A Telehealth-Based Transitional Care Model for Children with Medical Complexity

By utilizing nurses working at the top of their license, readmission rates were reduced for a diverse, high-risk patient population. Novel features of the program included minimal exclusion criteria; bridging inpatient and outpatient care teams; and the ability to address clinical questions, care coordination, and social determinants of health needs through a single point of contact. Successful implementation at a second hospital suggests that the model to reduce readmission rates in complex patients could be replicated elsewhere.