A Telehealth-Based Transitional Care Model for Children with Medical Complexity

Children with medical complexity (CMC) have a high risk of readmission and encounter numerous barriers to care after hospital discharge. Several programs have attempted to mitigate these challenges, with variable impact on readmission rates and care fragmentation.

We implemented a novel telehealth program utilizing the full scope of nursing practice to support hospital-to-home transitions and reduce readmission rates for CMC. The aim of our program was to achieve a 10% reduction in the baseline 30-day readmission rate for this population.

Eligible inpatients were those with one or more home health orders, a hospital stay of at least seven days, and a previous hospitalization/ED visit in the past year or an intensive care admission during the current hospitalization. The intervention consisted of a virtual nurse visit three to seven days after discharge, with additional follow-up as needed, and handoff to the outpatient team within 30 days to reduce care fragmentation. Our primary outcome was 30-day readmission rates compared to the historical baseline for similar patients. Secondary outcomes included the identification and resolution of care barriers and 30-day ED revisit rates.

From January 2020 to June 2024, 974 patients were enrolled in the program, and nurses completed 1,377 telehealth encounters. The 30-day readmission rate decreased from 17.6% to 10.1% over four years. We identified care barriers in 51% of encounters, primarily related to scheduling follow-up appointments (28.5%) and obtaining medical supplies (21.1%). The 30-day ED revisit rate declined from the preintervention baseline of 12.4% to 10.3%.

By utilizing nurses working at the top of their license, readmission rates were reduced for a diverse, high-risk patient population. Novel features of the program included minimal exclusion criteria; bridging inpatient and outpatient care teams; and the ability to address clinical questions, care coordination, and social determinants of health needs through a single point of contact. Successful implementation at a second hospital suggests that the model to reduce readmission rates in complex patients could be replicated elsewhere.