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    Progress Report

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    WHAT’S INSIDE: 1 Partners For Kids at a Glance 3 Letter From Tim Robinson, CEO, Nationwide Children’s Hospital 4 Letter From Sean Gleeson, MD, President, Partners For Kids 5 The Impact 8 About Partners For Kids 17 Key Results 25 Key Drivers: What’s Behind Partners For Kids’ Results

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    Partners For Kids at a Glance Unique children that Partners For Kids is responsible for annually: Approximately 325,000 Unique children enrolled in Care Navigation: 3,000 Providers in the Partners For Kids Network: 2,100+ including 446 behavioral health providers Practices Participating in Quality Improvement Programs: 33 Staff Members: 147 1

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    Area of Responsibility The Partners For Kids region comprises 34 counties, with a population that is 73% urban and 27% rural. Southeast South Central The Partners For Kids region is characterized by a higher rate of child poverty than other Ohio regions. Children in Poverty 5.3% to 12.9% 13.0% to 18.7% 18.8% to 24.9% 25.0% to 32.2% Partners For Kids Network 2

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    Letter From Tim Robinson, CEO, Nationwide Children’s Hospital Nationwide Children’s Hospital has become a model for how an academic medical center can improve the health of an entire population. We have worked hard to move health care “upstream:” instead of just treating young people when they come through our doors, we work to keep children well. We have built or rehabilitated hundreds of homes with our collaborators, because stable housing is critical to wellbeing. We provide workforce training, because a stable income allows people to better care for themselves. We run school-based clinics to reach children who do not regularly visit a primary care doctor. But for more than 25 years, the heart of our population health work has been Partners For Kids. In fact, Partners For Kids’ success in improving the health of children in south central and southeastern Ohio has made our other population health efforts possible. At the most basic level, it changed how we thought about the mission of our hospital. We have always aspired to give the best outcomes to all children through clinical programs, research and training of future medical professionals. Partners For Kids showed Nationwide Children’s that stepping outside of our walls and focusing on preventive care and population health management can also deliver best outcomes. Partners For Kids created a sustainable business model to support other population health efforts as well. Appropriate preventive care and management of complex conditions ultimately saves money when children do not need as much care in a hospital. Partners For Kids reinvests those savings into Nationwide Children’s school-based care, our work in communities and back into Partners For Kids to continue expanding program offerings. When policymakers and health care professionals talk about “value-based care,” the work exemplified by Partners For Kids is what they mean. I am proud to introduce this Progress Report and the incredible achievements of Partners For Kids. Tim Robinson 3

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    Letter From Dr. Sean Gleeson, President, Partners For Kids It is my honor to introduce the Partners For Kids Progress Report, a demonstration of what is possible when the country’s most dynamic pediatric accountable care organization collaborates with 2,100 health care providers, an elite children’s hospital, Ohio policymakers and the state’s Medicaid managed care plans. As you will see in these pages, Partners For Kids has worked together with these groups to use the principles of value-based care in improving the health of an entire population of children, some 325,000 every year. It is not easy. A population’s health outcomes are dependent on a huge number of factors, including social determinants, access to care, appropriate evidence-based practices, community resources and many others. The Progress Report lays out the expansive efforts Partners For Kids undertakes to address some of the most important factors and the successes we have achieved. Our doctors, nurses, pharmacists, social workers, quality improvement coaches and care coordinators engage every level of the health care system to make children healthier. Partners For Kids’ success also depends on our working alongside others to change outcomes for children – supporting providers in connecting with and serving patients more effectively in many cases, or assisting families themselves to achieve their goals in others. Children in south central and southeastern Ohio covered by Medicaid are some of the state’s most at-risk for poor health. Partners For Kids is making a difference for them and their families. Sean Gleeson, MD 4

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    THE IMPACT Reduction in Emergency Department Visits Patients at Partners For Kids-contracted primary care providers consistently have fewer visits to emergency departments (ED) than children in our region who see other providers. Average Results for 4 years (2015 to 2018) Members at Contracted Providers Averaged 26% Fewer ED Visits Non contracted Contracted ED Visits per 1,000 Members 24% 26% Less 27% Less 26% Less Less 2015 2016 2017 2018 ED visits are sometimes necessary, but they should be reserved for acute conditions. They are expensive and resource-intensive. EDs themselves are often overcrowded. Partners For Kids helps community providers reduce ED utilization by providing appropriate, high-quality preventative care and placing special emphasis on the ongoing care of chronic conditions that are common drivers of ED visits such as asthma. 5

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    Reduction in Inpatient Days Children have significantly fewer hospital inpatient bed days after they are enrolled in Partners For Kids’ Care Navigation program. Bed Days 2500 2000 2,309 Number of Inpatient Days 1500 1000 1,358 500 0 Pre-Enrollment Post-Enrollment With regular pediatrician visits, vaccinations and other preventative care, most children are healthy most of the time. But a small percentage of patients covered by Partners For Kids have conditions that require more involved ongoing care: visits to multiple specialists, physical and occupational therapy, and complicated medication regimens. These children can be at higher risk for hospitalization. Partners For Kids’ Care Navigation program focuses on these children and their families. By aiding them as they navigate regular, ongoing care and connecting them to important community resources, coordinators can help reduce their need for inpatient care. 6

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    Improvement in Prescribing Medications for Attention Deficit Hyperactivity Disorder Approximately 26,000 patients covered by Partners For Kids have been diagnosed with attention deficit hyperactivity disorder (ADHD), and approximately 20% of the total money spent on medications in the Partners For Kids system is spent on ADHD medications. Partners For Kids helps their affiliated practices make the most appropriate prescribing decisions. Improved ADHD Prescribing for Contracted Providers 56% Providers Prescribing Non Preferred Medications Increase in providers prescribing Providers Prescribing Preferred Mediciations preferred medications 54% % of Prescriptions 52% 50% Decrease in providers prescribing non preferred medications 48% 46% Jan. 2016 Jan. 2017 Jan. 2018 Jan. 2019 Dozens of similarly-acting medications can be prescribed for children with ADHD, and it can be difficult for providers to keep up with the differences among them. But it’s critical that each child receives the medication that is most likely to be of benefit. Partners For Kids pharmacists have developed a number of tools to help providers make the most appropriate decisions: evidence-based guidelines; alerts or reminders in electronic medical record systems before an ADHD prescription can be made; and regularly updated formularies so that physicians understand how the medications are covered by insurance. In addition, practices can participate in a quality improvement project focused on proper management of ADHD. The improved ADHD prescribing from 2016 to 2019 was associated with a savings of more than $1 million. 7

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    ABOUT PARTNERS FOR KIDS What is Partners For Kids? Partners For Kids is a crucial link between families, health Accountable care organizations are largely considered care providers and Ohio’s managed Medicaid system, the province of Medicare and adult health care systems. allowing children to get the high-quality care they need, Partners For Kids’ innovation is in using accountable care when they need it and where they need it. As one of the and value-based principles for a geographically distinct largest nonprofit programs of its kind in the United States, Medicaid pediatric population. Early, high-quality well care Partners For Kids has both the ability to improve children’s can help prevent later disease; coordinated care of chronic health and to save money for the overall health care system. and complex conditions can reduce the number of stressful, expensive hospital visits now and in the future. Partners For Kids uses an accountable care organization model. It brings together a premier pediatric medical center And because Partners For Kids has unique access to data – its home institution, Nationwide Children’s Hospital for hundreds of thousands of children, it has the ability to – and more than 2,100 individual providers. Working conduct population-level research to drive better health. in partnership, they can deliver coordinated services to more than 325,000 children per year in south central Partners For Kids was founded in 1994, long before the and southeastern Ohio, from primary care well checks to phrase “accountable care organization” had even been treatment for the most serious conditions. coined. Partners For Kids both helps define what a pediatric accountable care organization can be and continues to lead the way in value-based care. How Does Partners For Kids Work? The Ohio Department of Medicaid provides health care Partners For Kids pays the cost no matter how much higher coverage for some children with disabilities, for children than the original capitation fee it receives. Partners For Kids, whose families have low incomes, for children in Ohio’s then, is at full financial risk for the care of children. foster care program and for children who otherwise qualify for this form of public health insurance. These children are Partners For Kids takes that risk because it can improve the some of the state’s most vulnerable, and many are at risk of quality and value of care being given, ultimately saving money. experiencing inconsistent health care – potentially leading to Its close association with Nationwide Children’s Hospital, poorer overall health. a national leader in the quality improvement field, provides Partners For Kids the expertise to drive better medication The Ohio Department of Medicaid relies on private health prescribing practices, better access to reproductive health care insurance plans, called Medicaid managed care plans, to care, better care coordination when a child must see many administer that coverage. And the Medicaid managed care providers, and a multitude of other initiatives. plans rely on Partners For Kids to ensure that every dollar is being used wisely for children’s health in south central and Any provider who cares for a child covered by managed southeastern Ohio. Medicaid in south central and southeastern Ohio is ultimately paid for their services through Partners For Kids. Partners For Kids receives a set amount of money for each child But primary care providers who become contracted members upfront, called a capitation fee, and takes responsibility for of Partners For Kids receive payments above and beyond ensuring providers are paid when they care for those children regular Medicaid reimbursement for each adjudicated claim, – whether the care is medical, dental, vision, prescription or and they can also receive incentive payments for meeting behavioral health. If a child needs relatively little care, Partners certain quality goals. For Kids saves money and reinvests it into other programs to advance child health. If a child needs a great deal of care, Not only does Partners For Kids help set those goals, it gives the providers the resources to achieve them. 8

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    Provider Perspective: Partners For Kids and the Tools to Become a Better Physician P ediatric Associates is one of the largest private Over the next several years – particularly when Dr. pediatric practices in central Ohio, and one of Kreuck became chief medical officer of Pediatric the longest-standing contracted members of Associates and assumed more administrative duties Partners For Kids. So Kate J. Krueck, MD, probably – she came to realize Partners For Kids’ potential. first heard about Partners For Kids when she joined Yes, Partners For Kids still helps with Medicaid the practice in 2002. She doesn’t remember much payments. But it’s more than that: past an initial impression: “We have shared values,” Dr. Kreuck says. “I thought it was just the group that helped us get paid through Medicaid,” says Dr. Kreuck. “They Dr. Kreuck wants children to have a yearly visit; helped distribute money. That’s what I knew. And Partners For Kids actually provides a staff member to now I understand that helping me get paid is not help Pediatric Associates schedule those appointments. even the best thing Partners For Kids does. I would She wants to prescribe the medications that will be say the most important thing is that it gives me the most effective and covered by insurance; Partners tools to be the best physician I can be.” For Kids produces a preferred drug list and will set up educational sessions with their pharmacists. She That’s always been a goal for Dr. Kreuck since she came wants patients with asthma to have better control of out of residency and was “terrified of doing everything their conditions; Partners For Kids analyzed Pediatric wrong.” She realized early in her career that she would Associates’ managed Medicaid claims data to see how need to become proficient in treating patients with often their patients with asthma were going to an attention deficit hyperactivity disorder, and so she emergency department. taught herself, then worked to train her colleagues. “I actually participated in a Partners For Kids’ That experience led to her interest in process webinar on office management, and that’s not even and quality improvement (QI), which led her to my gig,” she says. “The point is, I practice medicine QI projects through the American Academy of more effectively because of the resources Partners For Pediatrics, which ultimately led back to Partners For Kids gives me.” Kids, because of its focus on QI. “The point is, I practice medicine more effectively because of the resources Partners For Kids gives me.” – Kate J. Krueck, MD 10

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    Patient Perspective: Making a Complicated Situation a Little Easier E ven ignoring medical conditions, life in the most obvious hurdle for Talia and her mom was just Banks home can be difficult. Shalonda Banks the logistics of getting the care Talia needed.” is a single mother with four children of her own. Complicated family issues led to her being Susan began keeping a close eye on Talia’s awarded custody of three other children in late 2018. appointment schedule and would call Shalonda when appointments were approaching. In some “It would be stressful if I had seven completely cases, it was a gentle reminder and Talia would see healthy kids,” says Shalonda. her doctors as scheduled; in others, the call helped Shalonda realize that the appointment should be But her daughter Talia’s medical conditions can’t changed. be ignored. Now 12, she has been a patient of Nationwide Children’s Hospital since she was born. Susan also kept tabs on Talia’s medications and Her first weeks were spent in the neonatal intensive had an idea of the timing for refills, Shalonda says. care unit. Most pressing now are her seizure disorder, When it seemed Talia was about to run out, Susan growth delay and asthma. She sees a neurologist, an would coordinate with providers to make sure new endocrinologist, a pulmonologist and a primary care prescriptions were available. physician at Nationwide Children’s. There were other issues as well. At one point, There are a lot of appointments and a lot of Shalonda felt that her daughter’s school did not prescriptions. So many that Shalonda was having understand the precautions that should be made trouble keeping up with them and being the kind of for Talia’s seizures. Susan attended an Individual caregiver she needed to be for the other children. Education Program meeting at the school with Shalonda, and as a medical professional, was able Enter Susan Vukovich, RN, a Partners For Kids to defuse some tension. Shalonda’s wishes were care coordinator. She was assigned for one child, understood and accepted. Talia. But as Susan recognizes, “When we provide resources to one child, we help a whole family.” “I know Susan is not a counselor, but sometimes I just want to talk to her about what we’re going “Our overall goal is to help families pull it together through,” Shalonda says. “I can talk about my stress, and become independent,” Susan says. “That means or I can ask her about some of the terms we heard getting them over the hurdles, and then setting the when we were at the endocrinology appointment. groundwork for them to move on their own. The Everything is a little easier because Susan is with us.” “Everything is a little easier because Susan is with us.” – Shalonda Banks, Mother 12

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    Partners For Kids Spheres of Influence Child: A child who receives the proper preventative care when well, or the best and most appropriate care when facing medical conditions, has the potential for better overall health. Family: Families benefit when their children are healthier, but Partners For Kids also works directly with families who have special challenges to help them navigate the often-stressful health care world. Care NATIONAL coordinators can help schedule multiple appointments in one day, reducing the number of trips a family must take; attend those appointments with families as a patient advocate; and connect families with important government and community resources. Primary Care: Primary care providers who are contracted members of Partners For Kids receive higher than typical payments for adjudicated managed Medicaid claims. But providers can also earn extra incentive payments while meeting certain goals for improved patient care – with resources supplied by Partners For Kids. Primary care providers have additional access to credentialing services, continuing medical education, pediatric pharmacists, quality improvement coaching and many other programs through Partners For Kids. HOSPITAL CHILD Behavioral Health: Ohio now includes behavioral health care in its Medicaid managed care system, and Partners For Kids offers those providers opportunities similar to those for primary care. With 1 in 5 young people now living with a severely impairing mental illness, the support Partners For Kids gives to behavioral health practitioners can be critically important. Medical and Surgical Care: Partners For Kids works in the “background” for many specialists, helping ensure specialty care is used when appropriate (and providing payment for that care). Partners For Kids’ focus on keeping children well and improving health in primary care means specialists can focus on cases that STATE require their expertise. Hospital: More than half of Nationwide Children’s Hospital’s patients are covered by Medicaid, and Partners For Kids plays a key role in making sure the hospital’s resources are utilized as effectively as possible for those children. Moreover, when Partners For Kids saves money, it is able to invest those funds in a variety of programs, such as school-based asthma therapy, to reinforce the overall mission of keeping children healthy. 13

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    Region: Children’s health needs vary by region and demographic; the access to resources for a child in rural southeastern Ohio may differ from the access for a child in urban central Ohio. Partners For Kids’ involvement in millions of patient and provider transactions across 34 counties allows it to see where there are gaps in service or quality, and the organization’s reach and affiliation with Nationwide Children’s allows it to expand access to care for all children in its area. PRIMARY REGION Medicaid Managed Care Plans: Partners For Kids CARE helps Medicaid managed care plans be the best possible stewards of the funds they receive from the State of Ohio. As the bridge between the plans and the actual health care that nearly 325,000 children receive, Partners For Kids helps children get the best care for the best value. State: Ohio’s future is as promising as the health of its youngest residents. Partners For Kids’ value-based care paradigm focuses on that specific group. It flips the traditional state Medicaid fee-for-service strategy, which emphasizes therapies and BEHAVIORAL treatments once children become sick, for FAMILY HEALTH a strategy designed to keep children well. National: At the federal level, accountable care organizations are thought to be important for adults, because they are responsible for the great majority of health care spending. Partners For Kids is a model for the rest of the country of how an accountable care organization can work for children, and ultimately allow them to grow into healthier adults. MEDICAID MEDICAL MANAGED AND CARE SURGICAL PLANS CARE 14

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    Provider Perspective: Partners For Kids Population Data and Improving Outcomes P artners For Kids has a vast collection of health the most common complications across the most data from the 325,000 children it covers. common surgical procedures. The insights gained Katherine J. Deans, MD, was one of the first from that work were important enough to publish people to dig into it for population-level insights to so that others could also benefit from what Partners improve care and spot trends. For Kids had learned. In a subsequent study, she and other trauma surgeons used the data to identify As director of the Center for Surgical Outcomes how often children who were the victims of non- at Nationwide Children’s Hospital, she researches accidental trauma, or abuse, were the victims of how processes and procedures can be improved for future abuse. all children who need surgery. But she has another motivation as well: as a general pediatric surgeon, Meanwhile, she interacts with Partners For Kids she operates on patients who are covered by Partners as a doctor. Primary care providers have a more For Kids. explicit relationship with the organization than a hospital-based subspecialist, Dr. Deans says, because Dr. Deans is both looking for insights in Partners of reimbursement and quality improvement at an For Kids data and has had a Partners For Kids care individual practice. Still, Dr. Deans knows that coordinator in her office as an advocate for a single Partners For Kids has an important role for pediatric family. subspecialists, even if those subspecialists don’t “There is a 35,000-foot view, and there is a ground- always understand it. level view,” says Dr. Deans. “Partners For Kids’ “We should be spending more time than we do strength is that it can represent them both. There is thinking about utilization management, because so much opportunity to work with and expand the health care is a limited resource,” she says. “We data to help individual patients.” should be asking, how is my decision-making Dr. Deans and research colleagues first examined affecting patients as a population? Because of my the data to help Partners For Kids understand involvement with Partners For Kids, I think more about it than I ever have before.” “There is a 35,000-foot view, and there is a ground-level view. Partners For Kids strength is that it can represent them both.” – Katherine J. Deans, MD 16

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    KEY RESULTS Partners For Kids’ Four-Year Trends: Results in Key Areas Health care plans in Ohio and across the country rely on the Healthcare Effectiveness Data and Information Set (HEDIS) to measure dozens of performance indicators. Partners For Kids uses these HEDIS statistics from Ohio’s Medicaid managed care plans to track effectiveness in helping providers give children high-quality care. Every primary care provider wants to give young people the care they need, but limited time and resources can make that challenging. Partners For Kids helps providers overcome those obstacles. As these HEDIS measures from 2015-2018 show, providers who are directly affiliated with Partners For Kids consistently improve in key high-quality care indicators and outperform other community providers in those same indicators. Childhood Well-Child Visits Children attributed to Partners For Kids-contracted primary care providers have higher well-visit rates than children attributed to non contracted providers. 70% Non contracted Contracted 60% % of Children Receiving Well Child Checks 50% 40% 30% 20% 10% 2015 2016 2017 2018 2015 2016 2017 2018 2015 2016 2017 2018 2015 2016 2017 2018 0% Well Child Checks for Infants Under 15 Months Well Checks for Preschoolers Most families know to take children to the doctor 12 and 15 months of age, a schedule that busy new when they are sick; it can be more difficult to have parents can find difficult to follow. Once a child turns children come in for well-child visits. But those 2 years of age, an annual well-visit is recommended. well-visits are crucial for keeping children healthy, for adhering to suggested immunization schedules or for One HEDIS measure tracks well visits for children ongoing management of chronic conditions. Those younger than 15 months; six or more well visits are visits ultimately help save families and the health care considered optimal for that age group. Another measure system time and money. tracks crucial well visits for children 3 to 6 years of age. The American Academy of Pediatrics and other Partners For Kids provides staff members to affiliated professional medical organizations recommend a set providers to help track patients’ well visit schedules, schedule for those visits. A very young child should to help make well-visit appointments for patients and have visits in the first week of life and at 1, 2, 4, 6, 9, to remind families when visits are due. 17

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    Adolescent Well-Child Visits and Immunizations Adolescents attributed to Partners For Kids-contracted primary care providers have higher well-visit rates and higher immunization rates than children attributed to non contracted providers. 90% Non contracted Contracted 80% % of Adolescents Receiving Recommended Well Visits and/or Vaccines 70% 60% 50% 40% 30% 20% 10% 2015 2016 2017 2018 2015 2016 2017 2018 2015 2016 2017 2018 2015 2016 2017 2018 2015 2016 2017 2018 2015 2016 2017 2018 0% Well Checks for Adolescents Meningococcal and Tdap Vaccines Meningococcal, Tdap and HPV Vaccines Rates of annual well-child visits often decline important for children as they approach adolescence. as children grow into adolescence, even though Even fewer are aware that in recent years, the adolescence is a crucial developmental period for future Centers for Disease Control and Prevention has health. Primary care providers are important resources recommended the human papillomavirus (HPV) throughout puberty as they provide medical guidance vaccine at ages as young as 9. about reproductive health and birth control. Decisions made during teenage years about diet, activity, drug One HEDIS measure tracks well visits for and alcohol use and host of other health-related issues adolescents and young adults 12 to 21 years of age. have a lifelong impact. Others track certain immunizations that adolescents have by age 13. Likewise, while most families know about the young child immunization schedule, many aren’t Partners For Kids, through a number of incentives always aware that meningococcal and Tdap (tetanus, and quality improvement projects, puts a special diphtheria, acellular pertussis) vaccinations are focus on adolescent health indicators. 18

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    Access to Primary Care Providers Children and adolescents attributed to Partners For Kids-contracted providers have higher rates of regular primary care visits than children and adolescents attributed to non contracted providers. 90% Non contracted Contracted 80% % of Children and Adolescents with Access to Primary Care 70% 60% 50% 40% 30% 20% 2015 2016 2017 2018 2015 2016 2017 2018 10% 0% Children and adolescents should receive the great This HEDIS measure is an indication of children majority of both well and sick care from primary and adolescents access to primary care. It uses age- care providers. A primary care provider’s ongoing based categories to determine the percentages of relationship with individual patients and families children and adolescents who have a primary care allows for better insight into medical management. visit (yearly or every other year, depending on the A regular visit, even for an illness, helps deepen and age). Partners For Kids-contracted providers have expand the relationship. Urgent, emergency and more regular visits than their non-contracted peers, specialty care have important roles, but should be a result of many Partners For Kids initiatives. reserved for special circumstances. 19

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    Appropriate Management of a Sore Throat Children attributed to Partners For Kids-contracted providers are appropriately tested and treated for pharyngitis at higher rates than other children. 90% Non contracted Contracted % of Children Appropriately Tested and Treated for Pharyngitis 80% 70% 60% 50% 40% 30% 20% 2015 2016 2017 2018 2015 2016 2017 2018 10% 0% Pharyngitis, or a sore throat from many possible antibiotics also contribute to population-level causes, is one of the most common reasons for antibiotic resistance, a public health threat. In those children to visit their primary care provider. It’s cases, antibiotics are unnecessary and potentially also a condition that can lead to the incorrect harmful. prescription of medications. Antibiotics are effective if the cause of the pharyngitis is bacterial, as with This measure tracks the appropriate diagnosis, strep throat (caused by A Streptococcus bacteria). testing and treatment of pharyngitis. A higher rate Antibiotics prescribed for viral pharyngitis are not means that antibiotics are prescribed after a positive only ineffective, but they may contribute to the bacterial test. Partners For Kids works with providers development of allergy or other adverse conditions to ensure that medications are prescribed only when for individual patients. These misprescribed they are most likely to benefit patients. 20

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    Provider Perspective: Responding to Pediatricians’ Needs P rimary care providers are “working in the Dr. Fuller points out that improved care, measured trenches” for individual children and families, with certain quality and care standards set by says Brad Fuller, MD. Dr. Fuller is one Partners For Kids and its physician committees, of those people on the front lines at Associated leads to financial incentives for contracted physicians Pediatrics in Westerville. as well. Medicaid reimburses providers at a lower rate than commercial insurers, and the incentives Partners For Kids, with its 325,000 covered children help to make up that difference, allowing practices every year and 34-county geographical area, may to accept more Medicaid patients. seem to be far removed from the daily concerns of a particular pediatrician. But Dr. Fuller, as chair of So: Partners For Kids sets certain care goals; Partners Partners For Kids’ Provider Leadership Committee, For Kids provides coaching and other resources to is proof of the ways that Partners For Kids works to practices so they can achieve those goals; Partners For align its own goals with the goals of the doctor. Kids incentivizes physicians when they achieve those goals; and patients get better care, leading to fewer The committee is composed of community physicians hospitalizations and savings for the health care system. who both give their own feedback to Partners For Kids and solicit feedback from other Partners For It’s a positive, reinforcing cycle that works for everyone. Kids-affiliated providers. Partners For Kids’ Board of Directors and its Provider Incentive Committee “I can’t think of an argument for a physician not to also have community provider members who help to join Partners For Kids,” says Dr. Fuller. tailor Partners For Kids’ operations to better support His practice has participated in a project to increase physicians. well-visits for adolescent patients and another to “Partners For Kids responds to what we recommend apply fluoride varnish to young children’s teeth. to make the process better,” says Dr. Fuller. “We The financial incentives that Associated Pediatrics want the same things. They want kids covered has earned with those projects and other quality by Medicaid to get the care they need, and in the improvements have allowed it to see more patients process save money for the health care system. We covered by Medicaid. want kids to get the care they need, and we know “If I want to provide the best care to the most kids, that as we improve that care, savings will follow.” Partners For Kids is an important resource,” Dr. Fuller says. “If I want to provide the best care to the most kids, Partners For Kids is an important resource.” – Brad Fuller, MD 22

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    Patient Perspective: Care Navigation and the Gift of Time E lijah Boddie was born 3 months preterm. He Elijah’s story is unusual, even for a NICU graduate. needed a nasogastric tube to eat, a ventilator A few months after discharge, he was diagnosed to breathe, and he developed the sometimes with the rare, genetic Senior-Loken syndrome. fatal intestinal condition called necrotizing Much of his health care now has little to do with enterocolitis. After 116 days of care in the what happened in the NICU. Instead, it focuses Nationwide Children’s Hospital Neonatal Intensive on the kidney and degenerative eye conditions Care Unit (NICU), he was well enough to go home. characteristic of Senior-Loken. He has specialist appointments at Nationwide Children’s twice But, as many families know, a NICU stay can be just a month; as his kidney function declines, those the intense beginning of a long medical journey. appointments may become even more frequent. It’s a journey that has been made easier because of a Elijah’s care coordinator, Jacinta Phillips, helps make care coordinator from Partners For Kids, says Elijah’s those appointments and schedules regular primary mother, Angel Boddie. And not always in ways care visits. She attends the most important ones Angel would have predicted. to make sure the family fully understands Elijah’s “It’s a shock to the system when you have a child conditions and treatments. She has worked with born with special medical needs, but you don’t have the Department of Ophthalmology to get insurance time to process that shock. You are so busy making approval for Elijah’s special glasses. medical decisions and worrying about your baby,” At other times, the Care Navigation program has Angel says. “I’m also a working mother with two helped the family apply for secondary insurance and other children. There wasn’t a chance to really accept Ohio’s Special Supplemental Nutrition Program for what was happening. You just have to take action Women, Infants and Children (WIC). and move forward. Elijah is now 2, a regular enough visitor to Partners For Kids has done a lot for my family, but Nationwide Children’s that he has a favorite spot, one of the most important things is that my care the hospital’s Magic Forest. Sometimes Angel reads coordinators have given me the time to be emotional. to him there between appointments; sometimes, They take some of the burden of planning and they play hide-and-seek. The Boddie family’s life scheduling appointments and figuring out the right may be complicated, but it’s a happy one. And people to call for help.” Partners For Kids has helped. “The care coordinators are a blessing,” says Angel. “Partners For Kids has done a lot for my family, but one of the most important things is that my care coordinators have given me the time to be emotional.” – Angel Boddie, Mother 24

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    KEY DRIVERS What’s Behind Partners For Kids’ Results Many factors have an impact on a single child’s health and the overall health of a pediatric population – everything from individual genetic makeup to the quality of housing in a neighborhood. Since its founding in 1994, Partners For Kids has focused on factors that involve the traditional delivery of health care: access to primary care physicians; education for providers about best practices; and evidence-based guidance of the most effective medications for common conditions. Those remain critical to improving the health of children. It’s clearer than ever, though, that addressing traditional health care delivery is not enough. “Social determinants of health” such as stable housing, educational opportunity and community safety play major roles in wellbeing. Behavioral health, once considered distinct from regular medical health care, is now seen as a vital component of caring for the “whole child,” and community pediatricians increasingly provide care for behavioral health conditions just as they do for ear infections and asthma. While continuing its commitment to improving traditional health care delivery, Partners For Kids is doing more than ever to tackle these other key parts of child wellness. The organization’s home institution, Nationwide Children’s Hospital, is a national leader in pediatric behavioral health and has one of the country’s most successful programs to address community social determinants. Partners For Kids leverages Nationwide Children’s expertise in those domains for children across south central and southeastern Ohio. Partners For Kids’ efforts to improve individual and population health focus on six main areas, which often overlap and intersect with each other: QUALITY CARE IMPROVEMENT NAVIGATION PHARMACY COACHING PATIENT BEHAVIORAL COMMUNITY AND OUTREACH HEALTH SCHOOL-BASED PROGRAMS 25

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    Quality Improvement Coaching Primary care providers have a number of motivations to improve the quality of the care they give to patients. First and foremost, they want children and their families to be as healthy and happy as possible. Higher quality, evidence-based preventive care and management of chronic conditions help achieve those outcomes. But there are increasing external motivations for quality improvement efforts as well. The Ohio Department of Medicaid, through the state’s Medicaid managed care plans, require practices to meet certain performance measures for reimbursement and credentialing purposes – a state movement toward value-based care. Quality improvement requires expertise and resources that providers may not have, however. That is where Partners For Kids comes in. In consultation with providers, Partners For Kids develops quality improvement projects to help practices provide better care to patients and boost performance measures. Partners For Kids then provides quality improvement coaches and resources to be on-site at community-based practices as providers implement those projects. 26

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    Recent Quality Improvement Initiatives: focuses on implementing fluoride varnish Preventive Care, Disease Management and programs within primary care practices for Behavioral Health children younger than 6 years. Partners For Kids: Preventive Care - Educates providers that fluoride varnish is Children and adolescents are more likely to stay a best practice for all young children, and is healthy when they have regular preventive care. not the exclusive province of dentists Partners For Kids has three ongoing preventive care quality improvement initiatives. - Provides materials to educate patient families on the importance of this treatment • Healthy Children. This project focuses on - Connects practices to fluoride varnish having children and adolescents complete their suppliers recommended well-child visits, particularly children younger than 15 months; children 3 to - Facilitates managed Medicaid reimbursement 6 years of age; and adolescents 12 to 21 years of for this treatment age. To accomplish this, Partners For Kids takes • Reproductive Health. For many reasons, a number of actions, including: including family sensitivities and religious - Identifying patients attributed to providers beliefs, reproductive health may go unaddressed who need well-child visits, which is especially in primary care. This project focuses on having important for practices that may not realize it addressed, through risk assessments for all certain children are attributed to them adolescents, anticipatory guidance to prevent - Providing staff members to contact these unplanned pregnancy or sexually-transmitted patient families to schedule visits infection and offering contraception for young women 15 to 19 years of age at risk for teen - Training schedulers at community practices pregnancy. Partners For Kids: to check for well-visit needs when families make prescription refill and other routine - Works with individual practices to requests understand community perceptions of contraception to enhance counseling - Educating practices on the health and approach financial benefits of completing well- visit activities during a sick visit, when - Provides resources on choosing contraceptive appropriate methods, developed with Nationwide Children’s experts • Oral Health. The American Academy of - Distributes contraceptive prescribing Pediatrics recommends that children first see a guidelines dentist at 1 year of age, or within six months after a first tooth appears. But many children - Hosts training events for providers and staff don’t, and cavities can result. This project Partners For Kids educates providers that fluoride varnish is a best practice for all young children, and is not the exclusive province of dentists. 27

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    County-wide Reduction in Asthma-Related Emergency Department Visits Since 2009, asthma-related Emergency Departments rates decreased 37% at Nationwide Children’s Hospital for Partners For Kids members who reside in Franklin County. 16 14 Asthma-Related ED Visits per 1,000 Members 12 10 8 6 4 2 0 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Disease Management of a patient’s Asthma Medication Ratio (an When children and adolescents are sick or have indication of how often children need controller chronic conditions, managing them appropriately medications vs. rescue medications). Partners can help them get well sooner or prevent more For Kids: serious issues. Partners For Kids focuses on - Trains providers on the administration of improving the management of certain common asthma control tests, the creation of action conditions. plans and documentation • Asthma. Among the most common and - Creates prescribing guidelines for asthma most preventable reasons for an Emergency medications Department visit is an asthma attack. Partners - Connects practices with electronic For Kids focuses on a formal review of how medical records (EMR) experts to include well a patient’s asthma is being managed at management plans in EMR each provider visit, regular follow-up visits, - Uses claims data to identify a practice’s an annually updated action plan for patients patients who are having difficulty controlling and their parents that intensifies therapy when asthma based on Asthma Medication Ratio asthma is becoming worse, and supervision 28

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    • Pharyngitis. Pharyngitis, or a sore throat asthma, otitis media (middle ear infection), from many possible causes, is one of the most upper respiratory infections and skin/soft tissue common reasons a child visits the doctor. infections. Partners For Kids: This project focuses on the evidence-based - Surveys patient families to determine why management of a sore throat – particularly they use the ED instead of primary care and ensuring that antibiotics are prescribed only works with Medicaid managed care plans to after a test confirms a bacterial cause. Partners address barriers such as lack of transportation For Kids: and perception of limited primary care - Educates practices on the need for proper appointment availability strep throat testing - Trains practices to educate families on - Helps insert alerts in electronic medical communicating with primary care before record systems to remind providers at the seeking care at emergency departments point of care about testing before an order - Provides education materials for families on prescribing antibiotics can be made common conditions, including when ED use • Ambulatory Sensitive Conditions. Emergency is appropriate department (ED) visits are expensive and - Develops individual action plans to resource-intensive. This project focuses on troubleshoot problems for patients with reducing ED use for conditions that are often chronic conditions better managed in primary care, such as Partners For Kids develops individual action plans to troubleshoot problems for patients with chronic conditions. 29

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    Behavioral Health - Creates and distributes prescribing guidelines In 2018, Ohio changed the way that Medicaid that support providers in choosing the most reimburses behavioral health services, bringing them cost-effective medications into the managed care plan system. This allowed - Develops provider-specific reports on Partners For Kids an increased opportunity to work prescription practices, so providers can with providers to improve behavioral health care. benchmark their own performance and Primary care providers are increasingly the front compare their practices to others line of behavioral health care, called on to screen for mental health conditions and to treat patients • Depression. This project focuses on screening, because access to behavioral health specialists is helping providers manage depression in primary limited. Partners For Kids is continuing to develop care, and connecting those providers with projects to improve care. behavioral health specialists. • Attention Deficit Hyperactivity Disorder • Suicide Prevention. This project focuses (ADHD). More than 25,000 children in the on screening for suicidal intentions and the Partners For Kids system have been diagnosed appropriate management and referral of at-risk with ADHD, and nearly 20% of the money patients. spent on medication for Partners For Kids • Antipsychotic Prescribing. An increasing patients is spent on ADHD medication. This number of children and adolescents are project focuses on screening and high-value prescribed antipsychotic medications – prescribing for ADHD. Partners For Kids: sometimes, more than one at a time. These - Trains practices to use evidence-based medications carry known health risks, but ADHD screening tools, including tools to the risks of combining these medications are collect information from parents and school unclear. This project focuses on reducing the personnel about symptoms prescription of multiple concurrent medications. 30

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    Provider Perspective: Getting Help on a “Pediatric Island” J ill Neff, DO, is the only pediatrician in staffers set up electronic alerts for Hometown private practice in Jackson County, Ohio. Her Pediatric Care to make those appointments, but Hometown Pediatric Care is about 65 miles from they also sent out postcards and made calls to the nearest interstate exit and has three employees. individual families. “I never see another pediatrician here. I am on a big This “patient outreach” service from Partners For pediatric island,” she says. “I can’t say what happens Kids morphed into a QI project to improve and for a pediatrician in a big city or in a big office, but track well-visit rates for Dr. Neff’s practice, also I am sure that Partners For Kids is important for supported by Partners For Kids staff. Successfully people like me in particular.” implementing that project resulted in additional incentive payments for Hometown Pediatric Care. What she means, in part, is that her small office must focus on the countless daily tasks of treating Partners For Kids’ quality improvement efforts children in 15-minute increments: having families often work that way, Dr. Neff says. The projects update paperwork, checking patients in and out, take on issues that are important to any practice dealing with every conceivable billing issue. Dr. Neff – well-visits, asthma care, prescribing the correct works on her own to stay current with best practices. medications – and Partners For Kids offers the support to improve performance. So it’s not always top of mind – or even possible with the available resources – to contact families “The well-visit project has absolutely worked,” says who haven’t scheduled their annual well-visit Dr. Neff. “We’re thinking all the time about them appointments. It’s not a priority to become familiar now. We’re now involved in the project to apply enough with quality improvement processes to fluoride varnish to our patients’ teeth at well visits. attempt a quality improvement (QI) project. We just needed a little nudge from Partners For Kids to do it. It’s not very much more work, we are That is where Partners For Kids comes in, says Dr. reimbursed for it, we get an extra incentive payment Neff. For the last six years, Partners For Kids staff for it, and some of our patients who do not regularly members have analyzed office and claims records see a dentist get a treatment that can improve their to determine which children need well visits in Dr. health. It’s helpful for everyone.” Neff’s geographic area. Those Partners For Kids “I can’t say what happens for a pediatrician in a big city or in a big office, but I am sure that Partners For Kids is important for people like me in particular.” – Jill Neff, DO 32

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    Care Navigation Many of the ways Partners For Kids impacts health is at the system or provider level. Individual children and families often don’t ever learn of Partners For Kids, even if the care they receive is improved because of it. But Partners For Kids works directly with a small percentage of families with special challenges through its Care Navigation program. In an average year, approximately 325,000 children are covered by Partners For Kids; approximately 3,000 children are actively engaged with a coordinator each month. These children have ongoing, chronic conditions; severe, acute conditions that require frequent medical care; or they are otherwise in situations that may cause them to seek more care than is typical. Their families may need help navigating an often complex medical system. Partners For Kids care coordinators, often nurses or social workers, provide that help. They conduct health- risk assessments, create individual care plans, and meet face-to-face with families to learn their individual struggles. Coordinators visit families at their homes, when needed, and they attend some medical appointments as advocates for their patients. Sometimes they help families stay current on prescription medications or help intervene with Medicaid managed care plans to obtain coverage for home health equipment. Outside of medical care, coordinators play important roles in connecting families to community resources that can help with housing, utility bill payment, transportation and other areas related to social determinants of health. With care coordinators’ help, families can better manage a child’s health conditions, often leading to fewer Emergency Department visits and hospital inpatient days. The program has been so successful that Partners For Kids doubled its Care Navigation staffing from 2017 to 2019 – from 60 full-time equivalents to 120. Representative Care Navigation Results: Inpatient Admissions Partners For Kids patients have fewer inpatient admissions after they are enrolled in Care Navigation. 350 300 340 # of Inpatient Admissions 250 200 238 150 100 50 0 Pre-Enrollment Post-Enrollment 33

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    Emergency Department Visits Behavioral Health Bed Days Children identified as high utilizers of the Children with a behavioral health concern had emergency department (ED) had a 44% decrease a 64% decrease in inpatient bed days after in ED visits after enrollment in Care Navigation. enrollment in Care Navigation. 800 800 700 700 757 # of Behavioral Health Bed Days 600 600 612 # of ED Visits 500 500 400 400 300 300 341 200 200 272 100 100 0 0 Pre-Enrollment Post-Enrollment Pre-Enrollment Post-Enrollment 34

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    Patient Perspective: Help Raising a Child With Complex Needs R ichard Yard was the “provider” for his children Richard nearly runs out of breath listing what as they grew into adults, not the “caretaker.” Partners For Kids care coordinators Susan Tortora Then his daughter Amy was born. and Sarah VanVoorhis have helped with over the years. They schedule appointments; they helped him Amy Atwood, now 9, has spastic quadriplegia, the fill out paperwork for more in-home nursing care; most severe form of spastic cerebral palsy. She needs they interacted with doctors and pharmacies when home nursing care, a wheelchair to get around, a insurance requires that prescriptions be written in a gait trainer, feet and hand braces, prosthetic shoes, certain way (Amy cannot swallow a pill); and they six daily medications, weekly therapy sessions and ensured that Amy’s home medical equipment is up a “huge number” of appointments with medical to date. specialists, in her father’s words. Richard’s job became Amy’s care, and at one point Through a series of difficult family events ending in they lost their home in the Columbus area. Care the death of Amy’s mother, Richard became a single coordinators helped arrange for a brief stay with a parent. His other children were grown. He would family member out of state, and ultimately helped have had little idea how to raise a child by himself, Richard and Amy move into the Ronald McDonald no matter the circumstances – but especially not House at Nationwide Children’s until their housing these circumstances. situation stabilized. “Before care coordination, I was just begging and Once it did, Richard needed assistance in getting pleading with anyone who could help me in any food and furniture. Care coordinators guided way,” says Richard. “We would need to go to one them to agencies that could help for free. When clinic, then another clinic. We needed to go to Richard couldn’t afford birthday presents, the care one kind of therapy then another kind of therapy. coordinators made sure Amy got something special. I didn’t know how to do any of it. Without care coordination, I eventually would have lost my mind. “It’s never going to be easy,” Richard says. “But it doesn’t seem impossible anymore, and our care At this point, if I really need help getting something coordinators are a big reason why.” done, I don’t call the doctor’s office first. I call the care coordinator.” “It’s never going to be easy, but it doesn’t seem impossible anymore, and our care coordinators are a big reason why.” – Richard Yard, Father 35

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    Pharmacy Pharmacists have a crucial, if sometimes under-recognized, role in the value-based care of a population. Medications are leading drivers of rising health care costs. Health care providers can have a difficult time keeping up with the newest evidence-based prescription practices. Children who do not have easy access to the drugs they need face poorer health outcomes. Pharmacists can help address all of these issues. So, Partners For Kids embeds pharmacists in many aspects of its overall work and also capitalizes on the deep pharmacy resources of Nationwide Children’s Hospital. Among Partners For Kids’ pharmacist roles: • Creating Prescribing Resources. Partners • Developing Electronic Medical Record For Kids pharmacists use medical evidence, Clinical Decision Support. Partners For Kids Nationwide Children’s expert opinion, pharmacists work with information technology insurance coverage and medication cost to create specialists to create alerts, favorites and order sets prescribing guidelines for common conditions in electronic medical record systems. These can seen in primary care – including acne, head inform decisions about a specific patient’s care. lice, gastroesophageal reflux (GER) and many others. They also maintain an updated Preferred • Medication Management. Using claims data, Drug List so that providers can quickly see Partners For Kids pharmacists can determine the exact medications covered by Medicaid when individual patients are adhering to a managed care plans. Importantly, Partners For medication schedule (by looking at filled and Kids pharmacists work with managed care plans refilled prescriptions), when patients could to ensure that recommended medications are be prescribed medications that are more covered under their formularies. cost-effective but still clinically appropriate, and when coverage changes may necessitate • Educating Community Providers. Partners For a change in prescriptions. Working with Kids pharmacists distribute prescribing resources providers, pharmacists can use this information online, through webinars and on a mobile app, to improve health outcomes and value-based but they also individually visit practices to work care for patients. face-to-face with prescribers. In addition, they can generate provider- and practice-specific reports to educate providers on their individual prescribing activities. Partners For Kids pharmacists are also intimately involved in quality improvement projects that have a significant drug component: Asthma Behavioral Health: ADHD Partners For Kids pharmacists use claims data to learn how Partners For Kids pharmacists often individual patients fill prescriptions for controller developed evidence-based prescribing medications vs. rescue medications – a smaller percentage of guidelines for patients with attention filled controller prescriptions can indicate poorly managed deficit hyperactivity disorder, and asthma and trigger certain interventions for a provider. worked with individual practices Pharmacists also create prescribing guidelines and train to increase the prescribing rate of practices on ordering preferred medications. preferred medications. 37

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    Big Lots Behavioral Health Prescribing Guidelines for Behavioral Health Medication List for Medicaid Plans Starting Daily Average Cost Per Drug Max Daily Dose Clinical Pearls Dose1 Script2 Preferred Stimulants Dextroamphetamine-Amphetamine 3:1 ratio dextro- to levo-amphetamine ratio.3 2.5-5 mg 40 mg $51 Immediate Release (Adderall®) Tablet can be crushed. Duration 4-6 hours. 3:1 ratio dextro- to levo-amphetamine ratio.3 Dextroamphetamine-Amphetamine 5-10 mg 40 mg $184 Capsule can be opened and sprinkled. Duration Long-Acting (Adderall XR®) 10-12 hours. Methylphenidate Immediate Release 5 mg 60 mg $45 Tablet can be crushed. Duration 4 hours. (Ritalin®) 50% is immediate release and 50% is extended Methylphenidate Long-Acting 10, 60mg: $346 release. Capsule can be opened and sprinkled. The 10-20 mg 60 mg (Ritalin LA®) 20, 30, 40mg: $174 10 mg strength is not available generically and is more expensive. Duration 8-10 hours. 30% is immediate release and 70% is extended Methylphenidate Long-Acting 10-20 mg 60 mg $174 release. Capsule can be opened and sprinkled. (Metadate CD®) Duration 8-10 hours. Preferred Non-Stimulants ® Guanfacine (Tenex ) 0.5 mg 4 mg $34 Monitor blood pressure. Taper when discontinuing. Take at the same time each day. Do not administer with high-fat meal. Tablet cannot be opened or Guanfacine Extended Release (Intuniv®) 1 mg 4 mg $314 crushed. Monitor blood pressure. Taper when discontinuing. Non-Preferred Stimulants Extended-release orally disintegrating tablet. 3:1 Amphetamine Extended Release ratio of dextro- and levo-amphetamine.3 Duration 3.1 mg 18.8 mg $407 Dispersable Tablet (Adzenys XR-ODT®) 10-12 hours. See package insert for mg conversion to mixed amphetamine salts. Long acting oral suspension 2.5mg/ml. 3:1 ratio of Amphetamine Extended Release dextro- and levo-amphetamine.3 Duration 12 hours. 2.5 mg 20 mg $330 Suspension (Dyanavel XR®) See package insert for mg conversion to mixed amphetamine salts. Amphetamine Immediate Release Immediate release tablet. 1:1 ratio of dextro- and 5 mg 40 mg $229 (Evekeo®) levo-amphetamine.3 Duration 4-6 hours. Tablet can be crushed. Duration 4 hours. When Dexmethylphenidate Immediate 2.5 mg 20 mg $29 switching from methylphenidate reduce dose by Release (Focalin®) half. 50% is immediate release and 50% is extended Dexmethylphenidate Long-Acting release. Capsule can be opened and sprinkled. 5 mg 30 mg $282 (Focalin XR®) Duration 10-12 hours. When switching from meth- ylphenidate, reduce dose by half. (Continued) 11 38

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    Patient Outreach Primary care practices work to provide excellent care when patients come in their doors. But what if patients aren’t coming in – if families aren’t scheduling well-child visits, or if they are visiting urgent care facilities or emergency departments for common conditions instead of primary care? Resource-limited practices don’t always have the time or staff members to reach out to those families. Partners For Kids’ Patient Outreach program aids those practices. Outreach coordinators can be embedded with primary care providers to make scheduling calls to families whose children are due for well checks, or to those who are regularly accessing acute care services when primary care would be more appropriate. Coordinators may also determine the obstacles preventing regular primary care visits, such as lack of transportation, and connect families to resources that can help. Just as importantly, outreach coordinators can inform providers about patients who have never visited but who should. Every child who has health coverage through Medicaid is “attributed” to a provider. Families have the ability to choose their own provider, of course, but those who rely on urgent care providers may not realize that they have primary care available to them as well. Primary care providers, in turn, may not know all of the patients attributed to them. Outreach coordinators use Medicaid data to identify those patients and make introductory and scheduling calls on behalf of practices. New Appointments Through Patient Outreach Partners For Kids relaunched its Patient Outreach program in May 2017. Since then, coordinators have helped scheduled thousands of appointments for dozens of practices. 2500 Outreach Attempts Appts. Scheduled Appts. Completed 2000 1500 1000 500 0 MAY-17 JUN-17 JUL-17 AUG-17 SEP-17 OCT-17 NOV-17 DEC-17 JAN-18 FEB-18 MAR-18 APR-18 MAY-18 JUN-18 JUL-18 AUG-18 SEP-18 OCT-18 NOV-18 DEC-18 JAN-19 FEB-19 MAR-19 APR-19 39

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    Behavioral Health One in five children lives with a significantly impairing mental illness. Half of all mental illness begins by 14 years of age. It has become increasingly clear that any strategy to improve the health of a single child or of an entire population must include efforts to address behavioral health. At the same time, many areas do not have enough behavioral health providers to meet the needs of young people, and so primary care providers are called on for these services. In 2018, Ohio brought behavioral health into the Medicaid managed care system, giving Partners For Kids a greater opportunity to help children receive it. Partners For Kids brings many of the resources it has long employed to improve physical health care – including medication education from pharmacists and quality improvement coaching – to bear in its work on behavioral health care. But since 2018, it has also begun new initiatives in a multipronged approach to expand and improve this care for children and adolescents. • Project ECHO. Project ECHO is a collaborative, conditions. Partners For Kids offers training for telehealth-based program for primary care those behavioral health clinicians and technical providers to become better educated and more assistance to maintain a population health comfortable in dealing with behavioral health registry in an effort to monitor and intervene in conditions. A “hub” team from Partners For behavioral health conditions. Kids, composed of a psychiatrist, psychologist, pharmacist, social worker and care manager, • School-Based Behavioral Health. Nationwide facilitates a videoconference discussion among Children’s Hospital provides behavioral health a group of primary care providers every two counseling and services in dozens of central Ohio weeks. Providers are invited to present their schools. Through those services, thousands of most challenging behavioral health cases, and children have participated in the Signs of Suicide participants learn together about the best Prevention Program and learned self-regulating evidence-based practices for managing those cases. behaviors from the PAX Good Behavior Game. Partners For Kids is working to expand these • Primary Care Behavioral Health Integration. services to schools in southeastern Ohio. Partners For Kids is working with a number of community practices in south central and • Quality Improvement. Through Partners For southeastern Ohio to help behavioral health Kids robust Quality Improvement Coaching clinicians become members of those practices. program, primary care practices are able to While a primary care provider focuses on physical implement and improve screening for ADHD, health needs, the behavioral health clinician has depression and suicidal thoughts and participate the expertise to manage mental and emotional in projects to improve the evidence-based prescription of ADHD medications. Partners For Kids offers Project ECHO, a telehealth-based program for primary care providers to become better educated in dealing with behavioral health conditions. 40

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    Patient Perspective: Advocating for a Family Through a Mental Health Crisis D awn Miller first met her care coordinator hospitalization, it became clear that one of her in the Nationwide Children’s Hospital providers was not meshing well with the family. inpatient psychiatric unit. Dawn’s daughter Dawn couldn’t figure out how to proceed. had been admitted for suicidal ideation, and Dawn felt shame that she had not fully realized her child’s “I didn’t know if I was stuck,” Dawn said. “I suffering. She worried about how she could possibly didn’t want to jeopardize Mackenzie’s health just care for the three other children at home while a because we weren’t getting along. I wanted to be as fourth was in crisis. supportive as I could be. I knew I could ask our care coordinator. I knew that even though he was part “All of this going on, I am trying to keep my of this system, he was on our side, and he was not daughter from dying, and now I have one more going to make me feel bad for asking.” person to talk to,” Dawn says of that meeting with the coordinator. “But he was calm and caring. I He intervened and helped Dawn and Mackenzie needed it. I started to understand there was a system transition to someone who fits with them better. in place that could help me and my family.” Dawn can name any number of other ways their care coordinator intervened for her and her Dawn and her daughter Mackenzie Starkloff, now family: connecting them with utility bill payment 18, became fully embedded in that system for resources; finding exactly the right person to speak nearly two years. On the behavioral health side, to about reinstating the family’s Supplemental Mackenzie was a patient in the hospital, then Nutrition Assistance Program benefits; and participated in an intensive outpatient program, introducing them to outside peer counseling when and then had ongoing therapy. another family member began to struggle. And on the care coordination side, a care “Two years ago, we had this intense crisis with coordinator from Partners For Kids became a trusted Mackenzie. Life or death,” says Dawn. “Now we’re partner to Dawn, in ways that she wouldn’t always more stable, and one of the big reasons why is our have expected. At one point after Mackenzie’s care coordinator.” “Two years ago, we had this intense crisis with Mackenzie. Life or death,” says Dawn. “Now we’re more stable, and one of the big reasons why is our care coordinator.” – Dawn Miller, Mother 42

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    Community and School-Based Programs Addressing traditional health care and its delivery is often considered the main function of an accountable care organization. But what if the efforts to get children to visit a provider still don’t result in an appointment? What if social and environmental obstacles, such as poor housing, hunger and unsafe neighborhoods, have such a detrimental effect on a child’s health that traditional care cannot overcome them? Nationwide Children’s Hospital is one of the country’s leaders in working with area partners to deliver care outside of traditional settings and to impact social determinants of health. Partners For Kids collaborates with Nationwide Children’s in many of these programs; in fact, the hospital developed many of them to extend the population health successes seen in Partners For Kids. And the savings that Partners For Kids realizes by focusing on value-based care are reinvested in these and other community programs. • Healthy Neighborhoods Healthy Families. - Offered workforce training, one of the In this signature program to address social catalysts to the hiring of hundreds of determinants of health in the neighborhoods neighborhood residents at Nationwide surrounding the hospital, Nationwide Children’s, Children’s and other employers the City of Columbus, a non-profit community - Provided mentorship and tutoring to students development organization and many others have: and families to increase kindergarten readiness, - Helped build or rehabilitate more than 350 high school graduation rates and post- single-family homes, with more on the way secondary education opportunities - Developed the 58-unit, apartment and - Announced the expansion of these efforts to townhouse complex called Residences at Linden, another distressed area of Columbus, Career Gateway with the help of a $5 million grant from JP - Begun work on 70 additional rental units Morgan Chase A 2018 publication in Pediatrics found that in the first nine years of Healthy Neighborhoods Healthy Families: Graduation rates Vacancy rates Homicides fell in the increased from decreased from neighborhood (even as 64% to 79%. >25% to less than 6%. city-wide numbers increased). 43

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    • School-Based Health Care. Care Connection • Infant Mortality. In 2014, Franklin County, is a partnership between Nationwide Children’s, Ohio’s overall infant mortality rate was 8.4 per area schools and primary care providers to 1,000 births, well above the national average provide access to health services in schools. This of 5.8. Nationwide Children’s and Partners care is not meant to replace a regular primary For Kids, along with local governments and care visit; an ultimate goal of Care Connection other groups helped create two interconnected is to connect families with regular providers. But organizations, Ohio Better Birth Outcomes and the program allows children, especially those CelebrateOne. Together, they: in the Partners For Kids system without regular - Work to improve reproductive health providers, to receive basic services including well planning, access and education checks, immunizations, physicals, behavioral health screenings and medications for common - Expand access to prenatal care and expand conditions. Care Connection: access to the highest-risk families - Operates full-service primary care clinics in - Create quality improvement projects to 13 schools enhance perinatal care - Provides behavioral health counseling in - Publicly promote practical strategies more than 40 schools to reduce infant mortality, such as maternal smoking cessation, safe sleeping - Offers school-based asthma therapy in more arrangements and 18-month birth spacing than 200 schools - Uses a Mobile Care Center to provide services in additional neighborhoods and schools - Runs a seating and wheelchair clinic at a special needs magnet school in Columbus, where approximately 50% of children have mobility issues 44

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    Provider Perspective: Project ECHO and Behavioral Health Care in School S chool-based health services are one of the most Hutmire was one of the first in her Project effective ways that Nationwide Children’s ECHO group to present. A child for whom Hospital and Partners For Kids reach young she had prescribed an ADHD medication had people who don’t have a regular health care provider. threatened self-harm. Hutmire immediately With 13 full-service clinics inside central Ohio stopped the medication and made a psychiatric schools, behavioral health services offered in dozens of referral. But she wanted to know: had she done the others and a Mobile Care Center, young people can right thing? Had the medication led to thoughts of have many health needs addressed between classes. self-harm? Crissie Hutmire, ANP, runs one of those full-service “I needed someone else’s opinion,” she said. clinics as part of Nationwide Children’s Hospital’s Care Connection. She gives immunizations and The ECHO hub team and her fellow providers physicals, orders bloodwork, makes diagnoses, helped talk through her concerns. Hutmire had prescribes medications and refers to other providers. followed Nationwide Children’s and Partners For She may also be the only health care contact for Kids’ prescribing guidelines. There were a number some young people with behavioral health concerns. of other factors that may have contributed to the child’s threat, and there was the possibility that it “I have to deal with mental health daily, especially had not been sincere. But Hutmire had been right to issues related to anxiety, depression and attention take the actions she did. deficit hyperactivity disorder (ADHD),” she says. “I do have some comfort in those areas, but I know I Hutmire’s colleagues also agreed that the next steps need to become better at it. That’s why I signed up were important. The child’s family has a number for Project ECHO.” of barriers to accessing non-school-based care and did not follow through on the psychiatric referral, Project ECHO is a telehealth-based program from Hutmire says. So she is continuing to follow up, Partners For Kids to help primary care providers with knowledge gained from Project ECHO. better care for children and adolescents with behavioral health issues. A “hub team” from Partners “I am the one who is there, at the school, and I have For Kids facilitates videoconference discussions an opportunity to help,” Hutmire says. “I want to among providers and encourages them to present give that family the tools to succeed if I can.” their most challenging cases and learn from each other. “I have to deal with mental health daily, especially issues related to anxiety, depression and attention deficit hyperactivity disorder.” – Crissie Hutmire, ANP 46

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