Home Health Care Availability and Discharge Delays in Children With Medical Complexity

Abstract

BACKGROUND: An increasing proportion of pediatric hospital days are attributed to technologydependent children. The impact that a pediatric home care nursing (HCN) shortage has on increasing length of hospital stay and readmissions in this population is not well documented. METHODS: We conducted a 12-month multisite prospective study of children with medical complexity discharging with home health. We studied the following 2 cohorts: new patients discharging for the first time to home nursing and existing patients discharging from the hospital to previously established home nursing. A modified delay tool was used to categorize causes, delayed discharge (DD) days, and unplanned 90-day readmissions. RESULTS: DD occurred in 68.5% of 54 new patients and 9.2% of 131 existing patients. Lack of HCN was the most frequent cause of DD, increasing costs and directly accounting for an average length of stay increase of 53.9 days (range: 4-204) and 35.7 days (3-63) for new and existing patients, respectively. Of 1582 DDs, 1454 (91.9%) were directly attributed to lack of HCN availability. DD was associated with younger age and tracheostomy. Unplanned 90-day readmissions were due to medical setbacks (96.7% of cases) and occurred in 53.7% and 45.0% of new and existing patients, respectively. CONCLUSIONS: DD and related costs are primarily associated with shortage of HCN and predominantly affect patients new to HCN. Medical setbacks are the most common causes of unplanned 90-day readmissions. Increasing the availability of home care nurses or postacute care facilities could reduce costly hospital length of stay.

Home nursing for children with home mechanical ventilation in the United States: Key informant perspectives

“…Providers described an overall severe deficiency in the workforce, particularly nurses with expertise in pediatrics and ventilator management. The American Academy of Pediatrics Section on Home Care, Committee on Child Health Financing's policy statement describes that, “Payments for home health care services should be sufficient to maintain an adequate provider work force with the pediatric‐specific expertise and skills to care for children with medical complexity or developmental disability.” 2 Despite strong support from pediatric leadership, we suspect that the largest limiting factor toward successful implementation of universal standards of care is severe resource scarcity which has been described as impacting care in several recent works 4,12,13 . It would be predictably impossible to provide 24‐h caregiving in a setting without ample home nursing support, and our study suggests that this is the case in the vast majority of regions.…”

“…In some regions, transitional care centers are utilized as intermediate models of care to prepare for complex discharges and can help to appropriately focus on transition readiness while liberating finite acute care beds 32 . However, despite the complexity of discharge and parental desire for tailored discharge teaching, 33 few transition‐focused centers exist and efficient discharge is often limited by home healthcare shortages 12,34 …”

The Moral Imperative of Home Health Care for Children: Beyond the Financial Case

“…The magnitude of the delayed discharges described by Maynard et al 3 is unacceptable. Children and families thrive in home environments with access to community resources and activities.…”

“…This has not been well studied, but a number of factors likely contribute to a shortage of personnel, all of which lead to home care services being an undervalued and thus underused medical service. As described by Maynard et al, 3 there is a shortage of qualified nurses with appropriate pediatric experience. The typical salary of a home care nurse is significantly lower than that of a nurse working in the inpatient setting.…”

“…2 CMC typically acquire the need for home care services during acute hospitalization, and arranging home care services is a vital part of discharge planning. In their article "Home Health Care Availability and Discharge Delays in Children With Medical Complexity, " Maynard et al 3 report the extent to which discharges of CMC were delayed primarily because of the unavailability of home care nursing (HCN). Among 185 CMC discharged from 4 children's hospitals in Minnesota, discharge was delayed 1582 days, the majority of which (>90%) were attributable to the unavailability of HCN, at an additional cost estimated at $5.72 million.…”