Improving the Transition from Hospital to Home for Clinically Complex Children
Danielle Altares Sarik, Mary Pat Winterhalter, and Christina J. Calamaro
Purpose: Clinically complex patients with multiple follow-up appointments and high acuity are at increased risk of poor outcomes as they transition from hospital to home. Patient navigation programs help patients and families through these transitions, but little exploration of the outcomes for the clinically complex pediatric population exist. This study describes the process of building a patient navigation program in a pediatric acute care setting, outlines the function of the patient navigation program, describes the pediatric population using these services, and evaluates the outcomes of the program.
Design/Methods: This retrospective review used data collected from January 1-December 31, 2015, from clinically complex pediatric patients age 0 to 20 years who received inpatient care at an East Coast pediatric hospital. Patient demographic characteristics and patient outcomes, including 30-day readmission and rate of “no show” at scheduled follow-up appointments, were analyzed.
Results: A total of 398 unique patients and 422 encounters were included in final analysis. The majority of patients were female (52.5%) and White (52.0%), with 6.5% of the patient population identifying Spanish as the primary language. On average, patients had 12 co-morbidities (SD: 10). Overall, 15.9% of patients were readmitted within 30 days of discharge, and there was a 12.9% “no show” rate for follow-up appointments.
Conclusions: The patient navigation program described represents a systematic improvement to streamline the transition of care process for clinically complex patients.
Practice Implications: Nurses play a critical role in improving the care of clinically complex children.