8 - All Hands Health Network: Impact of an Integrated Care for Kids (InCK) Model in Chicago, IL

Publication Number: 3007.8

Jennifer Saper, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States; Sophie Doemer, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States; Siddharth Sheth, Ann & Robert H. Lurie Children's Hospital of Chicago, CHICAGO, IL, United States; Matt Thalhamer, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States; Aubrey Biga, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States; Brittany Ward, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States; Chris Haen, Lurie Children's, Chicago, IL, United States; Karen Sheehan, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States; MIchelle Macy, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States

Background: The All Hands Health Network (AHHN) is an Integrated Care for Kids (InCK) model and recipient of this child-focused Center for Medicare and Medicaid Innovation (CMMI) award that aims to reduce expenditures and improve quality of care for children covered by Medicaid and CHIP. AHHN offers resource coordination (RC) to attributed children and youth in two underserved ZIP codes in Chicago. The impact of RC on healthcare costs, utilization, and unmet social needs is unknown.

Objective: To analyze changes in overall healthcare costs, utilization, and their caregiver- or self-identified social needs among AHHN members who received RC.

Design/Methods: Children enrolled in Medicaid and CHIP living in Chicago’s 60639 and 60651 ZIP codes were identified from the Illinois Medicaid registry. AHHN sorted members into 3 Service Integration Levels (SIL) based on specific clinical and social criteria, based on claims data (Table 1). Members were invited to complete Needs Assessment (NA) surveys via direct outreach, ED waiting room efforts, and local community events. RC was offered to families of children classified as SIL 2 from claims data or elevated to SIL 2 by their NA score. We focused our analyses on members who graduated from RC. Descriptive statistics were analyzed, including the number of member months in RC, cost per member per month (PMPM), utilization (events per 1,000), and overall NA scores before, during, and after RC.

Results: Of the 2,368 AHHN Members that completed a NA survey, 1,982 (83.7%) enrolled in resource coordination had sufficient cost and utilization data available from payer claims and 1,847 (77.8%) had post-RC NA scores. On average, members spent 4.8 months in RC. The overall cost per event was the lowest and the number of events per 1,000 was highest during RC (Figure 1). Decreased cost per event persisted after RC. On average, the total NA survey score decreased from baseline (3.8) to follow-up (3.3), with 33% of all NA scores decreasing over time (Figure 2).

Conclusion(s): Resource coordination is a tool that can help meet the clinical and social needs of children covered by Medicaid. Surveys can be used to identify needs and direct resource coordination toward addressing needs, ultimately helping to reduce higher-cost healthcare (e.g., ED and hospitalization), while maintaining overall visits. Broader implementation of community needs assessments, and outreach can positively impact population health and optimize healthcare utilization.

Table 1. Patient Member Categorization Strategies including clinical risk group, social need identification, and Needs Assessment Domains
AHHN Table 1_Pas 2025.pdf

Figure 1. Overall Utilization of RC Members from 2021-2024
AHHN FIgure 1_PAS 2025.pdf

Figure 2. Resource Coordination Enrolled Needs Assessment Evaluations before and after Care Coordination
AHHN Figure 2_PAS 2025.pdf