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Transfer + Coordination of Care
Parental Mental Health
WHEN the STRESS of the NICU PERSISTS
Assess the family for mental health concerns in the NICU and as the family transitions to resources in the community.
Many families will "keep it together" while they're in the NICU, but once they're home and out of immediate danger, they may start to fully feel the impact of the trauma associated with a complicated birth or NICU admission.
Because there is variability as to when mental health issues manifest, the assessment may need to occur more than once.

Community Resources
community resources
SUPPORT for AFTER THEY GO HOME
As part of the family assessment, determine which community resources, family supports, and services are needed, what the family’s preferences are for community supports, and what is available in their community.
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Maintain a robust, updated, comprehensive list of available community resources (e.g., Healthy Start, Early Intervention, Nurse Family Partnerships, etc.).
When making a referral to a program, include the appropriate cultural information in the referral.
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In states where applicable, request an initial early intervention assessment and an Individualized Family Service Plan (IFSP) be completed while the infant is still in the NICU. This promotes a relationship of trust, potentially decreasing barriers to follow-up care.
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Neonatal Therapists (occupational, physical, feeding, and/or speech and language therapists) should be part of the referral process for early intervention services.
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Assess every family for Part C* of Individuals with Disabilities Education Act (IDEA) eligibility and make a referral to qualifying families prior to discharge. Individuals with Disabilities Education Act (IDEA) is a law that makes free and appropriate education available to eligible children with disabilities. Part B of the law covers preschool age children, and Part C covers infants and toddlers. Part C of IDEA is a federal grant program that assists states in operating a comprehensive statewide program of early intervention services for infants and toddlers with disabilities (from birth through age 2 years) and their families.
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Upon admission, begin to identify the needs of infants with complex medical issues and start creating a care plan for the family. Do the same for babies with special developmental needs and families with special social needs. Begin coordination with relevant community partners well ahead of the infant’s discharge.
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Community Notifications
notification
PLANNING for EMERGENCIES
When medically indicated, confirm that the family understands the need and has a plan to notify local authorities (e.g., local emergency, fire, and police departments) about the presence oxygen in the home and the potential need for assistance during power outages.

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