Easing the Transition from Hospital to Home with Telehealth Nursing

Background: Transitions from the hospital to home for medically-complex children are multi-faceted and complicated, resulting in a higher potential for care failures and care gaps after discharge than the average population. This can lead to unplanned emergency use and readmissions which contribute to the high cost of care for these children. By providing telehealth nurse access for medically complex patients during the 30-day post-discharge period, we sought to identify and address challenges impacting implementation of the home care plan. The end goal is to determine if mitigation of these challenges will improve preventable emergency use and readmission rates.

Methods: Eligible patients, identified by an electronic medical record (EMR) registry, are those admitted at our academic children’s hospital with ≥1 home health order, length of stay ≥7 days, ≥1 hospitalization or emergency department encounter in the prior 12 months, and assignment to an inpatient team participating in the project. These factors were selected based on pre-implementation data showing that they are associated with higher readmission rates. The intervention model consists of a pre-discharge meeting between the telehealth nurse and family, 1 in-home telehealth visit within 7 days after discharge, and additional contacts as needed during the first 30 days. EMR data, case feedback and biweekly project team meetings were used to iteratively enhance the model and effectively reach patients.

Results: Process mapping work resulted in the creation of a patient eligibility registry, new EMR flowsheets to track telehealth visits and their outcomes, and a more efficient method for scheduling and initiating nurse telehealth visits. In 2020, 54.2% of the telehealth encounters (64 of 118 encounters) identified barriers to implementing the discharge plan or a new post-discharge problem, with 100% of these addressed by the telehealth nurse. Common themes included prescription issues, medication administration questions, coordination of outpatient services, and difficulty obtaining home health supplies. The 30-day readmission rate for the intervention cohort was 16.0%, compared to 17.7% of similarly-complex patients not enrolled in the program. Many patients lived outside of the hospital's metropolitan area and could not have been served with an in-person/ non-virtual model.

Conclusion: This project demonstrates that nurse telehealth visits are valuable for bridging transition of care gaps, by bringing to light challenges not apparent during the hospitalization and closing the loop on services recommended during the inpatient stay. Other benefits include the identification of post-discharge care barriers with resulting opportunities to enhance care coordination for all patients, and telehealth process improvements that are being leveraged across the healthcare system. Next steps include increasing enrollment of eligible patients, ongoing data analysis and process improvement as new patients are enrolled, financial evaluation of the program, and process optimization based on family survey feedback.