143 - Utilizing Telemedicine to Bridge the Hospital-to-Home Transition for Children with Medical Complexity

Poster Number: 143
Publication Number: 143.304

Rachel L. Haimowitz, Children's National Health System, Washington, DC, United States; Tina V. Halley, Children's National Health System, Silver Spring, MD, United States; Miriam Bloom, Children's National Health System, Washington, DC, United States; Michael Lotke, George Washington University School of Medicine and Health Sciences, Washington, DC, United States; Kavita Parikh, Children's National Health System, Washington DC, DC, United States

Background: Children with medical complexity (CMC) account for >60% of all children’s health care expenditures. Hospital-to-home (H2H) transition is often a high-risk period for CMC due to adjustments to medication regimen, involvement of multiple specialists, and complex care plans. Bear PATHS is a telemedicine program for recently discharged pediatric patients with the goal of bridging the H2H transition.

Objective: To evaluate the implementation and health outcomes of Bear PATHS program for CMC.

Design/Methods: Retrospective chart review of CMC discharged from a single tertiary care hospital and referred to Bear PATHS program between July 1 to December 22, 2021. CMC were defined as patients with multiple diagnoses or specialists and increased care coordination needs. Implementation outcomes included adoption (% eligible CMC referred to program) and feasibility (% completed telehealth follow-up), and health outcomes included identification of post-discharge issue (PDI) and healthcare utilization. PDI was defined as a concern that required additional steps to enact plan as intended or new issues. Unscheduled healthcare utilization included readmissions or unscheduled emergency room visit within 14 days. Descriptive statistics were conducted for data analysis.

Results: For program adoption, 136 CMC eligible of which 44 (32%) were referred to program. For program feasibility, of the 44 referred CMC, 27 (60%) completed their visit. Of those with completed visits, the majority of patients were 1-3 years and most commonly diagnosed with respiratory illness (Table). Among those with a completed encounter, 24 (89%) identified at least one PDI. Forty-one total PDI were identified, which were most often related to follow-up care (49%), medications (20%), and clinical status changes (17%) (Figure). Of the referred families (n=44), healthcare utilization did not vary significantly (p >0.05) between families who completed (n=27) and did not complete the Bear PATHS follow-up (n=17) (7% vs 0% for readmission respectively, and 11% vs 6% for ED encounter respectively).Conclusion(s): Telehealth is an important tool to aid in the H2H transition for CMC. Completion of post-discharge visits allows for identification of PDI and offers patients and providers the opportunity to troubleshoot issues in real-time. Future work will include increasing adoption and feasibility of the program for CMC, and evaluating health outcomes in a larger cohort.
Table. Sociodemographic information and primary diagnosis for CMC with completed Bear PATHS visits
Figure. PDI identified during telemedicine encounters for CMC