Improving care transitions for children with medical complexity

The transition from hospital to home is a stressful time for families of children with medical complexity. Providing care to more than 25,000 children with medical complexity, Gillette Children’s Specialty Healthcare is developing innovative strategies for improving care transitions for those with the highest complexity. Gillette nurse leaders Rhonda Cady, PhD, RN, and Kari Kubiatowicz, BSN, RN, have been collaborating with faculty and students in the center to improve systems of care for children and their families during hospitalization discharge.

With Cady and Kubiatowicz, Doctor of Nursing Practice student Megan Antolick, BSN, RN, recently co-led a project to implement a tool during the inpatient stay that helps families identify goals for their child during the post-discharge period. The team implemented the Post-Hospitalization Action Grid, developed by Boston Children’s Hospital, and used this to standardize family involvement in goal-setting with the inpatient care manager during their stay. Following the project pilot, staff indicated that the tool helped them prioritize care and coordinate with Gillette outpatient specialists during the transition from hospital to home. Common themes in family goals included finding support in communicating new care needs to providers in primary care and school, and addressing home nursing support gaps.

As the inpatient care manager who facilitated the goal planning with families in this project, Kubiatowicz noted that this project gave her the opportunity to pair the team’s goals with what matters most to patients. “The Action Grid brought care management from the background to the patients and families directly, which we loved,” she said. The project continues with ongoing evaluation and is being implemented in additional areas of the organization.