Interagency Collaboration to Improve Home Care of Children with Medical Complexity

BACKGROUND: Children with medical complexity (CMC) have higher hospitalizations and readmissions compared to children without medical complexity. While CMC were institutionalized in the past increasingly they are now cared for at home. Caring for individuals with disabilities at home and not congregate care settings is a Healthy People 2020 Objective. Home health nursing especially good-quality care is important for CMC. The current proposal is aimed at improving care delivery for CMC at home by developing a care model that features ongoing collaboration between home health nurses (HHN) primary-care physicians (PCP) and clinicians of the complex care program of a tertiary-care children's hospital. Our study directly addresses Maternal and Child Health Bureau (MCHB) Strategic Research Issues 1 2 and 4. OBJECTIVES: The specific aims of this study are to: develop and implement a model of care (Icollab) in which communication with HHN and PCP is maintained and clinical support is provided to HHN; evaluate whether Icollab is effective in reducing healthcare utilization of CMC and caregiver burden; and assess caregiver satisfaction in home health care HHN retention and collaboration with other healthcare providers. METHODS: We will develop and implement an intervention model (Icollab) that includes: (1) maintaining communication with HHN and PCP about clinical information about CMC and (2) providing clinical support to HHN. We will create an interdisciplinary intervention team in our children's hospital consisting of a pediatrician and a nurse. The intervention team will ensure communication with HHN and PCP by communicating clinical information (recommendations from clinic visits and ER visits and discharge summary). The team will provide clinical support to HHN via collaborative meetings and availability as a resource for clinical problem-solving with HHN. We will recruit 110 CMC discharged home on private-duty nursing services into this randomized trial. The intervention group (n=55) will receive the Icollab intervention for 6 months post-discharge from the hospital in addition to usual care. Children in the control group (n=55) will receive only usual care. Outcome measures will include healthcare utilization metrics (hospitalization rates ER visit rates and days to readmission) caregiver burden and caregiver satisfaction with home health care HHN retention and HHN collaboration with other healthcare providers. We hypothesize that Icollab will reduce healthcare utilization and caregiver burden and improve caregiver satisfaction with home health care increase HHN retention and increase HHN collaboration with other healthcare providers. We will perform a systematic process evaluation of the implementation of the intervention and standardize the Icollab model. IMPLICATIONS: How healthcare delivery of CMC can be structured to avoid fragmentation - especially surrounding transition across clinical settings - is an understudied area. Our results will address this gap by providing a critically needed evidence-base for interventions to improve the quality of healthcare delivery for CMC. Our study is aligned with the goals of MCHB.