Next Newborn / Neonatal Initiative

General Meeting
March 1, 2016

Medical Homes for Newborns At
Risk For or With Neonatal
Abstinence Syndrome (NAS)
Dr. Rita Gunter, MD, FAAP
Pediatric Physician Champion, Carolina
Collaborative Community Care

To begin….
• What is CCNC?
– CCNC through its infrastructure of local networks has over
two decades of success with many quality initiatives with
primary care clinicians and Care Coordination for Children
(CC4C)care managers to use the medical home approach

• What is a medical home?
– The AAP has recognized the value of the medical home
since 1967 for children with special health care needs and
infants exposed to opioids in pregnancy as considered
children with special health care needs
– The ideal AAP medical home approach provides
comprehensive, compassionate, coordinated, accessible,
continuous, family-centered and culturally effective

Initiative Background

• NAS continues at epidemic proportions and is increasing
• PQCNC NAS project has had great successes but has
focused on hospital-based care
• There is a need for improved processes for secure and
timely discharge once treatment has been completed
• Delays and increased lengths of stay have been seen with
some infants because of variable time and efforts needed
to develop safe discharge plans into the community
• There are gaps in primary care clinician and CC4C care
manager knowledge about NAS and how to support infant
development and parental skills

Initiative Background (cont.)
• Strong and early linkage of infants to medical
homes and CC4C care management are best
practices to assure safe discharge and follow
up in their communities
• A QI project with a focus on medical home
providers and care managers is needed to
develop standardized processes to monitor
and deliver evidence-based care for infants at
risk for or with NAS after discharge

Initiative Aim
• The goal is to assure all with infants at risk for or with NAS
receive timely, appropriate outpatient care in a medical
home
• Key measures that could be used to evaluate the success
include:
– Increased number of infants will have a visit within 48 hours of
discharge with their medical home
– Increased numbers of medical homes have a plan of care for
infants at risk for or with NAS before the first visit
– Increased knowledge and comfort of medical homes with
outpatient treatment and monitoring for NAS health and
developmental concerns for the infant and mother-infant dyad
– Number of infants with NAS with 6 or more well visits in the first
15 months (National Quality Forum Measure)

Initiative Reach
• The target population will be all newborns in
the NICU with a known diagnosis of NAS and
newborns in the newborn nursery with risks
for NAS
• The target facilities will be all delivery
hospitals

Initiative Impact
• A central component of the family-centered
medical home is partnering with the family on
the care of the child
• CCNC infrastructure of local networks and CC4C
care managers will help to facilitate the spread of
the medical home approach which is an
evidence-based intervention to support quality
care
• Medical homes and CC4C care managers can
assure linkages of infants and families to
community resources

Initiative Challenges / Barriers
• Access to a medical home in every community can be
limited
– Some medical homes may choose not to care for infants
with NAS
– Some medical homes will need additional training and
knowledge about care for infants with NAS and how to
support the mother and mother-infant dyad

• Difficulties with routine communication and
coordination between the NICU and medical homes in
other CCNC networks/communities
• Limited local resources and knowledge of resources to
support infants and their families

Supporting Materials
A management plan for NAS in neonates.

Prabhakar Kocherlakota Pediatrics
2014;134:e547-e561
©2014 by American Academy of Pediatrics