Care coordination for children transitioning from hospital to home: a literature review

The changing epidemiology of child health means that an increasing number of children with chronic and complex health issues live well into adulthood, most of whom will require life-long care coordination. The needs of these children cross multiple disciplines and involve many subsystems. The current economic climate places heavy demands on health care systems to exercise cost containing measures. Services are fragmented, hospital discharges are expedited, and patients are expected to assume a greater degree of responsibility for their own care. Coordination of the care of pediatric patients is left predominantly in the hands of parents with little knowledge of health care system functioning or awareness of available resources.
In order to ensure comprehensive patient care specific to patient needs it is necessary to identify gaps in service provision and advocate for the development of programs to address the fragmentation in care. Existing models of care coordination and chronic care management have focused predominantly on the adult population. This paper will focus on meeting the needs of children with complex and chronic medical conditions by exploring the various models for care and theory underpinning nursing children and families experiencing transitions. Suggestions for application of theory in practice will be achieved through the presentation of a case example.