A Novel Transitional Care Program for High Risk Infants

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Primary Author:</td>
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Rupalee Patel, RN, BSN, C-PNP, MSN, DNP (c)   </td>
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Co-Principal Investigators/Collaborators:</td>
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<p>Adebola Olarewaju, BSN, MSN, C-PNP, Sunshine Weiss, MD, Madhu Manani, RN, Priya Jegatheesan, MD, Dongli Song, MD, PhD, Balaji Govindaswami, MBBS, MPH</p>
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Organization:</td>
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Santa Clara Valley Medical Center</td>
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Abstract</h2>
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Purpose</h3>
<p>Provide caregiver education to minimize home care errors within 14 days of Neonatal Intensive Care Unit (NICU) discharge. Optimize health care access and utilization including High Risk Infant Follow-up (HRIF).</p>
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Background</h3>
<p>Despite current hospital teaching and public health efforts, NICU infants remain medically vulnerable and at risk for missing follow up appointments after discharge.</p>
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Materials & Methods</h3>
<p>The Babies Reaching Improved Development and Growth in their Environment (BRIDGE) program was developed in 2011 for infants meeting California Department of Health & Human Services HRIF eligibility. Prior to NICU discharge a pediatric nurse practitioner (PNP) established a relationship with infant families and worked with the inpatient multidisciplinary team. In the home after discharge, the PNP educated caregivers, prescribed needed medications, triaged and made appropriate appointments, and coordinated care with outpatient clinicians. Home feeding, medication, equipment use, and health care utilization were assessed. Based on the frequency of care errors discovered at home visits, caregiver education was modified to include targeted education to prevent the most common errors. In 2012 an additional PNP was hired to support program expansion and enrollment was expanded to include infants with multiple congenital anomalies, surgery, multiples, and passively cooled infants. Data collection was prospective and IRB approved.</p>
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Results</h3>
<p>In 2011, 166 infants were seen at 229 home visits; 230 errors were found: 30% in health care utilization, 12% home feeding, 13% medication and 23% with equipment use. Targeted caregiver education led to decreased home errors in the 108 infants at 272 visits in 2012, with rates of 14%, 4%, 5%, and 1%, respectively. HRIF follow up rates were maintained over 90%.</p>
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Conclusion</h3>
<p>Home visits by providers who bridge inpatient and outpatient infant needs can improve health, reduce health care cost, and may result in optimal growth and development for high risk infants.</p>
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Bibliography</h3>
<p>None</p>
<p>© Improvement Science Research Network, 2012</p>
<p>The ISRN published this as received and with permission from the author(s).</p>