Bridging the NICU to Home: Part 1 Implementing a NICU Discharge Planning Program - Evidence-Based Guidelines

This education is about:

• Evidence-based guidelines for NICU discharge preparation and transition planning
• The 4 core components of a discharge program: multidisciplinary team, anticipatory guidance, family and home needs assessment, and transfer and coordination of care
• Assessing physiologic, behavioral, and caregiver readiness for discharge
• Preparing families to feed a preterm infant at home
• The "warm handoff" to the primary care medical home and defining who leads communication after discharge
• Team-based discussion of 2 cases: a stable, late preterm infant; and a medically complex former 29-week infant with gastroschisis and chronic lung disease

Why it matters:

Preterm infants face a 3- to 4-fold higher risk of readmission after NICU discharge, most often for feeding and respiratory problems. Even stable-appearing late preterm infants can falter at home. Structured, family-centered discharge planning with clear coordination among the NICU, pediatrician, and community providers can prevent these gaps and reduce the stress of transitioning from the NICU to home.

What you will learn:

Dr. Vincent Smith opens with a concise review of consensus guidelines for NICU discharge preparation, outlining how anticipatory guidance, family and home needs assessment, and coordinated transfer of care fit together into a comprehensive discharge program. Dr. Smith then leads an interactive and lively case-based discussion with a pediatrician (Dr. Jill Kasper), NICU nurse and discharge coordinator (Heidi Gates), and feeding specialist (Cyler Romeo) to work through 2 cases: a routine, late preterm infant and a medically complex infant recovering from gastroschisis surgery. Learners see how each discipline evaluates readiness, teaches families, and builds the safety net that successfully supports infants and families transitioning from the NICU to the medical home.

Faculty

• Profile

  Heidi Gates, RN

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  Heidi Gates is a CN IV (Clinical Nurse IV) at Beth Israel Deaconess Medical Center, where she is involved in advanced nursing practices and patient care. Her professional background includes various roles in healthcare, emphasizing her expertise in clinical settings.

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  Heidi Gates, RN

  CN IV
  Beth Israel Deaconess Medical Center
  Lynnfield, Massachusetts

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  Jill Kasper, MD

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  Jill Kasper, MD, is a pediatrician and assistant professor of pediatrics at Boston University Chobanian & Avedisian School of Medicine and a primary care pediatrician at Boston Medical Center, where she serves as the medical director for the SOFAR clinic (Supporting Our Families through Addiction and Recovery) as well as interim division chief of primary care. Dr. Kasper graduated from Case Western Reserve University School of Medicine and completed her pediatrics training at Connecticut Children's Medical Center. Her clinical interests include primary care pediatrics, as well as healthcare for teen parents and their children. She also has a strong interest in the medical education of student and resident learners.

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  Jill Kasper, MD

  Clinical Associate Professor of Pediatrics, Boston University Chobanian & Avedisian School of Medicine
  Interim Division Chief, Primary Care Pediatrics, Boston Medical Center
  Boston, Massachusetts

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  Cuyler Romeo, MOT, OTR/L, SCFES, IBCLC

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  Occupational Therapist and Pediatric Feeding Specialist Cuyler Romeo’s extensive leadership and clinical experience are instrumental in the execution and management of Feeding Matters’ strategic initiatives. In partnership with the CEO, Jaclyn Pederson, Cuyler collaborates with constituents to identify, track, and assess innovative approaches to the PFD system of care. Cuyler also facilitates strategic partnerships with select professional associations including the American Occupational Therapy Association (AOTA). Prior to joining Feeding Matters, Cuyler served as a founding partner of Mealtime Connections, LLC, and gained valuable insight on funding trends and industry implications as the director of clinical innovations at Therapy 2000. She is currently a treating clinician in Banner-University Medical Center’s NICU and works to advance the feeding skill domain by facilitating AOTA’s mealtime Occupations: Feeding, Eating, and Swallowing Community of Practice.

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  Cuyler Romeo, MOT, OTR/L, SCFES, IBCLC

  Director of Strategic Initiatives, Feeding Matters
  Occupational Therapists and Feeding Specialist
  Banner University Medical Center Tucson - NICU
  Tucson, Arizona

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  Vincent Smith, MD, MPH

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  Dr. Vincent C. Smith, MD, MPH is Division Chief of Newborn Medicine at Boston Medical Center (BMC) and Professor of Pediatrics at Boston University Chobanian & Avedisian School of Medicine. Dr. Smith is a graduate of Texas A&M University, Stanford University School of Medicine, and the Harvard School of Public Health. He trained in pediatrics at Children’s Hospital and Boston Medical Center in the Boston Combined Pediatric Residency Program. He then completed a fellowship in neonatal-perinatal medicine through the Harvard wide program, a collaboration of Beth Israel Deaconess Medical Center, Brigham and Women’s Hospital, Massachusetts General Hospital, and Boston Children’s Hospital. He also completed a fellowship in health services research at Children’s Hospital. Dr. Smith serves as the medical director for the American Academy of Pediatrics’ Fetal Alcohol Spectrum Disorders Program. He is an active member of the Massachusetts Medical Society and Society for Pediatric Research. He is also a former member of the National Perinatal Association Board of Directors. In addition to parental NICU discharge readiness, his professional interests also include families affected by substance use and medical care for LGBTQIA+-headed families.

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  Vincent Smith, MD, MPH

  Division Chief of Newborn Medicine
  Boston Medical Center
  Boston University Chobanian & Avedisian School of Medicine
  Boston, Massachusetts