Transitioning Newborns from NICU to Home

A Resource Toolkit

Infants born preterm or with complex congenital conditions are surviving to discharge in growing numbers and often require significant monitoring and coordination of care in the ambulatory setting.

This toolkit includes resources for hospitals that wish to improve safety when newborns transition home from their neonatal intensive care unit (NICU) by creating a Health Coach Program, tools for coaches, and information for parents and families of newborns who have spent time in the NICU.

Although the transition of the fragile infant from intensive care specialist to the ambulatory care provider begins prior to hospital discharge, it is incomplete until the infant receives appropriate outpatient followup with their designated primary care provider. Over the days or weeks after discharge from the hospital, the infant is especially vulnerable to errors related to poor care coordination and incomplete communication because the responsibility for care is often not clearly specified. During the discharge planning and transition process, a Health Coach can help prepare the family to meet the needs of their fragile infant competently and confidently.

The Health Coach serves as a teacher, facilitator, and coach, remaining sensitive to parent/caregiver needs as they enact all these roles. This connection, void of bedside clinician responsibilities, offers the parent/caretaker an environment to openly express their fears or concerns that will ultimately create an improved partnership with the direct care providers.

This manual is designed to be adapted for any institution that cares for fragile newborn infants.

The aim of this program, which was originally developed and tested as the "Safe Passages" program at Texas Children’s Hospital in Houston, is to facilitate care transition from the NICU to ambulatory followup by enhancing the discharge process. The primary components of the intervention are:

  • Tools for Hospitals to Create a Health Coach Program.
  • Tools for Health Coaches.
  • Information Packets for Families.
  • Clinical Materials to Share With Primary Care Providers.
Page last reviewed December 2013
Page originally created December 2013
Internet Citation: A Resource Toolkit. Content last reviewed December 2013. Agency for Healthcare Research and Quality, Rockville, MD.