Utilizing Family-Centered Process and Outcome Measures to Assess Hospital-to-Home Transition Quality

Families of pediatric patients face numerous potential challenges during their transition from hospital settings to home. These include poor preparation for home care management, conflicting expectations regarding the recovery process, lack of support after discharge, and discontinuity of care.¹ Approximately 1 of 4 pediatric patients experience a postdischarge problem,² with one third of these requiring significant action from a health care provider.³ Thus, efforts to standardize pediatric hospitalization discharge processes and measure improvement in outcomes remains a clinical, research, and policy priority.

In the November/December 2016 issue of Academic Pediatrics, we reported on the development of 8 new caregiver-reported measures to assess the quality of hospital- and emergency department (ED)-to-home transitions.⁴ Our purpose with this commentary is to provide readers with a progress report of published studies related to this topic since we submitted the original article. Our original study was conducted by the Center of Excellence on Quality of Care Measures for Children with Complex Needs (COE4CCN), created by the national Pediatric Quality Measures Program mandated by the Children’s Health Insurance Program Reauthorization Act of 2009. These quality measures focus on care processes related to preparing families for hospital-and ED-to-home transitions and include assessments of the quality of discharge education, assistance with scheduling follow-up appointments, and written discharge instructions.

In 2017, Parast et al⁵ published a subsequent study describing the validation results of these 8 caregiver-reported quality measures. In this study, respondents received 2 surveys with items assessing the 8 COE4CCN quality measures along with items from the Child Hospital Consumer Assessment of Healthcare Providers and Systems survey, items assessing parent perceptions of discharge, items assessing whether all needed follow-up visits were scheduled or completed, and whether the child had a return ED visit or hospital readmission since discharge. The authors established convergent validity of the COE4CCN measures with items from the Child Hospital Consumer Assessment of Healthcare Providers and Systems survey and with the parent perceptions of discharge survey items. The authors also established predictive validity of the COE4CCN measure related to providing assistance with scheduling follow-up appointments, which was significantly associated with greater odds of successful scheduling or completion of all needed follow-up appointments.

In addition to the aforementioned 8 quality measures, other measures to assess pediatric hospital-to-home transition quality have been developed and/or validated since we submitted our original article. All of these measures are summarized in Table 1.^4–8 The COE4CCN also developed 2 medical record–based measures to assess the quality of hospital-to-home transitions.⁶ The first measure assesses the quality of a “transition record” (eg, discharge instructions) provided to patients and families, which recommends documentation of 9 key pieces of content, including medication and appointment lists, 24/7 telephone contact number if problems arise, and recommended follow-up tests. The second measure assesses whether timely discharge communication occurred between inpatient and outpatient providers.

Table 1.

Family-Centered Process and Outcome Experience Measures to Assess Hospital-to-Home Transition Quality

Authors	Measure Name	Data Source	Description	Strengths	Limitations
COE4CCN (Desai etal,4 Parast et al5)	Hospital-to-home Transition Quality Measures	Caregiver report	Eight quality measures (6 hospital-to-home measures; 2 ED-to-home measures) assessing processes of care related to the quality of discharge education, scheduling follow-up appointments, and written discharge instructions.	Evidence-based; established face validity, convergent validity, and predictive validity; each measure can be used individually	Pilot tested at a single site; noestablished predictive validity with readmissions or return ED visits after discharge.
COE4CCN (Leyenaar et al6)	Hospital-to-home Transition Quality Measures	Medical record	Two quality measures assessing the quality of 1) transition record provided to families containing 9 key components; and 2) timely discharge communication between inpatient and outpatient providers.	Evidence-based; established face validity; strong interrater reliability of medical record abstract tool (κ = 0.83–0.94 for eligibility; κ = 0.89–1.0 for scoring); pilot tested at multiple sites demonstrating substantial variation; each measure can be used individually	No established predictive validity with 7- and 30-day readmissions or return ED visits.
Weiss et al7	Quality of Discharge Teaching Scale (QDTS)	Caregiver report	An 18-item tool to assess the content and quality of teaching provided by the child’s nurse at the time of discharge.	High internal consistency reliability (Cronbach alpha 0.88–0.92); established construct validity and convergent validity.	Lengthy measure; no established predictive validity with PDCDS or 30-day readmissions/ return ED visits.
Weiss et al7	Readiness for Hospital Discharge Scale (Parent RHDS and Nurse RHDS)	Caregiver report; nurse report	A 29-item tool to assess parent perceptions of readiness for their child’s discharge on the day of discharge.	High internal consistency reliability (Cronbach alpha 0.83–0.92); established construct validity, convergent validity and predictive validity (established association between nurse RHDS and 30-day readmissions).	Lengthy measure; no established predictive validity between parent RHDS and 30-day readmissions/return ED visits.
Weiss et al7	Post-Discharge Coping Difficulty Scale (PDCDS)	Caregiver report	Eleven-item tool to assess the degree of parental difficulty in coping with stress, recovery, family self-management, support, confidence, and child’s adjustment after hospital discharge.	High internal consistency reliability (Cronbach alpha 0.84); established construct validity and convergent validity.
Desai et al8	Pediatric Transition Experience Measure (P-TEM)	Caregiver report	Eight-item measure to assess the quality of discharge preparation, support during transitions, care coordination, and follow-up care.	Short measure of full transition experience; established content validity; high internal consistency reliability (McDonald coefficient omega 0.84); invariance testing established similar interpretability of items across medical complexity groups).	Pilot tested at a single site; no established convergent or predictive validity (in progress).

COE4CCN indicates Left of Excellence on Quality of Care Measures for Children with Complex Needs.

Weiss et al⁷ further validated measures related to the quality of discharge teaching and readiness for hospital discharge with measures of postdischarge coping difficulty, 30-day ED return visits, and 30-day readmissions. The authors demonstrated a positive association between the quality of discharge teaching and readiness for discharge; however, the quality of discharge teaching was not associated with postdischarge coping difficulty, ED return visits, or readmissions. In contrast, parent-reported readiness for discharge was negatively associated with postdischarge coping difficulty, and nurse-reported readiness for discharge was associated with lower odds of readmission.

More recently, we developed a new 8-item caregiver-reported pediatric hospital-to-home transition experience measure (P-TEM), which assesses the quality of discharge preparation, support during transitions, care coordination, and follow-up care.⁸ The item constructs were based on a qualitative exploration of caregiver perceptions of successful hospital-to-home transitions.¹ We conducted cognitive interviews to improve the face validity of the measure, psychometric analyses to identify the most parsimonious measure to capture these constructs, and invariance testing to ensure similar interpretability of the measure across children with varying levels of medical complexity.

One of the challenges of using family-centered out-comes to assess the quality of care is that surveys may be time-intensive for respondents to complete, and surveys can be logistically burdensome and costly to administer. A key strength of the COE4CCN measures is that each measure can be assessed individually using a limited set of survey items without requiring completion of an entire instrument; therefore, this may help to minimize the administrative burden of administering these measures. The P-TEM also was developed with a similar goal in mind and underwent extensive psychometric testing to capture important constructs for successful transitions in a parsimonious, 8-item experience measure. However, compared with measures developed by Weiss et al, these measures have not been as extensively tested. For example, the Readiness for Hospital Discharge Scale has been validated in multiple populations and settings, and the Post-Discharge Coping Difficulty Scale was used in the evaluation of a recently published intervention to examine the utility of postdischarge nurse home visits for pediatric patients.⁹ In contrast, the COE4CCN caregiver-reported measures and P-TEM require further testing beyond a single institution to examine performance in multiple contexts, populations, and to demonstrate meaningful change in response to care transition interventions. Notably, the COE4CCN medical record measures are undergoing additional testing as part of the Pediatric Hospital Care Improvement Project, a new 8-hospital quality improvement collaborative to target improvement in these medical record–based measures in partnership with the Children’s Hospital Association and the Pediatric Research in Inpatient Settings network.

In the past decade, considerable efforts have been made to advance the field of quality improvement and measurement to reduce patient harm, maximize quality, and optimize health outcomes for children. It may be too early to know whether the measures described in this commentary will be widely adopted to assess the quality of pediatric hospital- or ED-to-home transitional care, as some of them were only recently developed. However, integrating these family-centered process and outcome measures in the standardized evaluation of pediatric hospital- and ED-to-home transition interventions will add to these quality measurement efforts, moving us toward systems of care that best meet the needs of pediatric patients and their families.

WHAT’S NEW.

Given the pervasiveness of postdischarge problems for children and families, improving pediatric hospital-and emergency department-to-home transition quality remains a priority. This article describes recent advancements in quality measurement to provide a patient and family-centered assessment of these transitions.