PC1237: Pediatric Post-discharge Telehealth Follow-up Program- a Pilot Project in the State of Qatar

Background: Discharging hospitalized patients and following them up is a complex process requiring essential documentation and coordination between multiple disciplines to ensure a safe transition. Multiple studies identified the post-discharge period as a time of vulnerability for patients, and an opportunity exists to improve patient care. Several risks are identified, coming from the lack of clear understanding of post-discharge instructions, including medication use, follow-up requirements, and the awareness of the new or worsening symptoms that might require urgent evaluation.
There is no standardized process in our pediatric inpatient units to ensure continued safe care while transitioning from inpatient settings to home and ambulatory care if needed. Therefore, the project piloted implementing a newly introduced follow-up telehealth program for post-discharge patients. The project aims to support the discharged patient in transitioning throughout the continuum of care. The project's primary outcomes are to evaluate the effect of the intervention on reducing the ED visits within 28 days for the same discharge diagnosis and the need for overbooking discharged patients in the clinics for follow-up.

Methods: A cross-sectional study was conducted in the pediatric inpatient units at Hamad General Hospital, Qatar, from September 2021 until February 2022. The project is divided into two phases, pre-and post-intervention. The project started with evaluating the current state by collecting pre-intervention data for ED visits post-discharge within 28 days for the same discharge diagnosis and the avoidable ambulatory overbookings. Then, patients were randomly selected over two months in the intervention phase to receive a phone follow-up by physicians within 48-72 hours after discharge. The physicians used a standardized checklist to go over the following: the understanding of the disease and the care plan, new concerns, medication reconciliation, review the warning signs and symptoms, when and where to seek medical advice if needed, and follow-up instructions.

Results: The total pre-intervention patients were 156, and 73 in the intervention group. Post-discharge ED visits with the same diagnosis were 14.7% within 28 days for the pre-intervention group. This improved to 6.8% after implementing the project. The need for overbooking discharged patients in the ambulatory clinics within 14 days of discharge also improved from 29.5% to 8.2%. (Figure 1). More than 90% of caregivers were very satisfied with the program and found it helpful in supporting the transition of care.

Conclusion: Implementing telehealth follow-up post-discharge programs can improve the transition of care and decrease the need for unnecessary ED and ambulatory clinic visits. In addition, patients and caregivers need to be supported beyond healthcare facilities. Technology is an effective tool in delivering convenient, timely, and patient and family-centered care.