Socioeconomic status influences the toll paediatric hospitalisations take on families: a qualitative study.

BACKGROUND: Stress caused by hospitalisations and transition periods can place patients at a heightened risk for adverse health outcomes. Additionally, hospitalisations and transitions to home may be experienced in different ways by families with different resources and support systems. Such differences may perpetuate postdischarge disparities. OBJECTIVE: We sought to determine, qualitatively, how the hospitalisation and transition experiences differed among families of varying socioeconomic status (SES). METHODS: Focus groups and individual interviews were held with caregivers of children recently discharged from a children's hospital. Sessions were stratified based on SES, determined by the percentage of individuals living below the federal poverty level in the census tract or neighbourhood in which the family lived. An open-ended, semistructured question guide was developed to assess the family's experience. Responses were systematically compared across two SES strata (tract poverty rate of <15% or ≥15%). RESULTS: A total of 61 caregivers who were 87% female and 46% non-white participated; 56% resided in census tracts with ≥15% of residents living in poverty (ie, low SES). Interrelated logistical (eg, disruption in-home life, ability to adhere to discharge instructions), emotional (eg, overwhelming and exhausting nature of the experience) and financial (eg, cost of transportation and meals, missed work) themes were identified. These themes, which were seen as key to the hospitalisation and transition experiences, were emphasised and described in qualitatively different ways across SES strata. CONCLUSIONS: Families of lower SES may experience challenges and stress from hospitalisations and transitions in different ways than those of higher SES. Care delivery models and discharge planning that account for such challenges could facilitate smoother transitions that prevent adverse events and reduce disparities in the postdischarge period. TRIAL REGISTRATION NUMBER: NCT02081846; Pre-results.

Optimizing a Nurse-led Transitional Home Visit Program in Preparation for a Randomized Control Trial.

INTRODUCTION: The Hospital to Home Outcomes study began with the end goal of evaluating the effectiveness of a single, nurse-led transitional home visit (home visit) program, for acutely ill, pediatric patients, which had been piloted at our institution. As part of the overall study design, building on prior randomized control trials that utilized a run-in period prior to the trial, our study team designed an optimization period to test the home visit and study procedures under real-world conditions. METHODS: For this optimization project, there were 3 process improvement goals: to improve the referral process to the home visit, to optimize the home visit content, and to define and operationalize measures of patient- and family-centered outcomes to be used in the subsequent randomized control trial. During the optimization period, a multidisciplinary study team met weekly to review family and stakeholder feedback about the iterative modifications made to the home visit process, content, and outcome measures. RESULTS: Optimization home visits were completed with 301 families across a variety of discharge diagnoses. The outcomes planned for the clinical trial were tested and refined. Feedback from families and stakeholders indicated that the content changes made to the home visits resulted in increased family knowledge of warning signs to monitor postdischarge. Thirty-one percent of families reported that they altered the care of their child after the home visit. CONCLUSION: Through iterative testing, informed by multistakeholder feedback, we leveraged patient and family engagement to maximize the effectiveness and generalizability of the home visit intervention.

The Family Perspective on Hospital to Home Transitions: A Qualitative Study.

BACKGROUND AND OBJECTIVE: Transitions from the hospital to home can be difficult for patients and families. Family-informed characterization of this vulnerable period may facilitate the identification of interventions to improve transitions home. Our objective was to develop a comprehensive understanding of hospital-to-home transitions from the family perspective. METHODS: Using qualitative methods, focus groups and individual interviews were held with caregivers of children discharged from the hospital in the preceding 30 days. Focus groups were stratified based upon socioeconomic status. The open-ended, semistructured question guide included questions about communication and understanding of care plans, transition home, and postdischarge events. Using inductive thematic analysis, investigators coded the transcripts, resolving differences through consensus. RESULTS: Sixty-one caregivers participated across 11 focus groups and 4 individual interviews. Participants were 87% female and 46% nonwhite; 38% were the only adult in their household, and 56% resided in census tracts with ≥15% of residents living in poverty. Responses from participants yielded a conceptual model depicting key elements of families' experiences with hospital-to-home transitions. Four main concepts resulted: (1) "In a fog" (barriers to processing and acting on information), (2) "What I wish I had" (desired information and suggestions for improvement), (3) "Am I ready to go home?" (discharge readiness), and (4) "I'm home, now what?" (confidence and postdischarge care). CONCLUSIONS: Transitions from hospital to home affect the lives of families in ways that may affect patient outcomes postdischarge. The caregiver is key to successful transitions, and the family perspective can inform interventions that support families and facilitate an easier re-entry to the home.