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, periodic neurodevelopmental
surveillance, resource assessment, and family psychosocial and
emotional supports.
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 ensure that patients receive
coordinated, timely, and site-appropriate health care services
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 - to
ascertain that the infant has settled into the home environment and
assess
family
functioning/compliance
with
treatment
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.
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-toface meetings or seminars organized by
the RHP
Goal: Participate in at least two (2) faceto-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-toface meetings or seminars organized by
the RHP
Goal: Participate in at least two (2) faceto-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-toface meetings or seminars organized by
the RHP
Goal: Participate in at least two (2) faceto-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
o
o
o
Eliminate barriers to care
Ensure timely delivery of services
Prevent or reduce patients lost to follow-up
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 and subsequent visits until
completion at 18-24 months of age
o Improve target patients’ long-term outcomes: growth, overall
health, neurodevelopment and behavior
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
o
o
o
Description of the process
Milestone Progress
Risk Areas Identified
Innovations/Quality improvements