The Southern Nevada Transitional Care Program for Children with Special Health Care Needs (CSHCN)) is a new project intended to increase access to high quality, comprehensive, home health services for severely disabled children in Clark County in Southern Nevada. The project will design a Transitional Care Program encompassing outreach, assessment, and an individually tailored array of comprehensive and coordinated home health and support services.
The project's goal is to increase access to high quality, home care services for CSHCN transitioning from hospital to home to improve care, reduce costs, and produce better health outcomes. This project will employ both process and outcome evaluation activities. Objectives are: 1) To facilitate an innovative, improved hospital discharge planning process for CSHCN; 2) To implement a comprehensive home health program incorporating best practices; and, 3) To collect, analyze and report data relative to improved care, reduced costs and improved outcomes for enrolled CSHCN.
The program will integrate continuity of care goals, incorporating Bright Futures and medical home practice principles, to increase access to home health services for CSHCN in Clark County, Nevada. There is a critical need to improve access to comprehensive home health services for children with special health care needs and their caregivers in Clark County. A continuing lack of consistent and organized discharge processes at area hospitals often prevents CSHCN from being able to access home health services that can improve short and long term health outcomes, reduce frequency of hospital readmissions, and generate cost savings for families and hospitals. Over 72% of Nevada's 2.7 million residents live in Clark County; 25%, or over 500,000, are children under age18. Estimates are that 12% to 15% of these children, or as many as 75,000, meet the definition of a CSHCN. Nearly 30% of these children are identified as having an unmet need for health care services. Due to continuing recession effects, discharge planners in the eight area hospitals that provide maternity care remain understaffed with large caseloads. Poor discharge planning results in CSHCN not receiving the home care and support services that are needed. The population to be served in this project is Children with Special Health Care Needs who are discharged from local hospitals and are in need of home care services.
Data collection, analysis, and overall evaluation will be conducted by Amanda Haboush-Deloye, Ph.D., a senior Research Analyst at the Nevada Institute for Children's Research and Policy at the University of Nevada, Las Vegas. Project findings will be widely disseminated to state and local policy makers with recommendations for actions needed to improve access to care for CSHCN in Clark County and throughout Nevada.