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

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.
• 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.