330 - Caregiver Experience and Self-efficacy Related to an Innovative Virtual Transition of Care Support Program

Poster Number: 330
Publication Number: 330.26

Background: Children with medical complexity have challenging hospital-to-home transitions, with significant potential for difficulty implementing the post-discharge care plan. Associated gaps and barriers to post-discharge care lead not only to higher healthcare utilization but also decreased home caregiver efficacy and adverse psychosocial impacts on patients/families.

Objective: To assess parent/caregiver perceptions of a novel virtual nursing intervention developed to improve post-discharge care transitions for children with high medical complexity (length of stay ≥7 days, ≥1 home health order, and ≥1 inpatient/ED encounter in the past year or need for ICU care) at two hospitals.

Design/Methods: The virtual nursing intervention consisted of 1) pre-discharge chart review and connections by the tele-nurse with the family and inpatient teams, 2) an in-home video visit 3-7 days after discharge with the patient, parent(s) and tele-nurse, 3) as-needed virtual contacts between the tele-nurse & parent(s) up to 30 days post-discharge, and 4) as-needed hand-offs to outpatient care coordinators, PCPs, etc. REDCapTM surveys were sent to enrolled families via email or text to assess the perceived value of the intervention, with explanatory phone calls before sending the survey to increase the response rate. The survey was available in English and Spanish with results de-identified.

Results: Surveys were completed by 56 parents/caregivers (response rate 32%) with 46% reporting that the program helped them avoid a readmission, 43% saying that it helped avoid an ED/urgent care visit and 52% saying that it helped avoid an after-hours phone call. As shown in Figures 1 and 2, parent-reported comfort with post-discharge home management also substantially improved with this intervention, with the predominant barriers to care associated with home health/ medical equipment orders and discharge medications. Evaluation of open-ended question responses (Table 1) also suggest that this program generally increased parent comfort with post-discharge care and provided specific benefits beyond usual discharge period support.

Conclusion(s): These results indicate that a nurse-led virtual transition of care intervention targeted at children with high medical complexity can improve post-discharge healthcare utilization from the parent/caregiver perspective, increase parent comfort with home management and mitigate barriers to care. Next steps include pairing these survey data with health system markers of efficiency and efficacy for this program and increasing enrollment capacity.