Patients and families randomized to this arm will receive best practice standard of care hospital-based transition planning in the hospital with routine outpatient care team follow-up post-discharge.

The GET2HOME intervention includes: 1) a pre-discharge telehealth huddle with the family, inpatient team, primary care team, and home care nursing; 2) a visual discharge task tracker (DTT) to monitor progress across care management tasks; and if desired by family and primary care 3) a post-discharge telehealth huddle 2-7 days after discharge with the family, inpatient team, primary care team, and home care nursing

Intervention bundle designed to improve discharge effectiveness

Yes/no to any: unplanned hospital readmission, ED revisit, or urgent care visit

Quality of Life assessment for child, caregiver and family; minimum score 0, maximum score 100; higher score means a better outcome

Family-reported challenges with medications, medical supplies, and follow-up

Pediatric Transition Experience Measure (P-TEM) is an 8-item, parent reported measure on a 0-100 scale, in which higher scores reflect better quality