Department
Nursing
Document Type
Poster
Abstract
Safe transitions home are critical for Children with Medical Complexity (CMC) at Gillette Children’s Hospital, particularly those enrolled in the Pediatric Cerebral Palsy Complex Care Program who often experience polypharmacy, technology dependence, and high service utilization. Missed discharge follow-up phone calls limit opportunities to identify medication errors, supply failures, and clinical deterioration that may lead to rehospitalization. Despite prior organizational efforts, follow-up call reach rates remained variable. The primary objective of this project was to increase the proportion of complex care patients reached within seven days of discharge, with secondary aims of reducing time to first contact and addressing post-discharge concerns. A review of post-2015 literature revealed recurring elements of effective transitions, including early follow-up planning, multidisciplinary involvement, discharge navigators, caregiver engagement, and verification of contact information. Meta-analyses demonstrated significant improvements in telephone follow-up reach when brief pre-discharge, face-to-face education was provided. The evidence-based intervention implemented a brief, scripted bedside visit within 24 hours of discharge, during which inpatient nurses confirmed contact information, reinforced follow-up expectations, and identified optimal call times. The Diffusion of Innovations theory informed adoption strategies, while the EPIS framework supported planning, implementation, and sustainment activities. Staff absences and inconsistent script utilization were the primary challenges encountered. Evaluation compared telephone reach performance between Summer 2024 (pre-intervention) and Summer 2025 (post-intervention). Outcomes demonstrated improvement in first-attempt reach (37.6% to 65.3%) and overall reach (46.2% to 71.4%). Mann–Whitney U, Chi-square, and ordinal logistic regression analyses confirmed statistically significant gains (p < .05). Based on these results, continued use of bedside discharge preparation is recommended. Incorporation into policy, periodic staff reinforcement, and expansion to additional populations may further improve transitional safety and reduce preventable rehospitalizations.
Publication Date
Fall 12-4-2025
Recommended Citation
Fadell-Mann, Katherine "Katie", "Improving Post-Discharge Follow-up Call Reach Rates in Complex Care Pediatric Patients at Gillette Children’s Hospital Through a Standardized Discharge Planning & Staff Education Quality Improvement Initiative Using the EPIS Framework" (2025). Student Scholarship. 18.
https://metroworks.metrostate.edu/student-scholarship/18
Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial-No Derivative Works 4.0 International License.
Comments
Fall 2025: Student Research Conference