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American Academy of Pediatrics National Conference and Exhibition
October 24, 2015
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Fragile neonates benefit from transitional medical home

WASHINGTON — Premature and critically ill newborns discharged from a neonatal ICU benefited from a comprehensive transitional medical home, which also reduced the number of primary care provider and emergency department visits, according to data presented at the 2015 AAP National Conference and Exhibition.

“The most important thing about our program is that it truly is a transitional medical home program, which partners with the primary care providers while the transitional team coordinates the care for all the babies’ ongoing medical problems,” Ricki F. Goldstein, MD, of the departments of pediatrics and neonatology at the Duke University Medical Center, told Infectious Diseases in Children. “By doing so, we reduce the number of subspecialty doctor visits and provide 24/7 pager availability to the families, which prevents a lot of emergency room visits.”

Ricki F. Goldstein, MD

Ricki F. Goldstein

The researchers examined a cohort of 172 neonatal patients from a single medical center. Study participants were enrolled in the transitional medical home intervention if they were aged less than 27 days, exhibited extremely low birth weight (less than 1000 g) or had a chronic illness requiring multiple medications.

The transitional medical home intervention included a follow-up from the NICU trained professionals 1-2 weeks after discharge, coordination with a PCP, and surveillance and treatment of acute and chronic medical issues. The intervention also provided families with a weekly call for the first month, as well as 24/7 pager access to the intervention team.

Study results showed that participants had a mean of 1.4 clinic visits and parents received a mean 2.5 phone calls from the intervention team. The program also resulted in over 200 pages from families made directly to the intervention team, potentially reducing the number of needless PCP and ED visits.

“Also, through our communication with the pediatricians, our program educates them how to take care of these complex medical problems for other babies in the future,” Goldstein said. – by David Costill

For more information:

Goldstein RF, et al. Abstract 3059. Presented at: 2015 AAP National Conference and Exhibition; Oct. 23-27; Washington D.C.

Disclosure: The researchers report no relevant financial disclosures.