Virtual Home Visit for a Child With Medical Complexity: Post-Discharge Considerations
by Dr. Kathleen Huth and the Virtual Home Visit Working Group.
The transition from hospital to home can be particularly challenging for children with
medical complexity.
High quality discharge planning involves ensuring medications and equipment are available to
the family, coordinating close follow up, and communicating clearly with caregivers
as well as with school, home nursing, and community agencies where applicable.
We asked Jack's family about some of the issues they have faced after discharge.
They want it and the pharmacy doesn't.
So they write a prescription.
And probably half the time, it's not a traditional prescription.
So the thing is pharmacies don't carry a lot of things in inventory that you think they
would right away.
So sometimes, it may take a couple of days for them to get it and order it.
And then you're dealing with insurance issues sometimes because, oh, it was written for
a 30 day supply, but we only fill a 90 day supply.
So you have all those things that they don't think of.
And then they think, oh, well, with equipment companies, we called them.
But sometimes, they don't respond in a timely manner.
Or it's a day or so later.
Or the equipment arrives.
Or when do you actually get the training on it?
Because it's all well and good.
And we're kind of hands-on people.
So I want to be involved.
But you don't do it-- you're not doing it daily.
And then you get home, and you're still trying to figure-- and the people from doing home
therapies and stuff, you get a quick 10 minutes on it.
And then you're left to still figure it out on your own.
I think that is super hard.
And I feel fortunate-- we ask a lot of questions.
And we're not afraid.
And not everybody is equipped to be that way.
So I think that's a really big challenge.
Then also it's not just us that have to learn it.
We have nurses that then we need to teach it to, and then teach it how it goes and the
routine.
And you set structures.
Because then their standards-- and they have a parent company that they need to report
to.
And they have different regulations.
And then you may do it a little differently.
So that's challenging.
And then there's-- most of the time, there's a third layer.
Because there's school nursing, too.
So what actually-- does some of it carry over into school?
Oh, do they need an order for that We can't do anything until you get this from the doctor.
Or it doesn't work in their daily routine.
And then how does it incorporate into your home, if it's a piece of equipment?
We're super grateful that we got a chest vest and cough assist.
But these are big pieces of equipment.
How do you keep them?
Where do you put them?
Where do they go?
How do you teach?
So there's a whole heck of a lot of considerations.
And I think a lot of your-- most of the time, it's major illnesses that you're dealing with.
So you're shell shocked.
And then you're going home.
And most of it's just on a piece of paper.
And usually, there's specialists involved.
And when you're getting discharged, those specialists aren't discharging you.
It's the overall doctor.
So they don't know all the finer nuances.
And I think that's a real struggle.
Children with medical complexity are at high risk of having issues post-discharge.
Being post-operative is one risk factor, as the child may have new equipment needs, new
accessibility needs, and they may have pressure injury or need specialized dressing supplies.
Another risk factor is having a new or changed diagnosis or a new or more involved homecare
need due to a change in clinical status.
A child with a history of frequent readmissions is at higher risk of issues post-discharge.
As well, the social situation is important to consider.
Jack has home nursing support, consistent caregivers, and an accessible home for his
medical equipment, which is not always the case.
Yet, his family faces many common issues in the transition from hospital to home.
Common issues that arise post-discharge may include prescription issues.
Families may be unable to obtain a medication due to issues with prior authorization or
lack of availability of the needed formulation at the pharmacy.
Sometimes, incorrect medication may be prescribed by the discharging team.
It may be unclear who is responsible for refills.
And families may be unsure who to contact after discharge, causing delays in administering
medication.
There may be issues with medical equipment.
There may be problems obtaining supplies in a timely fashion.
Or it may arrive and may be unable to fit in the home.
There may also be a lack of education on the use of new medical equipment.
Caregivers may face issues with the feeding regimen, particularly with mixing new formulas.
Wound care can be challenging after discharge, especially if there is difficulty obtaining
supplies and the family is not informed on who to call to arrange the delivery or for
refills.
Families also often face challenges in scheduling timely follow-up appointments.
Consider the following when discharging a with medical complexity from the hospital--
are there any new or changed medications?
Children may have important medications intentionally or unintentionally withheld during an admission
and are at increased risk for unintentional medication discontinuation following hospital
discharge.
Is there any numerical equipment?
Consider whether the family will receive the new equipment upon their return home after
discharge.
You should also inquire if there are any issues with the use of the equipment.
For example, if the family has received a new lift for safe transfers, ask the family
if it fits in the room.
Have they been shown how to use it?
And do they have the accompanying equipment, such as an appropriately sized sling?
Are there changes in the child's clinical status and home care needs?
Does the child have appropriate follow-up and contingency plans?
And is there any information that needs to go to the school or community providers?
Families are often faced with needing to educate and provide new orders for all of the community
providers that care for the child.
Follow up of a child with medical complexity after discharge should occur within 48 hours.
You should review and reinforce discharge instructions, perform a medication reconciliation,
evaluate home care needs, perform a physical examination of the child, assess the accessibility
of the home, and assess the social environment.