The investigators hypothesize that an intervention, within an established patient-centered medical home, aimed at reducing modifiable risks for hospitalization, can decrease hospital utilization among medically complex children.
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AI-rewrites the medical criteria so a patient or caregiver can understand them. Always confirm with the trial site.
(1) number of all-cause admissions, defined as any admission occurring during the study period
Timeframe: 18 to 24 months
(2) preventable admissions, defined by 2 independent physicians blinded to study assignment as an admission due primarily to one of the preventable factors identified from Phase 1 of the study
Timeframe: 18 to 24 months