Are pediatric patients being discharged before they’re ready?

Parents' perceptions of their child's health are a good predictor of hospital readmission.Because unplanned hospital readmissions put patients at risk, burden families and add to the cost of health care, many medical professionals are taking steps to reduce them. To push the effort, new Centers for Medicare & Medicaid Services (CMS) rules impose escalating penalties that decrease a hospital’s Medicare payments if patients are readmitted within 30 days of discharge.

Last week on Vector, we reported research suggesting that some readmissions may be incorrectly classified as preventable (and thereby penalized), particularly at pediatric hospitals. But what steps can be taken to reduce the number of truly preventable readmissions?

One step, highlighted here last week, is making post-discharge communications much simpler with texts and emails. But how can hospitals make sure their patients are ready to go home? A new study published in the International Journal for Quality in Health Care finds that in pediatric settings, the answers may be found in parents’ perceptions, which turn out to be good predictors of an unplanned readmission.

The researchers, led by Jay Berry, MD, a pediatrician in the Complex Care Service at Boston Children’s Hospital, interviewed a random sample of 348 parents of children who were readmitted to the hospital. Of the children studied, 26 percent had more than one complex chronic condition and 32 percent used durable medical equipment. Overall, 8 percent of the children were readmitted within 30 days of being sent home.

A deeper look at these families revealed that the likelihood of readmission was linked to parent perceptions of their child’s health status at the time of discharge: how comfortable the parents felt in contacting their child’s pediatrician and how well the families understood how to manage their child’s health. Of these perceptions, the families’ take on their child’s health was the most important; children had a lower readmission rate when their parents strongly agreed with the statement, “I felt that my child was healthy enough to leave the hospital.”

Addressing parental concerns of their child’s health before discharge could go a long way toward reducing the number of unplanned readmissions, Berry says. Most inpatient clinicians probably feel that they have done their jobs, yet some parents in the study had concerns about their child’s health at discharge even though they had already been sent home.

How does this happen? In some cases, parents “may have assessed their child’s health differently prior to discharge because they were rushed or eager to leave the hospital,” the researchers write. In other cases, “providers may have had difficulty assessing the health of children with complex illness at discharge because these children might not be able to return to ‘normal’ baseline status.”

Given the factors that can come into play at discharge, Richard Antonelli, MD, medical director of Integrated Care at Boston Children’s and a co-author on the study, emphasizes the importance of incorporating the families’ view into the decision-making process. He echoes the study’s call for family involvement in initiatives to improve the discharge process to assure that it is responsive to family needs and allows for successful care transitions.

The report’s findings will inform the creation of a standardized set of patient- and family-facing tools to help identify which children are at risk for unsuccessful transitions from the hospital, mitigate the factors that might hinder success and prepare the families for what to expect during and after hospital discharge. The next phase of the work will entail testing these tools and incorporating them into standard practice, Berry says.

Antonelli sees this as a key opportunity not just for patient engagement, but for quality improvement. “What better way for us to improve outcomes for the patients and families we serve than to include them as partners?” he asks.