The inpatient setting as an opportunity to assess healthcare transition

Most health care transition (HCT) interventions target the outpatient setting. However, hospitalization may serve as an additional touchpoint to identify patients who require transition services.

At a large urban pediatric hospital, inpatient care coordinators (CC) complete an EMR-based general assessment that includes an optional HCT screening item. Baseline data showed low item completion. The project aimed to increase the proportion of eligible admissions among patients aged ≥ 16 years with documented completion of the HCT screening item by 50% from the pre-intervention baseline within 6 months.

Using the Define, Measure, Analyze, Design, and Verify (DMADV) framework, monthly item completion among eligible admissions aged ≥ 16 years was tracked in a run chart. Training outcomes were assessed with anonymous before and after session surveys.

Stakeholders and process owners co-developed a standardized workflow that defined an age threshold for universal inpatient HCT screening (≥16 years) and delivered an interactive CC training session on HCT concepts and CC roles in HCT.

Documented completion increased from 44.0% in October 2024-74.4% in May 2025 (p = 0.004). In the training evaluation, after-session survey respondents reported higher self-reported confidence across survey items.

Implementing standardized inpatient workflow and CC education was associated with improved documented completion of an EMR HCT screening item among eligible admissions for patients 16 years and older. The results support the feasibility of using hospitalization as an additional touchpoint to document HCT status. Future phases will focus on implementing structural EMR changes and developing referral pathways between inpatient and outpatient CC to support patients who need additional HCT support.