Introduction: Family-centered communication at transitions of care can decrease readmissions and costs for children with medical complexity (CMC). The purpose of this quality improvement project was to improve the communication of postdischarge goals for CMC in a pediatric specialty setting. Methods: We used process improvement strategies to implement a Post-Hospitalization Action Grid (PHAG) and a standardized discharge handoff process. Families of hospitalized CMC at high risk for readmission received the pilot intervention over 3 months. Indicators of successful implementation included rates of use of the PHAG, perceptions of integrated care, and usability of the tool. Results: The PHAG was implemented with 11 of 40 eligible CMC families. Most staff agreed that the new process could improve the communication of postdischarge goals; however, perceptions of integrated care in the organization changed only minimally. Discussion: The PHAG facilitates family engagement in discharge transitions but requires organizational investment of resources to implement.
Bibliographical noteFunding Information:
The authors would like to thank Karen Brill, the Vice President of Patient Care at this organization, for her overall support of nurse-led quality improvement and research initiatives.
© 2019 National Association of Pediatric Nurse Practitioners
- Children with medical complexity
- family-centered care
- transitions of care
PubMed: MeSH publication types
- Journal Article