Decreasing Readmissions in Medically Complex Children

Practice Problem: There was a report of an existing practice problem of increased 30-day readmission rates in medically complex children at an outpatient clinic within an extensive hospital system. Hospital readmissions can cause clinical, social, and financial burdens to the patients and their families and thus reflected a need for interventions to reduce readmissions. PICOT: The PICOT question that guided this change project: In medically complex pediatric patients ages 0-17, what is the effect of a discharge intervention bundle in reducing all-cause 30day hospital readmissions compared to current practice within an 8-week timeframe? Evidence: The literature revealed 18 pertinent studies that fit the inclusion and exclusion criteria that promoted a discharge intervention bundle. The themes within the evidence included postdischarge telephone calls, follow-up appointments, medication reconciliation, and education with teach-back to reduce overall readmission rates. Intervention: The evidence-based intervention utilized the bundle of post-discharge telephone calls within 72 hours, follow up appointments within 7 days, and medication reconciliation with education and teach-back through in-person and virtual care. The clinic nurses championed the intervention and tracked all the data using a check sheet. Outcome: Evaluation of the outcome measures confirmed a decrease in all-cause 30-day readmissions from 23% to 14.5% within the project timeframe. Implications of the findings support the existing evidence for implementing a multifaceted bundle to decrease readmissions. Conclusion: The evidence-based change project decreased all-cause 30-day readmissions rates. The results of the project proved that implementing consistent discharge standards in medically complex children helped guide medical staff, improved patient outcomes, saved costs to the organization, and reduced 30-day all-cause hospital readmissions. DECREASING PEDIATRIC READMISSIONS 4 Decreasing Readmissions in Medically Complex Children All-cause hospital readmissions are considered a measure of quality in organizations across the country (Shermont et al., 2016). In the United States, the Affordable Care Act (ACA) was established to improve quality of care by supporting transitional care services, decreasing preventable hospital readmissions, and improving healthcare savings (Verhaegh et al., 2014). One program that supports the ACA is the Hospital Readmissions Reduction Program (HRRP), a value-based purchasing program that links the quality of care to payment based on readmission rates (CMS, n.d.). The program focuses on adult patients who are readmitted to the hospital with specific diagnoses such as myocardial infarction, heart failure, and chronic obstructive pulmonary disease. In recent years there has been an increased effort to reduce readmissions not only in adults, but also in medically complex children by implementing discharge interventions post hospitalization (Brittan et al., 2015; Coller et al., 2015; Coller et al., 2017; Finlayson et al.,2018). According to Coller et al. (2017), medically complex children were only 1% of the pediatric population but used a consumed third of all child healthcare spending (p. 381). Children with medical complexity often have multiple medical problems which require specialists, equipment, and high acuity of care (Stephens et al., 2017). This puts them at a greater risk of hospitalization, readmission and undesirable outcomes (Brittan et al., 2015). The purpose of this project was to implement a post-hospitalization discharge bundle that includes telephonic followup, outpatient or virtual follow-up appointments, medication reconciliation, and the teach-back method with patients and families to reduce all-cause 30-day hospital readmissions. The Department of Health and Human Services (HHS, 2020) has made policy changes during the COVID-19 emergency to allow health care providers the opportunity to use HIPAA-compliant DECREASING PEDIATRIC READMISSIONS 5 video communication such as Doxy.me to perform virtual visits for patients who cannot be seen in person. These virtual visits were utilized for the project as needed. Significance of the Practice Problem According to Bailey et al. (2019), the national rate of 30-day all-cause readmissions of patients older than one year of age in 2016 was 12.3% for Medicaid, 10.8% for private insurance, and 7.9% for uninsured (p.3). The average cost of all-cause 30-day hospital readmissions for all diagnoses was $12,500 (p.7), while the average cost for children with congenital malformations was as high as $19,000 per readmission (p.8). Furthermore, at the facility this project was conducted, the 2019 overall all-age, all-cause 30-day readmission rate was 15.3% (Hospital Care Data, n.d.). This was consistent with the national average of 15% (Robert Wood Johnson Foundation [RWJF], 2013). Based on data from the Children’s Hospital Association, the organization pediatric overall 30-day, all-cause readmission rate from 2019 was 10%, slightly lower than the national average of 11% (J. Mahla, personal communication, January 31, 2020). The Chronic Complex Clinics (CCC) overall 30-day, all-cause readmission rate from 2019 was 23%, much higher than the national average of 11% (B. Bavinger, personal communication, February 11, 2020). Though these statistics do not show the full impact of readmissions on the organization, clients, and their families, they revealed the need for further implementation of interventions to reduce overall hospital readmissions. Hospital readmissions cause clinical, social and financial burdens that are significant to the patient and family due to the cost of care, lost time at work and school, developmental effects for chronically ill children, and increased potential for hospital-acquired infections (Nakamura et al., 2014). Comorbidities, race, socioeconomic factors, access to healthcare, and chronic conditions are all factors that increase the risk of readmission (Flanagan et al., 2017). Some legal DECREASING PEDIATRIC READMISSIONS 6 and ethical factors considered were how prolonged hospitalizations and readmissions link to patient stress, poor results, and increased mortality (Mindru et al., 2016; Rosman et al., 2015). Initiation of discharge interventions to improve transitions and prevent pediatric hospital readmissions were essential for medically complex children and their families.