P0396 - Improving transitions of care for medically complex pediatric cardiology patients through a physician home visit program: A quality improvement project

Background:
Patients with congenital heart disease who are discharged following planned surgery or an acute illness are at high risk for re-admission within 14 days after discharge, especially if they have other medical devices such as gastric tubes and tracheostomy.
METHODLOGY:
Our goal was to decrease the 14 day re-admission rate in patients with congenital heart disease through home visits and close follow up conducted by a physician provider. Pediatric cardiology patients who had multiple admissions, defined to be at least two over a two month span, were selected for inclusion. Visits were generally performed within one week of discharge with the permission of the guardians, and generally consisted of medication reconciliation, including reviewing the containers of medications at the home and a brief medical examination to address any acute issues, which included weight checks or parental concerns. Following the visit, the patients were continued to be followed, with follow up phone calls and coordination with other specialists associated with their care.
PDSA methodology was utilized. The first cycle consisted of home visits with three patients. Based on these experiences, a checklist was developed, with an emphasis on medication reconciliation, and was utilized for the second cycle. The second PDSA cycle included patients with more medical complexity, including tracheostomy. The third PDSA cycle is ongoing, and consists of provider involvement prior to discharge of patient in order to facilitate care.
DISCUSSION/

Results:
In total, 9 home visits were done for 7 patients. 6 of the patients were selected due to frequent re-admissions while one was selected from the outpatient setting due to poor outpatient follow up. Two patients had additional home visits due to concerns regarding weight gain. 6 of 7 patients were less than 2 years of age, while one was 11 years old. 6 of 7 patients had gastric tubes, while 3 of 7 had both gastric tubes and tracheostomy.

In 5 of the 6 visits done after hospitalization, patients had significant cardiac medication reconciliation discrepancies that were corrected. One patient has not been re-admitted following the home visit while another patient was admitted based on findings from the home visit, and has not been re-admitted since. The other 4 patients who had a home visit were re-admitted on average 22 days after their previous admission whereas where as previously they had been re-admitted on average 6 days after the previous admission. The one outpatient had significant improvement in ambulatory follow up after the home visit.

Conclusion:
A physician home visiting program may be effective in reducing medical reconciliation discrepancies and re-admission rates for medically and socially complex pediatric cardiology patients. More home visits are planned to see if this practice would be effective in other high risk patients.