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[Home care of children with chronic diseases: cooperation between hospital and home care workers]
Insights
This study highlights the challenges and strategies for managing newborns with chronic conditions post-discharge. Effective multidisciplinary team integration and parent training are crucial for successful home care transitions.
Area of Science:
- Neonatal care
- Pediatric discharge planning
Background:
- Managing newborns with chronic conditions post-discharge requires specialized care.
- Frequent readmissions and complex care needs present significant challenges for healthcare teams.
Observation:
- The Trento hospital's Neonatal Care ward implemented a comprehensive discharge program.
- This program includes multidisciplinary team meetings, parent training, and home-care coordination.
- A home-hospital program was introduced in 1995 as an alternative to hospitalization.
Findings:
- A case study of Ahmed illustrates challenges, including language barriers and severe health issues.
- Care plans are individualized, focusing on the newborn's needs and family resources.
- Data from 1991-1995 show patient problems, interventions, and resource allocation.
Implications:
- Close integration among healthcare team members is essential for optimal patient outcomes.
- Tailored discharge programs improve the transition of care for high-risk newborns.
- Addressing parental needs, such as language support, is vital for successful home management.
Abstract:
Newborns with chronic problems needing continuous and special care even after discharge are not very frequent but represent a challenge for the caring team. The discharge program of the Neonatal Care ward of Trento hospital includes several steps: discharge meetings of teh neonatologist and the nurse responsible for the child, the head nurse, the psychologist and, when possible, the social worker; a training program for the parents; the coordination of communications and interventions of the home-care nurses and a detailed post-discharge planning. From 1995 a home-hospital program, as an alternative to the hospital admission was started. To describe how the team functions and stress the need of a close integration among the team members, the case of Ahmed is presented. This case faced the team with several challenges, because of the lack of parent's knowledge of the italian language and of the severity of the child's problems. Every care plan is developed building on newborn's needs and patients' resources. Data on the patients-problems dealt with from 1991 to 1995 and the interventions and resources needed are presented.