TABLE 4

Modifiable Drivers of Hospital Use Among CMC

Patient and Family DriversHealth Care Drivers
1. Medical technology or device complication1. Lack of practice-level capability and continuing education to perform effective care coordination, chronic condition management, data management
2. Postsurgical complication2. Absence of capacity/skill to redesign office activities
3. Harmful environmental exposure, including passive smoke and inappropriate supervision of the child3. Lack of parent input in clinical program design and execution
4. Nonadherence to prescribed treatments4. No home visitation
5. Nonadherence to follow-up recommendations after discharge5. Inadequate continuity or postdischarge follow-up
6. Neurologic disorders and possibly asthma are prevalent diagnoses among potentially preventable hospitalizations (unclear how modifiable, though awareness of their vulnerability may be relevant)6. Insufficient direct involvement/communication of PCP across inpatient–outpatient–subspecialty–community settings
7. Underrepresented (nonwhite) race/ethnicity or disadvantaged socio-demographics, for example, lower income or public insurance (less likely modifiable)7. No individualized and unified care plan
8. Insufficient payer or institutional commitment of resources to coordinate care for medically complex population, including ancillary services (nursing, social work, therapy, special education and mental health services)
9. Poor family experience with access, family-centered care, or psychosocial support