Post-Trial Sustainability and Scalability of the Benefits of a Medical Home for High-Risk Children with Medical Complexity

Objective To assess the sustainability of the benefits relative to usual care of a medical home providing comprehensive care for high-risk children with medical complexity (>= 2 hospitalizations or >= 1 pediatric intensive care unit [PICU] admission in the year before enrollment) after we made comprehensive care our standard practice and expanded the program. Study design We conducted pre-post comparisons of the rate of children with serious illness (death, PICU admission, or >7-day hospitalization) and health-system costs observed after program expansion (March 2014-June 2015) to those during the clinical trial (March 2011-August 2013) for each of the trial's treatment groups (usual care. n = 96, and comprehensive care, n = 105; primary analyses), and among all children given comprehensive care (n(post-trial )= 233. including trial usual care children who transitioned to comprehensive care post-trial and newly enrolled medically complex children, and n(Trial) = 105; secondary analyses). We also analyzed the findings for the trial patients as a 2-phase stepped-wedge study. Results In intent-to-treat analyses. rates of children with serious illness and costs were reduced or unchanged post-trial vs trial for the trial's usual care group (rate ratio [RR], 0.36; 95% CI, 0.20-0.64; cost ratio [CR], 0.68; 95% CI, 0.28-1.68). the trial's comprehensive care group (RR, 0.74: 95% CI, 0.39-1.41; CR. 0.67; 95% CI, 0.51-0.89). and among all children given comprehensive care (RR, 0.97; 95% Cl. 0.61-1.52; CR, 0.75; 95% CI, 0.61-0.93). Conservative stepped-wedge analyses identified overall benefits with comprehensive care across both study periods (RR, 0.46; 95% CI, 0.30-0.72; CR, 0.64; 95% CI, 0.43-0.99). Conclusions Major benefits of comprehensive care did not diminish with post-trial program expansion.