Home Sweet Home

Nurses assist hospitalized kids with the transition away from inpatient services

For any child who has been hospitalized for a long time, going home is a joyous event. For the young patients at Baltimore’s Kennedy Krieger Institute, a specialized pediatric rehabilitation facility, homecomings are the cumulation of theirs and their clinical teams’ hard work.

Before some patients at Kennedy Krieger can fully return to their lives outside the hospital, they participate in the Specialized Transition Program (STP), a comprehensive day rehabilitation program that acts as a bridge between inpatient care and functional independence at home. The program teaches the young patients how to become more independent with their healthcare needs and provides the highest level of outpatient rehabilitation necessary.

“We treat a lot of kids with brain injury,” said Kristine Mauldin, BSN, RN, CDDN, nurse case manager. Other patient populations include kids with developmental disabilities such as cerebral palsy; patients with chronic pain, hemiplegia, and spinal cord injury; and those recovering from various orthopedic surgeries.

Improving ADLs

In the program, to mimic the familiar, the day is set up like a school day, with patients participating five days a week for 4-6 hours per day. The average patient is in the program 20-40 days. The children go to “classes” for their various therapies. These can include working on goals related to activities of daily living, like preparing food in the fully operational kitchen.

Specialized Transition Program
PRACTICE MAKES PERFECT: Zion Harvey, a patient in the Specialized Transition Program, practices his fine motor skills under the watchful eye of Mary Beth Brown, RN. JEFFREY LEESER/thanks to Kennedy Krieger Institute

Children and their families set functional goals that will help them return to home, school, and the community. Mauldin explained, “We incorporate goals with input from the family, child, and therapist.” STP also has a classroom component, where the children can receive 1-to-1 educational instruction.

A significant part of the program is family education. At the time of admission, the child and their family meet with members of the interdisciplinary team to talk about goals for the admission.

A week later, a plan of care is set and the patient is assigned a case manager, who could be a nurse, who handles any questions or concerns. By the end of their time in the STP, 95% of patients will have met or exceeded their goals. Mauldin credits much of the program’s success to the work of its interdisciplinary team. Nursing, physical therapy, occupational therapy, speech-language pathology, neuropsychology, and other specialties collaborate with the rehabilitation physician to provide quality care to their patients.

At discharge, a third and final meeting sets the child up for life outside the STP, including the need for any additional outpatient therapies in the community. The nurses help set up follow-up appointments.

Patient Complexities

Patients in the STP Program can be on ventilators and have tracheostomies. They are more medically complex due to earlier discharge from the hospital. “We get a lot of patients transferred from inpatient to our services. They are medically stable, but at any moment that can change,” said Mauldin. The staff nurses in the program monitor the children, making sure they have the appropriate medications and are responding to them. Mauldin continued, “The nurses are important because many of our kids are medically fragile.”

As a nurse case manager, Mauldin manages all referrals and handles communication with staff regarding the referrals. One of her biggest responsibilities is handling insurance authorization. “One of the challenging things as a case manager is that insurance companies are often limiting what a child needs. That, for me, is frustrating. What we recommend for a child to receive is not always covered. We try to work with families within the constraints of their insurance,” she noted.

Back to School

When discharged, the patients return to traditional schools and community-based, outpatient rehabilitation. These are complex cases, however, and the patients continue to need special care.

A separate Kennedy Krieger Institute Community program, Specialized Health Needs Interagency Collaboration, trains local school nurses in managing these medically fragile students.

Mauldin remarked, “The reward is that we’re providing these intensive multidisciplinary services to help these children get back to life in their school, home, and community.”