Evaluating the Impact of a Pediatric Inpatient Social Care Program in a Community Hospital.

OBJECTIVES: To evaluate the impact of implementing a stakeholder-informed social risk screening and social service referral system in a community hospital setting. METHODS: We implemented a stakeholder-informed social care program at a community hospital in April 2022. The evaluation included patients aged 0 to 17 years admitted to the pediatric unit between April 2021 and March 2022 (1 year preimplementation) and between April 2022 and March 2023 (1 year postimplementation). For a random subset of 232 preimplementation and 218 postimplementation patients, we performed manual data extraction, documenting program process measures and preliminary effectiveness outcomes. We used χ square and Wilcoxon rank tests to compare outcomes between the preimplementation and postimplementation groups. Multivariable logistic regression was used to assess the preliminary effectiveness of the social care program in identifying social risks. RESULTS: Screening rates were higher in the postimplementation group for nearly all social domains. Compared with preimplementation, the postimplementation group had higher rates of social risks identified (17.4% vs 7.8% [P < .01]: adjusted odds ratio 2.9 [95% confidence interval 1.5-5.5]) on multivariate testing. Social work consults were completed more frequently and earlier for the postimplementation group (13.8.% vs 5.6% [P < .01]) and median (19 hours vs 25 hours [P = .03]), respectively. Rates of communication of social risks in discharge summaries were higher in the postimplementation group (46.8% vs 8.2% [P < .001]). CONCLUSIONS: The implementation of a stakeholder-informed social care program within a community hospital setting led to the increased identification of social risks and social work consultations and improved timeliness of social work consultations and written communication of social risks in discharge summaries for primary care providers.

Social and Medical Care Integration Practices Among Children's Hospitals.

OBJECTIVES: In response to evidence linking social risk factors and adverse health outcomes, new incentives have emerged for hospitals to screen for adverse social determinants of health (SDOH). However, little information is available about the current state of social risk-related care practices among children's hospitals. To address outstanding knowledge gaps, we sought to describe social risk-related care practices among a national sample of children's hospitals. METHODS: We analyzed responses to the 2020 American Hospital Association Annual Survey. Among children's hospitals, we calculated the prevalence of screening for social needs, strategies to address social risks/needs, partnerships with community-based organizations to address social risks/needs at the individual and community level, and rates of impact assessments of how social risk-related interventions affect outcomes. We also used χ2 tests to compare results by hospital characteristics. We weighted results to adjust for nonresponse. RESULTS: The sample included 82 children's hospitals. A total of 79.6% screened for and 96.0% had strategies to address at least 1 social risk factor, although rates varied by SDOH domain. Children's hospitals more commonly partnered with community-based organizations to address patient-level social risks than to participate in community-level initiatives. A total of 39.2% of hospitals assessed SDOH intervention effectiveness. Differences in social risk-related care practices commonly varied by hospital ownership and Medicaid population but not by region. CONCLUSIONS: We found wide variability in social risk-related care practices among children's hospitals based on the risk domain and hospital characteristics. Findings can be used to monitor whether social risk-related care practices change in the setting of new incentives.

Racial and Ethnic Disparities in Length of Stay for Common Pediatric Diagnoses: Trends From 2016 to 2019.

BACKGROUND AND OBJECTIVES: Inequities in pediatric illness include unequal treatment and outcomes for children of historically marginalized races/ethnicities. Length of stay (LOS) is used to assess health care quality and is associated with higher costs/complications. Studies show LOS disparities for Black and Hispanic children in specific diagnoses, but it is unclear how broadly they exist or how they change over time. We examined the association between race/ethnicity and LOS longitudinally for the most common pediatric inpatient diagnoses. METHODS: We used the 2016 and 2019 Kids' Inpatient Databases. The 10 most frequent diagnoses in 2016 were determined. For each diagnosis in each year, we assessed the association between race and LOS by fitting a generalized linear mixed effects model with a negative binomial distribution, accounting for clustering and confounding. Using descriptive statistics, we compared associations between the 2 years for trends over time. RESULTS: Our analysis included >450 000 admissions and revealed significantly longer LOS for Black, Hispanic, and/or Asian American or Pacific Islander, Native American, and other children in 8 of the 10 diagnoses in 2016, with mixed changes over time. Three new disparities emerged in 2019. The largest disparities were for Black children in most diagnoses. CONCLUSIONS: Kids' Inpatient Database data showed longer LOS for children of historically marginalized race/ethnicity with common pediatric inpatient diagnoses, which largely persisted from 2016 to 2019. There is no plausible biological explanation for these findings, and inequities in social needs, access to care, and quality of care likely contribute. Future directions include further study to understand and address contributing factors.

Parent Perspectives on Screening for Social Needs During Pediatric Hospitalizations.

OBJECTIVES: Social determinants of health have been demonstrated to be important drivers of health outcomes and disparities. Screening for social needs has been routinely performed and shown to be beneficial in ambulatory settings, but little is known regarding parent perspectives on screening during pediatric hospitalizations. This study sought to determine parental attitudes surrounding inpatient screening and screening process preferences in the hospital setting. METHODS: We conducted 17 semistructured interviews with English- and Spanish-speaking parents of hospitalized children at 1 tertiary and 2 community hospitals between July 2020 and February 2021, with questions probing opinions and experiences with social needs screening, comfort level with discussing social needs with hospital providers, and screening process preferences in the hospital setting. Interviews were recorded, professionally transcribed, and analyzed thematically. RESULTS: Participants were median age 32 years, with majority female and English-speaking, and nearly one-half with children admitted to a community hospital. Emergent themes included (1) importance of screening for social needs across multiple health care settings, (2) hospitals viewed as capable systems to respond to social needs, (3) most parents comfortable discussing social needs with inpatient providers, (4) appreciation for providers expressing caring and desire to help during inpatient screening, and (5) importance of a family-centered approach to inpatient screening. CONCLUSIONS: Parents reported positive perceptions regarding pediatric inpatient social needs screening importance and hospitals' ability to address social needs and identified multiple screening process preferences for the hospital setting that can inform the development of family-centered inpatient social needs screening strategies.

Clinical Stakeholder Perspectives on Pediatric Inpatient Screening for Social Needs.

OBJECTIVES: Social determinants of health are major drivers of health outcomes and quality of life. While several social needs screening tools have been created for use in primary care settings, the best procedures to incorporate these tools into hospital workflow remain unclear. This study aimed to elicit clinical stakeholder perspectives on proposed screening for social needs during pediatric hospitalizations, with particular focus on informing implementation strategies. METHODS: We conducted 23 semistructured interviews with pediatric clinical stakeholders (physicians, nurses, social workers, and case managers) at 1 tertiary and 2 community hospitals between July 2020 and January 2021, on topics including social needs screening practices, benefits and challenges to inpatient screening, and optimal screening and referral processes within hospital workflow. Interviews were recorded, professionally transcribed, and analyzed thematically. RESULTS: Participants ranged in age from 25 to 62 years, with nearly half working in community hospitals. Regarding inpatient social needs screening, themes emerged about benefits, including enabling clinicians to identify vulnerable patients/moments, and providing clinicians with comprehensive understanding of social context; barriers, including prioritization of medical needs, lack of clinician education surrounding screening, and lack of pre-established relationships; facilitators, including duration of time spent with families, and multidisciplinary clinicians; screening process preferences, including verbal screening, and integration into pre-existing systems; and referral process preferences, including resource provision with family empowerment, and care transition to outpatient clinicians. CONCLUSIONS: Clinical stakeholders identified multiple barriers, facilitators, and process preferences for pediatric inpatient social needs screening, which may inform the future development of feasible and sustainable implementation strategies.

Parent Perspectives During Hospital Readmissions for Children With Medical Complexity: A Qualitative Study.

OBJECTIVES: Children with medical complexity (CMC) have high readmission rates, but relatively little is known from the parent perspective regarding care experiences surrounding and factors contributing to readmissions. We aimed to elicit parent perspectives on circumstances surrounding 30-day readmissions for CMC. METHODS: We conducted 20 semistructured interviews with parents of CMC experiencing an unplanned 30-day readmission at 1 academic medical center between December 2016 and January 2018, asking about topics such as previous discharge experiences, medical services and resources, and home environment and social support. Interviews were recorded, professionally transcribed, and analyzed thematically by using a modified grounded theory approach. RESULTS: Children ranged in age from 0 to 15 years, with neurologic complex chronic conditions being predominant (35%). Although the majority of parents did not identify any factors that they perceived to have contributed to readmission, themes emerged regarding challenges associated with chronicity of care and transitions of care that might influence readmissions, including frequency of hospital use, symptom confusion, lack of inpatient continuity, resources needed but not received, and difficulty filling prescriptions. CONCLUSIONS: Parents identified multiple challenges associated with chronicity of medical management and transitions of care for CMC. Future interventions aiming to improve continuity and communication between admissions, ensure that home services are provided when applicable and prescriptions are filled, and provide comprehensive support for families in both the short- and long-term may help improve patient and family experiences while potentially decreasing readmissions.

Quality and Safety of Pediatric Inpatient Care in Community Hospitals: A Scoping Review.

BACKGROUND: Although the majority of children are hospitalized in nonchildren's hospitals, little is known about the quality and safety of pediatric care in community hospitals. OBJECTIVE: The aim of this study was to conduct a scoping review and synthesize literature on the quality and safety of pediatric inpatient care in United States community hospitals. METHODS: We performed a systematic literature search in October 2016 to identify pediatric studies that reported on safety, effectiveness, efficiency, timeliness, patient-centeredness, or equity set in general, nonuniversity, or nonchildren's hospitals. We extracted data on study design, patient descriptors, and quality outcomes and assessed the risk of bias using modified Newcastle-Ottawa Scales. RESULTS: A total of 44 articles met the inclusion criteria. Study designs, patient populations, and quality outcome measures were heterogeneous; only three clinical domains, (1) perinatal regionalization, (2) telemedicine, and (3) imaging radiation, were explored in multiple studies with consistent directionality of results. A total of 30 studies were observational, and 22 studies compared community hospital quality outcomes with other hospital types. The remaining 14 studies reported testing of interventions; 12 showed improved quality of care postintervention. All studies reported an outcome addressing safety, effectiveness, or efficiency, whereas timeliness, patient-centeredness, and equity were infrequently addressed. Risk of bias was moderate or high for 72% of studies. CONCLUSIONS: Literature on the inpatient care of children in community hospitals is limited, making it difficult to evaluate healthcare quality. Measures of timeliness, patient-centeredness, and equity are underrepresented. The field would benefit from more multicenter collaborations to facilitate the application of robust study designs and to enable a systematic assessment of individual interventions and community hospital quality outcomes.

Developing Prediction Models for 30-Day Unplanned Readmission Among Children With Medical Complexity.

OBJECTIVES: To target interventions to prevent readmission, we sought to develop clinical prediction models for 30-day readmission among children with complex chronic conditions (CCCs). METHODS: After extracting sociodemographic and clinical characteristics from electronic health records for children with CCCs admitted to an academic medical center, we constructed a multivariable logistic regression model to predict readmission from characteristics obtainable at admission and then a second model adding hospitalization and discharge variables to the first model. We assessed model performance using c-statistic and calibration curves and internal validation using bootstrapping. We then created readmission risk scoring systems from final model ß-coefficients. RESULTS: Of the 2296 index admissions involving children with CCCs, 188 (8.2%) had unplanned 30-day readmissions. The model with admission characteristics included previous admissions, previous emergency department visits, number of CCC categories, and medical versus surgical admission (c-statistic 0.65). The model with hospitalization and discharge factors added discharge disposition, length of stay, and weekday discharge to the admission variables (c-statistic 0.67). Bootstrap samples had similar c-statistics, and slopes did not suggest significant overfitting for either model. Readmission risk was 3.6% to 4.9% in the lowest risk quartile versus 15.9% to 17.6% in the highest risk quartile (or 3.6-4.5 times higher) for both models. CONCLUSIONS: Clinical variables related to the degree of medical complexity and illness severity can stratify children with CCCs into groups with clinically meaningful differences in the risk of readmission. Future research will explore whether these models can be used to target interventions and resources aimed at decreasing readmissions.

Patients' Perspectives on Reasons for Unplanned Readmissions.

Massachusetts has one of the highest rates of 30-day readmissions in the country. To identify patient-reported factors that may contribute to readmissions, we conducted semi-structured interviews with patients with unplanned readmissions within 30 days of inpatient discharge from the medicine services at an urban medical center between June and August 2016. Interviews with patients and/or proxies were conducted in English, Spanish, Mandarin, or Cantonese, then translated to English if necessary, transcribed verbatim, and deidentified. A team of four coders conducted the thematic analysis. Most patients did not identify factors associated with readmission beyond their underlying illness; however, a mismatch between the patient's clinical care needs and services available at postacute facilities, as well as poor communication between providers, facilities, and patients/proxies, were identified as contributing factors to readmissions. Non-English speaking patients and their families reported confusion with written discharge instructions, even if an interpreter provided verbal instructions. Patients will benefit from future interventions that aim to improve transfers to postacute care facilities, develop written materials in languages prevalent in the local population, and improve communication among providers, facilities, and patients and their families.

The Unwritten Rules of Mentorship: Facilitators of and Barriers to Effective Mentorship in Pediatric Hospital Medicine.

OBJECTIVES: Benefits of effective mentorship include career satisfaction and academic productivity. Given the youth of pediatric hospital medicine (PHM), effective mentorship is a widely acknowledged challenge. This study aimed to characterize successful pediatric hospitalists' past and current mentorship experiences and identify facilitators of and barriers to effective mentorship in PHM. METHODS: Semistructured phone interviews were conducted with peer-nominated pediatric hospitalists, exploring past and current mentorship experiences and approaches perceived to aid or hinder mentorship relationships from both the mentor and mentee perspectives. Interviews were recorded verbatim, professionally transcribed, and analyzed by using a general inductive approach. RESULTS: Sixteen interviews were conducted and transcribed. Participants reported having a median of 3 mentors and 6 mentees. Three themes emerged regarding how mentors can optimize mentorship: (1) comprehensive focus on the mentee, (2) setting of clear expectations, and (3) acknowledgment of mentors' limitations. Five themes emerged regarding how mentees can optimize mentorship: (1) preparation, (2) proactivity, (3) continual reevaluation of relationships, (4) willingness to seek mentorship outside of common venues, and (5) building of a mentorship team. Major barriers to effective mentorship included (1) mismatched expectations between mentor and mentee, (2) lack of available mentors in PHM, (3) lack of time/compensation for PHM mentors, and (4) geographic separation between mentor and mentee. CONCLUSIONS: Several themes emerged regarding facilitators of and barriers to effective mentorship in PHM. These "unwritten rules of mentorship" may serve as a guide to establish and maintain beneficial mentorship relationships and overcome challenges.