Better Communication to Prevent Life-Threatening Infections

Many children who are infected by RSV, or respiratory syncytial virus, feel like they have nothing more than a cold. But for some young children, RSV infection can be life-threatening. Each year, as many as 80,000 children under 5 years old across the United States are hospitalized with it.

A medication called Synagis helps prevent the most serious RSV-related consequences, and outpatient injections typically are covered by insurance only during the peak RSV season. Historically, that’s from November through March. But during the COVID-19 pandemic, the season shifted, which caused a problem for insurance organizations and medical providers.

Each year, the Nationwide Children’s Hospital administers monthly Synagis injections via home health care to high-risk children, like babies born preterm or with complex medical conditions. Approximately 300 of those children are covered by Medicaid and part of Partners For Kids. Partners For Kids, the nation's oldest and largest pediatric accountable care organization, is a partnership among Nationwide Children’s, Dayton Children’s Hospital and other care providers that is responsible for the health of more than 470,000 children covered by Medicaid managed care plans across 47 Ohio counties.

In 2021, RSV rates began peaking in early June, instead of in the fall. Nationwide Children’s needed to begin administering Synagis immediately, but Medicaid managed care plans historically only authorize payment for Synagis during the typical RSV season.

Because the RSV season had begun much earlier than expected, it took time to identify patients, coordinate the administration of the injections and receive authorization for payment from Medicaid plans. As a result, there was an unforeseen delay in administering Synagis to high-risk children.

At the beginning of 2022, Partners For Kids quickly formed a working group at Nationwide Children’s among Homecare, clinical pharmacists and infectious diseases specialists to coordinate the stop of Synagis administration in alignment with declining RSV rates.

“Partners For Kids was in a unique position to identify an opportunity to bring this group together to improve medication access,” said Kelin Wheaton, PharmD, PhD, Population Health Clinical Pharmacist at Partners For Kids. “We brought the experts into the decisions and created communication pathways among all parties.”

In the spring and early summer of 2022, this working group reconvened as RSV rates began to climb early once again. This time, Partners For Kids communicated the rising rates with the Ohio Department of Medicaid and the managed care plans so they knew to start the discussion about approving Synagis earlier than usual.

“Our working group was ready to go,” said Dr. Wheaton. “Ohio Medicaid and the plans were ready to approve Synagis and Nationwide Children’s was ready to administer it.”

As the 2022 RSV season progressed, the working group collaborated with specialty providers who have high-risk patients, including pulmonologists, cardiologists and neonatologists, and communicated with other hospitals about increasing RSV rates across Ohio. As a result, 2022 saw Synagis administrations aligned with high RSV rates, ensuring high-risk patients received injections at the right time to prevent hospitalizations.

The coming RSV season is currently too ambiguous to predict, but because the working group is operational and active, Partners for Kids can act quickly on Synagis authorization and administration whenever RSV rates begin peaking.

“Our goal is to align Synagis administration with increasing RSV rates,” said Dr. Wheaton. “As long as we're doing that, we're accomplishing our goal.”