hospitals are looking to partner with community hospitals — providing staff and expertise so patients can receive pediatric services for low-acuity, short-stay visits close to home, and at a lower cost than at a quaternary facility, says Ms. Whitecotton.

6. Post-acute care. Another aspect of pediatric care children's hospitals have to address when developing strategies to increase the value of healthcare is the lack of post-acute care services for children. Under the Patient Protection and Affordable Care Act, hospitals are losing Medicare funds for readmissions of certain patients. Facilities are incentivized to provide services throughout the continuum of care, ensuring patients are discharged to the appropriate care setting, whether home, a skilled nursing facility or a rehabilitation facility.

Children's hospitals face a challenge in that post-acute services are scarce — there are few nursing home-type facilities for children, and home health resources are limited. "When you get patients who need [additional] resources, they tend to stay in the hospital because those resources are not available in the community," Ms. Whitecotton says.

Children's hospitals: The same and different

Children's hospitals face several challenges that are different from those of general acute-care hospitals, including coordinating services for conditions that need both pediatric and adult care; determining children's hospitals' place in ACOs; and providing post-acute care services that the community lacks.

However, in the end, children's hospitals are working toward the same goals as general acute-care hospitals and share many of the same barriers. Both kinds of hospitals need to respond to healthcare reform by improving quality and lowering cost.

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