Neighborhood-Based Population Health Cuts Hospitalizations for Kids by One-Fifth

Health disparities persist across neighborhoods, and they particularly affect pediatric patients. Cincinnati Children’s Hospital Medical Center took aim at one marker of inequity—high rates of hospitalizations— with help from Epic’s population health functionality. They identified “hot spots,” two Cincinnati neighborhoods with elevated child hospitalization rates, and proactively connected residents of those neighborhoods to preventive care and community resources. As a result, children from these two neighborhoods spent 20% fewer days in the hospital.

The interventions were part of a three-year improvement effort to determine whether a holistic approach to care inside and outside the hospital could narrow the health inequity between neighborhoods.

“We often have a siloed mentality between health care, social services, and  local policy, while families and patients are off to the side,” said Dr. Andrew Beck, a pediatrician at Cincinnati Children’s. “We have really tried to remove those silos.”

The population health team at Cincinnati Children’s used Epic to identify children with chronic conditions, like asthma and diabetes, from two neighborhoods with high poverty, housing instability, food insecurity, and frequent hospitalizations. Clinicians are notified when children from one of these neighborhoods come in to the hospital, and they can easily follow up with those patients afterward. Clinicians can refer patients to community resources to ensure their care continues at home or school.

Providers are also taking information beyond the hospital, overlaying health outcomes with neighborhood data. For example, data shared by Cincinnati Children’ clinicians at a community meeting matched high asthma rates to a particular building complex, helping housing attorneys continue to advocate for better conditions there and reduce asthma-related hospitalizations.

“This neighborhood focus has been strengthened by accessible electronic health record data,” the team said in the study. “We have made early progress toward keeping children out of the hospital, and we now hope to scale this work to benefit kids across Cincinnati.”

Read the full study from Health Affairs or learn more in The Cincinnati Enquirer.

Epic community members can learn more about Cincinnati Children’s program on the UserWeb.