The Transition Home Plus program, originally called CHIP, was developed in 2007 with generous funding from CVS Caremark Charitable Trust to assist families of the most vulnerable premature infants who are at risk of medical problems once they are discharged from the hospital. Transition Home Plus is a successful model of coordinated care that has been shown to reduce rehospitalizations after infants leave the Neonatal Intensive Care Unit (NICU).
Modern neonatal care has resulted in dramatic improvements in the survival of premature infants. As a result, significant numbers infants with special health care needs are leaving the hospital. Once at home, they can require oxygen, cardiorespiratory monitoring and multiple medications. Infants with complex medical issues have increased rates of emergency room visits and rehospitalization after discharge from the NICU.
Caring for a particularly high-risk infant post-discharge is extremely challenging for many families, especially those facing additional economic, social and environmental issues. Transition Home Plus provides NICU and home-based specialized, therapeutic support and education for families of the most vulnerable infants, and is closely linked with primary care providers in the community. A multidisciplinary team of physicians, nurse practitioners, social workers, nutritionists, occupational therapists, parent consultants, and bilingual staff works with each family based on their individual needs. This program has resulted in significantly fewer rehospitalizations, with the greatest impact for low-income families.
In 2012, Women & Infants received a $3.2 million Healthcare Innovation Award from the Center for Medicare and Medicaid Innovation to expand the Transition Home Plus program.
With this grant the Partnering with Parents Program was created. This program has allowed Women & Infants to expand its transitional support services to serve all infants and families in the NICU for five days or longer. Partnering with Parents staff are able to serve families residing in Rhode Island, Massachusetts and Connecticut. This program was built upon the Transition Home Plus model, but also sought to partner with former NICU parents to provide support and education to families. Overall goals of the program are reduction in health care cost, providing quality care, and engaging community partners to provide comprehensive support to patients and families.
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