Title Pasitos de Bebé: NICU to Home
AAP Grant ID 1890
Project Year 2011
City & State Palo Alto, CA
Program Name CATCH Resident
Topic CSHCN/Disabilities
Program Description
Pasitos de Bebé: NICU to Home will create a bridge between the NICU and the medical home for underserved infants. Santa Clara Valley Medical Center (SCVMC) serves a diverse population of underserved, low resource, low education patients who face significant barriers when navigating the health care system. A network of SCVMC clinics with multilingual staff is their medical home. Establishing a medical home is essential for improved clinical outcomes thus reducing health disparities through care coordination and support navigating complex systems.
Our project will be organized into 3 parts: the clinical, the community and the clinical-community bridge. The bridge will be constructed by creating interventions built on information from listening through a needs assessment with NICU staff, interviews with community physicians, nurses, and key stakeholders, and focus groups with of parents of NICU graduates. In bringing together the voices of parents and key stakeholders, we will bridge the clinical and community gap by providing our information back to community physicians and by informing a nurse home visit program currently under development.
Clinic Level:
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.

Community Level
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.

Clinic-Community Bridge
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.

AAP District District IX
Institutional Name Stanford School of Medicine, 770 Welch Rd, Palo Alto, CA 94304-1602
Contact 1 Elizabeth Enlow
Contact 2
ID 41