Hospital-based case management for medically fragile infants: program design.

Abstract

A hospital-based multidisciplinary team is demonstrating services for medically fragile infants which facilitate transition from the hospital to the community and home. The team provides education and counseling for communities and families to overcome barriers to services. With individualized case management, the team facilitates family access to the community services they need in infant health, infant development and family functioning. The team plans the infant's discharge from the hospital and collaborates on the initial Individualized Family Service Plan (IFSP) with the family and local community providers. The initial IFSP details potential outcomes in the areas of infant health, infant development and family functioning for the first year the infant is home. Systematic home visits with the team's nurse or developmental consultant, the family and the local provider continue the education and counseling process during the infant's first year of life. This describes the educational aspect of case management services for medically fragile infants.