Children's Complex Care Coalition of North Carolina (4CNC) (2024-2025)
This project team explored how to improve systems of care for children with complex health needs in North Carolina, focusing on the critical transition from hospital to home. Nearly one in five children in the United States has special healthcare needs, and these children face heightened risks when returning home after hospitalization. To address these challenges, the team prepared for a comparative effectiveness randomized trial, set to launch in August 2025 at Duke and UNC hospitals, that will test high- versus low-intensity hospital-to-home transitional care for 480 children and youth with special healthcare needs.
During the 2024-2025 academic year, the team divided into three subteams: measurement, implementation readiness, and community engagement. The measurement subteam piloted “days at home” as a patient- and family-centered outcome for children with medical complexity, analyzing North Carolina Medicaid and Children’s Health Insurance Program claims data from 2016-2019. Results showed that children with complex chronic disease had fewer days at home and significant variation across counties.
The implementation readiness subteam partnered with Duke’s Population Health Management Office and the UNC Health Alliance to map the experiences of Transitional Care Managers. Their findings identified organizational barriers and assessed the implementation readiness of the two organizations for the forthcoming trial. Meanwhile, the community engagement team formed a ten-member Community Advisory Board that reflects geographic, racial, ethnic and linguistic diversity across the state. The board began meeting in spring 2025 and will provide ongoing input to ensure that family and caregiver voices shape the trial and its impact.
Timing
Fall 2024 – Spring 2025
Team Outputs
Children’s Complex Care Coalition of North Carolina: The Hospital to Home Transitional Care Study for Children and Youth with Special Health Care Needs (H2H-CYSHCN) (Poster presentation at the Fortin Foundation Bass Connections Showcase, April 16, 2025)
Pilot mixed-methods data on days at home as an outcome measure of CCHN
Transitional care workflows using human-centered design methodologies
See earlier related team, Children’s Complex Care Coalition of North Carolina (4CNC) (2023-2024).
Image: Baby boy grasping for a cherry in his fatter’s hand, by Ivan Radic, licensed under CC BY 2.0