Enhancing Care for High-Risk Newborns Post-NICU Discharge

Improving Care and Outcomes of High Risk Newborns after NICU Discharge using the Patient Care Navigation Program Ma Teresa C Ambat, MD Region 15 RHP Meeting El Paso First Healthplan, 1145 Westmoreland Drive July 30, 2014 1:00pm

Introduction o Among the most immature and sickest neonates, a comprehensive and coordinated post-discharge care is necessary to integrate primary and subspecialty care, surveillance, resource assessment, and family psychosocial and emotional supports. periodic neurodevelopmental o The High Risk Clinic follow-up program at the TTUHSC Pediatric Clinic provides foundation of this integrated care from NICU discharge until age 2 years. o Compliance with recommended follow-up medical care, however, continues to be problematic for many families of the sickest infants.

Description of the Project o Our solution: Establish a Patient Care Navigation Program within the High Risk Clinic, a neonatal follow-up program at Texas Tech University Health Sciences Center (TTUHSC) El Paso - Department of Pediatrics o Patient navigation - a process by which an individual (a patient navigator) guides patients through and around barriers in the complex care system to help coordinated, timely, and site-appropriate health care services ensure that patients receive o Barriers to quality care: financial and economic, language and cultural, communication, health care system, transportation, bias based on culture/race/age, fear

Description of the Project o Target infants born at < 32 weeks gestational age and/or infants whose birth weight was < 1500 grams a cohort of high-risk patients discharged from the El Paso Children s Hospital (EPCH) Neonatal Intensive Care Unit (NICU) o These patients are at highest risk of disconnection from organized health care due to multiple chronic conditions resulting from being born prematurely and other problems that arose during their birth hospitalization. The program will utilize an opt-out model to provide maximum inclusion of the targeted patient population. We will enroll patients and identify contact before NICU discharge.

Description of the Project o Patient navigation services: o Coordinate post-discharge follow-up care with primary and subspecialty care providers o Assist in system navigation for ancillary services (Rehab, DME, Home Health and Social services) o Facilitate communication between patient s family members and healthcare providers o Increase access to care management and family support ascertain that the infant has settled into the home environment and assess family functioning/compliance recommendations Others: identify local resources (child care, transportation etc.), help arrange financial support and assist with paperwork, community outreach and partnership with local agencies and groups, assistance with eligibility for social services - SSI, etc. - to with treatment

Project Milestones and Metrics DY 3 P2.1: Number of People Trained as Patient Navigators Goal: 1 Additional Patient Navigator hired and trained. P2.2: Develop Outreach Plan to Enroll Patient in Navigation Program Goal: Complete Patient Outreach Plan. P-10.1: (Customized) Report on types of services provided to high risk patients enrolled in the program. Goal: Complete report on those services provided to High Risk Patients. P-8.1: Participate in semi annual face-to- face meetings or seminars organized by the RHP Goal: Participate in at least two (2) face- to-face meetings/seminars I-10.2: Increase Number of Unique Patients served by Navigator Program Goal: 30 patients

Project Milestones and Metrics DY 4 P-8.1: Participate in semi annual face-to- face meetings or seminars organized by the RHP Goal: Participate in at least two (2) face- to-face meetings/seminars I-10.2: Increase Number of Unique Patients served by Navigator Program Goal: 36 patients (Total: 66 patients) DY 5 P-8.1: Participate in semi annual face-to- face meetings or seminars organized by the RHP Goal: Participate in at least two (2) face- to-face meetings/seminars I-10.2: Increase Number of Unique Patients served by Navigator Program Goal: 43 patients (Total: 109 patients)

Category 3 Measures IT 8.21. Developmental screening in the first 3 years of life. Targeted condition Premature infants enrolled in the program (< 32 weeks and or birth weight < 1500grams). Developmental screening is an integral part of the neurodevelopmental follow-up assessment of premature infants. Indicator: Children who had screening for risk of developmental, behavioral and social delays using a standardized screening tool documented by 12 months of age. IT 9.9. Transition record with specified elements received by discharged patients. Targeted condition Premature infants < 34 weeks admitted and discharged at El Paso Children s Hospital NICU. Measure: Percentage of patients who received transition record at the time of discharge. IT 8.25. Sudden Infant Death Syndrome Counseling. Targeted facility. All infants discharged from the El Paso Children s Hospital NICU. Measure: Percentage of patients who had documented SIDS counseling.

Benefits to the Community o Our patient navigators could achieve the most basic functions which are: o Eliminate barriers to care o Ensure timely delivery of services o Prevent or reduce patients lost to follow-up o Improve patient satisfaction. o Expected 3-year outcome for providers and patients: o Increase the number of premature patients returning to their first High Risk Clinic appointment completion at 18-24 months of age o Improve target patients long-term outcomes: growth, overall health, neurodevelopment and behavior and subsequent visits until

Long-term Goals o Growing Our Patient Navigation Program (Potential Strategies to expand our existing program and support services) o Provide Rehab services (PT, OT, ST) during High Risk Clinic visit o Add a dedicated social worker in to help grow our offering of support groups o Expand the criteria for enrollment in the Patient Navigator Program to include additional NICU graduates who are at risk for adverse outcomes as a consequence of their various diagnoses (e.g., infants with major congenital or chromosomal anomalies) o Expand the coverage by enrolling high-risk infants discharged from other NICU facilities in the region

Next Presentation o Description of the process o Milestone Progress o Risk Areas Identified o Innovations/Quality improvements

QUESTIONS? COMMENTS?