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How a Pediatric ACO Coordinates Care for Children with Disabilities

Case Study · July 28, 2016

In 2013, most children in Ohio who were eligible for Medicaid under its Aged, Blind and Disabled (ABD) criteria moved from fee-for-service to Medicaid managed-care plans. Partners for Kids, the nation’s largest pediatric accountable care organization (ACO), accepted financial responsibility for roughly 8,000 ABD children. It then implemented a delegated care-coordination program to meet the needs of the subset of children whom the managed-care plans identified as “high risk.”

Key Takeaways

  1. Before launching a care-coordination program, gather pertinent information about the population from claims data, electronic health records, and other sources.

  2. Start with a narrowly defined population or health condition before expanding the program. Recognize that not all patients can or should receive care coordination.

  3. Actively adjust the care-coordination model according to recruitment abilities, the needs of patients, and the resources available in the local health care system.

  4. Create processes for gaining buy-in from caregivers and providers.

  5. If taking on financial risk for the population, negotiate formal delegation of care-management functions.

The Challenge

The care-coordination capabilities of pediatric ACOs have the potential to improve quality and reduce costs for children with disabilities. In 2013, Ohio implemented legislation requiring that children in Medicaid’s Aged, Blind and Disabled (ABD) category enroll in Medicaid managed-care plans. Partners for Kids (PFK), which is the nation’s largest pediatric ACO and is affiliated with Nationwide Children’s Hospital, has financial responsibility for the medical care of the children enrolled in five Medicaid managed-care organizations in central and southeastern Ohio.

In July 2013, PFK accepted financial risk for an additional 8,000 Medicaid-eligible children with disabilities, constituting 2.6% of the pediatric population served by the ACO.

The Ohio legislation also said that managed-care plans must designate at least 1% of their membership as “high risk” and enroll them in formal care-management programs, subject to state requirements. Several managed-care plans delegated their care-management functions to PFK. The result: About 47% of PFK’s newly acquired ABD population had the potential to be identified as high risk and eligible for PFK’s care-coordination services.

The Goal

PFK used its pediatric expertise to develop a care-coordination program for this cohort of high-need patients. Consider this example described in the online summary of our ongoing study, funded by the Patient-Centered Outcomes Research Institute (PCORI), on ACO-provided care for children with disabilities:

The parents of a child with cerebral palsy receive a letter, from their state Medicaid program, outlining the option to enroll children like theirs in a managed-care plan that contracts with an ACO. The parents may be familiar with managed care, but they may not know what an ACO is and whether choosing this option would improve their child’s care.

PFK’s goal is to use care coordination to serve the needs of children like this one and their families.

PFK’s Prior Experience

In 2012, PFK received a $13.1 million Centers for Medicare and Medicaid Health Care Innovation award to improve care for Medicaid fee-for-service and managed care–eligible children with complex medical needs. Before the grant, provider groups and the health plans offered varying levels of care coordination, without a systematic approach to coordinating care across the population or a centrally organized staff of care coordinators.

The grant enabled PFK to experiment in developing a care-coordination program for children with neurological disorders who also required nutrition through artificial feeding tubes. The monthly rolling cohort totaled more than 470 children, most insured through fee-for-service Medicaid.

This early experience prepared PFK for the bigger tasks of (1) creating a care-coordination program that would function well when it acquired the additional disabled population of 8,000 ABD children and (2) providing the care-management functions delegated by the health plans. Most ACOs do not currently assume responsibility for children with disabilities, but many are considering the prospect, so PFK knew it had an opportunity to lead in this area.

The Execution

Implementing a care-coordination program for children with disabilities is largely uncharted territory. Here’s what PFK has done so far:

Selecting patients. Providing care coordination to all patients is impractical and unnecessary. Therefore, PFK identified a target group of patients most in need of care coordination. This group initially included children identified as “high risk” by each health plan’s proprietary risk-stratification methodology. In time, PFK added children in other categories, such as those with multiple ED visits and/or hospitalizations, those who had accrued more than $25,000 in charges within 6 months, discharged patients identified by the inpatient care team as needing care coordination, patients referred to care coordination by providers, and self-referrals.

From July 2013 to June 2016, PFK enrolled 3,072 children in care coordination, 422 of them from the newly acquired ABD population. (Not all children who are designated as high risk and eligible for care coordination are currently enrolled in the service, even though in the future they may be.)

Staffing. Trained care coordinators are integral to PFK’s care-coordination program. Between 2012 and 2015, PFK hired 30 care coordinators. The skill mix evolved, beginning with nurses and then adding social workers (to address complicated family dynamics) and an unlicensed staff coordinator (to improve team efficiency). In 2015, each 3-person team managed a panel of 75 to 150 patients. The staff members, based on-site at Nationwide Children’s Hospital, use a combination of phone and in-person interactions, including home visits and participation in clinical encounters with providers.

Working with managed-care organizations. Given Ohio’s requirement that the highest-risk managed-care beneficiaries (including Medicaid-eligible children with disabilities) have formal care-management plans, several managed-care organizations delegated care-coordination functions to PFK. These well-delineated agreements allow PFK to operate more effectively. For example, care coordinators have greater access to providers and their offices, where meetings with patients can occur.

Streamlining records. Care coordinators and hospital providers record all activity in a common electronic medical record (EMR). To facilitate coordination, the EMR documents episodes of care longitudinally, which requires substantial programming of the EMR’s capabilities. The communication- and scheduling-related benefits of the shared EMR are well worth the effort, in addition to the EMR’s basic tracking of care-coordination activities.

The Team’s Evolution

PFK’s efforts began in July 2012, when its leadership developed a rollout plan, aided by clinical expertise from the medical director of the Complex Healthcare Program at Nationwide Children’s Hospital. The first care coordinators hired were nurses and a dietitian. PFK created the basic structure and growth plan, enlisted a program manager to develop the team, and benefited from what the team learned as they worked with patients. In 2014, after the influx of the 8,000 new ABD patients, PFK settled on the triad model of nurse, social worker, and unlicensed staff coordinator.

The Metrics

PFK tracks several metrics for its care-coordination program. Here we present health care utilization data for a selected cohort of 163 ABD patients before and after they were enrolled in care coordination. Details are shown in the table, and highlights are listed here:

  • Inpatient admissions declined by 53%
  • Total inpatient days dropped by 42%
  • A 22% decline in emergency department visits did not reach statistical significance
Changes in Utilization for 163 Medicaid-Eligible ADB Children Enrolled in Care Coordination

Changes in Utilization for Medicaid-Eligible ADB Children Enrolled in Care Coordination. Click To Enlarge.

Moving forward, PFK plans to measure total costs of care for the ABD population, to compare data between care-coordination participants and nonparticipants, and to identify which clinical conditions are most amenable to care coordination. PFK is also developing surveys on quality of life, which it considers a critical metric.

Notably, the ABD population enrolled in care coordination at PFK is only a small subset of the ABD population for which it accepted financial risk in 2013. Therefore, our forthcoming PCORI-funded study will use multiple methods to compare the broader PFK ABD population’s experiences under the ACO model with those under the previous fee-for-service model.

The Hurdles

No new effort is without its challenges. Here are some of them:

  • Managing a large caseload of complex patients is often difficult for clinical staff who are new to care coordination, particularly when a patient’s clinical and social needs demand more attention than staff can provide to one person.
  • Recruiting and retaining qualified nurses and social workers is difficult as more organizations expand their care-coordination services. Educating staff currently in the clinical setting about the demands and rewards of care coordination takes great effort.
  • Helping caregivers and providers understand the role of the care-coordination team takes commitment. For example, providers sometimes perceive the care coordinator as disrupting the clinical workflow rather than adding a valuable service that patients need.
  • Consistent EMR documentation of care-coordination activities is a challenge when service lines sometimes differ in how they define and implement care coordination.
  • Because patients vary in how much care coordination they need, rigorously measuring its effects can be difficult, especially in an evolving program.


We thank the PFK staff who participated in this effort (Kimberly Conkol, Khrista Achtermann, Rory Weier) and Renée Ferrari, Mike Belden, and Marisa Bane for their research assistance. This research was funded through PCORI Award #IHS-1310-07863. The views presented are solely the responsibility of the authors and do not necessarily represent the views of PCORI, its Board of Governors, or its Methodology Committee.

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