Garnering Effective Telehealth 2 Help Optimize Multidisciplinary Team Engagement (GET2HOME)
Children With Complex Chronic Conditions
About this trial
This is an interventional health services research trial for Children With Complex Chronic Conditions
Eligibility Criteria
Inclusion Criteria:
- Patients with complex chronic disease based on a Pediatric Medical Complexity Algorithm (PMCA) score of 3 and their families
- Discharged from pediatric hospital medicine service at our hospital
Exclusion Criteria:
- Patients who live independently without a parent or guardian in the home, including those that live at skilled nursing facilities
- Patients admitted for end of life care
- Patients admitted for suicidal or homicidal ideation
- Patients who previously enrolled in the study
- Patients in county custody
Sites / Locations
- Cincinnati Children's Hospital Medical Center
Arms of the Study
Arm 1
Arm 2
No Intervention
Experimental
Standard Hospital-Based Care Coordination
GET2HOME Intervention
Patients and families randomized to this arm will receive best practice standard of care hospital-based transition planning in the hospital with routine outpatient care team follow-up post-discharge.
The GET2HOME intervention includes: 1) a pre-discharge telehealth huddle with the family, inpatient team, primary care team, and home care nursing; 2) a visual discharge task tracker (DTT) to monitor progress across care management tasks; and if desired by family and primary care 3) a post-discharge telehealth huddle 2-7 days after discharge with the family, inpatient team, primary care team, and home care nursing