Related Experiment Video
Updated: Jan 19, 2026
Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion
Published on: January 20, 2019
Identifying and Communicating Postdischarge Goals for Hospitalized Children With Medical Complexity: A Process
Insights
Implementing a Post-Hospitalization Action Grid (PHAG) improved family engagement during care transitions for children with medical complexity (CMC). However, broader organizational support is needed for full integration and impact on integrated care perceptions.
Area of Science:
- Pediatric healthcare quality improvement
- Patient-centered communication strategies
- Healthcare transitions for complex pediatric populations
Background:
- Family-centered communication during care transitions is crucial for reducing readmissions and costs in children with medical complexity (CMC).
- Effective communication of post-discharge goals is vital for ensuring continuity of care for CMC.
Purpose of the Study:
- To enhance the communication of post-discharge goals for CMC within a pediatric specialty setting.
- To implement and evaluate a quality improvement project focused on family-centered communication during care transitions.
Main Methods:
- Utilized process improvement strategies to introduce the Post-Hospitalization Action Grid (PHAG) and a standardized discharge handoff.
- Conducted a pilot intervention with high-risk CMC families over three months.
- Measured implementation success through PHAG utilization rates, perceptions of integrated care, and tool usability.
Main Results:
- The PHAG was implemented for 11 out of 40 eligible CMC families.
- A majority of healthcare staff believed the new process would improve post-discharge goal communication.
- Minimal changes were observed in organizational perceptions of integrated care.
Conclusions:
- The Post-Hospitalization Action Grid (PHAG) effectively promotes family engagement in discharge transitions for CMC.
- Successful implementation and broader impact necessitate significant organizational investment in resources and support.
Introduction:
Family-centered communication at transitions of care can decrease readmissions and costs for children with medical complexity (CMC). The purpose of this quality improvement project was to improve the communication of postdischarge goals for CMC in a pediatric specialty setting.
Methods:
We used process improvement strategies to implement a Post-Hospitalization Action Grid (PHAG) and a standardized discharge handoff process. Families of hospitalized CMC at high risk for readmission received the pilot intervention over 3 months. Indicators of successful implementation included rates of use of the PHAG, perceptions of integrated care, and usability of the tool.
Results:
The PHAG was implemented with 11 of 40 eligible CMC families. Most staff agreed that the new process could improve the communication of postdischarge goals; however, perceptions of integrated care in the organization changed only minimally.
Discussion:
The PHAG facilitates family engagement in discharge transitions but requires organizational investment of resources to implement.
More Related Videos
Related Concept Videos
01:21Planning Nursing Care I
01:31Discharge Summary Forms
Here's a detailed look at the key components and guidelines for preparing a discharge summary:
01:25Role of Communication in the Nursing Process II: Planning and Implementation
01:11Guidelines for Writing Outcome
Patient outcomes reflect the patient's response to the goal rather than what the nurse aims to achieve. Terminology should be observable and measurable to avoid the reader's interpretation. The desired outcome should be realistic and achievable in the designated care timeframe. Expected outcomes should align with adjunctive therapies. The outcome should enhance care...
01:29Documentation in Long-Term and Home Healthcare Setting
Long-Term Care Facilities
01:29Endocarditis IV: Nursing Management