Video Conference Discharge Process for NICU Infants with Medical Complexity.

Purpose: Discharging infants from the NICU is complex, requiring the coordination of multiple aspects of care. Patient follow-up includes transferring medical care to primary care providers (PCP) who initially may have to rely on parents/caregivers for details about the child's history and current needs. Improving communication between the NICU and primary care offices within this pediatric health system was a goal of the organization, especially as value-based care was launched. Design: A pilot program was introduced in which families, PCP, and NICU providers for medically complex infants were offered the opportunity to participate in video conference calls. Sample: Infants selected for this pilot were those discharging from a Level IV NICU for the first time with medical complexity, such as those who would require care from multiple specialists, those with nasogastric feeding tubes, gastrostomy feeding tubes, and/or requiring oxygen post-discharge. The agenda during calls consisted of a review of the infant's birth, NICU course, and post-discharge needs. Participants were encouraged to provide detail and ask clarifying questions. Main Outcome Variable: Outcomes of this project included the evaluation of satisfaction with newer phone call methods for all participants and tracking readmission rates for those infants whose families experienced the video conference call. Results: High satisfaction levels were recorded among stakeholders as evidenced by 77 percent of parents and NICU providers being "very satisfied" or "completely satisfied" and 96 percent of primary care physicians being "very satisfied" or "completely satisfied." The rate of 30-day readmission for those who participated in the pilot was 23 percent and those readmissions were not unexpected. Conclusion: Involving families and accepting primary care physicians into the discharge communication are satisfying to stakeholders and allow participants the opportunity to have bidirectional conversations regarding the unique care needs of infants discharged from the NICU with special needs.

Establishment of Nurse Case Manager Role in a Pediatric Orthopedic Team.

PURPOSE/OBJECTIVES: Incorporating a nurse case manager (NCM) directly into a pediatric orthopedic department was implemented to address gaps in processes that had previously led to common delays in discharge planning. The orthopedic NCM works within an interdisciplinary team and provides guidance and support for both elective and emergent pediatric admissions. Applying continuous improvement techniques, the NCM role included the review of existing processes and determination of root causes of delays. This article describes some of the unique challenges and new processes included in the NCM role in the pediatric orthopedic setting, several solutions created and implemented to address identified delays, and statistical results of anticipatory discharge planning. PRIMARY PRACTICE SETTING: An NCM role was initiated in the orthopedic department at a quaternary-level freestanding pediatric hospital. FINDINGS/CONCLUSIONS: After interdisciplinary planning and implementation, the NCM role was established within the orthopedic department to facilitate timely, efficient, safe, and sustained discharges of patients. Success was realized through decreased denials and decreased number of avoidable inpatient days. Once rapport was established and streamlined work was developed, a retrospective review of length of stay was conducted to compare time periods prior to and after embedding this position. Changes in discharge planning processes positively affected the average length of stay for patients managed by the NCM. Cost savings are found in decreased avoidable inpatient days, decreased number of denials of inpatient medical necessity, and improved progression of care, which resulted in timely transitions and discharges. The effects of a consignment process and web-based ordering of durable medical equipment were also evaluated. Although this process in and of itself did not seem to impact length of stay, it did foster an improvement in team satisfaction around discharge readiness. IMPLICATIONS FOR CASE MANAGEMENT: Pediatric orthopedic service teams benefit from the role of the NCM when there is interdisciplinary involvement and a focus on streamlining processes from preadmission through transition of care. Further study in a concurrent design will shed light on other factors that impact length of stay, such as specific diagnoses and medical complexity. Average length of stay is an effective metric for services with a high percentage of elective admissions but may not be as dependable for teams that do not have prescribed lengths of stay. Study with a specific focus around those factors that impact both team and family satisfaction is also indicated.

Creating a New Model of Care by Integrating Case Management Nurses in a Children's Hospital.

PURPOSE/OBJECTIVES: Nurse case managers (NCMs) have been identified as effective members of a care team in the development of effective and successful discharge plans. A pediatric hospital had an opportunity to change the model of case management (CM) in response to multiple initiatives. This article describes the process, barriers, and results of the integration of a new role into the care team. PRIMARY PRACTICE SETTING: The role development and integration were done at a quaternary-level pediatric hospital. FINDINGS/CONCLUSIONS: Introduction of the NCM role was accomplished through a multidisciplinary approach that employed continuous improvement, involvement of team and hospital leaders, and collaboration across multiple professions. The role was developed from one pilot to the eventual positioning of nine NCMs. Introduction of the new program resulted in a shift from a reactive dyad model of social worker-utilization management nurse to a proactive triad model of NCM-social worker-utilization management nurse. Success was measured by a decrease in the number of denials and an increase in the overturn of the denials received. Other results included the innovation of several processes that streamlined discharge planning and contributed to patient/family satisfaction. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Creation of a new nurse-led CM triad team can be accomplished through multidisciplinary support and a focus on continuous improvement. Further collaboration on discharge planning standards and CM is indicated. Additional research focused on the impact of nurse-led pediatric discharge planning as it relates to readmission reduction and appropriateness of level of care and length of stay is also needed.