Study Summary

Children with medical complexity are frequently hospitalized and commonly face difficulties when they are discharged from the hospital. The additional care these children require after discharge (e.g., new medications, follow-up appointments) adds to an already complex burden of care and often problems arise after discharge. Caretakers of the child may face uncertainty of who to call when these problems arise—the hospital or their primary care provider. Given the challenges with discharge transition, there is a need to compare the effectiveness of interventions to support transition from hospital to home that are family-centered and fit with the complexity of chronic illness and life.

The Garnering Effective Telehealth 2 Help Optimize Multidisciplinary team Engagement (GET2HOME) intervention has 3 parts:

  1. a pre-discharge telehealth huddle on Microsoft Teams which allows families to speak with both the hospital team and their outpatient care team (physicians, home care nurses, pharmacists) before they leave the hospital,

  2. a discharge task tracker which allows families in the hospital to know which tasks are completed and which tasks still need to be completed before discharge, and

  3. a post-discharge telehealth huddle on Microsoft Teams which allows families to reconnect with the hospital team and their outpatient care team a few days after discharge.

We have successfully put the GET2HOME intervention into routine care at our hospital with families, physicians, nurses, and pharmacists rating the intervention positively. In our first aim we will compare the effectiveness of the multifaceted telehealth intervention to standard hospital-based care coordination through a pragmatic randomized controlled trial of children with complex chronic disease on:

  1. 30-day urgent healthcare reutilization outcomes (readmission, emergency department visits, and urgent care visits);

  2. Patient- and family-reported outcomes of transition effectiveness, 7- and 30-day quality of life and return to baseline health status and baseline routines; and

  3. Patient- and family-reported outcomes of 60- and 90-day quality of life and return to baseline status.

We hypothesize that the GET2HOME intervention, as compared to standard hospital-based care coordination, will reduce 30-day reutilization and improve patient- and family-reported outcomes, reducing time to return to baseline status.