Fellow: Audrey Uong, Pediatric Hospital Medicine Fellow, Children’s Hospital at Montefiore/Albert Einstein College of Medicine
Article: Coller, Ryan J., et al. “Complex Care Hospital Use and Postdischarge Coaching: A Randomized Controlled Trial.” Pediatrics 2018; 142(2): doi:10.1542/peds.2017-4278.
Article: Coller, Ryan J., et al. “Complex Care Hospital Use and Postdischarge Coaching: A Randomized Controlled Trial.” Pediatrics 2018; 142(2): doi:10.1542/peds.2017-4278.
Summary: This was a prospective randomized controlled trial that examined the effectiveness of a caregiver coaching intervention on reducing hospital use in children with medical complexity. This caregiver coaching model, termed Plans for Action and Care Transitions (PACT) was created to prevent hospitalizations with two major goals: (1) to help caregivers recognize critical symptoms and create executable action plans for when these critical or “red-flag” symptoms occur, and (2) to support care transition to the community after discharge from the hospital. The investigators found that patients enrolled in the PACT intervention group versus usual care had lower hospitalization rates, lower hospitalization incident rate ratios noted in adjusted analyses, and lower all-cause 30 day readmissions. The authors also found decreased mortality in the PACT intervention group, though this was not the original intent of this study and may not be related to the intervention.
Key Strengths: This is one of few randomized controlled trials investigating the efficacy of a caregiver coaching intervention, created using caregiver interviews, systematic literature review, and a national expert panel, which was effective in reducing hospitalizations in children with medical complexity. This is a generally low-cost intervention (at least in institutions with a program for children with medical complexity), which may enhance its generalizability. Interviews with caregivers in the intervention group also suggested that the personalized action plans and care transition support that were part of this intervention were helpful and reduced caregiver anxiety. Finally, although the authors enrolled fewer patients than they had planned for in their power analysis, they were still able to find a statistically significant difference between the two groups, suggesting that the PACT intervention may be even more effective than discussed in this article.
Key Limitations: The authors of this article focused on a specific subset of hospitalized pediatric patients—children with medical complexity who were already enrolled in a medical home program at that institution. Caregivers of these patients are likely more familiar with the healthcare system due to repeated exposure. Therefore, it may be challenging to generalize these findings to a broader population of hospitalized pediatric patients. This was also a single center study, so readmissions and hospitalizations were documented based on the electronic medical record and patient report and may not be completely accurate. Although the intervention was generally low-cost, it did involve hiring of a transitions coach who made home visits. This limits generalizability for institutions that may not have the resources to train or fund a transitions coach.
Major Takeaway: Despite already being enrolled in a medical home program, a caregiver coaching intervention focused on creating personalized action plans and supporting care transition to community effectively decreased hospitalizations in children with medical complexity.
How this article should impact our practice: This article adds to a growing body of literature in pediatric hospital medicine emphasizing the importance of standardized discharge counseling, patient-oriented action plans, and caregiver support after hospital discharge to decrease adverse events and readmissions. In practice, we should partner with our outpatient colleagues to create plans to prevent hospitalizations, and enroll children with medical complexity into a medical home.
Key Strengths: This is one of few randomized controlled trials investigating the efficacy of a caregiver coaching intervention, created using caregiver interviews, systematic literature review, and a national expert panel, which was effective in reducing hospitalizations in children with medical complexity. This is a generally low-cost intervention (at least in institutions with a program for children with medical complexity), which may enhance its generalizability. Interviews with caregivers in the intervention group also suggested that the personalized action plans and care transition support that were part of this intervention were helpful and reduced caregiver anxiety. Finally, although the authors enrolled fewer patients than they had planned for in their power analysis, they were still able to find a statistically significant difference between the two groups, suggesting that the PACT intervention may be even more effective than discussed in this article.
Key Limitations: The authors of this article focused on a specific subset of hospitalized pediatric patients—children with medical complexity who were already enrolled in a medical home program at that institution. Caregivers of these patients are likely more familiar with the healthcare system due to repeated exposure. Therefore, it may be challenging to generalize these findings to a broader population of hospitalized pediatric patients. This was also a single center study, so readmissions and hospitalizations were documented based on the electronic medical record and patient report and may not be completely accurate. Although the intervention was generally low-cost, it did involve hiring of a transitions coach who made home visits. This limits generalizability for institutions that may not have the resources to train or fund a transitions coach.
Major Takeaway: Despite already being enrolled in a medical home program, a caregiver coaching intervention focused on creating personalized action plans and supporting care transition to community effectively decreased hospitalizations in children with medical complexity.
How this article should impact our practice: This article adds to a growing body of literature in pediatric hospital medicine emphasizing the importance of standardized discharge counseling, patient-oriented action plans, and caregiver support after hospital discharge to decrease adverse events and readmissions. In practice, we should partner with our outpatient colleagues to create plans to prevent hospitalizations, and enroll children with medical complexity into a medical home.