Time-motion observations to characterize the developmental environment in a paediatric post-acute care hospital.

BACKGROUND: Chronically hospitalized children are at risk for neurodevelopmental delay, compounded by restricted social interactions, movement and environmental stimulation. We measured patients' movements and interactions to characterize developmentally relevant aspects of our inpatient environment and identify opportunities for developmental enrichment. METHODS: As part of a quality improvement initiative to inform neurodevelopmental programming for children with medical complexity at our paediatric post-acute care specialty hospital, we conducted >232 hours of time-motion observations. Trained observers followed 0- to 5-year-old inpatients from 7 am to 7 pm on weekdays, categorizing observations within five domains: Where, With, Position, State and Environment. Observations were collected continuously utilizing REDCap on iPads. A change in any domain initiated a new observation. RESULTS: Patients were median 1 year and 8 months of age (range 2 months to 3 years 9 months) with a median length of hospitalization of 514 days (range 66-1298). In total, 2636 unique observations (or median 134 observations per patient-day [range 95-210]) were collected. Patients left their rooms up to 4 times per day for median 1 h and 34 min (range 41 min to 4 h:30 min). Patients spent 4 h:6 min (2 h:57 min to 6 h:30 min) interacting with someone and 3 h:51 min (57 min to 6 h:36 min) out of bed each day. Patients were simultaneously out of their beds, interacting with someone and awake for 2 h:21 min (51 min to 4 h:19 min) each day. CONCLUSIONS: Despite a care model prioritizing time out of bed and social interaction, time-motion observations indicate patients spent many of their waking hours in bed and alone. Quantifying our inpatients developmental opportunities will inform neurodevelopmental programming initiatives.

The Effect of a Comprehensive Care Transition Model on Cost and Utilization for Medically Complex Children With Cerebral Palsy.

INTRODUCTION: Our aim was to evaluate cost and acute care utilization related to an organized approach to care coordination and transitional care after major acute care hospitalization for children with medical complexities, including cerebral palsy. METHODS: A retrospective cohort of 32 patients from Ranken Jordan Pediatric Bridge Hospital (RJPBH) who received the Care Beyond the Bedside model was compared with 151 patients receiving standard care elsewhere across Missouri. Claims data (2007-2012) were obtained from MoHealthNet, Missouri's Medicaid program, for all children with moderate to severe cerebral palsy (defined using approximated Gross Motor Function Classification System levels) who had at least one hospital visit during the study period (N = 183). Risk-adjusted linear and Poisson regression models were used to analyze per-member-per-month costs and three indicators of acute care utilization (emergency department visits, readmissions, and inpatient days). RESULTS: RJPBH patients were associated with statistically significant reductions in per-member-per-month costs (-21%), hospital readmissions (-66%), and inpatient days (-57%). DISCUSSION: RJPBH's enhanced interprofessional medical home-like model, including intense care coordination, psychosocial therapy, family and caregiver empowerment, and transitional care, may be keys to reducing cost and unnecessary hospital use for children with medical complexities with cerebral palsy who receive Medicaid.