Comprehensive Transitional
Medical Home for Medically
Fragile Infants: Redesigning the
Model for Post-discharge Care
Ricki F. Goldstein MD
Professor of Pediatrics
Director, High-Risk Infant Follow-up Program and
Special Infant Care Clinic
Division of Neonatology
Duke University Medical Center
The Problem
 Extremely premature and critically ill term
infants
 discharged home with a complex mix of
pulmonary, cardiac, gastrointestinal, endocrine
and neurologic problems
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Multiple medications
Complicated feeding regimens
Special equipment
Limited insurance coverage for nursing care
 Few pediatricians and family medicine physicians
have the training, experience, and availability to
optimally care for these fragile infants during their
most vulnerable first year of life.
Present system of care
 Frequent lack of continuity of primary care
 house-staff clinics
 large pediatric and family medicine practices
 health departments
 Multiple subspecialty clinic appointments scheduled
soon after discharge
 Frequent visits to the emergency room for acute
problems (triaged at night)
 Inconsistent quality of community case management
 Poor communication, fragmentation and/or
duplication of care
Consequences
 Delayed or ineffective care
 acute illnesses or complications develop into
severe, even life-threatening problems
 feeding and nutritional difficulties lead to failure to
thrive
 Frequent use of emergency room
 Evaluated by physicians unfamiliar with neonatal
problems
 Multiple visits with eventual admission
 Rehospitalization
 Often straight to PICU
Solution
 Comprehensive Transitional Medical Home
(TMH)- funded by The Duke Endowment
 Tertiary care medical center team
 Health care providers with special training,
experience, availability and commitment
 Medical follow-up during “transitional” period
between neonatal hospitalization and care by
general pediatric medical home
 Chronic medical problems more stable
 Growth and nutrition established
 Parents more comfortable and confident
Goals of TMH Home Program
 Maximize long-term medical and developmental
outcomes
 Comprehensive medical care
 Improved community case management
 Decrease overall cost of post-discharge medical
care
 Educate well-child care providers in the longterm care of infants with complex medical
problems
Research
 A large, single-center randomized trial of
comprehensive care for preemies in Dallas
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Well-baby care
Acute and chronic illnesses and complications
Experienced physicians and nurse practitioners,
Available 5 days/week in clinic and by pager 24/7
 Results
 Substantially reduced life-threatening illnesses
resulting in death or admission to a PICU
 Reduced cost of post-discharge care during the
first year of life.
Broyles et al JAMA 2000;284:2070-6.
Research
 Children’s hospital-based multidisciplinary
clinic in Kansas
 provides comprehensive and coordinated care for
medically complex children
 ensures that each patient receives all necessary
medical, nutritional, and developmental care
 Results
 Significant decrease in total Medicaid costs
Casey PH et al. Arch Pediatr Adolesc Med. 2011;165(5):392-398.
Proposed TMH model of care
 Immediate medical follow-up within 1-3 days after
discharge.
 Co-management of acute illnesses related to
neonatal problems (ability for next day visit)
 Surveillance and treatment of chronic medical
problems with coordination of consulting subspecialist visits when needed.
 Ongoing feeding and motor evaluations and
arrangement for intervention services
Proposed TMH model of care
 24/7 pager availability, by experienced
physician or nurse practitioner familiar with
the babies' medical problems
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Parents to call with questions and acute problems
Primary care provider when seeing child
ER physicians
Admitting hospital
Eligibility criteria
 Extreme prematurity:
 Less than or equal to 26 weeks gestation at birth
 Chronic medical problems in premature or term infants
 Chronic lung disease of infancy
 Feeding problems (e.g. G-tube, NG tube, severe
gastroesophageal reflux, dysphagia)
 Surgical necrotizing enterocolitis, other short-gut syndrome
 Severe respiratory failure
 ECMO
 Congenital diaphragmatic hernia with PPHN
 Congenital heart disease requiring delayed or multi-staged
correction (in future)
 Severe brain injury
 Hypoxic ischemic encephalopathy
 Severe intraventricular/intracranial hemorrhage
 Periventricular leukomalacia, neonatal stroke
Evaluation of TMH Program
 Acute illnesses (type and how treated)
 Growth during first year
 Timeliness of immunization administration
including Synergis and Flu shots
 Emergency room visits (reasons and outcome)
 Sub-specialty clinic visits (type and number)
 Rehospitalizations, including but not limited to
PICU stays (reasons and length of stay)
 Early intervention services (type, when initiated)
Evaluation of TMH Program
 Nature of phone calls received from parents
and the outcome of advice given.
 Nature of phone calls received from WCC
providers or outside ER’s and the outcome
of advice given.
 Neurodevelopmental outcome at 9-12
months of age
 Cost of all medical care during the first year
after discharge (including primary care and
specialty visits, acute care, hospitalizations,
ER visits, medications, etc)
Measureable goals
 Improve continuity of care and decrease
duplication of services
 compare number of different well-child care and subspecialty providers over first year
 Decrease emergency room visits
 Decrease number of and length of stay
during rehospitalizations to Duke or other
hospital
 Decrease PICU admissions and length of
stay
Measureable goals
 Improve medical and developmental
outcomes of our most medically fragile NICU
(and eventually PCICU) graduates.
 Decrease post-discharge cost to third party
payers for NICU and PCICU graduates
medically fragile infants during the first year
of life.
Present and future partners
 North Piedmont Community Care Network
 Local post-discharge visits and early coordination
of care
 Initial communication with case managers in other
counties
 North Carolina Children’s Accountable Care
Collaborative
 Hospital based case manager to serve as liaison
to all medical providers and community agencies
 Work closely with TMH program to improve
outcomes and decrease cost of care for Medicaid
patients.