Hospital to Home Outcomes

Hospital to Home Outcomes (H2O): A Study to Improve the Fluidity of Transitions Between Hospital and Home

Home Nurse Visit post discharge.

To identify barriers to successful transitions that are most meaningful to patients and families, and use these identified barriers to iteratively adapt an existing nurse home visit program to address these barriers. This study will also test the efficacy of a nurse home visit intervention in improving post-discharge outcomes through a randomized controlled trial.

Inclusion Criteria:

• Patient is under 18 years of age Patient is admitted to Cincinnati Children's Hospital Medical Center to hospital medicine, community pediatrics, adolescent medicine, neurology or neurosurgery.

Exclusion Criteria:

• Patient to be discharged someplace other than home (e.g., residential facility, psychiatric facility)
• Patient's home residence is outside the home nursing service area
• Patient is eligible for "traditional" home nursing services
• Caregiver is non-English speaking