Transcript Model Home Asthma Intervention Programs

Model Home Asthma
Intervention Programs
How to Listen
• What is working and what is making it work?
• What am I hearing that resonates with me?
• What can I take away to use in my work?
• What is the Wabi Sabi (beauty in the
impermanent, incomplete, imperfect) in these
stories?
How to Listen
3
Questions to Run On
What successful strategies and approaches are
asthma programs using to conduct in-home
interventions?
What kinds of partnerships are these programs
brokering to be more effective?
What actions can I take scale up my efforts on inhome interventions?
Model Home Asthma
Intervention Programs
Susan Steppe, LAPSW
Director, CHAMP Asthma Program
Le Bonheur Children's Hospital
Le Bonheur CHAMP
Changing
High-Risk
Asthma in
Memphis through
Partnership
Susan Steppe, LAPSW, Program Director
Christie F. Michael, M.D., Medical Director
Christina Underhill, Ph.D., Manager of Evaluation
May 17, 2016
Le Bonheur Children’s Hospital
Le Bonheur Children’s Hospital
• 255 Bed Facility
• Ranked as one of the Nation's "Best Children's
Hospitals" by U.S. News & World Report
• Serving the Mid-South including West
Tennessee, Eastern Arkansas, Northern MS,
and the boot heel of MO.
Why Asthma? Why Memphis?
–Shelby County - 192.6/10,000
–State of Tennessee - 102.1/10,000
–31% of all pediatric asthma ED visits in
Tennessee in 2013 occurred in Shelby
County.
Data from the TDOH, Division of Planning and Assessment. Hospital Discharge Data
System, (2013). Nashville, TN
Criteria for CHAMP
Heavy users of the hospital
based services
• 3 ED visits/1 year
• 2 hospitalizations/obs/year
• PICU/2 years
Obstacles and Opportunities in H-R Asthma
• Fragmented health
care/access when you need it
• Adherence/self management
• Social determinants
CHAMP Metrics
1. Reduce emergency department
utilization.
2. Reduce hospitalizations/
observations.
3. Produce desired results at lower
cost.
CHAMP Multi-Disciplinary Team
• Medical Services Team
–
–
–
–
Sub-specialty clinic -A&I with Pulmonology support
24/7 Call Line
Sick call Triage and follow-up
Connect to PCPs
• Community Based Services Team
– Enroll/engage
– Home visits/Asthma Education/ Environmental and
supplies/ Meds. Rec./case management and
tracking/referrals for services
– Schools
CHAMP Picture
Medical follow-up
visits
Initial Clinic
Visits
Sick Call Triage
24/7 calls
AAP to PCP
Engage and enroll
in home.
Home
Environmental
Assessment
Deliver environmental
supplies.
Referrals for services
School Visits/AAP
Case Monitoring and
reaching out.
CHAMP Data Registry – UTHSC BMI
• Monthly download of TennCare Encounter data on all
enrollees.
• A powerful tool for case management.
• A powerful tool for tracking outcomes
– Medical encounters
– Cost of care for all encounters
• Woven in work flow of work – use of I-pads.
Environmental Landscape in Memphis
• Poor housing stock
• Landlord friendly laws and codes
• High concentration of families living in
poverty
• Warm, humid climate
• Did I mention a river?
CHAMP Environmental Components
Individual Level
• Home Assessment using EPA Assessment
(built into CHAMP Registry)
• Provision of basic cleaning supplies and
instructions.
• Advocacy with Landlords
• Connection to Le Bonheur Medical-Legal
Partnership
• Referral to Lead/Healthy Homes program
LCHWB Environmental Components
Community Level
• Memphis Healthy Homes Partnership
– 20 cross-sector agencies with shared mission: “Every child in
Memphis will grow up in a healthy home”.
– 90 agency staff received EPA healthy homes training
– Developing a shared referral system – braiding the funding
streams and tracking shared outcomes
– Working to improve housing policies and codes
• 3 HHP partners selected for Corporation for National and
Community Service (CNCS) GHHI PFS feasibility study
• Working to establish Memphis as a Green and Healthy
Homes Initiative (GHHI) city using the GHHI model
Quarterly ED Utilization
36% reduction over 13 quarters.
* This data is drawn from TennCare encounter records but has not been
independently verified.
ED Utilization – 6 months
44 % reduction in 6-month utilization over quarters (12 reporting periods).
* This data is drawn from TennCare encounter records but has not been
independently verified.
Avoidable Hospitalizations
* This data is drawn from TennCare encounter records but has not been
independently verified.
Quarterly Hospital/Obs.
48.2% reduction in the percentage of children hospitalized per quarter, over 13 quarters.
* This data is drawn from TennCare encounter records but has not been
independently verified.
Asthma-related Cost as of 9/30/15
UPDATE INFORMATION
Reduction in Cost of Care
Measurement
6th
Period
2013
Number Enrolled
190
7th
9th
2014 8th 2014 2014
220
271
382
10th
2014
464
11th
2015
483
12th
2015
13th
2015
498
527
Average Cost per
CHAMP
$1,904 $1,041
$1,648 $1,971 $2,469 $2,600 $1,499 $2,206
Before CHAMP
$3,812 $3,812
$3,812 $3,812 $3,812 $3,812
$3812 $3,812
Percent Reduction
50.1%
56.8%
60.7%
72.7%
48.3%
35.2%
31.8%
Baseline data “Before CHAMP” calculated using the participants enrolled by the end of 8 th qtr.
Average cost of care per year, per child is $1,917 or 49.7% cost reduction per year, per child.
*Cost information is based solely on Pre-Champ and During Champ cost information drawn from TennCare cost data. This has
not been independently verified by a third party.
* This data is drawn from TennCare encounter records but has not been
independently verified.
42%
Champ Receives EPA Award
(Still basking in the glow)
2015 National Environmental Leadership Award in
Asthma Management
May 7, 2015 in Washington, D.C.
Future of CHAMP
• 2016 Community Team Focus on Housing and
Adherence
• Plan to pilot community based components with
patients managed by Le Bonheur Pediatrics (not the
same criteria)
• Constructing framework for funding through Pay for
Success (PFS) also known as Social Impact Bonds
• Seeking other options for sustainability.
Questions?
Model Home Asthma
Intervention Programs
Kevin Kennedy, MPH, CEIS
Environmental Health Specialist
Children’s Mercy Hospitals & Clinics Kansas City, MO
Hospital to Home
Asthma Management
Kevin Kennedy, MPH, CIEC
Center for Environmental Health
2015 WinnerHUD Secretary’s Award
for Healthy Homes
©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13
Disclosures
Kevin Kennedy, MPH, CIEC
– None relevant to this discussion
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Dept. of Environmental Health
Staff• 4-Environmental Hygienists,
• 2-Health Coordinators (Respiratory
Therapists)
• 1-Community Health Specialist
Assessment, consulting, training and
research in homes, schools,
childcares, and communities
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Patients with Asthma as
Primary Diagnosis
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CMH
Location
2010
2011
2012
2013
2014
5 year
Average
Clinics
6989
6147
7007
6499
7141
6756
ED/UCC
5440
5168
5765
5883
6318
5714
Inpatient
1240
932
1330
1288
1525
1263
Total
13,699
12,247
14,102
13,670
14,984
13,740
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Using Data to Identify High-Risk Asthma Patients
who might benefit from additional services
Hanson, et. al., Developing a risk stratification model for predicting future health care use in
asthmatic children, 2016, Annals of Allergy, Asthma & Immunology, 116(1), 26–30.
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High Risk Asthma Protocol (HRAP):
Provide consistency of care in the screening and evaluation of patients with
asthma who are classified as high risk, and ensuring they receive coordinated care
involving comprehensive resources associated with improved outcomes.
Elements
• Education
• Inpatient consults offered
– Guidelines based asthma
action plan
– Environmental Health
Referral
– Social work
– Screen for complications of
steroid use
– Contact PCP
Outpatient Elements
• Education
• Spirometry
• Exhaled nitric oxide
• Asthma Control Test (ACT)
• Allergy Testing
• Social work
– Depression and adherence
screening
– Case management
©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13
Asthma Control
Test (ACT)
• ACT completed on all
patients with asthma dx in
last 2 years in a primary
care clinic (specialty
clinics is primary asthma
dx at visit) and have ACT
documented in the
electronic medical record
(EMR).
• Started QI in 2011 with
average 15%
• Current average 70%,
with a goal of 90%.
©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13
All HRAP
Caregivers in
Asthma Class
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Asthma Action Plan
(AAP)
• Goal is for every
asthma patient at
CMH to have an
National
Guidelines- based
AAP that should be
updated in the EMR
at least once per
year.
• Inpatient at 95%,
outpatient at 93%.
©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13
Indicators for the need of an
Home Environmental Assessment
• Patients have symptoms that don’t respond
to “regular” treatment.
• Patient’s symptoms respond to treatment,
but require it to be continued. (Remain aware
of patient compliance with treatment / therapy
issues)
• Unique environmental conditions reported
that suggest an assessment is warranted.
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Home Assessment Referral Process
38
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Options for Referrals
(Referrals actually can come from anyone)
•
•
•
•
•
39
Environmental Health Education
General Assessment and Case Management
Referrals to other organizations and agencies
Community Benefit support
Grant and Research programs when available
©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13
CMH Paradigm Shift: Offering Environmental
Assessment Services System-Wide
• Developed Environmental Consult Process for Entire
Hospital Including the Following Steps:
– Education and Triage
– Review Health & Environmental History
– Referral and Communication
– Hypothesis Generation
• Assessment & In-home Education
• Assessment Reporting with Issues & Actions
• Follow-up & Case Management - E. Health Notes in
Patient Care File
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Kansas City
Asthma
Friendly
Home
Partnership
Program
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Tell Us About
Your HomeEnvironmental
Risk Test
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Next Steps
Environmental Health Notified
• Patient’s family is contacted within 2 Business Days
• Environmental Health History Obtained
• Education, Referrals and Recommendations are
Provided
• Total Asthma Risk Calculated
CEH Team
• Case review & service determination
– Education Only
– Home Assessment
– Grant Program Enrollment
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Asthma Risk Stratification
3 components:
– Acute Care Visits
– ED Visits, Hosp. PICU, Visits
to Urgent Care
– Current Asthma Status
– Asthma Control Test
– Environmental Risk Test
– Tell Us About Your Home
Tabulate Total Asthma Risk
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Stratify clients based on combination
of health status and reported
home environmental risks
• Divide assessment services into levels
– Basic Assessment Services
• Visual Assessment & In-home Education
• Assessment Reporting with Issues & Actions
• Follow-up & Case Management
– Advanced Assessment Services
• Basic Services, plus
• Advanced Environmental Investigation
• Environmental Measurement and Sampling
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Level II - Family Interaction
Timeline
Home assessment multi-visit model•
•
•
•
•
•
Health Visit-Environmental History
Home Assessment
Assessment Report Delivery
Education and Interventions Implemented
Follow up Assessment
Follow up Report Delivery
©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13
Case Management System
• Survey and
management tool
• HIPAA secure
system with logging
capabilities
• Manage step by step
“touches” with family
• Built reports
• Run queries for stats
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Consent
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Home Assessments Should Promote:
Keep It:
 Dry
 Clean
 Safe
 Well-Ventilated
 Pest-Free
 Contaminant-Free
 Well-Maintained
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Assessing Family’s Home
Site & Building Assessment
Mechanical &
Appliance
Assessment
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Healthy Home Keep it Principles
similar to CMH Home Assessment Domains
Healthy Home
Keep It:
Dry
Clean
Safe
Ventilated
Pest-Free
Contaminant-Free
Well-Maintained
CMH Home
Assessment Domains:
Air Flow & Circulation
Allergens & Dust
Moisture Control
Chemical Exposure
Safety & Injury
Prevention
©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13
Room by Room
Assessment
Domains of Qualitative
Assessment:
– Air Flow &
Circulation
– Allergens & Dust
– Moisture Control
– Chemical
Exposure
– Safety and Injury
Prevention
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Assessment Report
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Assessment Report
includes a Healthy Home
Action Plan for Family• Connects Home
Assessment to Interventions
• Identifies what our HH
program will do and what
the family is asked to do
• Prioritizes interventions
based on hazard risk
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Healthy Home Kits- Basic and Advanced
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Follow-up with Primary Provider in EMR
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Simple Home-based
Interventions Improve Health
• Overall health improvements for asthmatic
children were significant (p<0.05) along with
improved the indoor environmental quality
when heating, ventilation, and air conditioning
(HVAC) servicing, dehumidification, and
enhanced filtration (MERV 12) were used.
*Johnson L, Ciaccio C, Barnes C, Kennedy K, Forrest E, Pacheco F,
Dowling, P and Portnoy J. Low cost interventions improve indoor air quality
and children’s health. Allergy Asthma Proc. 2009 Jul-Aug; 30(4):377-85
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Reduced Health Utilization after Home
Assessment and Case Management
300
Home assessment after
referral for case
management by pediatric
allergy specialists in a
hospital-based clinic
Case management:
education, clinic visits,
environmental
assessment, care
coordinator
250
200
150
100
50
0
ED
Hospitalizations
1 Year Before Enrollment
Clinic Visits
Year After Enrollment
Barnes CS, Amado M, Portnoy J, Allergy Asthma Proc. 2010 Jul;31(4):317-23
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Asthma Friendly Home Partnership
2014/2015
Provider Referral:
Risk stratification
based on utilization,
ACT score, and
environmental risk
60
54
# Of Acute
Care Visits12 months
before
50
40
30
Case management:
asthma and healthy
home education,
environmental
assessment
&intervention
20
10
17
10
6
0
Low Risk
High Risk
65%
81%
reduction reduction
Unpublished Data, 2015
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# Of Acute
Care Visits-6
months after
Community Programs Must
Be Collaborations
MCE Services, LLC; Blue Hills Community Services-CDC; KCMSD Head
Start-child care; City of KCMO, Climate Control; Northland Neighborhood,
INC; Project Eagle-Head start/KCK; KCK Public Library; Big Brother Big
Sister of KCMO; City of KCMO-Weatherization Program; Bridging the
Gap; Old Northeast, Inc.-NA; Associated Youth Services-Hip Hop Health
Fairs; American Red Cross; MAPESHU-KU Medical Center; UMKC School
of Nursing; KCK Housing Authority; WYCO Health, Dept of Air Quality; City
Vision Ministries; UG Wyandotte County Community Development;
Westside Community Action; EPA Region 7; Mid America Regional
Council; KC Chronic Disease Coalition; Center School District; Allergy
Zone; Mercy & Truth Medical Missions; Maternal Child Health Coalition;
Healthy Indoor Environments Coalition; Allergy, Asthma, Foundation of
America; Guadalupe Center; UMKC Environmental Studies; KCMO Public
Library; Kansas City Neighborhood Alliance; WYCO Rental Licensing;
Kiddie Kollege; Clinical Reference Lab; El Centro; Baker Environmental;
Children’s Mercy Family Health Partners; Johnson County Health Dept.;
Neighborhood Centers Division; Dangerous Building Demolitions; and
CMH- Safety & Injury Prevention
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Community PartnershipsRules of Thumb, cont’d
• Have clear, specific deliverables
• Don’t pay in advance
• Have a written agreement
• Develop a work plan
• Schedule frequent, regular meetings
• Success is not a guarantee
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Community PartnershipsRules of Thumb, cont’d
• Remember: the capacity of agencies
can change for better or worse.
• Don’t burn bridges.
• Adjust benchmarks and deliverables
for community partners as neededbe flexible (to a point).
• What goes around comes around.
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New Tools to Help You
• Standardized approaches for home assessment
– Have been developed
– Being taught to environment assessment professionals
– Certified laboratories
– Database software tool for environmental assessment
• Environmental practice parameters to clinical guidance
– Furry animals (Annals of Allergy Asthma & Immunology, 2012, Vol. 108)
– Rodents(Annals of Allergy, Asthma & Immunology, 2012 Vol.109)
– Cockroaches (Jour. of Allergy & Clinical Immunology, 2013 Vol.132)
– Dust mites (Annals of Allergy, Asthma & Immunology, 2013 Vol.111)
– Fungi (Split into 6 papers to be published 2016)
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Kevin Kennedy, [email protected]
Center for Environmental Health
Children’s Mercy Hospitals & Clinics
816-960-8918
©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13
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Model Home Asthma
Intervention Programs
Frances Martini, MBA,
Director, Integrated Population Health Management,
Government Programs
Blue Cross Blue Shield Tennessee
Southeast Regional Asthma Summit:
Interventions for Asthma: Improving Outcomes
Frances Martini, BSN, MBA
May 17, 2016
Background
The Asthma Allergy Foundation of America (AAFA’s)
Asthma Capitals report looks at asthma prevalence,
environmental risk factors and patient medical utilization
in the largest 100 cities to find the “most challenging
places to live with asthma.”
In the top 10 cities of challenging places to live with
asthma in 2015, Memphis ranked 4th and Knoxville 6th.
http://www.aafa.org/media/Fall-Allergy-Capitals-List-2015.pdf
Background
Asthma continues to be a serious public health problem.
Approximately 140,000 children in Tennessee have asthma.
Asthma is identified in the top 10 primary disease
conditions for high cost claims in the BlueCare East/West
and TennCareSelect populations.
Background
Emergency department visits are an indicator of uncontrolled
asthma. Asthma morbidity can be measured by the numbers
of visits asthma sufferers make to the emergency department,
and this is where the reality of the true burden of asthma can
be seen in individuals whose condition is poorly controlled.
We see this in our population.
http://health.utah.gov/asthma/data/reports/burdenreport/EDVisits.pdf
BlueCare All (excluding Select Kids, CHOICES, Select Community, BC Plus)
Ages 4 and Under
Top 10 Chronic Conditions
Percent of Total Paid Dollars
Period 1
Percent of Members
Period 1
Period 2
11.7%
Congestive Heart Failure
0.6%
12.4%
0.7%
13.2%
Asthma
Cancer
Behavioral/Chemical Dependency
10.4%
11.9%
9.7%
9.4%
1.6%
9.2%
1.6%
2.6%
2.6%
2.8%
2.7%
3.3%
Cardiovascular Disease
0.7%
2.8%
2.0%
Neurology
Congenital Anomalies
Obesity
Neonatal
Ear/Nose/Throat
CONFIDENTIAL – FOR RELEASE TO GROUP HEALTH PLAN ONLY
Period 2
0.6%
0.4%
1.6%
0.4%
1.4%
0.2%
1.0%
0.2%
0.7%
1.1%
0.9%
1.3%
0.6%
0.2%
0.8%
0.2%
0.5%
1.7%
0.5%
1.8%
70
BlueCare All (excluding Select Kids, CHOICES, Select Community, BC Plus)
Ages 5 to 20
Primary Chronic Disease Incidence and Cost
Top 10 Chronic Conditions
Percent of Total Paid Dollars
Period 1
Behavioral/Chemical Dependency
Percent of Members
Period 1
Period 2
17.9%
11.9%
18.1%
12.1%
16.9%
Asthma
10.6%
17.3%
11.0%
12.2%
Cancer
2.3%
11.8%
2.4%
5.6%
Obesity
4.8%
6.6%
5.7%
6.8%
Neurology
Cardiovascular Disease
Congestive Heart Failure
Diabetes
Hematology
1.0%
6.4%
1.0%
4.5%
1.3%
4.8%
1.4%
3.7%
0.2%
3.6%
0.3%
2.4%
0.9%
2.5%
0.9%
0.8%
1.1%
Neonatal
CONFIDENTIAL – FOR RELEASE TO GROUP HEALTH PLAN ONLY
Period 2
0.3%
0.3%
0.5%
0.1%
0.7%
0.1%
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Establish a Focused Approach
Member Identification
- Referrals
- Stratification
Member Outreach – Face to Face
- PH Case Manager
- Home Health Agency
- Outreach Team
Member Assessment
- Education
- Environmental Assessment
- Access
Connection to Follow-up Care
- PCP
- Specialist
- School Partners
Goals
Improve Asthma health outcome measurements for
our members by reducing gaps in care and improving
the percentage of BlueCare Tennessee members with
asthma using appropriate medications as determined
by HEDIS.
Reduce Asthma Emergency Department (ED) visits,
Asthma inpatient/hospital admissions, increase the
use of appropriate medications (HEDIS) and improve
the members continuity of care.
Problem
An individual’s care is often fragmented and treatment
compliance is difficult to evaluate.
It may be difficult and challenging for primary care
providers to ascertain what monitoring or medications are
lacking for each patient/member.
Members may seek care for their asthma in multiple
settings (primary practitioner office, specialist office,
hospital, home health care, emergency room, community
outreach events/health fairs) and therefore the primary
practitioner may not have a comprehensive picture of the
member.
Identified Barriers from 2015 Analysis
Member/parent or guardian non-compliance / failure to
adhere to treatment recommendations and obtain
appropriate follow-up care
Members are unreachable / failure to show for scheduled
appointments/case manager is unable to contact them
Lack of provider awareness / lack comprehensive picture of
member behavior / ED utilization and follow up
Challenges of Medicaid Population Health
To improve population health “it’s the housing, it’s the
lack of access to food, it’s the broken families, it’s all
that messy stuff. It’s a complex story so it can’t have
a medical fix to make it work.”
Dr. David B. Nash
Dean of the Jefferson School of Population Health
76
Interventions (Actions for Improvement)
June 2013, our population health program was
implemented. Members with asthma are offered
enrollment in our Asthma Program. At a minimum, the
program provides education and health coaching by
Registered Nurses.
In December 2013, a monthly report was developed to
assist Emergency Services Management care coordinators
and PHM case managers in identifying members 18 yrs of
age and younger that have 3 or more asthma related ED
visits in a 3 month period (with a primary diagnosis of
asthma).
Interventions (Actions for Improvement)
An Embedded Care Coordinator was embedded in 2 high
volume provider offices (Memphis - 2013 and Johnson City
- 2015) to facilitate the coordination of the members care
The Embedded Care Coordinator assists in the referral and
transition of asthma members for home health care and
asthma education and environmental assessment as
indicated.
- Referrals to CHAMP (Changing High-Risk Asthma in
Memphis through Partnership). NOTE: Memphis
based
- Referrals for home health care and asthma education
and environmental assessment.
In 2014, an initiative was developed to coordinate with
school health services.
2015 Key Strategy
In 2015, our staff was redesigned into regional
integrated care coordination teams. The goal is building
strong partnerships within each staff’s community to
ensure local knowledge and access to members,
community agencies and providers to redesign care for
individuals with very complex needs. Each region is
unique in terms of assets, challenges and member
personality.
The goal is to enhance member-facing contact and
coordination with external partnerships including
providers (practitioners, facilities and ancillary service),
community partners (housing, food, clothing,
medication assistance, financial assistance, child care
services).
ED Program Strategy
Continue to improve the coordination of care with timely PCP
follow after 3 or more asthma related ED visits in 3 months.
Outreach to member/parent/school
Engage PCP
Assess member – Face to face
Facilitate the coordination of care and exchange of information
between the ED, PCP and the home health care.
ED Outcomes
Year
Members
<18 Years
with 3 or
Average days
more Asthma Follow up Follow up > to follow up
ED visits
<28 days 28 days
<28 days
Average
days to
follow up No Follow
>28 days up
2014
1047
743
304
8.13
NM
NM
2015
863
334
413
8.8
124.4
116
81
HEDIS Results
Our HEDIS Measures for Asthma have improved!
HEDIS 2015
AMR
HEDIS 2016
Overall
63.22%
66.59%
BCE
66.60%
69.73%
BCM
MMA
63.29%
BCW
55.55%
58.39%
TCS
70.39%
72.48%
Overall
26.34%
29.47%
BCE
30.30%
32.42%
BCM
36.23%
BCW
17.58%
21.68%
TCS
33.45%
34.39%
We are continuing efforts to change the trend.
Educational outreach
Support of in-school clinics/telemedicine
Community resources/coordination
Initiatives to incentivize both the member and the
provider.
• Pay for gaps
• Pharmacy calls to members
2016 Initiatives
Expanding collaboration with identified Home Health agencies
to implement protocols for Home Visit follow up post asthma
event. Home Health RFP in process.
Effective 8/1/16: Implement pilot program with 10 Hamilton
County schools. Through a grant with BCBST Community
foundation, nebulizers and associated supplies will be
provided to each school, school nurses trained and protocols
established to provide care for children with asthma
symptoms. Goal is to prevent ED utilization, identify children
needing coordination with PCP and facilitating the follow up.
Questions?
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