1. Through interviews with key stakeholders including neonatologists, community physicians, nurses, and other NICU staff, gather data on the process of discharge and transition to medical home and what problems exist in the process.
2. Obtain baseline outcomes data such as readmission rates, follow-up appointments made and attended, and use of emergency services outside medical home.
1. Engage parents of NICU graduates in focus groups to assess retrospectively, what needs were and were not met in the NICU and how NICU staff and community physicians can further assist NICU graduates in the transition to home.
2. Formally survey current NICU parents both at discharge and after discharge about preparedness for discharge, knowledge of the medical home, and resources needed.
1. Integrate information derived from focus groups and surveys into developing programs based out of SCVMC that will assist with post discharge care coordination.
2. Present data to community pediatricians and develop a structured program to assist these physicians with easing the transition to the medical home and the coordination of care thereafter.