Interdisciplinary team looks at ways to improve the hospital discharge process for pediatric patients

February 11, 2013

By Toni Cardarella

LaVerne Manos
Laverne Manos, DNP, RN

When a patient in the acute care pediatric unit at The University of Kansas Hospital is about to be discharged, a staff member talks with the parents or other caregiver about what should be done once they leave the hospital. Parents are told about the importance of a follow-up with the child's primary care provider, but it's not always clear whether that appointment is ever made or kept.

While the parent may nod in agreement during the discharge, there are distractions, particularly with the youngest patients. Maybe the caregiver just forgets to follow up with their child's primary care physician — or the family doesn't even have a primary care provider.

"No matter what we've tried, there are human complications that come into play, and we can't always make sure that follow-up primary care appointment happens," says LaVerne Manos, DNP, RN, a clinical instructor at the University of Kansas School of Nursing, and lead investigator on a $1 million, three-year grant from the U.S. Health Resources and Services Administration to develop a new interdisciplinary model for the transition care of patients discharged from the hospital's pediatrics unit.

What Manos hopes to do is identify ways a transition team can continue care of these young patients after they leave the hospital, including answer questions caregivers may have about proper care and prescriptions, and help them follow up with a primary care provider.

Manos and the project team will work with 75 to 80 staff members in the hospital's pediatric unit to create and implement a new interprofessional collaborative practice (ICAP) model. The ICAP model is a new model in health care, based on growing evidence that a patient-centered practice in a collaborative team environment can improve patient outcomes.  

Manos' goal for the grant is to establish a sustainable new sustainable collaborative care model  that will result in better follow-up care and reduce re-admittance rates, a model, Manos says, that could be adopted in other acute care settings at the hospital. 

Need for new model

Mitzi Scotten, M.D., an associate professor of pediatrics and director of the cystic fibrosis pediatrics clinic, says the need for an improved model is crystal clear.

"The more chaotic and busy a clinic gets, the more lapses there are going to be in the perfect discharge," says Scotten, who is medical coordinator on the Manos grant. Scotten says some of that has to do with communication among health professionals.

"It's not just a pediatric problem. It happens in other areas of health care as well. But we think it's critically important for someone to follow up with the kids, particularly the at-risk children, on things like their medications and their visit to a primary care doctor after they are discharged."

In this new model, a transition team of professionals from multiple disciplines focus on what is necessary in the discharge process for at-risk patients and their families between the time they leave the hospital and a follow-up visit to a primary care provider. The goal is to make it a less confusing time for patients and their families, with better communication before that last hour when the discharge process usually takes place, and focusing on providing a more team-oriented interprofessional approach to the transition care of patients.

The research project involves 25 nurses, eight attending physicians, 30 pediatric residents, a pharmacist, dietician, a discharge planner, an occupational therapist, physical therapist, respiratory therapist, behavior therapist and others who interact with patients on the unit.

Patient populations

About 30 percent of the approximately 900 pediatric patients treated at The University of Kansas Hospital don't have a medical home, so a follow-up after a hospital stay is often in an urgent care or other clinic where the health care professionals are unfamiliar with their case, Scotten says. The research project is focusing on ways to achieve better transition care for that population, for patients who have more than one diagnosis, and for patients from non-English speaking families.

Identifying effective communication tools for patients in those populations as well as with members of the transition team is crucial for a new care model, Manos says. The transition team will identify the best communication plan for each patient, whether that's text, email, cell phone or a grant-provided iPad.

The Health Resources and Services Administration, which is funding the study, is an agency of the U.S. Department of Health and Human Services and the primary federal agency for improving access to health care services for people who are uninsured, isolated, or medically vulnerable.

In addition to developing the model, Manos says the project will advance interprofessional education for the more than 280 students assigned to the hospital's pediatrics unit each year for their clinical experience. Every layer of the project is interprofessional, Manos says, beginning with the team from the KU Schools of Nursing, Medicine and Health Professions who wrote the grant and with each activity throughout the study.

However, she adds, "It's the patient who is at the center of the team."

Last modified: Mar 11, 2013