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Hospital-based case management for medically fragile infants: program design.

Y Gillette, N B Hansen, J L Robinson

    Patient Education and Counseling
    |February 1, 1991
    PubMed
    Summary
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    This study highlights a multidisciplinary team

    Area of Science:

    • Pediatrics
    • Healthcare Management
    • Community Health

    Background:

    • Medically fragile infants require specialized care transitions from hospital to home.
    • Families face barriers accessing essential community services for infant health and development.
    • Effective case management is crucial for successful integration of these infants into community settings.

    Purpose of the Study:

    • To describe a hospital-based multidisciplinary team's services for medically fragile infants.
    • To detail the process of facilitating hospital-to-community transition and access to services.
    • To outline the educational and case management components supporting infant health and family functioning.

    Main Methods:

    • Individualized case management by a multidisciplinary team.

    Related Experiment Videos

  • Collaboration with families and local providers on discharge planning and Individualized Family Service Plans (IFSPs).
  • Systematic home visits by team nurses or developmental consultants during the infant's first year.

    • Main Results:

    • Facilitation of family access to community services for infant health, development, and family functioning.
    • Development of initial IFSPs outlining expected outcomes for the first year post-discharge.
    • Continued education and counseling through home visits to support the infant's transition and family well-being.

    Conclusions:

    • A multidisciplinary team approach with individualized case management effectively supports medically fragile infants' transition.
    • Education and counseling are key components in overcoming service barriers for these families.
    • The described model enhances infant health, development, and overall family functioning in the community.