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

Abstract

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.

Barriers and Facilitators to Implementing Interventions for Reducing Avoidable Hospital Readmission: Systematic Review of Qualitative Studies

“…Updated literature search for potential qualitative studies from March 2020 to October 2021 identified 5 additional studies that were considered eligible (Supplementary file 4). A total of thirteen qualitative studies, 9,10,[23][24][25][26][27][28][29][30][31][32][33] were included. Details of literature search and study selection are presented in Figure 2.…”

“…Individual interviews Thematic analysis Registered nurses (n = 7), primary care physicians (n = 9), paramedics (n = 3), advanced practice registered nurses (n = 3). Riddle 2020, US 32 To elicit suggestions for improving a nurse visit intervention for reducing hospital readmission.…”

“…9,10,25,33 Design quality and packaging: Different supporting instruments, such as software plug-in to electronic health records, implementation checklists and service delivery guidelines, were developed to facilitate the delivery of interventions in different organizations. 23,32 However, these innovations may not fit in existing infrastructure. Some hospitals reported difficulties in integrating peridischarge intervention application software with existing electronic health records.…”

Disconnection in Information Exchange During Pediatric Trauma Transfers: A Qualitative Study

“…For pediatric patients, parent and guardian (hereafter referred to as "parents") communication with clinicians impacts patient safety, parent experience, and hospital utilization (9,(13)(14)(15). Unfortunately, communication challenges not only exist, but the awareness of these problems among clinicians is limited.…”

Is It Time to Revisit Pediatric Postdischarge Home Visits for Readmissions Reduction?

“…In this issue of the Journal of Hospital Medicine, Riddle et al 3 explored the perspectives of key stakeholders to understand the factors driving increased reutilization after postdischarge home visits in the H2O trial and obtained feedback for improving potential interventions. The investigators used a qualitative approach that consisted of telephone interviews with 33 parents who were enrolled in the H2O trial and in‐person focus groups with 10 home care RNs involved in the trial, 12 hospital medicine physicians, and 7 primary care physicians (PCPs).…”