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Delays in Discharge of Children with Complex Health Care Needs: What Causes Them and How Bad Are They? :

December 3, 2018

Inpatient services appear to have more and more children with complex healthcare needs requiring substantive discharge planning prior to discharge.

Inpatient services appear to have more and more children with complex healthcare needs requiring substantive discharge planning prior to discharge. Often this planning involves ensuring that there are available personnel such as home nurses and equipment brought to a child’s home. While one might hope that such discharge planning could be done as expeditiously, experience shows it often is not, resulting in prolonged stays for children with medical complexity (CMC). How prolonged are those stays, and once home?  To answer this question, Maynard et al. (10.1542/peds.2018-1951) share with us the results of a 12-month multisite prospective study of 185 children with medical complexity from 4 children’s hospitals in Minnesota divided into two cohorts—one being discharged for the first time, and the other being discharged home to previously established nurses who provide care at home.

While you might expect that discharge planning could be delayed in this population of complex patients, this study demonstrates just how prolonged that delay is.  For example, discharge delay occurred in 68.5% (n=54) of new patients and 9.2% (n=131) of existing patients.  In those new patients, the average delay to discharge was an average of 53.9 days (with a range of 4 to 204 days) and 35.7 days (range of 3-63 days) for existing patients at an estimated cost overall of $5.7 million dollars.  Why the long delays?  The authors identified lack of home care nursing as the major reason as well as what types of patients are more apt to have the most prolonged delays getting to discharge. 

So what is the takeaway of this article beyond the alarming delays captured in this study? We asked Dr. Garey Noritz, who oversees the Complex Health Care Program at Nationwide Children’s Hospital, to share his take on this study in an accompanying commentary (10.1542/peds.2018-2960). He points out the undervaluing of home care and the lack of sufficient rehabilitation facilities for CMC.  He more specifically notes a major shortage of nurses who can provide this type of care in a home or rehab facility setting and why that shortage exists.

The high number of days that delay discharges are simply unacceptable as are the higher number of readmissions following discharge for CMCs. Yet the solution is one that requires making working conditions and salaries comparable if not better for home nurses than inpatient or office nurses.  While the onus rests with Medicaid managed-care organizations and other insurers, as pediatricians, we need to do more perhaps in partnership with CMC families to help advocate for reducing the delays that prohibit sending a child home sooner than later.  As we move toward population health and value-based care, the situation for home nurses needs to improve—and we need to advocate more strongly to make that happen.

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