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

Area of Science:

• Pediatric Healthcare
• Nursing Practice
• Health Services Research

Background:

• Children with medical complexity (CMC) face high readmission risks and care barriers post-discharge.
• Existing programs show variable success in reducing readmissions and care fragmentation for CMC.

Purpose of the Study:

• To implement and evaluate a telehealth program using full-scope nursing practice to improve hospital-to-home transitions for CMC.
• To achieve a 10% reduction in the 30-day readmission rate for CMC.

Main Methods:

• A telehealth intervention involved virtual nurse visits 3-7 days post-discharge for eligible inpatients.
• Follow-up care and handoff to outpatient teams within 30 days aimed to reduce care fragmentation.
• Primary outcome: 30-day readmission rates; Secondary outcomes: care barrier identification/resolution and 30-day ED revisit rates.

Main Results:

• The 30-day readmission rate decreased from 17.6% to 10.1% over four years (January 2020-June 2024).
• Nurses identified care barriers in 51% of encounters, notably appointment scheduling and medical supply acquisition.
• The 30-day ED revisit rate declined from 12.4% to 10.3%.

Conclusions:

• Leveraging nurses' full scope of practice effectively reduced readmissions in a high-risk pediatric population.
• The program's novel features included minimal exclusion criteria, integrated care teams, and a single point of contact for diverse needs.
• Successful replication at another hospital indicates the model's potential for broader implementation to reduce readmissions in complex patients.