Adherence to Well-Child Care and Home Visiting Enrollment Associated with Increased Emergency Department Utilization

  • Neera K. GoyalEmail author
  • Courtney M. Brown
  • Alonzo T. Folger
  • Eric S. Hall
  • Judith B. Van Ginkel
  • Robert T. Ammerman



Pediatric primary care and home visiting programs seek to reduce health disparities and promote coordinated health care use. It is unclear whether these services impact high-cost, emergency department (ED) utilization. We evaluated the association of well-child care (WCC) and home visiting with ED visit frequency for children < 1 year with an established medical home.


Retrospective cohort study using linked administrative data for infants ≥ 34 weeks’ gestation from 2010 to 2014, within a multisite, academic primary care system. Latent class analysis characterized longitudinal patterns of WCC. Multivariable negative binomial regression models tested the independent association between WCC patterns and home visiting enrollment with ED visits.


Among 10,363 infants, three WCC latent classes were identified: “Adherent” (83.4% of the cohort), “Intermediate” (9.7%), and “Decreasing adherence” (7.0%). Sixty-one percent of the sample had ≥ 1 ED visit in the first 12 months of life, and 73% of all ED visits were triaged as non-urgent. There was a significant interaction effect between WCC pattern and insurance status. Among Medicaid-insured infants, “Intermediate” and “Decreasing adherence” WCC patterns were associated with a lower incident rate of ED visits compared with the “Adherent” pattern (incident rate ratios (IRR) 0.88, p = 0.03 and 0.79, p < 0.001 respectively); this effect was not observed among privately-insured infants. Home visiting enrollment was independently associated with a higher rate of ED visits (IRR 1.24, p < 0.001).


Among infants with an established medical home, adherence to recommended WCC and home visiting enrollment was associated with greater ED use for non-urgent conditions.


Well-child care Home visiting Emergency department Medical home Infant 



The authors have no financial relationships relevant to this article to disclose. This work was supported by Grant R40 MC29447 through the US Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.

Compliance with Ethical Standards

Conflicts of interest

The authors have no conflicts of interest relevant to this article to disclose.


  1. Abdus, S., & Selden, T. M. (2013). Adherence with recommended well-child visits has grown, but large gaps persist among various socioeconomic groups. Health Affairs,32(3), 508–515.CrossRefGoogle Scholar
  2. Anugu, M., Braksmajer, A., Huang, J., Yang, J., Ladowski, K. L., & Pati, S. (2017). Enriched medical home intervention using community health worker home visitation and ED use. Pediatrics,139(5), e20161849.CrossRefGoogle Scholar
  3. Beck, A. F., Tschudy, M. M., Coker, T. R., Mistry, K. B., Cox, J. E., Gitterman, B. A., et al. (2016). Determinants of health and pediatric primary care practices. Pediatrics,137(3), e20153673.CrossRefGoogle Scholar
  4. Benchimol, E. I., Smeeth, L., Guttmann, A., Harron, K., Moher, D., Petersen, I., et al. (2015). The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) Statement. PLoS Med,12(10), e1001885.CrossRefGoogle Scholar
  5. Brousseau, T., & Sharieff, G. Q. (2006). Newborn emergencies: The first 30 days of life. Pediatric Clinics of North America,53(1), 69–84.CrossRefGoogle Scholar
  6. Butun, A., Linden, M., Lynn, F., & McGaughey, J. (2019). Exploring parents’ reasons for attending the emergency department for children with minor illnesses: A mixed methods systematic review. Emergency Medicine Journal,36(1), 39–46.PubMedGoogle Scholar
  7. Davis, T., Meyer, A., Beste, J., & Batish, S. (2018). Decreasing low acuity pediatric emergency room visits with increased clinic access and improved parent education. Journal of the American Board of Family Medicine,31(4), 550–557.CrossRefGoogle Scholar
  8. Folger, A. T., Bowers, K. A., Dexheimer, J. W., Sa, T., Hall, E. S., Van Ginkel, J. B., et al. (2017). Evaluation of early childhood home visiting to prevent medically attended unintentional injury. Annals of Emergency Medicine,70(3), 302–310.CrossRefGoogle Scholar
  9. Goyal, N. K., Ammerman, R. T., Massie, J. A., Clark, M., & Van Ginkel, J. B. (2016). Using quality improvement to promote implementation and increase well child visits in home visiting. Child Abuse and Neglect,53, 108–117.CrossRefGoogle Scholar
  10. Goyal, N. K., Folger, A. T., Sucharew, H. J., Brown, C. M., Hall, E. S., Van Ginkel, J. B., et al. (2018). Primary care and home visiting utilization patterns among at-risk infants. Journal of Pediatrics,198, 240–246.CrossRefGoogle Scholar
  11. Hadland, S. E., & Long, W. E. (2014). A systematic review of the medical home for children without special health care needs. Maternal and Child Health Journal,18(4), 891–898.CrossRefGoogle Scholar
  12. Hagan, J. F., Shaw, J. S., & Duncan, P. M. (Eds.). (2017). Bright futures: Guidelines for health supervision of infants, children and adolescents (4th ed.). Elk Grove Village, IL: American Academy of Pediatrics.Google Scholar
  13. Health Resources and Services Administration. (2010). Maternal, infant, and early childhood home visiting program. Retrieved from
  14. Kercsmar, C. M., Beck, A. F., Sauers-Ford, H., Simmons, J., Wiener, B., Crosby, L., et al. (2017). Association of an asthma improvement collaborative with health care utilization in Medicaid-insured pediatric patients in an urban community. JAMA Pediatrics,171(11), 1072–1080.CrossRefGoogle Scholar
  15. Koball, H., & Jiang, Y. (2018). Basic facts about low-income children: Children under 18 years, 2016. Retrieved from
  16. Kroner, E. L., Hoffmann, R. G., & Brousseau, D. C. (2010). Emergency department reliance: A discriminatory measure of frequent emergency department users. Pediatrics,125(1), 133–138.CrossRefGoogle Scholar
  17. Lambert, L. (2016). Collaboration of home visiting and primary care clinicians. Current Problems in Pediatric and Adolescent Health Care,46(4), 130–131.CrossRefGoogle Scholar
  18. Lee, H. C., Bardach, N. S., Maselli, J. H., & Gonzales, R. (2014). Emergency department visits in the neonatal period in the United States. Pediatric Emergency Care,30(5), 315–318.CrossRefGoogle Scholar
  19. Marshall, A., Altman, D. G., Royston, P., & Holder, R. L. (2010). Comparison of techniques for handling missing covariate data within prognostic modelling studies: A simulation study. BMC Medical Research Methodology,10, 7.CrossRefGoogle Scholar
  20. Martsolf, G., Fingar, K. R., Coffey, R., Kandrack, R., Charland, T., Eibner, C., et al. (2017). Association between the opening of retail clinics and low-acuity emergency department visits. Annals of Emergency Medicine,69(4), 397–403.CrossRefGoogle Scholar
  21. Matone, M., O’Reilly, A. L., Luan, X., Localio, A. R., & Rubin, D. M. (2012). Emergency department visits and hospitalizations for injuries among infants and children following statewide implementation of a home visitation model. Maternal and Child Health Journal,16(9), 1754–1761.CrossRefGoogle Scholar
  22. McDermott, K. W., Stocks, C., & Freeman, W. J. (2018). Overview of pediatric emergency department Visits, 2015. Statistical brief. Healthcare Cost and Utilization Project. Retrieved January 16, 2019, from
  23. Minkovitz, C. S., Hughart, N., Strobino, D., Scharfstein, D., Grason, H., Hou, W., et al. (2003). A practice-based intervention to enhance quality of care in the first 3 years of life: The Healthy Steps for Young Children Program. JAMA,290(23), 3081–3091.CrossRefGoogle Scholar
  24. Morrison, A. K., Schapira, M. M., Gorelick, M. H., Hoffmann, R. G., & Brousseau, D. C. (2014). Low caregiver health literacy is associated with higher pediatric emergency department use and nonurgent visits. Academic Pediatric,14(3), 309–314.CrossRefGoogle Scholar
  25. National Committee for Quality Assurance. (2019). Patient-Centered Medical Home Recognition. Retrieved September 5, 2019, from
  26. Paradis, H. A., Belknap, A., O’Neill, K., Baggett, S., & Minkovitz, C. S. (2018). Coordination of early childhood home visiting and health care providers. Children and Youth Services Review,85, 202–210.CrossRefGoogle Scholar
  27. Pethe, K., Baxterbeck, A., Rosenthal, S. L., & Stockwell, M. S. (2019). Why parents use the emergency department despite having a medical home. Clinical Pediatrics,58(1), 95–99.CrossRefGoogle Scholar
  28. Pomerantz, W. J., Schubert, C. J., Atherton, H. D., & Kotagal, U. R. (2002). Characteristics of nonurgent emergency department use in the first 3 months of life. Pediatric Emergency Care,18(6), 403–408.CrossRefGoogle Scholar
  29. Radcliffe, J., Schwarz, D., & Zhao, H. (2013). The MOM Program: Home visiting in partnership with pediatric care. Pediatrics,132(Suppl 2), S153–S159.CrossRefGoogle Scholar
  30. Rasooly, I. R., Mullins, P. M., Alpern, E. R., & Pines, J. M. (2014). US emergency department use by children, 2001–2010. Pediatric Emergency Care,30(9), 602–607.CrossRefGoogle Scholar
  31. Riney, L. C., Brokamp, C., Beck, A. F., Pomerantz, W. J., Schwartz, H. P., & Florin, T. A. (2018). Emergency medical services utilization is associated with community deprivation in children. Prehospital Emergency Care,17, 1–8.Google Scholar
  32. Rushton, F. E., Byrne, W. W., Darden, P. M., & McLeigh, J. (2015). Enhancing child safety and well-being through pediatric group well-child care and home visitation: The Well Baby Plus Program. Child Abuse and Neglect,41, 182–189.CrossRefGoogle Scholar
  33. Sarver, J. H., Cydulka, R. K., & Baker, D. W. (2002). Usual source of care and nonurgent emergency department use. Academic Emergency Medicine,9(9), 916–923.CrossRefGoogle Scholar
  34. Zickafoose, J. S., DeCamp, L. R., & Prosser, L. A. (2013). Association between enhanced access services in pediatric primary care and utilization of emergency departments: A national parent survey. The Journal of Pediatrics,163(5), 1389–1395.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Neera K. Goyal
    • 1
    • 2
    • 9
    Email author
  • Courtney M. Brown
    • 3
    • 4
  • Alonzo T. Folger
    • 5
    • 6
  • Eric S. Hall
    • 5
    • 7
  • Judith B. Van Ginkel
    • 5
  • Robert T. Ammerman
    • 5
    • 8
  1. 1.Department of PediatricsSidney Kimmel Medical College of Thomas Jefferson UniversityPhiladelphiaUSA
  2. 2.Nemours/Alfred I. duPont Hospital for ChildrenWilmingtonUSA
  3. 3.Nationwide Children’s HospitalColumbusUSA
  4. 4.Department of PediatricsThe Ohio State UniversityColumbusUSA
  5. 5.Department of PediatricsUniversity of CincinnatiCincinnatiUSA
  6. 6.Division of Biostatistics and EpidemiologyCincinnati Children’s Hospital Medical CenterCincinnatiUSA
  7. 7.Perinatal InstituteCincinnati Children’s Hospital Medical CenterCincinnatiUSA
  8. 8.Division of Behavioral Medicine and Clinical PsychologyCincinnati Children’s Hospital Medical CenterCincinnatiUSA
  9. 9.Department of PediatricsNemours/Thomas Jefferson UniversityPhiladelphiaUSA

Personalised recommendations