Hospital-to-Home Care Coordination for Children and Youth With Special Health Care Needs

What this Trial Is About

Researchers are evaluating the hospital-to-home transitional care interventions (H2H-TCI) for children and youth with special health care needs (CYSHCN) who are hospitalized. The study aims to compare the effectiveness of two approaches—focused dose versus extended dose interventions—on health service use and parent-reported confidence. It also examines how these interventions work among vulnerable subgroups and studies the implementation process using a mixed methods design. Participants will be randomly assigned to receive either a focused dose or an extended dose H2H-TCI. The focused dose group receives a single phone call from a clinical interventionist within 72 hours after hospital discharge, which follows a structured template including follow-up care access, medication review, and family education. The extended dose group receives the same initial call plus weekly phone calls for one month, delivered by a trained transition coach using the Care Transitions Intervention© model. During the study, data will be collected from electronic health records and caregiver reports to measure acute care use within 30 days post-discharge and caregiver confidence at baseline and 30 days after discharge. Secondary outcomes include emergency visits, readmissions, follow-up visit attendance, caregiver strain, mental health-related quality of life, and quality of care transitions assessed at various time points up to 90 days post-discharge. The study includes safety oversight by a Data Safety and Monitoring Board and secure data handling procedures, with participation lasting through these follow-up assessments.

Hospital-to-Home Transitional Care Interventions (H2H-TCI) Children/Youth With Special Health Care Needs (CYSHCN)