Megan Brooks

September 16, 2014

The patient-centered medical home is ideal for babies discharged from the neonatal intensive care unit (NICU), say those in charge of neonatal care at the University of Kansas Hospital in Kansas City.

Debbie Pennington, RN

"It fits this population very well, and we believe we are the only ones with this model in the country," Debbie Pennington, BSN, RN, clinical program coordinator for the home, said in an interview with Medscape Medical News.

She and her colleagues discussed their program at the National Association of Neonatal Nurses (NANN) 30th Annual Educational Conference in Phoenix, Arizona.

"Preterm babies are often discharged with a number of unresolved medical issues, which require careful, coordinated follow-up," said Prabhu Parimi, MD, medical director of the NICU and neonatal medical home at University of Kansas Hospital. They are at increased risk for physical, neurodevelopmental, and behavioral issues during infancy and childhood.

The American Academy of Pediatrics recommends that premature infants have multidisciplinary care from physicians who have spent time in the NICU. But currently, follow-up care for these children is generally "fragmented" and requires multiple visits to subspecialists, placing "tremendous stress" on the family, Dr. Parimi said.

Traditional neonatal follow-up clinics focus largely on evaluation and management of neurodevelopmental and, to some extent, other clinical issues, but the care offered is not holistic, he explained.

Prabhu Parimi, MD

Managing these at-risk infants and their families in an integrated system of healthcare delivery akin to the medical home model will facilitate coordination of care and more effectively meet patients' substantial healthcare needs.

The care of premature babies discharged from the NICU "should be brought under one umbrella, and that's the concept of the neonatal medical home," Dr. Parimi said.

The neonatal medical home at the University of Kansas Hospital offers specialty care and primary care 24/7 in one clinic based at the hospital.

"We are not just following these babies for their problems related to their prematurity, but actually doing all of their preventative health care," Pennington explained. "We take care of their immunizations, their well-child visits, and we are taking their telephone triage calls, seeing them when they are sick."

One big "value add" for these families, she said, is the familiarity and relationship that has been built with healthcare providers while the baby was in the NICU. "These are the same team members that have followed their child in the NICU, so they know the child's medical history and problems. We can provide individualized care," she explained.

For example, "when the phone rings and the baby has a respiratory infection and we know that that baby has underlying lung disease and went home on oxygen, that's a very different telephonic conversation than another baby that was maybe not as critically in the NICU," Pennington said.

Convenience is also a big plus for families. "They may see many different specialists at a single appointment. The family only has to come to one place, at one time, take off only one day of work."

At age 5 years, the child is transitioned to general pediatrics. "Our goal is to commit to them to optimize outcomes until they are school-age," Pennington said.

The neonatal medical home model can be replicated, she said, but it does take "a level of commitment" at the institutional and provider level. "We are on a journey to seek accreditation from the National Center for Quality Assurance for the clinic," Pennington said.

National Association of Neonatal Nurses (NANN) 30th Annual Educational Conference: Abstract 703. Presented September 11, 2014.

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