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Improving post-discharge outcomes by facilitating family-centered transitions from hospital to home
Investigator (PI): Shah, Samir
Performing Organization (PO): (Current): Cincinnati Children's Hospital Medical Center, Division of Hospital Medicine / (513) 636-4200
Supporting Agency (SA): Patient-Centered Outcomes Research Institute (PCORI)
Initial Year: 2014
Final Year: 2018
Record Source/Award ID: PCORI/IHS-1306-00811
Funding: Total Award Amount: $2,267,361
Award Type: Contract
Award Information: PCORI: More information and project results (when completed)
Number of Subjects: 1600
Abstract: Background: The transition from the hospital to home is a vulnerable time for patients and families. Many families find that they lack confidence in caring for their child at home safely. One in five families have reported that they struggle with this transition, and have a hard time navigating between the hospital, home, and primary care follow-up, especially if the hospital stay involved a new diagnosis or treatment plan. While there is a high readmission rate for adults, this rate is lower for children. Therefore, there may be other transition outcomes that patients and families find meaningful. Objectives: The goal of our study is to improve the outcomes of inpatient to outpatient transitions for hospitalized children and their families. The main focus of our study is to test if nurse home visits designed to address family-identified barriers will improve outcomes that patients and families find meaningful. We will test this idea in three steps. We want to develop an understanding of patient and family perspectives on transitions by having families identify barriers they've experienced and define outcomes of transitions that are most meaningful to them. We will use ideas from our first step to improve an ongoing nurse home visit program by testing small changes in the process to see what will benefit families most in the visits. We will ask families to participate in a study, and families will either receive normal care, or a nurse home visit. We will determine if the program is successful in helping families by (1) asking families questions after they are discharged from the hospital about unplanned trips to the hospital, emergency room, or doctor, as well as other questions that will be developed based on families' thoughts in our first step; and (2) comparing the answers to these questions between the families that received standard-of-care and those that received a nurse home visit. Methods: In our first step, families will participate in focus groups and will discuss what aspects of the transition from hospital to home were most difficult for them. In our second step, we will use the feedback from the first step to try to improve a nurse home visit program to best address transition issues that families identified. In our third step, families will either receive standard-of-care or a nurse home visit. All families will be called after discharge to see if they had to return to the hospital, emergency room, or doctor, as well as to ask some questions that families in the first step identified as important. Patient outcomes: We are testing to see if a nurse home visit provided after discharge from the hospital makes families more comfortable with caring for their child, and improves other outcomes. We believe that getting input from families in the first two steps of our study will help make the visits the best for families. If the visits are successful, we hope that other hospitals would try this program to improve outcomes. More on this project: (1) Tubbs-Cooley HL, Pickler RH, Simmons JM, Auger KA, Beck AF, Sauers-Ford HS, Sucharew H, Solan LG, White CM, Sherman SN, Statile AM, Shah SS; H2O Study Group. Testing a post-discharge nurse-led transitional home visit in acute care pediatrics: the Hospital-To-Home Outcomes (H2O) study protocol. J Adv Nurs. 2016 Apr;72(4):915-25. doi: 10.1111/jan.12882. PubMed PMID: 26817441. (2) Solan LG, Beck AF, Brunswick SA, Sauers HS, Wade-Murphy S, Simmons JM, Shah SS, Sherman SN; H2O Study Group. The Family Perspective on Hospital to Home Transitions: A Qualitative Study. Pediatrics. 2015 Dec;136(6):e1539-49. doi: 10.1542/peds.2015-2098. PubMed PMID: 26620060. (3) H.S. Sauers-Ford, J.M. Simmons, S.S. Shah; H2O Study Team. Strategies to Engage Stakeholders in Research to Improve Acute Care Delivery. Journal of Hospital Medicine. 2016 Feb;11(2):123-5. doi: 10.1002/jhm.2492. (4) In Care Transitions, a Chance to Make or Break Patients' Recovery--A narrative on what happens when patients are harmed by poorly executed transitions between health care settings.
MeSH Terms:
  • Child
  • * Continuity of Patient Care
  • Family
  • Family Health
  • Focus Groups
  • Home Care Services
  • Hospitalization
  • Humans
  • Inpatients
  • * Outcome Assessment, Health Care
  • Outpatients
  • * Patient Discharge
  • Patient Participation
  • Patient Preference
  • Patient Readmission
  • Pediatrics /organization & administration
Country: United States
State: Ohio
Zip Code: 45229
UI: 20143564
CTgovId: NCT02081846
Project Status: Completed
Record History: ('2017: Project extended to 2018.',)