A Qualitative Study of Increased Pediatric Reutilization After a Postdischarge Home Nurse Visit.

BACKGROUND: The Hospital to Home Outcomes (H2O) trial was a 2-arm, randomized controlled trial that assessed the effects of a nurse home visit after a pediatric hospital discharge. Children randomized to the intervention had higher 30-day postdischarge reutilization rates compared with those with standard discharge. We sought to understand perspectives on why postdischarge home nurse visits resulted in higher reutilization rates and to elicit suggestions on how to improve future interventions. METHODS: We sought qualitative input using focus groups and interviews from stakeholder groups: parents, primary care physicians (PCP), hospital medicine physicians, and home care registered nurses (RNs). A multidisciplinary team coded and analyzed transcripts using an inductive, iterative approach. RESULTS: Thirty-three parents participated in interviews. Three focus groups were completed with PCPs (n = 7), 2 with hospital medicine physicians (n = 12), and 2 with RNs (n = 10). Major themes in the explanation of increased reutilization included: appropriateness of patient reutilization; impact of red flags/warning sign instructions on family's reutilization decisions; hospital-affiliated RNs "directing traffic" back to hospital; and home visit RNs had a low threshold for escalating care. Major themes for improving design of the intervention included: need for improved postdischarge communication; individualizing home visits-one size does not fit all; and providing context and framing of red flags. CONCLUSION: Stakeholders questioned whether hospital reutilization was appropriate and whether the intervention unintentionally directed patients back to the hospital. Future interventions could individualize the visit to specific needs or diagnoses, enhance postdischarge communication, and better connect patients and home nurses to primary care.

Improving Recruitment and Retention Rates in a Randomized Controlled Trial.

High recruitment and retention rates in randomized controlled trials are essential to ensure validity and broad generalizability. We used quality improvement methods, including run charts and intervention cycles, to achieve and sustain high recruitment and retention rates during the Hospital-To-Home Outcomes randomized controlled trial. This study is examining the effects of a single nurse-led home health care visit after discharge for an acute pediatric hospitalization. A total of 1500 participants were enrolled in the 15-month study period. For study recruitment, we assessed the percentage of patients who enrolled in the study among those randomly selected to approach (goal ≥50%) and the percentage of patients who refused to enroll from those randomly selected to approach (goal ≤30%). For intervention completion, we examined the percentage of patients who completed the home visit intervention among those randomized to receive the intervention (goal ≥95%) were examined. Follow-up rates were tracked as the percentage of patients who completed the 14-day follow-up telephone survey (goal ≥95%). The study goals for 2 of the 4 metrics were met and sustained, with statistically significant improvements over time in 3 metrics. The median enrollment rate increased from 50% to 59%, and the median refusal rate decreased from 37% to 32%. The median intervention completion rate remained unchanged at 88%. The 14-day follow-up completion median rate increased from 94% to 96%. These results indicate that quality improvement methods can be used within the scope of a large research study to achieve and sustain high recruitment and retention rates.

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.