Care Coordination Program for Children With Complex Chronic Conditions Discharged From a Rural Tertiary-Care Academic Medical Center.

Objectives: Hospital discharge offers an opportunity to initiate coordination of follow-up care, preventing readmissions or emergency department (ED) recidivism. We evaluated how revisits and costs of care varied in a 12-month period between children in a care coordination program at our center (enrolled after hospital discharge with a tracheostomy or on a ventilator) and children with complex chronic condition discharges who were not enrolled.

Methods: Children ages 1 to 17 years were retrospectively included if they had a hospital discharge in 2017 with an code meeting complex chronic condition criteria or if they were in active follow-up with the care coordination program.