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Basic Information
Discharge Planning Team
WHO ARE the ESSENTIAL MEMBERS of the NICU TRANSITION TEAM?
Everyone has a role to play in the discharge planning process.
Our goal is to build discharge planning teams with members who bring diverse skills, insights, and expertise - and who keep families at the center of everything they do.
This section discusses how to build a team that support families as they transition from being with their baby in the NICU to caring for them at home.

TEAM MEMBERS and THEIR ROLES
In addition to the family, the discharge planning team may include clinical nurses, physicians, mid-level providers (e.g., neonatal advance practice nurses and physician assistants), discharge coordinators, discharge planners, case managers, psychologists, social workers, and other providers as needed.
Because the personnel available in each NICU vary, it is important to focus on the role a team member will play and not their specific title.

Often the physician’s role in discharge planning is to ensure the baby has met the physiological discharge criteria and that the family has completed the comprehensive discharge planning program. The physician or designee is generally responsible for providing a warm hand off to the medical home that will assume the care of the infant and family after they leave the NICU.
Primary care providers and discharge coordinators provide ongoing technical and emotional support for families.
NICU staff who have established rapport with the family play an important role as the family transitions from NICU to home. Members of the nursing team who have worked most closely with the family during their baby’s hospitalization will be the best prepared to help the family as they plan for discharge. They not only know the infants’ health history, they also have experience working with the family and may have insights about parents’ perceived strengths and unique vulnerabilities.
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NICU social workers have a wide range of responsibilities. Their role is dependent on what other resources are available in each NICU. Some families will not be clear about the role of the NICU social worker and may have misgivings about their involvement. This is especially true for families who have experienced the negative effects of involvement with the child welfare system. It is helpful to clearly establish the role of social workers in the NICU setting. Providing all families with written information about available social services and supports and the role of the NICU social worker is advisable early in a family’s NICU stay.
NICU psychologists support families by providing positive therapeutic interventions, emphasizing techniques that support and facilitate parent-infant bonding. They can administer appropriate mental health screenings and provide timely referrals, in support of the families’ health and wellbeing. If your NICU does not have a psychologist, others may assume these roles if they have proper training and expertise.
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Learn more about NPA's National Network of NICU Psychologists (NNNP).
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OUR GOAL :

INTERDISCIPLINARY TEAM with the
FAMILY at the CENTER
ESSENTIAL MEMBERS of the TEAM
It takes a community to care for a baby. This is especially true when a baby has special medical or developmental needs.
Families need reliable support. We can help build supportive communities during NICU discharge education and transitions planning.
While families are welcome to invite the members of their family and community who can help, we should accept responsibility for making sure that the essential members of the neonatal intensive care team are a part of a transition planning.
INFANT CARE GIVERS
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At the beginning of the discharge planning process, identify the people who will be primary caregivers for the baby and ask how willingly that responsibility is assumed.
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Those individuals, and any others that the family prefers, will be the primary recipients of the NICU discharge preparation program.
CONSISTENT NURSING PROVIDER
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Families benefit from having consistent bedside nursing that allows the nurse and family to become familiar with each other. Some units are able to achieve more consistency by having primary nursing and/or nursing teams for each infant.
FAMILY SUPPORT PEOPLE
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Some families may benefit from having more support people than just the parents participate in the discharge planning process.
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During the assessment process, encourage families to invite their preferred support people to participate using their method of choice (i.e., remote, in person, etc.).
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Some examples of support people include, but are not limited to:
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extended family
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partners
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caregivers (night nurses and child care providers, for example)
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close friends
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church, temple, or spiritual leaders
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doulas and midwives
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home health aides
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community members
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DISCHARGE COORDINATOR / DISCHARGE PLANNER / CASE MANAGER
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This individual(s) is responsible for:
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ordering durable medical equipment
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helping arrange follow-up appointments
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coordinating services for after discharge
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physical or occupational therapy (PT or OT)
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home health care
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private duty nursing
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Also, this individual is responsible for assisting the family with contacting the fire department and/or electric company and creating a plan if they lose electricity at home.

SUPPORTING SIBLINGS
While it may or may not be appropriate for some siblings to join the discharge and transition team, ALL siblings need age-appropriate support to understand the NICU experience, the babies’ medical and developmental needs, and the resulting changes in their home life.
Positive interventions could include sibling support programs, activities, classes, and resources. When able, use Child Life specialists to help with sibling support programming.

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