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.

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