Improving transitions in care for children with complex and medically fragile needs: a mixed methods study

Area of Science:

• Pediatric Healthcare
• Health Services Research
• Patient Transition Management

Background:

• Children with medical complexity represent a resource-intensive population within the Canadian healthcare system.
• Current hospital discharge processes for these children are suboptimal.
• There is a need for a provincial strategy to enhance care transitions for medically fragile children.

Purpose of the Study:

• To develop recommendations for a provincial strategy supporting care transitions for children with complex medical needs.
• To address policy and practice gaps in the discharge process for medically fragile children and their families.

Main Methods:

• A mixed-method, multiphase project involving various stakeholders.
• Phase 1: Documenting family experiences during hospital discharge.
• Phase 2: Stakeholder interviews (pediatricians, nurses, administrators) to identify barriers and facilitators.
• Phase 3: Consensus meeting to refine recommendations for a provincial strategy.

Main Results:

• Six case studies of children with complex care needs (ages 15 days to 9 years).
• Interviews highlighted inter-institutional communication challenges as a major barrier.
• A consistent finding was the critical need for improved care coordination during transitions.
• A consensus meeting yielded six recommendations for a provincial strategy.

Conclusions:

• The project identified significant policy and practice gaps in care transitions for children with medical complexity.
• A collaborative, patient-centered approach informed the development of recommendations for a provincial strategy.
• Enhanced coordination and communication are crucial for optimizing discharge and home reintegration for these children.