Improving the Transition From Hospital to Home for Clinically Complex Children

Danielle Altares Sarik; Mary Pat Winterhalter; Christina J. Calamaro


Pediatr Nurs. 2018;44(6):281-287. 

In This Article

Abstract and Introduction


Purpose: Clinically complex patients with multiple follow-up appointments and high acuity are at increased risk of poor outcomes as they transition from hospital to home. Patient navigation programs help patients and families through these transitions, but little exploration of the outcomes for the clinically complex pediatric population exist. This study describes the process of building a patient navigation program in a pediatric acute care setting, outlines the function of the patient navigation program, describes the pediatric population using these services, and evaluates the outcomes of the program.

Design/Methods: This retrospective review used data collected from January 1-December 31, 2015, from clinically complex pediatric patients age 0 to 20 years who received inpatient care at an East Coast pediatric hospital. Patient demographic characteristics and patient outcomes, including 30-day readmission and rate of "no show" at scheduled follow-up appointments, were analyzed.

Results: A total of 398 unique patients and 422 encounters were included in final analysis. The majority of patients were female (52.5%) and White (52.0%), with 6.5% of the patient population identifying Spanish as the primary language. On average, patients had 12 co-morbidities (SD: 10). Overall, 15.9% of patients were readmitted within 30 days of discharge, and there was a 12.9% "no show" rate for follow-up appointments.

Conclusions: The patient navigation program described represents a systematic improvement to streamline the transition of care process for clinically complex patients.

Practice Implications: Nurses play a critical role in improving the care of clinically complex children.


As an innovative trend in patient-centered care, the goal of patient navigation is to increase access to care, aid in diagnosis and treatment of multiple disease processes, and improve patient outcomes (Freeman, 2012; Pedersen & Hack, 2010). The concept of patient navigation was originally developed in the 1990s by Dr. Harold Freeman in order to address delays in treatment for socioeconomically disadvantaged individuals in New York City (McVay, 2014). Although many early patient navigator programs have used registered nurses (RNs), programs have since expanded to include a variety of licensed healthcare professionals and community lay workers (Hedlund et al., 2014; McVay, 2014; Pedersen & Hack, 2010). Evidence suggests that patient navigators have been able to effectively reduce barriers to appropriate surveillance and diagnostic resolution, including access and coordination concerns, especially for vulnerable or underserved populations (Baik, Gallo, & Wells, 2016; Freeman, 2012; Krok-Schoen, Oliveri, & Paskett, 2016; McVay, 2014; Natale-Pereira, Enard, Nevarez, & Jones, 2011; Schwaderer & Itano, 2007). However, no uniform template or consistent standards for program creation or navigator role exist (Pedersen & Hack, 2010), with structure and goals differing based on patient population and institutional needs.

Nationally, over 15% of U.S. children have special healthcare needs (Data Resource Center for Child & Adolescent Health, 2010). Of these children, 42.1% require increased medical, educational, and mental health services, with over 13% of families reporting 11 hours or more a week spent providing their children's care (Data Resource Center for Child & Adolescent Health, 2010). National trends point to a significant increase in the total number of children identified as medically complex. This may be attributed to increased survival rates of children born with congenital conditions or prematurely (Burns et al., 2010). Such medical complexity is often characterized by high health-care utilization and an increased need for care coordination (Simon, Mahant, & Cohen, 2012).

Additionally, clinical complexity may complicate the process of discharge from hospital to home, as multiple treatments and specialist appointments are needed (Boykova, 2016). Non-adherence to recommended appointment schedules is common, and may increase risk of readmission and morbidity. A recent study of readmission in Medicaid beneficiaries found that completion of follow-up appointments within seven days of discharge was associated with significant decreases in the risk of readmission in the clinically complex patient population (Jackson, Shahsahebi, Wedlake, & DuBard, 2015).

In the inpatient setting, use of a transition of care intervention to address concerns surrounding discharge teaching and planning may have the potential to improve care coordination for complex patients as well as decrease readmission (Auger, Kenyon, Feudtner, & Davis, 2014). In adult populations, patient navigation may be associated with improved care and health outcomes in patients undergoing treatment for cancer (Baik et al., 2016; Freeman, 2012; Krok-Schoen et al., 2016), among other life-threatening conditions (Metsch et al., 2016). However, no such studies currently exist in the pediatric population.

As patient navigation programs continue to evolve and spread (Hedlund et al., 2014), a gap exists in rigorous evaluation of the impact and effectiveness of such programs for the clinically complex pediatric population. The purpose of this article is to describe the integral role RN navigators play for clinically complex children as they transition from hospital to home in one acute care pediatric hospital. The authors aim to describe the process of building a patient navigation program in a pediatric acute care setting, outline the function of the patient navigation program, describe the pediatric population using these services, and evaluate the outcomes of the program, including 30-day readmission rates and follow-up appointment completion rates.