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Special Article

Summary of STARNet: Seamless Transitions and (Re)admissions Network

Katherine A. Auger, Tamara D. Simon, David Cooperberg, James Gay, Dennis Z. Kuo, Michele Saysana, Christopher J. Stille, Erin Stucky Fisher, Sowdhamini Wallace, Jay Berry, Daniel Coghlin, Vishu Jhaveri, Steven Kairys, Tina Logsdon, Ulfat Shaikh, Rajendu Srivastava, Amy J. Starmer, Victoria Wilkins and Mark W. Shen
Pediatrics January 2015, 135 (1) 164-175; DOI: https://doi.org/10.1542/peds.2014-1887
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Abstract

The Seamless Transitions and (Re)admissions Network (STARNet) met in December 2012 to synthesize ongoing hospital-to-home transition work, discuss goals, and develop a plan to centralize transition information in the future. STARNet participants consisted of experts in the field of pediatric hospital medicine quality improvement and research, and included physicians and key stakeholders from hospital groups, private payers, as well as representatives from current transition collaboratives. In this report, we (1) review the current knowledge regarding hospital-to-home transitions; (2) outline the challenges of measuring and reducing readmissions; and (3) highlight research gaps and list potential measures for transition quality. STARNet met with the support of the American Academy of Pediatrics’ Quality Improvement Innovation Networks and the Section on Hospital Medicine.

Current research and quality improvement efforts to optimize transitions of care for children to and from the hospital are fragmented in part because of a lack of evidence base and standardization of outcomes. Despite national attention to the subject and a large number of quality improvement activities in pediatric transitions, clear evidence for specific drivers of pediatric readmissions is limited. Although researchers continue to define the “who” and “why” of preventable pediatric admissions, several large collaboratives have embarked on efforts to improve care transitions and reduce readmissions (Table 1). With a goal of improving inpatient to outpatient transitions, many individual institutions have established pediatric readmission teams by using a value proposition derived from adult populations.1–3 Whether these initiatives will be successful in improving hospital transition and reducing readmissions remains unclear in the absence of a well-defined pediatric research model.

View this table:
TABLE 1

Examples of Efforts in Pediatric Transitions

Quality improvement leaders working on hospital to home transitions of care within the American Academy of Pediatrics’ (AAP) Quality Improvement Innovation Networks identified the need to address many of these issues based on the current state of research. With the support of the Quality Improvement Innovation Networks and the Section on Hospital Medicine, they convened this expert panel to begin synthesizing existing work and coordinating future work. The Seamless Transitions and (Re)admissions Network (STARNet) met in December 2012. STARNet participants consisted of experts in the field of pediatric hospital medicine quality improvement and research, and included physicians and key stakeholders from the Children’s Hospital Association, private payers, representatives from the current transition collaboratives, and key national groups. The goal of this meeting was to synthesize ongoing hospital-to-home transition work, discuss goals of the STARNet organization, and develop a plan to centralize transition information for the use of clinicians, researchers, and quality improvement projects in the future. This report summarizes the discussions of the STARNet meeting. The objectives of this report are to (1) review the current knowledge regarding hospital-to-home transitions; (2) outline the challenges of measuring and reducing readmissions; and (3) highlight research gaps and potential measures for transition quality.

Current Knowledge Regarding Pediatric Hospital-to-Home Transitions

Care transitions are “a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location.”4 Examples of pediatric transitions include the following: home to primary care provider (PCP), PCP to subspecialist, PCP to emergency department (ED), ED to hospital, and hospital to home. The transition between the hospital and the outpatient setting can be complex given the shared responsibility between inpatient providers, outpatient providers, the child, and their caregiver(s). Effective communication, care coordination, contingency planning, and family engagement are all key components of care transition quality. Certain populations of children require additional transitional support because of medial complexity.

Communication

Written communication between care providers at hospital discharge is often inconsistent, untimely, lacking in essential information, and includes excessive nonessential information for both pediatric and adult patients.5–7 These breakdowns can introduce the risk of adverse outcomes.8 Researchers have identified essential informational elements for written discharge communication for both PCPs and hospitalists.6,9 In particular, Quality Improvement researchers from the Value in Inpatient Pediatrics network found that PCPs identify changes in medical management, follow-up appointments, and pending laboratory results as important components of discharge communication.10 Inpatient to outpatient verbal hand off may decrease readmission-related resource utilization in certain adult populations,11 but this remains an understudied component of hospital to home transitions. Other frameworks and recommendations for the transition process improvement include shared care plans for complex children, condition-specific discharge bundles, and defining discharge timing, but more implementation work is needed.12–14

Care Coordination/Contingency Planning

Care coordination is the “deliberate organization of patient care activities between two or more participants… to facilitate the appropriate delivery of health care services.”15 Care coordination is a fundamental tenet of successful transition. Assigning an individual or team responsibility for the inpatient to home transition can decrease pediatric readmission or ED use after discharge.16

Family Engagement

Although the transfer of health care information at hospital discharge is critical for pediatric patients, it is only 1 small part of the transition process. The family also plays a key role in the transition. During a hospital stay, a team of nurses, physicians, pharmacists, respiratory therapists, and parents/caregivers provide care. However, at discharge the burden of daily care as well as assessment of clinical status becomes the sole responsibility of the parent/caregiver under the guidance of their outpatient medical providers. The transition to home with a child with complex medical needs is often a very stressful change for parents.17,18 Involving parents in the transition process increases their ability and confidence to care for their child.19 Identification of parents who are uncomfortable with discharge could allow for mitigation before hospital discharge.20,21 Finally, family discharge preparation should be tailored to level of English language proficiency (with appropriate translation when appropriate) and health literacy.22,23

Family-centered care (FCC) promotes partnership with families by using the principles of information sharing, respect and honoring differences, partnership and collaboration, negotiation, and care in the context of the family and community.24 FCC in both the inpatient and outpatient setting may aid the hospital to home transition. The principles of FCC have been adopted readily in the pediatric inpatient setting through family-centered rounds allowing for family input on discharge goals, timing, and outpatient arrangements.25 Additionally, FCC in the PCP office decreases unmet health care needs related to transitions and offers families opportunity for shared decision-making.24 One uninvestigated yet potential use of FCC is the inclusion of the patient/caregiver in the discharge communication from the inpatient to outpatient care team. This approach would allow for shared decision-making between health care providers and the family; shared decision-making can help families feel less conflicted about treatment options.26 Family engagement in discharge processes may also lead to innovations around utilization of technology for after discharge care such as texting check-ins or telehealth.

Children With Medical Complexity

Finally, children with chronic conditions may be most vulnerable to suboptimal hospital to home transitions because they use the health care system more frequently and require more complex care coordination.27 Miscommunication between caregivers in the home has led to medication errors in children with chronic conditions.28 The AAP Council on Children With Disabilities published a report on children with complex needs and home care that outlines the areas that need to be addressed when coordinating discharge planning from hospital to home. These include the stability of the child’s medical condition, family, home, community, medical home, training for caregivers, home care nursing, supplies, and insurance coverage. After discharge, continued review of these areas is needed to ensure the best outcome for the child.12 Care coordination for children with special health care needs continues to be problematic and requires timely, effective communication to be successful.29

Other Pediatric Care Transitions

Although STARNet was originally convened to address the inpatient to outpatient transition, the group acknowledged the importance and potential applicability of evidence from various pediatric transitions. For example, a significant body of literature focused on the transitions between PCP and specialists exists. The majority of PCPs and specialists prefer a comanagement approach, especially for children with serious illness or complex medication management.30,31 In the outpatient setting, communication has been improved with the use of electronic medical records.31 It is plausible that shared electronic medical records from the inpatient and outpatient settings would assist inpatient to home transitions.32 Several templates with essential communication elements have been established, including a shared care plan referral form with designated sections to divide responsibility of documentation between parents, PCPs, and specialists.33,34 Such shared templates may serve as a model for hospital discharge improvement efforts.

Checklists and standardized handover for within the hospital transition have shown improvement in communication and accuracy of information shared between providers.35,36 The I-PASS study37–39 seeks to optimize transitions to develop safe, reliable, and efficient hand-offs within the inpatient setting. These concepts could be applied and investigated in hospital to home transition.

Challenges of Measuring and Reducing Readmissions

Readmission is a key measure in current Centers for Medicare and Medicaid Services Medicare reimbursement policy. Attention was given to this metric because of high readmission rates for adults with certain conditions, such as congestive heart failure, pneumonia, and after acute myocardial infarction.40–44 Pediatric readmission rates for a variety of conditions have only recently become widely available.45–47 Overall these rates tend to be lower than those seen in adults. Furthermore, the conditions leading to frequent adult readmission are different than those that result in pediatric readmissions.46

The relationship between pediatric readmission and quality of care is unclear. For example, in 1 study of pediatric readmission, higher readmission rates were observed in states with higher overall care quality scores.48 Another study revealed the documentation of a PCP follow-up plan at discharge was associated with an increase in 30-day readmission rates for pediatric patients.49 Despite the unclear relationship between pediatric readmission and hospital quality, pediatric readmissions have recently been added to Medicaid reimbursement policies in several states, including Texas, Illinois, and New York.50–54

Superficially, readmission rates seem to be a straightforward quality metric that is easy to measure. However, several methods exist to calculate pediatric readmission rates. “All cause” readmission rates include both planned and unplanned readmissions. A more specific focus on unplanned readmissions requires either excluding readmissions based on certain diagnosis and procedure codes46,55 or utilizing individual hospital designations of planned versus unplanned. State Medicaid offices have chosen “potentially preventable readmissions” as the metric upon which reimbursement is determined. The potentially preventable readmissions are defined by using proprietary software developed by 3M-Health Information Systems.56 Unfortunately, the current methods to identify unplanned and potentially preventable readmissions rely on expert opinion and have not been formally validated. Therefore, researchers, improvement scientists, and policy makers must weigh the pros and cons of each method to measure pediatric readmission.

Due to the lower overall pediatric readmission rates compared with adults, researchers and improvement scientists must be aware of the challenges of studying broad interventions applied to all hospitalized patients. In addition to the challenge of identifying the most appropriate measure of readmission, sample size considerations are important for each environment. As a consequence many existing discharge studies are underpowered to detect a change in readmission.16 For readmission reduction quality improvement projects, the challenge is having enough readmission events across each subgroup or substrata to learn rapidly if improvement interventions are having their desired effect.57 For institutions with limited resources, interventions might best be targeted to those children who are at highest risk of readmission.

Certain populations of children have been identified as having higher risk of readmission. At 1 hospital, children with neurologic and oncologic diagnoses comprised the largest groups of patients with short-term readmissions.47 Nationally, the highest rates of 30-day readmission occurred in children with neoplasms.46 When looking over a longer span of time, the highest 365-day rehospitalization rates take place among a small percentage of children with neuromuscular conditions and technology dependence.58 This group accounts for 3% of patients seen at children’s hospitals but 20% of all admissions and 25% of all hospital charges.58 Although the preventability of these hospitalizations is not completely known, readmissions in children with episodic chronic, single lifelong chronic, or multiple and complex clinical risk groups were deemed “more likely preventable” 25% of the time.59 Thus, greatest impact on pediatric readmissions may be achieved through a focus on developing interventions to reduce readmissions for children with specific complex conditions.

Inpatient factors, outpatient factors, and previous health care utilization may be important for determining who is at risk for pediatric readmission. We present a conceptual model of factors contributing to pediatric readmission based on the STARNet discussions and existing literature (Fig 1). In the outpatient arena, a child’s underlying disease process may be a key factor in readmission risk given higher readmission rates for certain conditions and in children with multiple chronic conditions.46,58,60 The patient/families’ ability to care for disease is dependent on outpatient supports, including financial resources.61,62 Ability to care for disease is also related to medical complexity, knowledge, and access to outpatient care.63,64 In the inpatient realm, discharge processes and clinical status likely play a role in readmission.16,65 In particular, a caregiver report of lack of discharge readiness has been associated with readmission risk.21 Additionally, in adults impaired functional status at discharge is associated with readmission.66 Finally, markers of previous health care utilization, although not direct risk factors, may be useful in trying to identify which children are at risk for readmission.58,60,67

FIGURE 1
FIGURE 1

Factors influencing readmission risk of a pediatric patient. Blue circles represent outpatient factors and underlying disease processes. Green circles represent previous health care utilization. Yellow circles represent factors during the hospitalization.

The evidence base for the link between care transition redesign and readmission is drawn primarily from the adult medical literature. In a systematic review of studies of adult readmission interventions, no single intervention was found to be effective in reducing 30-day readmission rates.68 However, some intervention bundles have shown to be effective in reducing readmissions in adults.69–71 In particular, the complex discharges that involve multiple interventions to support patient self-care are most effective.72 For pediatric populations, a systematic review of discharge interventions suggests inpatient tailoring and education with teach-back with postdischarge support may prevent subsequent utilization.16

Preventability of pediatric readmissions is a topic of uncertainty and debate. At a single tertiary care center, 20% of readmissions were rated as preventable on a 5-point Likert preventability scale.59 Readmissions after surgical procedures were more likely preventable than readmissions after medical hospitalizations. Readmissions for central venous catheter infections or ventriculoperitoneal shunt malfunctions (8.5% of the total sample) were considered more likely to be preventable, both of which occurred in patients with underlying serious chronic illnesses. In a second study, readmission after and related to care on a pediatric hospital medicine service was examined. A 14-point classification system was used to classify readmissions into 1 of 3 groups: physician-related, caregiver-related, or disease-related. Preventable readmissions, defined as admissions with at least 1 physician or caregiver-related reason for readmission, comprised 25% of all readmissions.73

The relative importance of the parent/child/health care provider relationships, the role of the discharging hospital, and the outpatient environment on readmission risk remains unclear. Although between-hospital variation in readmissions exists for certain conditions,46 the variability for common pediatric conditions is less (ie, for certain conditions discharging hospitals have very similar readmission rates).45 There is much still to be learned about how the discharge process should be reconstructed to improve outcomes such as medication adherence, trust in providers, and patient-centered disease management. Further assessment is also needed to identify if and how avoidance of a return to ED or hospital setting results in resource savings versus resource reallocation.

Readmission Research Gaps

Transitions are an important aspect of care for all hospitalized children. Using readmission as a metric of successful transition has inherent challenges. Future research in the pediatric readmission realm should focus on the following:

  • Reasons for readmissions, factors that contributed to the readmission, attribution of these causal factors, and potential to mitigate these factors to reduce preventable readmission.

  • The variability in readmission rates attributable to the discharging hospital and further understanding how much the quality of hospital care affects readmission in pediatric populations.

  • Understanding which patients are at high risk for readmission, and recognizing that the relative infrequency of readmission requires enrollment of large numbers of children in interventional studies of readmission prevention.

Measures of Hospital-to-Home Transition

The ultimate goal of transition research must be to ensure the highest quality patient care and prevent harm that can result from poor transitions of care. Given the gaps in understanding pediatric readmission, we propose several other potential measures of hospital-to-home transition (Table 2). These hospital-to-home outcome measures require further study for feasibility, measurement reliability and validity, and effectiveness in preventing harm. Once transition outcome measures are established, interventions to optimize transitions should be further evaluated with a rigorous approach by using quality improvement research methods. Measures may reflect health care utilization, medication adherence/safety, caregiver perspectives, and other aspects of transitions.

View this table:
TABLE 2

Potential Hospital-to-Home Transition Measures

Next Steps for STARNet

This first STARNet meeting offered an opportunity to analyze and synthesize much of the latest, ongoing research and quality improvement work relevant to transitions in care from hospital-to-home. STARNet was envisioned to serve as the nexus for pediatric hospital-to-home transitions work. Many other overlapping domains in health care are relevant to discussions about pediatric transition-related work, including but not limited to care coordination with the primary care medical home, patient-centered outcomes, and national payment reform interests. We have therefore begun to engage primary care pediatricians, family members, payers, and pediatric-to-adult transition experts in an effort to build a broader multistakeholder group that will create a more expansive strategy for improving all pediatric transitions of care, between any 2 points in the health care system. Once convened, this steering committee would work to coordinate a shared national agenda, potentially serving to develop a clearinghouse for transition resources, integrate front-line clinical, research, and quality improvement work, and/or secure funding for sustainability. In the same manner that patient care fragmented across settings is inadequate, an uncoordinated change agenda for pediatric transitions falls short of our potential to transform the system. STARNet aspires to break down barriers between transition-related work with the goal of seamless transitions for our children and high value care. Clear and mutually agreed upon transition agendas are paramount to this effort.

Footnotes

    • Accepted October 1, 2014.
  • Address correspondence to Katherine Auger, MD, MSc, 3333 Burnet Ave, MLC 9016, Cincinnati, OH 45229. E-mail: katherine.auger{at}cchmc.org

  • Dr Auger has participated in the concept and design, and drafting the initial manuscript and revising manuscript; Drs Simon, Cooperberg, Gay, Kuo, Saysana, Stille, Fisher, Wallace, Berry, Coghlin, Jhaveri, Kairys, Ms Logsdon, Drs Shaikh, Srivastava, Starmer, Wilkins, and Shen have participated in the concept and design, and drafting and revising manuscript; and all authors approved the manuscript as submitted.

  • FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

  • FUNDING: The American Academy of Pediatrics provided support for travel. Dr Simon is supported by a cooperative agreement with the Agency for Healthcare Research and Quality and Centers for Medicare and Medicaid Services, grant U18HS020506, part of the Children’s Health Insurance Program Reauthorization Act Pediatric Quality Measures Program; and award K23NS062900 from the National Institute of Neurologic Disorders and Stroke. None of the sponsors participated in design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript. Its contents are solely the authors and do not necessarily represent the official view of the funders. Funded by the National Institutes of Health (NIH).

  • POTENTIAL CONFLICT OF INTEREST: Dr Jhaveri represented Blue Cross Blue Shield Association; the other authors have indicated they have no potential conflicts of interest to disclose.

References

  1. ↵
    Society of Hospital Medicine. BOOST, Better Outcomes by Optimizing Safe Transitions. Available at: www.hospitalmedicine.org/AM/Template.cfm?Section=Home&TEMPLATE=/CM/HTMLDisplay.cfm&CONTENTID=27659. Accessed November 3, 2013
  2. Boston Medical Center. Project RED: Re-Engineered Discharge. Available at: https://www.bu.edu/fammed/projectred/. Accessed April 15, 2014
  3. ↵
    Institute for Healthcare Improvement. STAAAR: State Action on Avoidable Rehospitalizations. Available at: www.ihi.org/engage/Initiatives/completed/STAAR/Pages/default.aspx. Accessed April 15, 2014
  4. ↵
    1. Coleman EA,
    2. Boult C,
    3. American Geriatrics Society Health Care Systems Committee
    . Improving the quality of transitional care for persons with complex care needs. J Am Geriatr Soc. 2003;51(4):556–557pmid:12657079
    OpenUrlCrossRefPubMed
  5. ↵
    1. Kripalani S,
    2. Jackson AT,
    3. Schnipper JL,
    4. Coleman EA
    . Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. 2007;2(5):314–323pmid:17935242
    OpenUrlCrossRefPubMed
  6. ↵
    1. Harlan GA,
    2. Nkoy FL,
    3. Srivastava R,
    4. et al
    . Improving transitions of care at hospital discharge—implications for pediatric hospitalists and primary care providers. J Healthc Qual. 2010;32(5):51–60pmid:20854359
    OpenUrlPubMed
  7. ↵
    1. van Walraven C,
    2. Seth R,
    3. Austin PC,
    4. Laupacis A
    . Effect of discharge summary availability during post-discharge visits on hospital readmission. J Gen Intern Med. 2002;17(3):186–192pmid:11929504
    OpenUrlCrossRefPubMed
  8. ↵
    1. Moyer VA,
    2. Singh H,
    3. Finkel KL,
    4. Giardino AP
    . Transitions from neonatal intensive care unit to ambulatory care: description and evaluation of the proactive risk assessment process. Qual Saf Health Care. 2010;19(suppl 3):i26–i30pmid:20959314
    OpenUrlAbstract/FREE Full Text
  9. ↵
    1. Coghlin DT,
    2. Leyenaar JK,
    3. Shen M,
    4. et al
    . Pediatric discharge content: a multisite assessment of physician preferences and experiences. Hosp Pediatr. 2014;4(1):9–15pmid:24435595
    OpenUrlAbstract/FREE Full Text
  10. ↵
    1. Leyenaar JK,
    2. Bergert L,
    3. Mallory LA,
    4. et al
    . Pediatric primary care providers’ perspectives regarding hospital discharge communication: a mixed methods analysis. Acad Pediatr. (in press)
  11. ↵
    1. Hess DR,
    2. Tokarczyk A,
    3. O’Malley M,
    4. Gavaghan S,
    5. Sullivan J,
    6. Schmidt U
    . The value of adding a verbal report to written handoffs on early readmission following prolonged respiratory failure. Chest. 2010;138(6):1475–1479pmid:21138883
    OpenUrlCrossRefPubMed
  12. ↵
    1. Elias ER,
    2. Murphy NA,
    3. Council on Children with Disabilities
    . Home care of children and youth with complex health care needs and technology dependencies. Pediatrics. 2012;129(5):996–1005pmid:22547780
    OpenUrlAbstract/FREE Full Text
    1. White CM,
    2. Statile AM,
    3. White DL,
    4. et al
    . Using quality improvement to optimise paediatric discharge efficiency. BMJ Qual Saf. 2014;23(5):428–436pmid:24470173
    OpenUrlAbstract/FREE Full Text
  14. ↵
    1. Berry JG,
    2. Blaine K,
    3. Rogers J,
    4. et al
    . A framework of pediatric hospital discharge care informed by legislation, research, and practice. JAMA Pediatr. 2014;168(10):955–962pmid:25155156
    OpenUrlCrossRefPubMed
  15. ↵
    1. McDonald KM,
    2. Sundaram V,
    3. Bravata DM,
    4. et al
    . Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. Vol 7. Rockville, MD: Care Coordination; 2007
  16. ↵
    1. Auger KA,
    2. Kenyon CC,
    3. Feudtner C,
    4. Davis MM
    . Pediatric hospital discharge interventions to reduce subsequent utilization: a systematic review. J Hosp Med. 2014;9(4):251–260pmid:24357528
    OpenUrlCrossRefPubMed
  17. ↵
    1. Hartman DM,
    2. Medoff-Cooper B
    . Transition to home after neonatal surgery for congenital heart disease. MCN Am J Matern Child Nurs. 2012;37(2):95–100pmid:22357070
    OpenUrlCrossRefPubMed
  18. ↵
    1. Boykova M,
    2. Kenner C
    . Transition from hospital to home for parents of preterm infants. J Perinat Neonatal Nurs. 2012;26(1):81–87, quiz 88–89pmid:22293645
    OpenUrlCrossRefPubMed
  19. ↵
    1. Griffin T,
    2. Abraham M.
    Transition to home from the newborn intensive care unit: applying the principles of family-centered care to the discharge process. J Perinat Neonatal Nurs. 2006;20(3):243–249, quiz 250–251
    OpenUrlCrossRefPubMed
  20. ↵
    1. Lerret SM,
    2. Weiss ME
    . How ready are they? Parents of pediatric solid organ transplant recipients and the transition from hospital to home following transplant. Pediatr Transplant. 2011;15(6):606–616pmid:21736682
    OpenUrlPubMed
  21. ↵
    1. Berry JG,
    2. Ziniel SI,
    3. Freeman L,
    4. et al
    . Hospital readmission and parent perceptions of their child’s hospital discharge. Int J Qual Health Care. 2013;25(5):573–581pmid:23962990
    OpenUrlAbstract/FREE Full Text
  22. ↵
    1. Giuse NB,
    2. Koonce TY,
    3. Storrow AB,
    4. Kusnoor SV,
    5. Ye F
    . Using health literacy and learning style preferences to optimize the delivery of health information. J Health Commun. 2012;17(suppl 3):122–140pmid:23030566
    OpenUrlCrossRefPubMed
  23. ↵
    1. Mitchell SE,
    2. Sadikova E,
    3. Jack BW,
    4. Paasche-Orlow MK
    . Health literacy and 30-day postdischarge hospital utilization. J Health Commun. 2012;17(suppl 3):325–338pmid:23030580
    OpenUrlCrossRefPubMed
  24. ↵
    1. Kuo DZ,
    2. Frick KD,
    3. Minkovitz CS
    . Association of family-centered care with improved anticipatory guidance delivery and reduced unmet needs in child health care. Matern Child Health J. 2011;15(8):1228–1237pmid:21057865
    OpenUrlCrossRefPubMed
  25. ↵
    1. Muething SE,
    2. Kotagal UR,
    3. Schoettker PJ,
    4. Gonzalez del Rey J,
    5. DeWitt TG
    . Family-centered bedside rounds: a new approach to patient care and teaching. Pediatrics. 2007;119(4):829–832pmid:17403858
    OpenUrlAbstract/FREE Full Text
  26. ↵
    1. Brinkman WB,
    2. Hartl Majcher J,
    3. Poling LM,
    4. et al
    . Shared decision-making to improve attention-deficit hyperactivity disorder care. Patient Educ Couns. 2013;93(1):95–101pmid:23669153
    OpenUrlCrossRefPubMed
  27. ↵
    1. Berry JG,
    2. Hall M,
    3. Hall DE,
    4. et al
    . Inpatient growth and resource use in 28 children’s hospitals: a longitudinal, multi-institutional study. JAMA Pediatr. 2013;167(2):170–177pmid:23266509
    OpenUrlCrossRefPubMed
  28. ↵
    1. Walsh KE,
    2. Mazor KM,
    3. Stille CJ,
    4. et al
    . Medication errors in the homes of children with chronic conditions. Arch Dis Child. 2011;96(6):581–586pmid:21444297
    OpenUrlAbstract/FREE Full Text
  29. ↵
    1. Stille CJ,
    2. Antonelli RC
    . Coordination of care for children with special health care needs. Curr Opin Pediatr. 2004;16(6):700–705pmid:15548935
    OpenUrlCrossRefPubMed
  30. ↵
    1. Forrest CB,
    2. Glade GB,
    3. Baker AE,
    4. Bocian AB,
    5. Kang M,
    6. Starfield B
    . The pediatric primary-specialty care interface: how pediatricians refer children and adolescents to specialty care. Arch Pediatr Adolesc Med. 1999;153(7):705–714pmid:10401803
    OpenUrlCrossRefPubMed
  31. ↵
    1. Stille CJ,
    2. McLaughlin TJ,
    3. Primack WA,
    4. Mazor KM,
    5. Wasserman RC
    . Determinants and impact of generalist-specialist communication about pediatric outpatient referrals. Pediatrics. 2006;118(4):1341–1349pmid:17015522
    OpenUrlAbstract/FREE Full Text
  32. ↵
    1. Coleman EA,
    2. Smith JD,
    3. Raha D,
    4. Min SJ
    . Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 2005;165(16):1842–1847pmid:16157827
    OpenUrlCrossRefPubMed
  33. ↵
    1. Stille CJ,
    2. Mazor KM,
    3. Meterko V,
    4. Wasserman RC
    . Development and validation of a tool to improve paediatric referral/consultation communication. BMJ Qual Saf. 2011;20(8):692–697pmid:21339312
    OpenUrlAbstract/FREE Full Text
  34. ↵
    1. Stille CJ,
    2. Fischer SH,
    3. La Pelle N,
    4. Dworetzky B,
    5. Mazor KM,
    6. Cooley WC
    . Parent partnerships in communication and decision making about subspecialty referrals for children with special needs. Acad Pediatr. 2013;13(2):122–132pmid:23356961
    OpenUrlCrossRefPubMed
  35. ↵
    1. Nakayama DK,
    2. Lester SS,
    3. Rich DR,
    4. Weidner BC,
    5. Glenn JB,
    6. Shaker IJ
    . Quality improvement and patient care checklists in intrahospital transfers involving pediatric surgery patients. J Pediatr Surg. 2012;47(1):112–118pmid:22244402
    OpenUrlCrossRefPubMed
  36. ↵
    1. Agarwal HS,
    2. Saville BR,
    3. Slayton JM,
    4. et al
    . Standardized postoperative handover process improves outcomes in the intensive care unit: a model for operational sustainability and improved team performance*. Crit Care Med. 2012;40(7):2109–2115pmid:22710203
    OpenUrlCrossRefPubMed
  37. ↵
    1. Starmer AJ,
    2. Spector ND,
    3. Srivastava R,
    4. Allen AD,
    5. Landrigan CP,
    6. Sectish TC,
    7. I-PASS Study Group
    . I-pass, a mnemonic to standardize verbal handoffs. Pediatrics. 2012;129(2):201–204pmid:22232313
    OpenUrlFREE Full Text
    1. Starmer AJ,
    2. O’Toole JK,
    3. Rosenbluth G,
    4. et al.
    Development, implementation, and dissemination of the I-PASS handoff curriculum: a multisite educational intervention to improve patient handoffs. Acad Med. 2014;89(6):876–884
    OpenUrlCrossRefPubMed
  39. ↵
    1. Sectish TC,
    2. Starmer AJ,
    3. Landrigan CP,
    4. Spector ND,
    5. I-PASS Study Group
    . Establishing a multisite education and research project requires leadership, expertise, collaboration, and an important aim. Pediatrics. 2010;126(4):619–622pmid:20876168
    OpenUrlFREE Full Text
  40. ↵
    1. Dharmarajan K,
    2. Hsieh AF,
    3. Lin Z,
    4. et al
    . Hospital readmission performance and patterns of readmission: retrospective cohort study of Medicare admissions. BMJ. 2013;347:f6571pmid:24259033
    OpenUrlAbstract/FREE Full Text
    1. Krumholz HM,
    2. Merrill AR,
    3. Schone EM,
    4. et al
    . Patterns of hospital performance in acute myocardial infarction and heart failure 30-day mortality and readmission. Circ Cardiovasc Qual Outcomes. 2009;2(5):407–413pmid:20031870
    OpenUrlAbstract/FREE Full Text
    1. Friedman B,
    2. Basu J
    . The rate and cost of hospital readmissions for preventable conditions. Med Care Res Rev. 2004;61(2):225–240pmid:15155053
    OpenUrlAbstract/FREE Full Text
    1. Shalchi Z,
    2. Saso S,
    3. Li HK,
    4. Rowlandson E,
    5. Tennant RC
    . Factors influencing hospital readmission rates after acute medical treatment. Clin Med. 2009;9(5):426–430pmid:19886100
    OpenUrlAbstract/FREE Full Text
  44. ↵
    1. Krumholz HM,
    2. Parent EM,
    3. Tu N,
    4. et al
    . Readmission after hospitalization for congestive heart failure among Medicare beneficiaries. Arch Intern Med. 1997;157(1):99–104pmid:8996046
    OpenUrlCrossRefPubMed
  45. ↵
    1. Bardach NS,
    2. Vittinghoff E,
    3. Asteria-Peñaloza R,
    4. et al
    . Measuring hospital quality using pediatric readmission and revisit rates. Pediatrics. 2013;132(3):429–436pmid:23979094
    OpenUrlAbstract/FREE Full Text
  46. ↵
    1. Berry JG,
    2. Toomey SL,
    3. Zaslavsky AM,
    4. et al
    . Pediatric readmission prevalence and variability across hospitals. JAMA. 2013;309(4):372–380pmid:23340639
    OpenUrlCrossRefPubMed
  47. ↵
    Gay JC, Hain PD, Grantham JA, Saville BR. Epidemiology of 15-day readmissions to a children’s hospital. Pediatrics. 2011;127(6). Available at: www.pediatrics.org/cgi/content/full/113/2/e1505
  48. ↵
    1. Feudtner C,
    2. Pati S,
    3. Goodman DM,
    4. et al.
    State-level child health system performance and the likelihood of readmission to children’s hospitals. J Pediatr. 2010;157(1):98–102
    OpenUrlCrossRefPubMed
  49. ↵
    1. Coller RJ,
    2. Klitzner TS,
    3. Lerner CF,
    4. Chung PJ
    . Predictors of 30-day readmission and association with primary care follow-up plans. J Pediatr. 2013;163(4):1027–1033pmid:23706518
    OpenUrlCrossRefPubMed
  50. ↵
    New York State Department of Health Division of Quality and Evaluation Office of Health Insurance Programs. Potentially preventable hospital readmissions among Medicaid recipients: New York State, 2007. Published 2007. Available at: www.health.ny.gov/health_care/managed_care/reports/statistics_data/2hospital_readmissions.pdf. Accessed September 27, 2013
  51. Texas Health and Human Services Commission. Potentially preventable readmissions in the Texas Medicaid population, state fiscal year 2011. Published 2012. Available at: www.hhsc.state.tx.us/reports/2012/PPR-Readmissions-FY2011.pdf. Accessed September 27, 2013
  52. Illinois Department of Healthcare and Family Services. Department of Healthcare and Family Services potentially preventable readmissions policy. Available at: https://www2.illinois.gov/hfs/SiteCollectionDocuments/PPR_Overview.pdf. Accessed October 14, 2014
  53. Texas Health Care, Regional Healthcare Partnership-Region 6. Potentially preventable readmissions in the Texas Medicaid population. Published 2014. Available at: www.texasrhp6.com/potentially-preventable-readmissions-in-the-texas-medicaid-population/. Accessed June 18, 2014
  54. ↵
    NYS Health Foundation. Grant outcome report. Published 2012. Available at: http://nyshealthfoundation.org/uploads/gor/reducing-hospital-readmissions-mathematica-june-2012.pdf. Accessed October 20, 2014
  55. ↵
    3M Health Information Systems. Potentially preventable readmissions classification system: methodology overview. Published 2008. Available at: http://multimedia.3m.com/mws/mediawebserver?66666UuZjcFSLXTtNXMtmxMEEVuQEcuZgVs6EVs6E666666–.
  56. ↵
    1. Goldfield NI,
    2. McCullough EC,
    3. Hughes JS,
    4. et al
    . Identifying potentially preventable readmissions. Health Care Financ Rev. 2008;30(1):75–91pmid:19040175
    OpenUrlPubMed
  57. ↵
    1. Benneyan JC
    . Statistical quality control methods in infection control and hospital epidemiology, Part II: Chart use, statistical properties, and research issues. Infect Control Hosp Epidemiol. 1998;19(4):265–283pmid:9605277
    OpenUrlCrossRefPubMed
  58. ↵
    1. Berry JG,
    2. Hall DE,
    3. Kuo DZ,
    4. et al
    . Hospital utilization and characteristics of patients experiencing recurrent readmissions within children’s hospitals. JAMA. 2011;305(7):682–690pmid:21325184
    OpenUrlCrossRefPubMed
  59. ↵
    1. Hain PD,
    2. Gay JC,
    3. Berutti TW,
    4. Whitney GM,
    5. Wang W,
    6. Saville BR
    . Preventability of early readmissions at a children’s hospital. Pediatrics. 2013;131(1). Available at: www.pediatrics.org/cgi/content/full/131/1/e171pmid:23230064
    OpenUrlAbstract/FREE Full Text
  60. ↵
    1. Kenyon CC,
    2. Melvin PR,
    3. Chiang VW,
    4. Elliott MN,
    5. Schuster MA,
    6. Berry JG
    . Rehospitalization for childhood asthma: timing, variation, and opportunities for intervention. J Pediatr. 2014;164(2):300–305pmid:24238863
    OpenUrlCrossRefPubMed
  61. ↵
    1. Victorino CC,
    2. Gauthier AH
    . The social determinants of child health: variations across health outcomes - a population-based cross-sectional analysis. BMC Pediatr. 2009;9:53pmid:19686599
    OpenUrlCrossRefPubMed
  62. ↵
    1. Williams DR,
    2. Sternthal M,
    3. Wright RJ
    . Social determinants: taking the social context of asthma seriously. Pediatrics. 2009;123(suppl 3):S174–S184pmid:19221161
    OpenUrlAbstract/FREE Full Text
  63. ↵
    1. Auger KA,
    2. Kahn RS,
    3. Davis MM,
    4. Beck AF,
    5. Simmons JM
    . Medical home quality and readmission risk for children hospitalized with asthma exacerbations. Pediatrics. 2013;131(1):64–70pmid:23230073
    OpenUrlAbstract/FREE Full Text
  64. ↵
    1. Auger KA,
    2. Kahn RS,
    3. Davis MM,
    4. Simmons JM
    . Pediatric asthma readmission: asthma knowledge is not enough [published online ahead of print September 17, 2014]? J Pediatr. doi:10.1016/j.jpeds.2014.07.046pmid:25241184
    OpenUrlPubMed
  65. ↵
    1. Bergert L,
    2. Patel SJ,
    3. Kimata C,
    4. Zhang G,
    5. Matthews WJ Jr
    . Linking patient-centered medical home and asthma measures reduces hospital readmission rates. Pediatrics. 2014;134(1). Available at: www.pediatrics.org/cgi/content/full/134/1/e249pmid:24936001
    OpenUrlAbstract/FREE Full Text
  66. ↵
    1. Hoyer EH,
    2. Needham DM,
    3. Atanelov L,
    4. Knox B,
    5. Friedman M,
    6. Brotman DJ
    . Association of impaired functional status at hospital discharge and subsequent rehospitalization. J Hosp Med. 2014;9(5):277–282pmid:24616216
    OpenUrlCrossRefPubMed
  67. ↵
    1. Bloomberg GR,
    2. Trinkaus KM,
    3. Fisher EB Jr,
    4. Musick JR,
    5. Strunk RC
    . Hospital readmissions for childhood asthma: a 10-year metropolitan study. Am J Respir Crit Care Med. 2003;167(8):1068–1076pmid:12684246
    OpenUrlCrossRefPubMed
  68. ↵
    1. Hansen LO,
    2. Young RS,
    3. Hinami K,
    4. Leung A,
    5. Williams MV
    . Interventions to reduce 30-day rehospitalization: a systematic review. Ann Intern Med. 2011;155(8):520–528pmid:22007045
    OpenUrlCrossRefPubMed
  69. ↵
    1. Coleman EA,
    2. Parry C,
    3. Chalmers S,
    4. Min SJ
    . The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166(17):1822–1828pmid:17000937
    OpenUrlCrossRefPubMed
    1. Koehler BE,
    2. Richter KM,
    3. Youngblood L,
    4. et al
    . Reduction of 30-day postdischarge hospital readmission or emergency department (ED) visit rates in high-risk elderly medical patients through delivery of a targeted care bundle. J Hosp Med. 2009;4(4):211–218pmid:19388074
    OpenUrlCrossRefPubMed
  71. ↵
    1. Brock J,
    2. Mitchell J,
    3. Irby K,
    4. et al.,
    5. Care Transitions Project Team
    . Association between quality improvement for care transitions in communities and rehospitalizations among Medicare beneficiaries. JAMA. 2013;309(4):381–391pmid:23340640
    OpenUrlCrossRefPubMed
  72. ↵
    1. Leppin AL,
    2. Gionfriddo MR,
    3. Kessler M,
    4. et al
    . Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials. JAMA Intern Med. 2014;174(7):1095–1107pmid:24820131
    OpenUrlCrossRefPubMed
  73. ↵
    Wallace S, Dejohn C, Nead J, Nag P, Quinonez R. A novel systematic approach to the analysis of pediatric hospital readmissions. In: Pediatric Hospital Medicine National Meeting; July 27–31, 2011; Kansas City, MO
    1. Institute of Medicine (United States)
    . Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001
    1. Weiss M,
    2. Johnson NL,
    3. Malin S,
    4. Jerofke T,
    5. Lang C,
    6. Sherburne E
    . Readiness for discharge in parents of hospitalized children. J Pediatr Nurs. 2008;23(4):282–295pmid:18638672
    OpenUrlCrossRefPubMed
    1. Bernstein HH,
    2. Spino C,
    3. Baker A,
    4. Slora EJ,
    5. Touloukian CL,
    6. McCormick MC
    . Postpartum discharge: do varying perceptions of readiness impact health outcomes? Ambul Pediatr. 2002;2(5):388–395
    OpenUrlCrossRefPubMed
    1. Strickland B,
    2. McPherson M,
    3. Weissman G,
    4. van Dyck P,
    5. Huang ZJ,
    6. Newacheck P
    . Access to the medical home: results of the National Survey of Children with Special Health Care Needs. Pediatrics. 2004;113(suppl 5):1485–1492pmid:15121916
    OpenUrlAbstract/FREE Full Text
    1. Seid M,
    2. Varni JW,
    3. Bermudez LO,
    4. et al
    . Parents’ perceptions of primary care: measuring parents’ experiences of pediatric primary care quality. Pediatrics. 2001;108(2):264–270pmid:11483786
    OpenUrlAbstract/FREE Full Text
    1. Solomon LS,
    2. Hays RD,
    3. Zaslavsky AM,
    4. Ding L,
    5. Cleary PD
    . Psychometric properties of a group-level Consumer Assessment of Health Plans Study (CAHPS) instrument. Med Care. 2005;43(1):53–60pmid:15626934
    OpenUrlPubMed
    1. Flocke SA
    . Measuring attributes of primary care: development of a new instrument. J Fam Pract. 1997;45(1):64–74pmid:9228916
    OpenUrlPubMed
    1. Roy CL,
    2. Poon EG,
    3. Karson AS,
    4. et al
    . Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005;143(2):121–128pmid:16027454
    OpenUrlCrossRefPubMed
    1. Walz SE,
    2. Smith M,
    3. Cox E,
    4. Sattin J,
    5. Kind AJ
    . Pending laboratory tests and the hospital discharge summary in patients discharged to sub-acute care. J Gen Intern Med. 2011;26(4):393–398pmid:21116868
    OpenUrlCrossRefPubMed
    1. Ruth JL,
    2. Geskey JM,
    3. Shaffer ML,
    4. Bramley HP,
    5. Paul IM
    . Evaluating communication between pediatric primary care physicians and hospitalists. Clin Pediatr (Phila). 2011;50(10):923–928pmid:21576183
    OpenUrlAbstract/FREE Full Text
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Pediatrics
Vol. 135, Issue 1
1 Jan 2015
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Summary of STARNet: Seamless Transitions and (Re)admissions Network
Katherine A. Auger, Tamara D. Simon, David Cooperberg, James Gay, Dennis Z. Kuo, Michele Saysana, Christopher J. Stille, Erin Stucky Fisher, Sowdhamini Wallace, Jay Berry, Daniel Coghlin, Vishu Jhaveri, Steven Kairys, Tina Logsdon, Ulfat Shaikh, Rajendu Srivastava, Amy J. Starmer, Victoria Wilkins, Mark W. Shen
Pediatrics Jan 2015, 135 (1) 164-175; DOI: 10.1542/peds.2014-1887
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