Purpose: The purpose of this study is to describe the post-discharge needs of children and adolescents when transitioning home after an inpatient comprehensive rehabilitation stay following an acute neurological injury and to evaluate if trends in those needs changed with implementation of a discharge nurse intervention.
Design: Retrospective medical record review was conducted 1-year prior (T1) and 1-year after (T2) a discharge nurse intervention.
Methods: Medical charts of 80 pediatric patients with acute neurological injury (T1 = 39; T2 = 41) were reviewed. Post-discharge communication from the 8-week post-discharge period was reviewed to identify and categorize care coordination needs, using 18 pre-defined care coordination categories. T1 and T2 findings were compared using two sample proportion z-test.
Findings: Patients discharged following inpatient rehabilitation for acute neurological injury have unmet care coordination needs. The proportion of unmet needs decreased significantly for 10/18 care coordination categories after implementation of the discharge nurse intervention.
Conclusions: Data from this study support proactive care coordination by inpatient rehabilitation nurses to reduce unmet post-discharge care coordination needs and provides preliminary evidence that the role of a discharge nurse may have a positive impact on the transition from inpatient rehabilitation to home.
Keywords: Rehabilitation; brain injury; care coordination; community resources; discharge; spinal cord injury; transition.