Development of a Multidisciplinary Medical Home Program for NICU Graduates

  • Katie FeehanEmail author
  • Folasade Kehinde
  • Katherine Sachs
  • Roschanak Mossabeb
  • Zek Berhane
  • Lee M. Pachter
  • Susan Brody
  • Renee M. Turchi
From the Field



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.


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.


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.


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.


Neonatal intensive care unit (NICU) Medical home Prematurity Care coordination Family centered care 



We would like to thank the clinical and administrative staff that has contributed to data collection, both directly and indirectly. Most importantly, we would like to thank our patients’ families and caregivers who have entrusted the NSP team with overseeing the healthcare delivered to their children.


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© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Center for Children and Youth with Special Health Care Needs, St. Christopher’s Hospital for ChildrenPhiladelphiaUSA
  2. 2.Department of Neonatal-Perinatal MedicineSt. Christopher’s Hospital for ChildrenPhiladelphiaUSA
  3. 3.Department of Neonatal-Perinatal Medicine, Temple University HospitalSt. Christopher’s Hospital for ChildrenPhiladelphiaUSA
  4. 4.Dornsife School of Public HealthDrexel UniversityPhiladelphiaUSA
  5. 5.Value Institute, Christiana CareNewarkUSA
  6. 6.Thomas Jefferson College of Population HealthPhiladelphiaUSA
  7. 7.NextGen System Support, St. Christopher’s Hospital for ChildrenPhiladelphiaUSA

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