Transitioning Newborns from NICU to Home

Achieving a high degree of care coordination and communication is critical to assure the safety of the discharge process and as a result achieve good outcomes.  Collaboration occurs in four areas.

1. The Health Coach teaches caregivers how to coordinate care for their infant, which fosters independence.
2. The discharge process is standardized to include the use of an enhanced personal health record (PHR) and specific instructions, including handouts tailored to the needs of individual infants and families, so that caregivers recognize and respond appropriately to common problems that infants encounter in the post discharge period.
3. Information technology (IT) is used to enhance communication with caregivers and with community providers, in particular the primary care provider. Health IT has the potential to facilitate communication and coordination of care among the several disciplines and settings of ambulatory care but is not a required component of this intervention.
4. Clinical materials, specific to each infant, are provided to primary care providers (PCPs) to enhance their knowledge and skill in managing the common problems of NICU graduates. This information should be provided electronically if possible.

The structural elements of the discharge process are the organization and system, caregiver, infant, NICU team, and PCP. Better outcomes result from effective processes, and poor outcomes result from ineffective processes (poor communication, poor understanding by caregiver, lack of knowledge and skills by PCP, and non-standardized discharge process).

Key processes include:

• Family (caregiver) education/empowerment.
• Use of IT.
• Toolkits.
• Standardized discharge templates (if these are part of the electronic records management system in use).
• Well-informed PCP.

Key outcomes include:

• Healthy, safe infants.
• Fewer emergency department visits and missed appointments.
• Competent, confident caregivers.
• Enhanced caregiver satisfaction.

The Health Coach is a skilled, sensitive professional who helps families to become competent and confident caregivers who can advocate for the needs of their infant. Thus, the role of the Health Coach is as an educator, not as a caregiver. While the background of the Health Coach could be in nursing or social work, in our experience, an experienced, master's-prepared health educator may be better able to "coach" parents rather than "do for" them. Previous experience in patient education is vitally important. Training in specific skills in the NICU can be accomplished during the orientation period. 

Training and Scheduling of the Health Coach

Once identified, the Health Coach should be properly trained on the enhanced discharge process. During orientation, introduce the Health Coach to the entire NICU health care team. Familiarize the Health Coach with local PCPs and family advocacy groups. Attending staff meetings; hosting "meet and greets;" and placing signage in the units, newsletters, and Emails are all effective methods to get the word out about your new Health Coach.

It is important for the Health Coach to be accessible to the familes and health care team, whether by pager, phone, or Email. Some families visit only in the morning, some only at night, and some stay throughout the day.

The Health Coach should be available during non-traditional hours to accommodate families. For example, the Health Coach may have 2 late days per week to meet with families that visit in the evenings. Also, the Health Coach may have a mid-shift of 11:00 a.m. to 7:00 p.m., as opposed to a traditional 8:00 a.m. to 5:00 p.m. schedule.

Elements of a Health Coach Job Description

The activities of the Health Coach in the NICU setting include the following:

• Acting as a teacher, facilitator, and coach, remaining sensitive to family/caregiver needs to foster the development of families into competent caregivers for their fragile infant.
• Coaching families/caregivers to positively care and advocate for their infant.
• Coaching families to collaborate with the health care team, including participation in rounds.
• Being accessible to families and NICU staff by phone, pager, or Email.
• Using effective communication techniques, including read-backs, to educate families.
• Interviewing families to assess their understanding of their infants' medical conditions, procedures, and required medications.
• Assisting families in mastering the care of their infant, such as performing procedures and giving medications.
• Providing families with educational material pertinent to their infant's care regarding medical conditions, medications, and procedures.
• Developing an individualized discharge plan for families and outlining the competencies that are needed.
• Developing an individualized PHR with brief, educationally appropriate fact sheets. Assist with conversion of these sheets into an electronic format if available and useful.
• Transmitting each infant's PHR/completed discharge template either by fax or electronically to their PCP before discharge.
• Assisting families with scheduling education classes such as CPR and car seat trial appointments.
• Assisting families in making appointments for ongoing care after discharge.
• Identifying and addressing barriers to discharge as they arise, including identifying a PCP, assuring adequate transportation, and coordinating followup appointments and tests.
• Contacting the families weekly by phone or Email regarding their preparations for discharge and their understanding of their infant's medical conditions and needs.
• Proactively addressing barriers to coordinated care after discharge during followup calls.