A Quality Improvement Intervention Bundle to Reduce 30-Day Pediatric Readmissions

Abstract

Introduction: Pediatric hospital readmissions can represent gaps in care quality between discharge and follow-up, including social factors not typically addressed by hospitals. This study aimed to reduce the 30-day pediatric readmission rate on 2 general pediatric services through an intervention to enhance care spanning the hospital stay, discharge, and follow-up process. Methods: A multidisciplinary team developed an intervention bundle based on a needs assessment and evidence-based models of transitional care. The intervention included pre-discharge planning with a transition coordinator, screening and intervention for adverse social determinants of health (SDH), medication reconciliation after discharge, communication with the primary care provider, access to a hospital-based transition clinic, and access to a 24-hour direct telephone line staffed by hospital attending pediatricians. These were implemented sequentially from October 2013 to February 2017. The primary outcome was the readmission rate within 30 days of index discharge. The length of stay was a balancing measure. Results: During the intervention, the included services discharged 4,853 children. The pre-implementation readmission rate of 10.3% declined to 7.4% and remained stable during a 4-month post-intervention observation period. Among 1,394 families screened for adverse SDH, 48% reported and received assistance with ≥ 1 concern. The length of stay increased from 4.10 days in 2013 to 4.30 days in 2017. Conclusions: An intervention bundle, including SDH, was associated with a sustained reduction in readmission rates to 2 general pediatric services. Transitional care that addresses multiple domains of family need during a child’s health crisis can help reduce pediatric readmissions.

Identifying Children at Readmission Risk: At-Admission versus Traditional At-Discharge Readmission Prediction Model

“…History of prior hospital admissions, medical complexity, and non-acute post-discharge were found important features in predicting readmission, which is consistent with the previous investigations [22,24,28,49]. Although these factors are not easily modifiable for most conditions, comprehensive intervention strategies including better discharge planning (e.g., telephone call) and care coordination can mitigate the risk of pediatric readmission [13,31,50,51]. The findings of prior hospital visits in all three readmission models suggest that there might exist an unresolved system issue associated with the quality and clarity of discharge education and access to pediatric care for a certain patient population [36].…”

“…Compared to adult and Medicare readmission rates, pediatric readmission rates remained unchanged, and one study even reported a national increment (8.2%) between 2010 and 2016 [11,12]. Consequently, readmission reduction efforts gained significant recent attention among healthcare providers and professionals in devising ways of reducing readmission risk among children [13,14]. An improved readmission prediction model could help hospitals and healthcare providers to identify high-risk patient groups and, implement interventions in timely manner that reduce the risk of unplanned readmission within days of discharges.…”

“…Second, pediatric readmission prevention often requires multi-faceted programs including clinical and non-clinical interventions (e.g., targeting social determinants of health). These interventions often involve coordinated participation from various care providers, hospitals, and healthcare insurers (e.g., MCOs) [13]. The skewed readmission timing distribution coupled with the delay in health information exchange between healthcare providers might jeopardize multifactorial interventions plan due to limited time availability [29,30].…”

Feasibility of implementing systematic social needs assessment for children with medical complexity

“…When parents of CMC reported unmet social needs (i.e., “positive” response to ≥ 1 items in the SSNAC questionnaire), a standardized approach guided complex care program staff’s assessment and response. Assessment of reported unmet social needs was guided by a template developed in collaboration with long-standing partners from Legal Aid of North Carolina’s statewide Medical-Legal Partnership program [ 26 ]. The assessment template was tailored to correspond with SSNAC screening questions and provided staff with the following approaches for response to unmet social needs: (a) providing information to families about how to meet the social need; (b) directly assisting the family with their social need; and/or (c) making a direct referral to a community-based agency/partner with additional resources and expertise to meet the need.…”

Disease Severity and Risk Factors of 30-Day Hospital Readmission in Pediatric Hospitalizations for Pneumonia

“…Given the significance of hospital variation in readmissions, a systems-based approach may be necessary to prevent readmissions and improve hospital quality. Evidence suggests that discharge transition plans, follow-up care, and addressing adverse social determinants of health are useful interventions to reduce hospital readmission rates [44,45].…”