Development of a Multidisciplinary Medical Home Program for NICU Graduates

Matern Child Health J. 2020 Jan;24(1):11-21. doi: 10.1007/s10995-019-02818-0.


Objective: Typical primary care practices are often not equipped to meet the medical, developmental or social needs of infants discharged from a neonatal intensive care unit (NICU). These needs are exacerbated for infants and caregivers residing in poverty. This article discusses a multidisciplinary, family-centered medical home designed to address the needs of this special population.

Methods: This is a descriptive analysis of a cohort of patients in the Next Steps Program (NSP), a multidisciplinary primary care medical home. Key program elements include: continuity of care from the NICU to primary care, routine developmental surveillance, care coordination, and proactive screening to address medical and social needs.

Results: The NSP has become a primary referral source for local NICUs, with a total of 549 medically fragile infants enrolled from its inception in 2011 through 2016. Caregivers and patients experience psychosocial stressors at averages statistically significantly higher than the rest of the Commonwealth of Pennsylvania and the US. Although patients in the program use medical resources beyond that of typically developing infants, hospital utilization among this patient cohort is trending down.

Discussion: Caring for medically fragile NICU graduates can be daunting for families given the array of necessary services, supports, and resources to maximize their potential. A multidisciplinary primary care medical home, such as the NSP, is a successful model of patient care demonstrating favorable associations with health care utilization, care coordination, and addressing/improving family functioning and their experience.

Keywords: Care coordination; Family centered care; Medical home; Neonatal intensive care unit (NICU); Prematurity.

MeSH terms

  • Community Health Services / organization & administration*
  • Continuity of Patient Care / organization & administration*
  • Family Nursing
  • Humans
  • Infant, Newborn
  • Intensive Care Units, Neonatal*
  • Interdisciplinary Studies
  • Patient Care Team*
  • Patient Discharge*
  • Patient-Centered Care / organization & administration*
  • Pennsylvania
  • Primary Health Care / organization & administration*
  • Program Development
  • Social Determinants of Health