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. 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 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.