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Meet Us

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HOSPITALS

Rady Children’s Hospital - San Diego

[San diego, CA]

Vania Domingues, MS, RN

Ms. Domingues is a certified pediatric nurse with over 17 years of nursing experience. She received her Bachelors in Nursing from UMass Dartmouth and completed a Masters in Leadership of Healthcare Organizations at UC San Diego. Over the last eight years, she has become an integral part of Rady Children’s leadership team, most notably as a nurse manager. In response to her deep passion for bedside nursing, she has recently transitioned back to direct patient care and is serving pulmonary and complex pediatric patients in both acute and community-based settings.

Dedicated Discharge Navigator Nurses +

Key Elements:

  • Integrate discharge navigator nurses into existing care teams
  • Discharge questionnaire + discharge needs/equipment assessment with families
  • Meet identified needs via patient-specific interventions

Target Population:

  • High-risk patients, determined via pre-calculated risk score
 

Loma Linda University Children’s Hospital

[Loma Linda, CA]

Invest Joy Cocjin, MSN, BSN, RN

Ms. Cocjin is a Clinical Nurse Specialist for Acute Care Pediatrics and Stepdown unit at Loma Linda University Children’s Hospital. Ms. Cocjin started her nursing career in a skilled nursing facility, eventually transitioning into the world of pediatrics. She graduated from Loma Linda University School of Nursing with a Bachelors of Science in Nursing and Master of Science-CNS. Prior to her current role, she practiced in the pediatric CTICU for six years at LLCH and is currently enrolled in a Doctorate of Nursing Practice program.

Enhanced Discharge Communication +

Key Elements:

  • Complete an initial discharge needs assessment and have pre-discharge conversation with families
  • Provide families with a discharge folder
  • Hold a weekly interdisciplinary meeting with the care team (MD, RN, RT, social work, case manager & PT/OT/ST)

Target Population:

  • Patients who are vent-dependent in an acute care stepdown unit
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Lucile Packard Children’s Hospital Stanford

[Palo Alto, CA]

Melissa Gustafson, MSN, RN, CPN

Ms. Gustafson graduated from the University of Rhode Island in 2008 with her Bachelors of Science in Nursing and soon began her career at Children’s Hospital of Philadelphia. Her initial practice was on the Renal/Adolescent unit, followed shortly thereafter with a placement in the PICU lasting through May 2015. During her time there, Ms. Gustafson received her Master of Science as a Pediatric Nurse Practitioner at Villanova University; however, she did not begin her NP career until she moved to California in 2015 and began working at Lucile Packard Children’s Hospital with the PAN’s Clinic. Over the last year, she has transitioned to general pediatrics in a consultative role for medically complex children.

Dedicated Discharge Pharmacist +

Key Elements:

  • Pharmacist review of discharge orders 24 hours prior to discharge to make any needed corrections to medications
  • NP to follow-up on any new medication that will be started at discharge
  • Creation of a Medication Action Plan (MAP) + review with families during teaching
  • Final check-in with family and bedside nurse a few hours before discharge

Target Population:

  • Children with medical complexity
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Children’s Hospital Los Angeles

[Los Angeles, CA]

Anna Kitabjian, MSN RN CPNP

Ms. Kitabjian graduated summa cum laude from California State University, Northridge’s Accelerated Bachelors in Nursing program in August of 2012.  After working as a bedside nurse at CHLA for over 5 years, she went on to receive her Masters of Science in Nursing from the University of California, Los Angeles (UCLA), and graduated summa cum laude as a Pediatric Nurse Practitioner and Clinical Nurse Specialist. Ms. Katabjian currently works as the first and only Pediatric Nurse Practitioner on the Hospital Medicine Complex Care Team and is working on her Doctorate of Nursing Practice from the University of Alabama at Birmingham.  She has extensive experience teaching as adjunct faculty for the schools of nursing at CSUN and UCLA, teaching both undergraduate and graduate nursing courses. Ms. Katabjian loves to volunteer and give back to her community with her God given talents; she volunteered during the Special Olympics World Games in 2015 as both an on the field nurse as well as nurse coordinator, as a camp nurse many times per year at the Painted Turtle since 2014, and recently went on an orthopedic medical missions trip to Honduras in 2015. In her spare time, she loves to read, go to the beach, and spend time with friends and family.

Proactive Drafting of Discharge Plans +

Key Elements:

  • Create a draft version of discharge documents and provide to the family draft for review 48 hours prior to discharge
  • 24 hours prior to discharge, discuss any questions the caregiver might have regarding discharge instructions, medications, education, and follow-up appointments

Target Population:

  • Children with medical complexity
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UC Davis Children’s Hospital

[Sacramento, CA]

Angie Marin, MSN, RN-C

Ms. Marin is a certified pediatric nurse with nearly 40 years of pediatric nursing experience. She is a graduate of California State University Sacramento, receiving a Bachelor of Science in Nursing in 1980 and a Master of Science in 2004, and is currently the manager of an inpatient med/surg pediatric unit at UC Davis Medical Center and Children’s Hospital in Sacramento, CA. Ms. Marin is also the chapter president of the Greater Sacramento Society of Pediatric Nurses and serves on the chapter development and support committee as the west coast regional lead.

Anticipatory Discharge Huddles +

Key Elements:

  • An interdisciplinary daily discharge huddle to identify patients who are likely to be discharged the following day
  • Relevant services work together to identify discharge issues/barriers
  • Family and beside nurse notification of expected discharge

Target Population:

  • Pediatrics unit, with the exception of a few patient populations
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CHOC Children’S Hospital

[Orange, CA]

Brittney Anderson, DNP, CPNP

Ms. Anderson is the Supervisor of Patient Care Services Quality & Safety at CHOC Children’s Hospital. Her responsibilities include leading safety and quality initiatives, developing staff to improve their knowledge of unit and organizational quality improvement efforts, managing CHOC’s databases for Nursing Quality Indicators, and serves as an expert in nurse practitioner scope of practice. Having begun her nursing career in the NICU, Ms. Anderson also served as a general, thoracic, and trauma NP. She received both her Doctorate of Nursing Practice in EBP and Master of Science degree as a Pediatric Nurse Practitioner from Arizona State University, and she graduated from California State University, Long Beach with two Bachelors of Science degrees in Nursing and Health Care Administration.

Dedicated Discharge Navigator Nurses +

Key Elements:

  • Integrate discharge navigator nurses into existing care teams
  • Discharge questionnaire + discharge needs/equipment assessment with families
  • Meet identified needs via patient-specific interventions

Target Population:

  • High-risk patients, determined via pre-calculated risk score
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UCLA Mattel Children’s Hospital

[Westwood, CA]

Laurie Reyen, MSN, RN, CNSC

Ms. Reyen is the Clinical Nurse Specialist for Parenteral and Enteral Nutrition at Mattel Children’s Hospital at UCLA. She and her team work with a large population of children on home parenteral and enteral nutrition throughout the continuum of care. Ms. Reyen is a graduate of the Bachelor’s and Master’s programs in nursing at UCLA and is a Certified Nutrition Support Clinician.

Enhanced Discharge Teaching +

Key Elements:

  • Receive draft discharge plans 48 hours prior to discharge
  • Tailor teaching to draft plans and educate family 24 hours prior to discharge
  • Confirm discharge teaching using teach-back on day of discharge

Target Population:

  • Patients on the GI service
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Monroe CarelL Jr Children’s Hospital at Vanderbilt

[Nashville, TN]

Sarah Wilkerson, MSN, RN, CPNP

Ms. Wilkerson has been a nurse for 15 years. After graduating with an undergraduate degree in Premed from Wofford College in Spartanburg, SC, she changed gears to attend nursing school following a stint in the Peace Corps in Jamaica. Ms. Wilkerson has worked as an NP in the Program for Children with Medically Complex Needs for 3.5 years, prior to which she staffed an inpatient unit as a nurse for 12 years.

Dedicated Discharge Pharmacist +

Key Elements:

  • Pharmacist review of discharge orders 24 hours prior to discharge to make any needed corrections to medications
  • NP to follow-up on any new medication that will be started at discharge
  • Creation of a Medication Action Plan (MAP) + review with families during teaching
  • Final check-in with family and bedside nurse a few hours before discharge

Target Population:

  • Children with medical complexity
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CORE TEAM

Jenni Baird, PHd, MPH, MSW, RN, CPN
[Principal Investigator]

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Institute for Nursing and Interprofessional Research | Children’s Hospital Los Angeles

Dr. Baird is Director of the INIR at CHLA. Her program of research has focused on the family’s experience of pediatric care delivery systems, with a particular emphasis on the ways in which communication among nurses, interprofessional members of the care team, and families impacts quality, satisfaction, and safety for children with medical complexity. Her role as a nurse scientist is focused on mentorship of clinical nurses as they identify, evaluate, and incorporate evidence-based changes into their existing patterns of practice. Dr. Baird’s clinical work as a registered nurse in both acute and critical care pediatric settings, along with her training in social work, public health, and health services research methodologies, provide a rich background and the clinical and scientific expertise necessary to effectively lead the CANDLE Collaborative. Dr. Baird additionally serves as chair of the Society of Pediatric Nurses’ Research and Clinical Practice committee.

 

Jay Berry, MD, MPH
[Co-Investigator]

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Department of Pediatrics | Division of Medicine | Boston Children’s Hospital

Dr. Berry is Assistant Professor of Pediatrics at Harvard Medical School and attending physician with the Complex Care Service at BCH. His research has focused on integrating pediatric providers across the care continuum to improve care planning and health outcomes for children with medical complexity. Dr. Berry assisted with the development of hospital readmission quality measures for national use through the Center of Excellence of Pediatric Quality Measurement (CEPQM) at BCH, and his readmissions work, published in the Journal of the American Medical Association, was the first to describe the problem of children with medical complexity experiencing recurrent readmissions and the rapid accumulation of hospital resources and costs these children consume. Additionally, as the director of the Children’s Hospital Association’s Complex Care Quality Improvement and Research Collaborative, co-chair of the Academic Pediatrics Association Complex Care Special Interest Group, and member of the Pediatric Research in Inpatient Settings executive council, Dr. Berry has a long-standing history of collaboration and data sharing with hospitals throughout the U.S. that serve children with medical complexity.

 

Kevin Blaine, MAEd
[Director]

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Institute for Nursing and Interprofessional Research | Children’s Hospital Los Angeles

Mr. Blaine currently serves as Senior Research Associate for the INIR at CHLA. He has particular expertise in intervention development, novel research methodologies, program design and evaluation, and learning theory. Mr. Blaine’s research interests include care coordination and transitions of care for children with medical complexity, post-discharge healthcare utilization among hospitalized children, hospital-based interprofessional team functioning, and health information reconciliation.

 

Cynthia Caceres
[Administrator]

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Institute for Nursing and Interprofessional Research | Children’s Hospital Los Angeles

Ms. Caceres is Senior Administrative Assistant for the INIR at CHLA. She has served in a variety of leadership and program development roles during her tenure at CHLA, and she is driven by collaborative teamwork, solution-oriented process improvement, and evidence-based principles in project administration.

 

Elaine Linn
[Family Partner]

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Project Leadership | Family Voices of California

Ms. Linn has spent nearly 25 years uniting national, statewide, and local nonprofit, community, public, and corporate partners in public health policy efforts. In her work helping nonprofit organizations achieve their advocacy goals, she has collaborated with health care providers, academic institutions, patient advocacy organizations, patients and consumers, hospitals, and pharmaceutical manufacturers, in the areas of pharmacy, psychiatry, ophthalmology, and genetics, as well as diabetes, sepsis, social work, disability, and women’s and children’s health to engage communities, promote awareness, reduce stigma, and increase access to care. Ms. Linn is a public affairs consultant and the parent of two sons, including one who has Down syndrome and multiple related health conditions. She has worked with the California Children’s Hospital Association, conducting grassroots advocacy outreach and education related to the California Children’s Services program redesign and the ongoing federal health reform proposal. She serves as a member of the State Council on Developmental Disabilities Sacramento Regional Area Council, and as a member of the California and National Down Syndrome Advocacy Coalitions. Ms. Linn previously served as Chair of the American Diabetes Association Sacramento Mission Delivery Committee, and as a member of the UC Davis Health System Community Advisory Board. She also co-founded the Down Syndrome Information Alliance in Sacramento and served on its Board of Directors for several years.

ADVISORS

James C. Gay, MD, MMHC

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Professor of Pediatrics
Vanderbilt University Medical Center

Medical Director of Utilization Management
Assistant Chief of Staff
Monroe Carell Jr. Children’s Hospital

For over 20 years, Dr. Gay has studied pediatric hospital admissions and readmissions to better understand the population of patients who are frequently readmitted, their hospitalization needs and the preventability of their readmissions. He has particular expertise in the pediatric home health services utilization, patients with primary mental health conditions admitted to acute care hospitals, and post-discharge phone calls as a means to identify potential discharge complications. Dr. Gay also serves as the physician champion on behalf of MCJCH for the Children’s Hospital Solutions for Patient Safety project, which seeks to reduce selected hospital acquired conditions and readmissions in children’s hospitals across the US.

 

Mark Brittan, MD, MPH

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Assistant Professor of Pediatrics
University of Colorado Denver

Pediatric Hospitalist
Children’s Hospital Colorado

Dr. Brittan’s research centers on improving hospital discharge and understanding etiologies of pediatric readmissions, especially for children with medical complexity. His clinical and research activities strive to enhance current healthcare systems and develop new systems of care in order to facilitate care transitions and reduce readmissions for hospitalized children. Dr. Brittan has also assisted in the creation of novel electronic tools to enable point-of-care coordination and discharge planning, and he has received a NRSA T32 Primary Care Research Fellowship through the Children’s Outcomes Research (COR) and Colorado Health Outcomes (COHO) programs for his outstanding efforts to construct innovative approaches to discharge care.

 

Michael Steiner, MD, MPH

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Pediatrician-In-Chief
UNC Children’s Hospital

In his current role, Dr. Steiner oversees a division that includes the Hospitalist Section, an active complex care outpatient program, newborn care and two primary care clinics. He has worked with others across the division and throughout the hospital on joint interventions to both increase the proportion of early-in-the-day discharges and decrease medication errors at discharge. Of note, the division recently completed a grant-funded program to improve hospital-to-home transitions that resulted in a 22% decrease in hospital readmission and improved patient satisfaction. He currently serves as co-Chair of the Physician Leadership Committee for a new Medicaid health plan in the state which will further his role providing care to children with medical complexity (CMC). His recent research has studied health service utilization for CMC, particularly examining the overlay of the social determinants on complex medical disease.

 

John Stephens, MD

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Professor of Internal Medicine and Pediatrics
UNC Children’s Hospital

Dr. Stephens is a hospitalist within the Division of Hospital Medicine in the Department of Medicine and is jointly appointed in the Department of Pediatrics. He also serves as Director of Quality Improvement and Scholarship for UNC Hospital Medicine. Dr. Stephens’ research interests include quality improvement, transitions of care from inpatient to outpatient settings, and promotion of scholarly activities among trainee physicians.

 

Jayne Rogers, MSN, RN, NEABC, CPHQ

 

Director of Nursing for Inpatient Medicine
Boston Children’s Hospital

Ms. Rogers is a pediatric nurse with over 30 years of clinical and administrative experience, and she has been actively involved over the last four years in the development of national pediatric discharge standards and their subsequent testing and refinement. She has designed and led multiple, novel quality improvement initiatives, and is currently the chair of the Nursing Advisory Council of the nationally renowned I-PASS Project.

 

Juno Duenas

 

Executive Director
Support for Families

Ms. Duenas is the mother of four children, one of whom has severe disabilities. She has been Executive Director of Support for Families since 1991 and is actively involved in leadership roles in San Francisco, the Bay Area, throughout California and nationally. Ms. Duenas has served as the Chair of the San Francisco High Risk Interagency Coordinating Council, the Chair of the Improving Transitions Outcomes Project, a steering committee member of CA Early Start Family Resource Center Network, and a Family Voices Council Member.

 

Pip Marks

 

Director
Family Voices of California

Ms. Marks attended her first parent support group meeting at Support for Families 31 years ago when her oldest son was born with spina bifida and hydrocephalus. Prior to joining FVCA in March 2013, she was the Director of Education and Support for the Hydrocephalus Association for 18 years where she worked extensively with families and professionals affected by hydrocephalus. Ms. Mark’s son remains her guiding light in her work as she focuses on improving the lives of children and youth with special health care needs.

 

Eileen Fry-Bowers, PhD, JD, MS, RN, CPNP

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Associate Professor
Hahn School of Nursing and Health Science, University of San Diego

Dr. Fry-Bowers received her bachelor’s degree, magna cum laude, from Loma Linda University School of Nursing; her master’s degree from the University of Rochester School of Nursing; and her Juris Doctor, summa cum laude, from Whittier Law School, and her PhD from UCLA School of Nursing, with an emphasis in health services. Dr. Fry-Bowers is an elected Fellow of the American Academy of Nursing (FAAN). She has been a Faculty Policy Fellow for the American Association of Colleges of Nursing (AACN) and is serving her second term on the AACN Health Policy Advisory Council. She is a member of the Editorial Advisory Board and Co-Editor of the Health Policy Department for the Journal of Pediatric Health Care and serves on the Editorial Board for the journal, Policy, Politics and Nursing Practice. In addition, she continues in her second term on the Research Committee for the National Association of Pediatric Nurse Practitioners (NAPNAP). Dr. Fry-Bowers’ current research and policy interests include improving child and family well-being through social policy; pediatric workforce education and practice issues; and the impact of legislative and regulatory change on the delivery of pediatric health services.

 

Catherine Goodhue, MN, RN, CPNP

 

Adjunct Assistant Professor of Medical Education
Keck School of Medicine, University of Southern California

Program Committee Co-Chair
National Association of Pediatric Nurse Practitioners (LA Chapter)

Nurse Practitioner, Trauma Program
Children's Hospital Los Angeles

 

Lori C. Marshall, PhD, MSN, RN

 

Adjunct Assistant Professor
Keck School of Medicine, University of Southern California

Administrator, Patient Family Education and Resources
Children's Hospital Los Angeles