Effective Referral Strategies between the NICU and Part C Early Intervention: An Evidence-Based Quality Improvement Initiative

Background: Preterm birth, defined as the delivery of an infant prior to 37 weeks gestation, is a significant risk factor for developmental delays. As such, the timely referral of preterm infants to the Individuals with Disabilities Education Act (IDEA) Part C Early Intervention (EI)) is vital to the successful treatment of developmental delays and the reduction of disabilities later in life. The neonatal intensive care unit (NICU) involved in this initiative has been one of the lowest referring NICUs to EI services despite being one of the largest NICUs in Utah. Upon review, a dysfunctional referral process between this NICU and local EI programs led to over 235 (63%) infant referrals being lost between January 2022 and April 2023. Methods: A six-phase quality improvement implementation process was undertaken to assess the current referral problems and draft a new workflow that would address deficiencies. A series of detailed collaboration meetings with the NICU and the six local EI programs in this hospital's catchment area were undertaken. These meetings worked to analyze the current referral workflow and assess the feasibility of new workflow designs. Workflow success was measured by counting the number of referrals sent by the NICUs compared to the number of referrals received by local EI programs. Staff members were interviewed after implementation to assess usability, feasibility, and satisfaction with new referral processes. Interventions: Based on assessment findings and stakeholder feedback, a new referral workflow was designed and implemented. The new workflow incorporated elements of evidence-based referral strategies, including a standardized presentation of EI services to NICU families followed by a phone call between NICU care managers and local EI programs. Lastly, medical records were faxed to complete the referral process. The final workflow incorporated two phone calls and two faxes: one fax and phone call at admission to the NICU and one fax and phone call at discharge from the NICU. During the six-week project, no referrals were lost between the NICU and the six local EI programs (n=30, 100%). All referrals sent by the NICU were received. However, phone calls were placed by NICU staff only 24% of the time when making a referral. Although individual perceptions of the workflow varied, most NICU and EI program staff members agreed that the phone calls were valuable to the referral process to troubleshoot faxing issues and/or to form relationships between the agencies. However, simplifying the referral process to one phone call and one fax at discharge was preferred. Based on the initial success of this project, the hospital system care management executives decided to implement the same referral workflow across all 24 system hospitals in Utah. Evidence-based referral strategies that incorporate standardized education of families and utilize NICU to EI phone calls decreased lost referrals. This project has the potential to greatly increase referral-based access to EI services for Utah NICU graduates.

1 Effective Referral Strategies between the NICU and Part C Early Intervention: An Evidence-Based Quality Improvement Initiative Robin A. Woodbury, Sara E. Hart College of Nursing: The University of Utah NURS 7703: DNP Scholarly Project III March 20, 2025 2 Abstract Background Preterm birth, defined as the delivery of an infant prior to 37 weeks gestation, is a significant risk factor for developmental delays. As such, the timely referral of preterm infants to the Individuals with Disabilities Education Act (IDEA) Part C Early Intervention (EI)) is vital to the successful treatment of developmental delays and the reduction of disabilities later in life. Local Problem The neonatal intensive care unit (NICU) involved in this initiative has been one of the lowest referring NICUs to EI services despite being one of the largest NICUs in Utah. Upon review, a dysfunctional referral process between this NICU and local EI programs led to over 235 (63%) infant referrals being lost between January 2022 and April 2023. Methods A six-phase quality improvement implementation process was undertaken to assess the current referral problems and draft a new workflow that would address deficiencies. A series of detailed collaboration meetings with the NICU and the six local EI programs in this hospital’s catchment area were undertaken. These meetings worked to analyze the current referral workflow and assess the feasibility of new workflow designs. Workflow success was measured by counting the number of referrals sent by the NICUs compared to the number of referrals received by local EI programs. Staff members were interviewed after implementation to assess usability, feasibility, and satisfaction with new referral processes. Interventions Based on assessment findings and stakeholder feedback, a new referral workflow was designed and implemented. The new workflow incorporated elements of evidence-based referral 3 strategies, including a standardized presentation of EI services to NICU families followed by a phone call between NICU care managers and local EI programs. Lastly, medical records were faxed to complete the referral process. The final workflow incorporated two phone calls and two faxes: one fax and phone call at admission to the NICU and one fax and phone call at discharge from the NICU. Results During the six-week project, no referrals were lost between the NICU and the six local EI programs (n=30, 100%). All referrals sent by the NICU were received. However, phone calls were placed by NICU staff only 24% of the time when making a referral. Although individual perceptions of the workflow varied, most NICU and EI program staff members agreed that the phone calls were valuable to the referral process to troubleshoot faxing issues and/or to form relationships between the agencies. However, simplifying the referral process to one phone call and one fax at discharge was preferred. Conclusion Based on the initial success of this project, the hospital system care management executives decided to implement the same referral workflow across all 24 system hospitals in Utah. Evidence-based referral strategies that incorporate standardized education of families and utilize NICU to EI phone calls decreased lost referrals. This project has the potential to greatly increase referral-based access to EI services for Utah NICU graduates. Keywords: IDEA Part C Early Intervention, NICU graduates, referral strategies 4 Effective Referral Strategies between the NICU and Part C Early Intervention: An Evidence-Based Quality Improvement Initiative Problem Description In 2020, the preterm birth rate in Utah was approximately 10%, which mirrors the national average (Hamilton et al., 2021). Preterm birth, defined as the delivery of an infant prior to 37 weeks gestation, is a significant risk factor for developmental delays across multiple domains including cognitive (Adrain et al., 2020; Brydges et al., 2018; Yaari et al., 2018), language (Barre et al., 2011; Kovachy et al., 2015, Stipdonk et al., 2020; Zimmerman et al., 2018), motor (Allotey et al, 2018; Evensen et al., 2020; Spittle et al., 2018), and social-emotional development (Blasco et al., 2018; Cassiano et al., 2020, Hee Chung et al., 2020). Without intervention, these delays can persist into school age, adolescence, and even adulthood (Kovachy et al., 2015; Mathewson et al., 2017). As such, the timely referral of preterm infants to the Individuals with Disabilities Education Act (IDEA) Part C Early Intervention (EI)) is vital to the successful treatment of developmental delays and reducing disabilities later in life (Finlay-Jones et al., 2019; Lewis, 2021). Historically, the neonatal intensive care unit (NICU) involved in this initiative has been one of the lowest referring NICUs to EI services statewide (Hintze, 2024). From January 2022 to April 2023, the NICU has a record of attempting to send 375 referrals to EI programs (Redford, 2024). However, EI offices statewide only have a record of receiving 140 (37%) referrals during that same period (Hintze, 2024). In short, a dysfunctional referral process led to over 235 (63%) infant referrals being lost. 5 Available Knowledge Collaborations between NICUs and EI have taken many forms and are usually based on local needs. Many reports in the literature were limited to specific locations and systems, therefore lacking generalizability. However, several main themes emerged during the literature search that informed this quality improvement initiative. Without clear and accountable workflows, NICU graduates often were not referred to EI even when staff reported adequate knowledge of EI services (Greene & Patra, 2016; Mirzaian et al., 2022; Tang et al., 2012). Interventions to simply increase staff and parent knowledge of the importance of EI services have been ineffective at increasing referral numbers (Jimenez et al., 2013; Jimenez et al., 2017). Therefore, changes in workflow patterns will be more effective than education-based interventions. Workflows that incorporated frequent in-person or other close-proximity collaboration opportunities between NICU and EI staff reported greater success at referring eligible infants (Hussey-Gardner et al., 2002; Xue et al., 2023). Some hospital systems have embedded EI providers who rotate with NICU physicians to determine infant eligibility and discuss referrals to EI with parents directly while their infants are still in the NICU (Hussey-Gardner et al., 2002). Others rely on mandated, long-term organizational relationships that provide universal monitoring and treatment referrals for NICU graduates, such as the Tracking Infants Progress Statewide (TIPS) program in Nebraska (Jackson & Needelman, 2007). Although the exact mechanisms varied, establishing close relationships between NICU and EI providers was vital to successful referrals. Phone calls and in-person conversations were more effective at establishing these relationships than faxing referrals (Atkins et al., 2020; Jimenez et al., 2013; Miller et al., 1993; Petersen et al., 2024). Faxing referrals to EI led to many communication holes and often 6 required a follow-up phone call to ensure delivery (Atkins et al., 2020). Face-to-face or verbal communication promotes successful referral partnerships between NICU and EI providers. Lastly, the timing of EI referral matters to the long-term developmental success of NICU graduates (Finlay‐Jones et al., 2019; Lewis, 2021). Even low-risk NICU graduates were much more likely to benefit from EI services than members of the general population (Miller et al., 2019). One study estimated that 94.5% of high-risk NICU graduates would automatically qualify for EI services, but only 40% had connected with EI (Mirzaian et al., 2022). Many studies agreed that the optimal timing of EI referral is during the NICU stay (Greene & Patra, 2016; Jackson & Needelman, 2007; Jimenez et al., 2013; Laadt et al., 2007; Lakshmanan et al., 2022; Little et al., 2015; Tang et al., 2012). Waiting for a referral to be completed at a NICU follow-up clinic appointment or for a referral to be initiated by the parent leads to low completed referrals (Atkins et al., 2020; Baggett et al., 2020; Greene & Patra, 2016; Jimenez et al., 2013; Miller et al., 2023; Miller et al., 1993). Therefore, interventions to increase NICU referrals to EI should take place in the NICU before discharge. Rationale Implementing a new referral workflow and collaboration design between the NICU and EI offices required several important elements outlined in the Johns Hopkins Evidence Based Practice Model (JHEBP) for Nurses and Health Care Providers. As noted in the first step of the model, a thoughtful inquiry was made that considered and addressed the presence of bias and assumptions. Buy-in from all stakeholders was a key step to fully defining the existing process and creating a full picture of the question at hand. Learning about current evidence-based referral practices implemented in other organizations was critical to project success. However, reflecting on the context of those reported 7 recommendations through critical thinking and clinical reasoning was necessary since it may not be possible to mirror all program elements exactly. This crucial step, outlined in the Practice, Evidence, Translation (PET) element of the JHEBP model, supported the need for a new process that incorporated vital elements of successful referral workflows but also accommodated local hospital and EI office situations and needs. Feedback from the staff involved in implementation was critical to the success of this EBP project. Quality improvement is continuous and needs to be revisited to remain relevant and effective. After the new referral process was implemented, further reflection was needed to analyze its effectiveness and sustainability. Without adequate reflection, processes can appear to be successful but lack sustainability in the long term. Specific Aims The purpose of this Doctor of Nursing Practice (DNP) Quality Improvement (QI) initiative is to increase the number of completed referrals to EI from the NICU to improve quality years of life for NICU graduates. Confirming that the number of referrals sent matches the number of referrals received by establishing a robust referral workflow will ensure that these vulnerable infants are offered vital, low-cost, evidence-based EI services after hospital discharge. Methods Context The NICU involved in this initiative is located at a Level II trauma center serving Utah County, central Utah, and parts of southern Utah. This NICU has a large catchment area serving both urban and rural communities. It is one of the largest level III NICUs in Utah, with approximately 55 beds. The NICU currently employs two-to-three full-time social workers and one nursing discharge coordinator who refers families to EI services. However, PRN social workers are also commonly used to cover the services needed on this unit. 8 Six local early intervention (EI) programs currently receive regular referrals from this NICU, including Provo Early Intervention, Kids Who Count (Southern Utah Valley), Kids on the Move (Northern Utah Valley), Central Utah Early Intervention, Summit County Early Intervention, and Primetime 4Kids (Vernal). Catchment areas for each program are designated by the school district or county boundaries. Each EI office has a staff member designated to accept incoming referrals. Intervention(s) This DNP initiative worked to develop and implement a new referral workflow process in six phases. Phase one included gathering consent and buy-in from all stakeholders prior to assessing current referral practices. Several layers of leadership and front-line staff at both the NICU and EI programs needed to be briefed to establish buy-in and a willingness to participate. This initiative used a top-down approach by interviewing top executives first, followed by midlevel leadership and then frontline staff. Feedback from the Regional Director of Care Management resulted in significant adjustments to the workflow that ensured it could be adopted more widely across the hospital system if successful. This also ensured that needed resources and supports were in place for frontline workers to implement the new workflow successfully. It was additionally determined that the referral criteria used in the NICU did not reflect current evidence-based practices. This resulted in a meaningful change to the project criteria to include referral to EI for all infants in the NICU regardless of current diagnosis, prognosis, or length of stay. It is anticipated that this change will significantly increase the number of referrals to EI. Simultaneously, buy-in and approval from leadership at Baby Watch (the statewide leadership of Part C Early Intervention) was also obtained, allowing each local EI office 9 leadership team to participate. Each EI local office intake specialist was briefed on the purpose of this project and their role in its success. Each of these meetings was documented using a meeting summary or full transcript (See Appendix A). Phase two included diagraming the current referral processes at each facility and looking for possible sources of inaccuracies. Two interviews were conducted with the NICU discharge coordinator to document and assess current referral processes. The NICU social workers later confirmed that they use the same process. Each local EI office was interviewed and asked to confirm their referral intake process. The results of these meetings were compiled and presented in a PowerPoint presentation to all participants (see Appendix B). All stakeholders were presented with conclusions regarding problems with the current process that could lead to missed referrals. Consensus among all stakeholders was reached confirming that a new process was needed to improve referral outcomes between the health system and EI. Phase three included presenting the proposed new workflow based on the evidence collected during the literature review and successful practices implemented in other states. Feedback was requested from each staff member, and adjustments were made as needed for feasibility. A final workflow draft was completed and presented to the NICU, care management, and all six EI offices for final approval (See Appendix B). All stakeholders agreed to implement the new workflow as designed. A final workflow graphic was completed to capture the new workflow and make it easy to understand and follow. (See Appendix C). Phase four involved finalizing the documents and supporting tasks needed for the new workflow to be successfully implemented. A draft of the new “release of information consent” was sent to all stakeholders for approval. This document standardized the presentation of EI services to NICU families. Adjustments were made based on the feedback received, and a 10 finalized version with stakeholder logos was created (See Appendix D). To ease the transfer of accurate referral documentation, an updated list of fax machine numbers and contact details for all local EI offices was created and shared with care management leadership. This information was used to create automatic dialing on the updated care management fax system. A new workflow launch meeting took place between all stakeholders. This meeting acted to form relationships between the current stakeholders, many meeting each other for the first time. Final questions were answered, and all resources were reviewed to ensure that all stakeholders understood the process and were ready to begin the six-week implementation. The new workflow was implemented during phase five. The project lead contacted case management and each local EI office biweekly to gather data, including referrals sent and received. Variations in the workflow were noted when they occurred and documented for future analysis. To assess the likelihood of this new workflow being permanently adopted, and to identify any needed adjustments, in-depth discussions were completed with each staff member involved in implementation during phase six. Standard questions were asked about useability, feasibility, and satisfaction, and themes were identified. (See Appendix E). Study of the Intervention(s) The effectiveness of the intervention was determined by comparing the number of referrals sent by the NICU to the number of referrals received by local EI programs. Referral numbers were compared for consistency, with the expectation that the new referral workflow would result in the number of referrals sent and received equaling one another. When the number of referrals sent and received did not equal one another, an inquiry was opened to discover the cause of the lost referral. Care management was contacted on a bi-weekly basis for six weeks to 11 gather the number of referrals sent to local EI programs during that time. All six participating local EI programs were also contacted biweekly to assess the number of referrals received. These communications took place via email. Additionally, qualitative data from postimplementation discussion groups was used to assess the useability, feasibility, and satisfaction of stakeholders with the new referral process. Measures To determine the effectiveness of this EBP quality improvement project, the referrals sent by the NICU were compared to the number of referrals received by local EI programs. Referral numbers from all organizations were inputted into a table for comparison (See Appendix F for table template). The number of referrals missing was recorded. The number of times that the workflow was not implemented as designed was also recorded. The type of deviation was also noted. The number of missed referrals during the project period was compared to the average number of missed referrals over the previous data collection period (Jan 2022-April 2023). The data collected via bi-weekly email was recorded onto a table in Microsoft Word. The data collected included the number of referrals received by each EI program, the number of referrals sent by the NICU to the six EI offices, and how each referral was received, phone call, fax, or both. (see Appendix F). To measure the feasibility, usability, and satisfaction of the new workflow, a standard list of open-ended questions was poised to all staff involved in implementation. Open-ended questions were used to allow for detailed responses for content analysis (See Appendix E). See the notes in Appendix E to determine which questions were designed to measure feasibility, usability and/or satisfaction. Responses were analyzed for common themes and the most repeated responses noted for analysis. 12 Analysis Descriptive statistics were used to compare the number of referrals sent to the number of referrals received by each EI program. Due to the small sample size, Fishers exact chi-square tests were used to determine if the number of completed referrals differed significantly after implementation. Measures of clinical significance were used in addition to statistical significance to assess if the impact of the intervention warranted a workflow change. A content analysis was completed to evaluate the qualitative data generated from the open-ended questions during the post-implementation discussion groups with all stakeholders. These meetings were conducted via recorded video conferencing. The data from the autogenerated transcripts were used to organize the data into categories. Themes were identified and analyzed in an effort to understand the barriers and benefits to the new workflow being adopted long term. Ethical Considerations No potential competing interests or conflicts of interest were identified. This project was determined by the University of Utah and Intermountain Nursing Research Board to be a nonhuman subject’s research quality improvement project and is thus not subject to the Institutional Review Board. Results Biweekly referral counts for the six local EI programs and the NICU are noted in Table 1. In total, local EI programs reported receiving 34 referrals from the NICU during the six-week intervention. The NICU reported sending 30 referrals. EI programs accidentally counted some referrals twice during the data collection period due to the two-phone call/fax workflow, which led to the mismatched referral counts. However, upon analysis, no referrals were lost during the 13 intervention period (n=30, 100%). This result was statistically and clinically significant compared to the old workflow value of 37% received (chi-square value of 0.00001, p<.00001). Local EI programs reported that phone calls were placed by the NICU only 24% of the time, with 76% of the referrals being received via fax alone Although individual perceptions of the workflow varied, most staff members agreed that the phone calls were valuable to the referral process in troubleshooting faxing issues and/or to form relationships between the agencies. Others felt that faxing alone was sufficient if no issues arose. Most staff reported that two phone calls and two faxes were confusing and repetitive. Universally, all staff members involved in the workflow intervention reported that they would like to keep the new workflow but make some changes by reducing the number of faxes and/or phone calls. Discharge was identified by staff as the most appropriate time to send referral information. Summaries of post-implementation discussion groups are noted in Appendix E. This project was undertaken from December 2nd to January 12th, overlapping the holidays of Christmas and New Year. Staff absences led to some delays in data collection. Discussion Summary Despite the variations in workflow implementation seen during this project implementation, all intended referrals sent from the NICU were received by local EI programs. This shows a vast improvement, considering the volume of lost referrals prior to the new workflow. The NICU’s implementation of a more reliable faxing system in combination with phone calls appears to have been effective at reducing or eliminating lost referrals. This intervention involved collaboration between many offices, hospitals, executives, managers, and agencies willing to improve this workflow based on the perceived value of EI. Communication and the willingness to collaborate were invaluable to the success of this project. 14 Agreeing to a workflow that satisfied the needs of all organizations and met the evidence-based criteria also required flexibility and compromise with all stakeholders involved. Without a shared commitment to the value of EI and the willingness to meet multiple times to design an effective workflow, this project’s success would have been hindered. Based on the initial success of this project, the hospital system care management executives decided to implement the same EI referral strategy across all their 24 hospitals in Utah. Interpretation There was a noted increase in referrals to EI from the NICU during the project. (Figure 1). However, during the project data collection period it was discovered that some local EI programs were inputting NICU referrals into the database using free text instead of the allocated drop-down menus. The free text entries could not be identified by the system and therefore were not included in the auto-generated NICU referral report. This may have led to some inaccuracies in the EI referral data pulled by this report. All referral information for the project was confirmed directly with local EI programs, but historical data may not be fully reflective of all NICU referrals received in past years. In addition, NICU care managers referred solely to EI during the project. Historically, the NICU also referred infants to a local newborn home visiting program through the county health department. This change in referral criteria may have contributed to the volume of infants referred to EI during the project timeframe. As the NICU begins to reincorporate other programs for referrals, EI referral numbers may stabilize to pre-project levels. With only six weeks to implement the project and the overlap with the holiday season, more time may be needed to ensure consistent application of the workflow including ensuring phone calls are placed with each referral. Assessing further reasons for neglecting phone calls in 15 the referral process is also warranted. A new fax system was also implemented by NICU staff during this project. This change, combined with the addition of phone calls, may have led to further deviations in the workflow as staff members adjusted to these changes simultaneously. Based on staff feedback, limiting the workflow to one phone call and one fax may also be advisable for sustainability and satisfaction. Not losing a single referral during this project was an unexpected finding. Inconsistencies in staff referral implementation, awareness, and commitment to resolving this issue were noted. However, the general satisfaction of the staff and the overall success of EI referrals with the implementation of this new workflow contributed to ensuring eligible infants were connected to their local EI program after discharge from the NICU. Limitations This project was implemented in one NICU and six local EI programs ranging from rural to suburban. Results may not be transferable to other settings. In addition, based on organizational needs, interviews were conducted either with individuals or in a group. With group interviews, conformity bias may have affected the responses of participants. To counteract this effect, everyone in the group was called on by the project leader to respond to each question. However, the pressure to agree with the most often expressed view may have impacted the results. With the inconsistency of phone call placement during this project, it is difficult to draw firm conclusions on the impact of phone calls in the workflow. However, incorporating phone calls as part of the referral workflow had some noted benefits. Phone calls are a low-tech referral strategy that is not dependent on a particular software or internal charting system and, therefore, can be implemented widely and quickly. Phone calls also act as an important quality check to 16 counteract faxing errors that arise. Without phone calls, some referrals would most likely have been lost during this project. Lastly, most staff members in this project felt that phone calls also served to keep staff members in both organizations connected in a way that promotes functional working relationships. Therefore, it is posited that a similar referral strategy could be implemented in other settings with relative ease, resulting in a low-cost and highly effective referral solution. Conclusions A longer implementation time is needed to fully assess the impact of this quality improvement initiative and to gather further data on sustainability and usability. As this referral workflow is implemented in other hospitals in this same medical system, similar quality improvement efforts should be made to ensure the workflow is effective in these new environments. To ensure all NICU graduates are offered the same access to EI services regardless of the hospital system of their birth, more work is needed to analyze the workflows between NICUs and EI in other hospital systems and assess the need for quality improvement initiatives at these locations. Further analysis is also needed to assess how many NICU graduates referred to EI end up enrolling in EI services. Even with NICU referrals being consistently received, if families opt out of EI services or refuse evaluation by EI, then adjustments may be needed to understand the issues surrounding this potential trend. Additionally, performing an analysis to assess if all infants that meet the inclusion criteria are being offered a referral from NICU staff will also be informative. In Utah, a NICU stay automatically qualifies infants for EI services at birth. This project has the potential to greatly increase access to EI services for Utah NICU graduates, therefore, 17 decreasing the likelihood these infants will need special education or continued medical services later in life. Reducing the need for special education and medical care has many cost implications for the State of Utah and can lead to better quality of life for NICU graduates and their families. Acknowledgments I would like to thank all the staff involved in this initiative, including the local EI program managers, NICU care managers, Baby Watch and hospital executives including Lisa Davenport, Eliza Hintze, Amber Kayembe, Wendy Robinson, Diane Lawson, Maria Lupita Aguayo, Melanie Linford, Miran Chavez, Jacqueline Swan, Natalie Carter, Sheli Monson, Kerri Abney, Sidney Egbert, Mary Slack, and Nancy Coca. 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Academic Pediatrics, 22(2), 253262. https://doi.org/10.1016/j.acap.2021.10.006 Lewis, A. K. (2021). Cultural and Linguistic Diversity Among Children and Families Referred for Diagnostic Evaluation of Developmental Delay and Disability: Implications for Service Delivery. Journal of Policy & Practice in Intellectual Disabilities, 18(2), 113119. https://doi.org/10.1111/jppi.12358 Little, A. A., Kamholz, K., Corwin, B. K., Barrero-Castillero, A., & Wang, C. J. (2015). Understanding Barriers to Early Intervention Services for Preterm Infants: Lessons From Two States. Academic Pediatrics, 15(4), 430-438. https://doi.org/10.1016/j.acap.2014.12.006 Mathewson, K. J., Chow, C. H. T., Dobson, K. G., Pope, E. I., Schmidt, L. A., & Van Lieshout, R. J. (2017). Mental health of extremely low birth weight survivors: A systematic review and meta-analysis. Psychological bulletin, 143(4), 347-383. https://doi.org/10.1037/bul0000091 Miller, K., Marvin, C., & Lambert, M. (2019). Factors Influencing Acceptance Into Part C Early Intervention Among Low-Risk Graduates of Neonatal Intensive Care Units. Infants & 22 Young Children: An Interdisciplinary Journal of Early Childhood Intervention, 32(1), 2032. https://doi.org/10.1097/IYC.0000000000000130 Miller, K., Prokasky, A., Roberts, H., McMorris, C., & Needelman, H. (2023). Associations between risk factors, developmental outcomes, and executive function in neonatal intensive care unit graduates at 2 years: A retrospective study [Article]. Infant & Child Development, 32(3), 1-11. https://doi.org/10.1002/icd.2411 Miller, M., Mutton, C., & Williams, B. F. (1993). Collaborative experiences for NICU and early childhood education personnel. Neonatal network : NN, 12(7), 37-42. https://search.ebscohost.com/login.aspx?direct=true&db=mdc&AN=8413148&site=ehost -live Mirzaian, C. B., Ghadiali, T., Vestal, N., Song, A., Vanderbilt, D., & Lakshmanan, A. (2022). Rates of connection to early intervention from the neonatal intensive care unit in a high risk infant follow-up program. Journal of Perinatology, 42(10), 1412-1414. https://doi.org/10.1038/s41372-022-01408-3 Petersen, M., Nordlund, H. L., Koreska, M., & Brødsgaard, A. (2024). Bridging the gap between healthcare sectors: Facilitating the transition from NICU to the municipality and home for families with premature infants. Journal for Specialists in Pediatric Nursing, 29(2), 1-12. https://doi.org/10.1111/jspn.12426 Redford, S. (2024). Utah Valley Hospital NICU Early Intervention Referral Colloboration [Interview]. Spittle, A., Orton, J., Anderson, P. J., Boyd, R., & Doyle, L. W. (2015). Early developmental intervention programmes provided post hospital discharge to prevent motor and cognitive 23 impairment in preterm infants. Cochrane Database of Systematic Reviews(11). https://doi.org/10.1002/14651858.CD005495.pub4 Stipdonk, L. W., Dudink, J., Utens, E. M. W. J., Reiss, I. K., & Franken, M.-C. J. P. (2020). Language functions deserve more attention in follow-up of children born very preterm. European journal of paediatric neurology : EJPN : official journal of the European Paediatric Neurology Society, 26, 75-81. https://doi.org/10.1016/j.ejpn.2020.02.004 Tang, B. G., Feldman, H. M., Huffman, L. C., Kagawa, K. J., & Gould, J. B. (2012). Missed Opportunities in the Referral of High-Risk Infants to Early Intervention. Pediatrics, 129(6), 1027-1034. https://doi.org/10.1542/peds.2011-2720 Xue, X., Zong, X., Valentine, G., & Hussey-Gardner, B. (2023). Maryland’s PRIDE: Evaluation of an Early Intervention Program Embedded Within a NICU and NICU Follow-Up Program [Article]. Journal of Early Intervention, 1. https://doi.org/10.1177/10538151231179113 Yaari, M., Mankuta, D., Harel- Gadassi, A., Friedlander, E., Bar-Oz, B., Eventov-Friedman, S., Maniv, N., Zucker, D., & Yirmiya, N. (2018). Early developmental trajectories of preterm infants. Research in Developmental Disabilities, 81, 12-23. https://doi.org/10.1016/j.ridd.2017.10.018 Zimmerman, E. (2018). Do Infants Born Very Premature and Who Have Very Low Birth Weight Catch Up With Their Full Term Peers in Their Language Abilities by Early School Age? Journal of Speech, Language & Hearing Research, 61(1), 53-65. https://doi.org/10.1044/2017_JSLHR-L-16-0150 24 Tables and Figures Table 1 Biweekly Referral Counts from Six Local EI Programs and NICU Dates NICU KOTM KWC PEIP Summit Central PT4K Discrepancy 0 EI Program Total 13 2 Missing Phone Call 12 Dec 2-Dec 15 11 3 8 1 1 0 Dec 16-Dec 29 10 4 4 2 0 0 0 10 0 8 Dec 30-Jan 12 9 7 0 2 0 2 0 11 2 6 25 Figure 1 NICU Referrals to EI during 2022-2025 from Dec 2- Jan 12 NICU Referrals to EI 2022-2025 90 80 82 70 60 50 54 59 40 30 30 20 10 5 0 All NICUs Statewide 2022-2023 8 Project NICU Site 2023-2024 2024-2025 26 Appendix A Meeting Minutes Summary Effective referral strategies between the NICU and Part C Early Intervention: An Evidence Based Quality Improvement Initiative Date 2.20.24 Participants Provo Early Intervention Director 2.23.24 Director of Maryland’s Pride 2.23.24 Early Childhood Performance Specialist Division of Early Intervention and Special Education Services: Maryland State Department of Education 2.29.24 Part C Data Manager Division of Early Intervention and Special Education Services: Maryland State Department of Education Part C Coordinator for State of Virginia 3.5.24 Kids Who Count Leadership Team 3.12.24 Director of Developmental TIPS: Tracking Infant Progress Statewide 3.14.24 NICU Discharge Coordinator Summary Discussed possibility of NICU referral project. Stated her program’s commitment to participate. Discussed features of Maryland’s Pride program and current NICU referral strategies. See narrative summary Discussed features of NICU referrals to EI in Maryland. See narrative summary. Discussed features of NICU referrals to EI in Virginia. See narrative summary. Discussed possibility of NICU referral project. Stated their program’s commitment to participate. Discussed features of NICU referrals to EI in Nebraska through the Developmental TIPS program. See narrative summary. Discussed current process for NICU referrals to EI. Obtained current referral 27 Director of Women and Children’s Services 3.19.24 NICU Manager Intake Supervisor for Early Intervention Colorado Team 3.20.24 Physical Therapist with Helping Hands-Part C Agency in American Samoa 3.26.24 Director of KOTM 3.27.24 Wyoming Part C Coordinator 3.28.24 Welcome Baby Director 3.29.24 Project Director of Family Visiting Programs-Rhode Island Department of Health 4.9.24 Rhode Island Part C Coordinator-Executive Office of Department of Health and Human Services. Part C Coordinator/Babies Can’t Wait Director criteria and referral numbers for Jan 2023 till April 2024. Discussed features of NICU referrals to EI in Colorado. See narrative summary. Discussed features of NICU referrals to EI in American Samoa. See narrative summary. Discussed project and committed KOTM’s desire to be involved. Discussed features of NICU referrals to EI in Wyoming. See narrative summary. Discussed NICU referral project. Declined full involvement for Welcome Baby at this time due to concerns with representation. Discussed features of NICU referrals to EI in Rhode Island. See narrative summary. Discussed features of NICU referrals to EI in Georgia. See narrative summary. Director of Office of Child Health -Department of Public Health 4.18.24 Baby Watch Director 5.20.24 Assistant Dean of Graduate Studies at U of U College of Nursing Met to discuss progress of NICU referral strategies research Met to discuss possibility of completing DNP Scholarly Initiative at hospital chain facility. Planned next steps for approval. 28 6.5.24 Chief Nursing Officer Director of Women and Children Services 7.30.24 Assistant Dean of Graduate Studies at U of U College of Nursing 8.2.24 New NICU Discharge Coordinator 8.9.24 Departing NICU Discharge Coordinator Baby Watch Director 8.9.24 Baby Watch CSPD Coordinator NICU Manager 8.19.24 Provo Early Intervention Program Director 8.20.24 Central Utah Early Intervention Director 8.20.24 Primetime 4Kids Assistant Director 8.20.24 8.21.24 Primetime 4Kids Intake Specialist KOTM Leadership Team Summit County Early Intervention Director Summit County Early Intervention Nurse Discussed data and need for effective referral strategy. Voiced her support of the project. Discussed next steps for project approval through hospital system. Met to discuss current experience in hospital project approval process. Made plans for next steps. Met to discuss project with replacement discharge coordinator due to retirement Discussed status of project and next steps including interviewing local program directors Discussed intervention proposal. Stated her commitment to try the new process. She was concerned with the referral disparity and wanted to improve this process. Discussed new workflow proposal. Received feedback. See auto-generated transcript. Discussed new workflow proposal. Received feedback. See auto-generated transcript. Discussed new workflow proposal. Received feedback. See auto-generated transcript. Discussed new workflow proposal. Received feedback. See auto-generated transcript. Discussed new workflow proposal. Received feedback. See auto-generated transcript. 29 8.22.24 9.3.24 9.5.24 Kids Who Count Intake Specialist Kids Who Count Leadership Team Baby Watch Director Baby Watch CSPD Coordinator Baby Watch CSPD Coordinator Kids Who Count Leadership Team Discussed new workflow proposal. Received feedback. See auto-generated transcript. Discussed status of project and brainstormed next steps Lead a discussion on the finalized workflow process. Made edits in preparation to send to NICU as final draft. Drafted script for consent form for NICU to sign. Summit County Early Intervention Director KOTM Leadership Team Central Utah Early Intervention Director Provo Early Intervention Program Director 9.11.24 Primetime 4Kids Assistant Director NICU Manger NICU Discharge Coordinator NICU Social Worker NICU Social Worker 9.17.24 DDI Vantage Director 9.19.24 DDI Vantage Tooele Branch Nurse DDI Vantage Tooele Intake Specialist Discussed finalized workflow process considering feasibility and acceptability. Discussed how to fax medical records to EI offices through iCentra. NICU will follow up on this process/ Received commitment from NICU staff to trail new process for 4-6 weeks. Discussed new workflow proposal. Received feedback. See auto-generated transcript. Discussed new workflow proposal. Received feedback. See auto-generated transcript. 30 10.14.24 10.31.24 Director of Case Management Discussed proposed new Intermountain Canyons workflow. Concerns about Region staff burden and HIPPA compliant fax machines discussed. Director to take information to legal and compliance team. Meet again in two weeks to discuss the results. Director of Case Management After reviewing policy and for Intermountain Canyons procedures, the Director Region communicated that the threeway phone call was not in NICU Manager line with current hospital system practices. However, CSPD Coordinator at Baby the case workers would be Watch required to present a consent form to release information to Project Chair families that is developed by the hospital system. Consent would be obtained in using the case managers’ own words. Use of a script is not currently a hospital system practice. After obtaining consent, the case manager would place a phone call to the local EI program (separate from the family) and then fax the medical records information using Care Port. NICU manager expressed that she felt we were missing an opportunity to increase the quality of referrals since the current practices are ineffective in her experience. Baby Watch expressed concern that a script would not be used adding for opportunity for 31 misrepresentation of EI services. A meeting was set with to compile an education module about EI for case managers with hospital educational consult. 11.4.24 11.7.24 The expected launch date moved to late November. Baby Watch CSPD Discussed results of meeting. Coordinator Baby Watch Edited NICU script to create a checklist. Discussed and drafted questions to ask during meeting with IH educational consult on Thursday. Director of Case Management Based on our conversation, I for Intermountain Canyons wrote down the following Region dates for our project implementation. Hospital Educator Director Nov 14th- Have education CSPD Coordinator Baby materials drafted and sent to Watch unit educators Nov 15th-Nov 22ndEducators will inform and educate unit case managers on the new workflow Dec 2nd-Go live with the project Bi-weekly check-ins during the project via Teams with Case Management Executives Transition to monthly after project. Yearly after stability is established. The workflow has adjusted slightly to the following: 1. Parent signs the release of the information consent form. Provide 32 brochure from Baby Watch as well as discuss 5 checklist items. 2. Case manager calls EI (without family) to inform of the referral 3. Faxes initial medical documentation via Care Port 4. Around 48 hrs from discharge, call EI again to inform them of the discharge date and fax the final discharge summary. In addition, the workflow changes, the hospital has committed to referring ALL babies in the NICU to EI. 11.18.24 Five local EI program leaders: Kids Who Count Leadership Team Discussed new referral workflow. Questions arose about timing of entering referral in BTOTS. Summit County Early Intervention Director KOTM Leadership Team Central Utah Early Intervention Director 11.19.24 12.2.24 Primetime 4Kids Assistant Director CSPD Baby Watch Coordinator Kids Who Count Leadership Team Edited workflow for clarity. Discussed questions about referral timing and 45 day compliance. Will follow up with Baby Watch Leadership. Formed relationships between stakeholders. Many meeting each other for the first time at 33 Summit County Early Intervention Director KOTM Leadership Team Provo Early Intervention Leadership NICU Discharge Coordinator NICU Manager NICU Care Manager NICU Care Manger Director of Case Management for Intermountain Canyons Region Hospital Educator Director CSPD Coordinator Baby Watch NICU Unit Educator Baby Watch Part C Leadership this Launch. Discussed final questions about workflow. Set project dates. Began data collection. 34 Appendix B PowerPoint Presentation Outlining Current Workflow and Proposed New Workflow Slide 1 !""!#ABC!DE!"!EEFGDHAEFA!IB!HD-!A.!!LDAM!DLB#ND FLODPFEAD#D!FEGQDBLA!EC!LABRLSDFLD!CBO!L#!D -FH!ODTNFGBAQDBUPERC!U!LADBLBABFABC!D ER-BLD.RRO-NEQVDELVDUPMVD#PMVDOLPDHANO!LA NLBC!EHBAQDR"DNAFMD#RGG!I!DR"DLNEHBLI BLDPFEABFGD"NG"BGGU!LADR"DAM!DE!TNBE!U!LAHD"REDAM!D OR#AREDR"DLNEHBLIDPEF#AB#! ©UNIVERSITY OF UTAH HEALTH, 2018 35 Slide 2 BACKGROUND ! Clinical Rotations at both UVH and Baby Watch ! 6 EI Offices in Catchment area of Utah Valley Hospital NICU (UVH NICU) ! UVH one of the lowest referring NICUs historically ©UNIVERSITY OF UTAH HEALTH, 2018 36 Slide 3 BACKGROUND ! From Jan 2022 to April 2023, UVH sent 375 referrals to EI. EI only received 140. (Disparity of 235 referrals unaccounted for). There was a disparity of 75 referrals to Welcome Baby. ! Meetings with Kris, Wendy, Maria Black and Nursing Research Council, Welcome Baby, and EI Leadership. ©UNIVERSITY OF UTAH HEALTH, 2018 37 Slide 4 PROBLEM STATEMENT ! Welcome Baby and EI: Intake confusion and referral loss ! NICU-referral loss to both Welcome Baby and EI ! Lack of cohesive referral structure between all three organizations ©UNIVERSITY OF UTAH HEALTH, 2018 38 Slide 5 PURPOSE STATEMENT The purpose of this Doctor of Nursing (DNP) Quality Improvement (QI) initiative is to increase the number of completed referrals to EI from UVH NICU to decrease the number of days lived with a disability and improve quality years of life for NICU graduates. ©UNIVERSITY OF UTAH HEALTH, 2018 39 Slide 6 SETTING AND PARTICIPANTS ! UVH NICU & 6 EI offices in Catchment Area ! NICU discharge coordinator (1), NICU social workers (2) & Intake Specialists (6) ! NICU and EI Leadership (2 &6) ©UNIVERSITY OF UTAH HEALTH, 2018 40 Slide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©UNIVERSITY OF UTAH HEALTH, 2018 41 Slide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©UNIVERSITY OF UTAH HEALTH, 2018 6%$7F*%*+'2#FI!6+%I0 42 Slide 9 CURRENT NICU REFERRAL PROCESS !"#$%F'()*+H$) -".FIIFH$) +0H1-12#) "FI34-05#)%H)6!) H0)7#23H.#) 8-1(9):-55#")H$) +-+#0)34-0%9) ;-0#$%)IF5$I) 0#2#-I#)3H$I#$%) <4#3=)1HL)F$) 6?@)'H0)0#3H0"I) %H)1#)I#$% A@)"#+-0%.#$%) '-L#I)0#3H0")%H)6!) H0)7#23H.#) 8-1( ! B-3=)H')C##"1-3=)BHH+I ! B-3=)H')+-0#$%)F$MH2M#.#$%)F$)0#'#00-2)+0H3#II ! B-3=)H')'H0.-2)3H22-1H0-%FH$I)EF%4)6!)-$")7#23H.#)8-1() FF9#9)F$3H00#3%)3H$%-3%)F$'HG)34-$5#I)F$)-".FIIFH$)30F%#0F-G) #%399H) ©UNIVERSITY OF UTAH HEALTH, 2018 43 Slide 10 CURRENT EI PROCESS !"#"$%"F'()F*+H-F .I01 ! ! ! ! ! I23"+4F5(3$#F I2*H+-(4$H2F*+H-F !"#H+6F$24HF78!9F !.F!"%$":F.I01F +"#H+6 0H24(#4F'(-$;<F4HF ="4F>?FI2$4$(;F !"%$": @(%"F*$+34F%$3$4F :$4A$2FBCFM(<3 N+(23#+$?4$H2F7++H+3 '()"3F-$33"6F6>"F4HFF"$2GF>2#H--H2F+"*"++(;F-"4AH6 H""6$2GF4A+H>GAF+"#H+63F*H+F+";"%(24F6(4( '($;>+"F4HF#H24(#4F*(-$;$"3 .HF#H24(#4F$2*H+-(4$H2F*H+F#;(+$*$#(4$H2F$*F2""6"6F ©UNIVERSITY OF UTAH HEALTH, 2018 44 Slide 11 EVIDENCE BASED PRACTICE ! Warm vs. Cold Referral Methods Warm=Allows for two-way, real-time communication with automatic feedback (i.e. in person conferences, phone calls) Cold=Pushes information and does not allow for two way communication (i.e. fax, email, voicemail, text) Warm referral methods are much more effective than cold. ©UNIVERSITY OF UTAH HEALTH, 2018 “Warm” referral methods were more effective than “cold” referral methods. Warm referral methods include in person conversations or three-way phone calls between NICU, early intervention, and NICU graduate’s family. Warm referral methods occur prior to discharge or at discharge from the NICU. This method allows for oral communication and clarification of information as well as forming a direct link between trusted NICU staff and early intervention. By allowing for three-way discussion, NICU graduates get referred without the delays or miscommunications caused by cold referral methods. Families see the NICU and EI staff 45 working as a team with trusted relationships making families more likely to enroll in EI after discharge leading to better developmental outcomes. Warm referral methods also created regular contact points between EI and NICU staff making collaboration more effortless. In turn, consistent collaboration leads to a relationship of familiarity and trust between NICU and EI staff that is essential to promoting effective referral systems. Cold referral methods include fax, voicemail, and email that does not allow for three-way communication between NICU, EI and discharging families. Cold referral methods happen separately and often after discharge from the NICU. Written materials are also less effective as referral methods and educational resources than oral methods. Failure to contact families after discharge from NICU is also more common with cold referral methods. Expecting parents to call and self-refer is also an ineffective cold referral method. Cold referral methods lead to miscommunications and often lack timely feedback loops. Cold referral methods do not contribute to continuing collaboration and can lead to ineffective referral systems. 46 Slide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©UNIVERSITY OF UTAH HEALTH, 2018 47 Slide 13 NEXT STEPS 1. Set up meeting with Mary, Nancy, Sydney, Kerri, Kris and Wendy to discuss possible solutions to trial for 6 weeks based on literature. Separate meetings on same topic with local EI programs. (2-3 weeks) 2. Have pilot meeting to ensure consistency in new workflow process and troubleshoot (All stakeholders) (Late Sept) 3. On site meetings with Robin to ensure all elements in place for launch of new referral process (Late Sept) 4. Launch new referral process of 6 weeks. (Sept-October) 5. Evaluate for effectiveness and long-term acceptance. (Nov-Dec). ©UNIVERSITY OF UTAH HEALTH, 2018 48 Appendix C Referral Workflow Handout Early Intervention Referral Workflow 49 Appendix D NICU Referral Script from Consent to Release Information Babies who are sick for a long time sometimes have problems growing and developing such as: • • • • • Trouble eating Trouble sleeping Talking later than expected Crawling and walking later than expected Problems with social and emotional skills The sooner these problems are found and looked at, the faster your baby can reach their full potential. That is why Intermountain Health works with the Baby Watch Early Intervention Program to help babies after they leave the hospital. The Baby Watch Early Intervention Program has 15 local programs that provide home visits, parent coaching, and personalized support to eligible babies in Utah. The visits are in your home and teach you simple ways to help your baby during daily routines and activities. Early Intervention is different from home health. Early Intervention, also known as EI, is: ü A choice for parents and caregivers o You know your baby best and can choose to participate or not. ü A team effort o A group of experts comes to your home to help. Your team may include specialists in child development, nursing, speech therapy, physical therapy, occupational therapy, social work, and other areas. ü A process that starts with a FREE evaluation 50 o The local EI program will visit your home to check all parts of your baby’s development and see if they need help. ü A FREE service for families with Medicaid or CHIP o If you do not have Medicaid or CHIP, you pay a small monthly fee based on family size and income. Early Intervention does not bill private insurance. ü A program that lasts until your child’s 3rd birthday o Until then, the team will check your child’s progress once a year to see if they still need help. Our team wants to refer your baby to Early Intervention. The first step is for us to have a short phone call with the local Early Intervention program while you are still here at the hospital. Would you be willing to allow us to call Early Intervention on your behalf? Your local Early Intervention program is: Their contact information is: 2024 babywatch.utah.gov 51 Appendix E Standard Questions for Discussion Groups & Response Table Purpose: To evaluate the feasibility, usability and satisfaction of the new referral workflow between NICU and 7 local EI programs Format: Small group interviews with NICU staff and 7 EI offices individually 1. 2. 3. 4. 5. What did you like about the new process? (Satisfaction) What did you dislike about the new process? (Satisfaction) What elements of the new process were easy and effective? (Usability) What elements of the new process were unnecessary or cumbersome? (Usability) Were the discomforts of implementing the new process worth the results obtained? (Feasibility) 6. Would you vote to continue the new process as designed, keep the new process with some changes or return to the old process? (Feasibility) Local Early Intervention Programs Question 1. What did you like about the new workflow? (Satisfaction) Response Summary I liked getting babies from the NICU and being able to administer services to these vulnerable babies. Getting actual referrals from the hospital, huge pikes from both UVH and AFH. Phone calls helped with quality checks and feeling more connected to hospital staff. 52 Having a standardized way to receive referrals was helpful. I like that we captured all the babies and can provide services to these infants. Phone calls were good so I can know the referrals were coming. The faxes worked well. Having a concrete process that is standardized for accountability. I liked getting referrals before discharge and at discharge. 2. What did you dislike about the new workflow? (Satisfaction) Referrals for babies not discharged from hospital can be confusing. What is the best way to handle communicating with the parents when their infant may die? I feel like we are bothering parents to call them before their infant has a discharge timeframe. Redundancy in having 2 phone calls and 2 faxes. Added to some confusion. 53 Faxes coming as only a cover sheet instead of the actual text was challenging and requires an extra step. When the links on the coversheets were not working, I didn’t have a contact at the hospital to call to assist me. The only referrals we received were via fax, without phone calls. Having a phone call would have been helpful so I knew who to reach out to when I encountered this issue. Nothing Being available for phone calls can be a hit or miss. Maybe distracting if being called too often since we are all direct providers and don’t have a person in the office answering the phone. Nothing. 3. What elements of the workflow were easy and effective? (Usability) Phone calls were helpful so I knew when I could expect a referral. 54 Faxes and phone calls were easy to receive. Having the organization and purpose of the workflow was helpful. No extra work on our end. No complaints. We made a spreadsheet for data collection. Helped with sharing and accountability. Faxes were easy to receive and read. 4. What elements of the new workflow were unnecessary or cumbersome? (Usability) Knowing about an infant before discharge was unnecessary and added to confusion to the parents when we call. New fax coversheets added an extra step. But it was not too hard and now that I understand that is how faxes will come, it is fine. Facesheet faxes instead of actual text. No contact to call after facesheet information was not working. Extra steps of logging into 55 computer could work well, but does add extra step. Two phone calls and faxes can seem redundant. Just one phone call and fax at discharge would work better. Being available to take phone calls was hard for us since we are usually out visiting with families administering services when phone calls come. We don’t have someone in the office to answer the phone. The calls come to our cell phones. If the NICU is okay leaving messages sometimes, then this would be alright. Phone calls did not add any additional benefit. Faxes were fine. 5. Were the discomforts of implementing Yes the new workflow worth the results obtained? (Feasibility) Yes. I am worried about Babywatch being critical that we don’t contact the family every 56 week if their child is still in the hospital. More guidance on how to handle contacts with families still in the hospital would be appreciated. Yes Yes Yes Yes 6. Would you vote to continue the new workflow as designed, keep the new workflow with some changes, or return to the old workflow? (Feasibility) Keep with changes; not contacting parents before discharge or ensuring that we have a standard communication process with families, so our communication is effective and appropriate. Keep with changes; streamline the number of faxes and phone calls to reduce redundancy. Be sure that care managers leave a call back number with us during their referral so we can reach out if we need to follow up. 57 Keep with changes. Having a contact person to call would be sufficient. I could work with the factsheet faxes if I had someone to call. Having phone calls would be helpful. We didn’t receive any phone calls during the project even though they were supposed to happen based on the new workflow. Keep the new process but change to only one phone call and one fax at discharge. Keep with changes; remove phone calls. Keep the same, but suggest phone calls only for those sickest babies, based on acuity. Hospital Question 1. What did you like about the new workflow? (Satisfaction) Response Summary I liked calling EI programs on the phone. They answered quickly, or returned my call 58 quickly, and we were able to troubleshoot together. I had the opposite experience. They rarely answered and I left voicemails, and no one called back. The new process seemed more legitimate. Having a process was helpful and Careport allowed me to see if the referral was received or sent. We didn’t have that ability before. 2. What did you dislike about the new workflow? (Satisfaction) Careport drop down fax numbers are not working or accurate. I have had to resend several times. I think calling and faxing twice was repetitive. The new process was extra work. I would talk to families about EI and they would be thinking about it. I would follow up and they would still be thinking about it. Created extra work and faxing/calling twice is repetitive. When I was covering for other care managers, there wasn’t a great way to track where 59 families were in the referral process if it wasn’t charted in the patient chart. 3. What elements of the workflow were easy and effective? (Usability) 4. What elements of the new workflow were unnecessary or cumbersome? (Usability) Care Port is easier to use than the prior system 5. Were the discomforts of implementing the new workflow worth the results obtained? (Feasibility) Yes (1) Calling and faxing twice seemed unnecessary (All care managers agreed this was the case) Maybe (2). We used to refer a lot to Welcome Baby and I think the increase in referrals is due partly to us only referring to EI during the project. 6. Would you vote to continue the new workflow as designed, keep the new workflow with some changes, or return to the old workflow? (Feasibility) Keep with changes (All care managers agreed) 60 Appendix F Data Collection Table Template Dates Dec 2-Dec 15 Dec 16-Dec 29 Dec 30-Jan 12 NICU KOTM KWC PEIP Summit Central PT4K EI Program Total Discrepancy Missing Phone Call