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Ma Teresa C Ambat, MD Region 15 RHP Meeting El Paso First Healthplan , 1145 Westmoreland Drive

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.

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Ma Teresa C Ambat, MD Region 15 RHP Meeting El Paso First Healthplan , 1145 Westmoreland Drive

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  1. 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

  2. Introduction • 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. • 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. • Compliance with recommended follow-up medical care, however, continues to be problematic for many families of the sickest infants.

  3. Description of the Project • 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 • 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 • Barriers to quality care: financial and economic, language and cultural, communication, health care system, transportation, bias based on culture/race/age, fear

  4. Description of the Project • 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) • 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.

  5. Description of the Project • Patient navigation services: • Coordinate post-discharge follow-up care with primary and subspecialty care providers • Assist in system navigation for ancillary services (Rehab, DME, Home Health and Social services) • Facilitate communication between patient’s family members and healthcare providers • 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.

  6. Project Milestones and Metrics

  7. Project Milestones and Metrics

  8. Category 3 Measures

  9. Benefits to the Community • Our patient navigators could achieve the most basic functions which are: • Eliminate barriers to care • Ensure timely delivery of services • Prevent or reduce patients lost to follow-up • Improve patient satisfaction. • Expected 3-year outcome for providers and patients: • 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 • Improve target patients’ long-term outcomes: growth, overall health, neurodevelopment and behavior

  10. Long-term Goals • Growing Our Patient Navigation Program (Potential Strategies to expand our existing program and support services) • Provide Rehab services (PT, OT, ST) during High Risk Clinic visit • Add a dedicated social worker in to help grow our offering of support groups • 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) • Expand the coverage by enrolling high-risk infants discharged from other NICU facilities in the region

  11. Next Presentation • Description of the process • Milestone Progress • Risk Areas Identified • Innovations/Quality improvements

  12. Questions? Comments?

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