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Development of a Multidisciplinary Medical Home Program for NICU Graduates
Katie Feehan1, Folasade Kehinde2, Katherine Sachs3
1Center for Children and Youth with Special Health Care Needs, St. Christopher's Hospital for Children, 160 E. Erie Ave, Philadelphia, PA, 19134, USA. kam442@drexel.edu.
Insights
A multidisciplinary medical home improves care for fragile infants after neonatal intensive care unit (NICU) discharge. This model addresses medical, developmental, and social needs, showing reduced hospital use and better family functioning.
Area of Science:
- Neonatal care
- Primary care
- Family medicine
Background:
- Neonatal intensive care unit (NICU) graduates have complex medical, developmental, and social needs.
- Poverty exacerbates these challenges for infants and their caregivers.
- Standard primary care practices are often ill-equipped to manage these specialized needs.
Purpose of the Study:
- To describe a multidisciplinary, family-centered medical home model designed for NICU graduates.
- To evaluate the effectiveness of this model in addressing the needs of a vulnerable patient population.
Main Methods:
- Descriptive analysis of the Next Steps Program (NSP), a multidisciplinary primary care medical home.
- Key elements: NICU-to-primary care continuity, developmental surveillance, care coordination, and medical/social needs screening.
Main Results:
- The NSP enrolled 549 medically fragile infants from 2011-2016, becoming a key NICU referral source.
- Patients and caregivers experience significantly higher psychosocial stressors compared to national averages.
- Despite higher resource use than typical infants, hospital utilization within the cohort is decreasing.
Conclusions:
- Caring for NICU graduates requires extensive services and support for families.
- A multidisciplinary primary care medical home, like the NSP, is a successful model.
- This model shows positive associations with healthcare utilization, care coordination, and improved family functioning.
Objective:
Typical primary care practices are often not equipped to meet the medical, developmental or social needs of infants discharged from a neonatal intensive care unit (NICU). These needs are exacerbated for infants and caregivers residing in poverty. This article discusses a multidisciplinary, family-centered medical home designed to address the needs of this special population.
Methods:
This is a descriptive analysis of a cohort of patients in the Next Steps Program (NSP), a multidisciplinary primary care medical home. Key program elements include: continuity of care from the NICU to primary care, routine developmental surveillance, care coordination, and proactive screening to address medical and social needs.
Results:
The NSP has become a primary referral source for local NICUs, with a total of 549 medically fragile infants enrolled from its inception in 2011 through 2016. Caregivers and patients experience psychosocial stressors at averages statistically significantly higher than the rest of the Commonwealth of Pennsylvania and the US. Although patients in the program use medical resources beyond that of typically developing infants, hospital utilization among this patient cohort is trending down.
Discussion:
Caring for medically fragile NICU graduates can be daunting for families given the array of necessary services, supports, and resources to maximize their potential. A multidisciplinary primary care medical home, such as the NSP, is a successful model of patient care demonstrating favorable associations with health care utilization, care coordination, and addressing/improving family functioning and their experience.
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