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Transfer + Coordination of Care
Primary Care Involvement
SELECTING a PEDIATRIC CARE PROVIDER
When discharge planning begins, the family should identify the primary care provider or practice that will be providing follow-up care for the infant.
A primary care provider needs to be chosen prior to the infant being discharged.
If the family has not chosen a primary care provider, the NICU team can help them make this selection.
If they are not already involved in the discharge planning process, the NICU team should provide sign out to the infant’s pediatrician at the time of discharge.

Primary Care Contact
primary care
TRANSITIONING CARE to the PEDIATRICIAN
Within 48 hours of discharge, contact the medical home and make them aware of the history of the infant’s hospitalization and the plan for their discharge.
This can be done by a telephone call, text message, fax, or email.
When possible, provide important contact information to the medical home.
Invite and encourage ongoing communication about the infant’s health history and hospitalization.
At minimum, include the following information in this communication:
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infant’s name in the hospital and after discharge (if they are different)
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medical diagnoses
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discharge medications and administration instructions
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results of major procedures (e.g., sleep studies, modified barium swallows, bronchoscopy, etc.)
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test results and pending tests
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follow-up appointments arranged and those that need to be scheduled
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interpreter or communication needs
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connections to resources for specific diagnoses or special needs (e.g., Trisomy 21, Multiples of America, etc.)
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a description of the resources the family needs (e.g., counseling services, mental health, financial resources, etc.)
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With complex medical or social situations, prior to the infant being discharged it is helpful to get the primary care provider involved. Update them regularly.
Primary care providers should collaborate on the development of a new (or comment on an existing) plan for follow-up care.
A warm handoff is preferred for complex medical and/or social situations. If social worker (or equivalent) is involved, it is preferred for them to give a warm handoff to the social worker from the primary care facility.
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The discharge summary should be provided to the medical home, preferably on the day of discharge but as close to discharge as possible.
This summary should be delivered no more than one week after NICU discharge.
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IMPORTANT: Confirm that the summary has reached the intended providers.
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nicu contact
NICU Contact
CHECKING IN with the FAMILY
A NICU representative - preferably someone with medical expertise such as a nurse, patient navigator, discharge coordinator, mid-level provider, social worker, etc. - will call the family with in a few days after discharge to assess their understanding of the following:
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discharge instructions
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feedings and how to mix feedings
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medications and medication administration instructions
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follow up appointment dates/times and reason for appointment.

During the call, the NICU representative may also inquire about the following:
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general well-being of infant and family
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any anticipated or unanticipated issues/challenges that have arisen
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referrals/appointments needed that have not been made
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