Hospitalization accounts for almost 50% of child health expenditures. Adverse psychosocial effects of hospitalization are broadly recognized. Studies indicate that hospital admission is often highly dependent on provider discretion, and that hospital services provided could be delivered often in alternative settings. We propose to study Home Nurse Enhanced Primary Care (HNEPC) as a new alternative to hospital care for common acute illness in children. Effectiveness will be determined using an experimental design with random assignment of eligible episodes to treatment (HNEPC) and control (inpatient) groups. Essential characteristics of HNEPC design are: 1) ability to adjust to the unique and changing needs of different families and illnesses; 2) unique opportunity in home-based interventions to promote health enhancing behavior; 3) capacity to deliver services comparable to those provided to hospital inpatients for selected, common illness episodes; 4) immediate accessibility; and 5) integration in both primary care and hospital care systems. Phases for this proposal include research pilot, main study, and analysis. During the research pilot, 66 illness episodes will be cared for with HNEPC and research instruments will be piloted in field situations and refined. During the subsequent main study phase, 640 subjects will be admitted to HNEPC and 626 subjects will be admitted to a control group sample.
Specific aims are to assess the following hypotheses. 1) HNEPC quality of care will be equal to or greater than that for control episodes. Quality measures will include family distress, family satisfaction, provider evaluation of quality, adverse medical events, time until the child returns to normal activity, parent perceptions of child health following the index episode (rehospitalization, emergency department use, office visits). 2) HNEPC will be accepted well by families and providers. 3) the potential for implementing HNEPC is substantial for all socioeconomic areas. 4) Net impact of HNEPC on eligible episodes and on overall community hospitalization rates (34% reduction) will be substantial. 5) The cost of care for eligible episodes on HNEPC enrollment days will be less than half that on non-enrollment days.
