TOP 25 - Improving support at home: Using quality improvement to increase discharge home health referrals for infants with in utero opioid exposure

Publication Number: 3753.TOP 25

Julia F. Litzky, The University of Vermont Children's Hospital, Chittenden, VT, United States; Sydney Tetreault, The University of Vermont Children's Hospital, Burlington, VT, United States; Katy Leffel, Vermont Department of Health, Waterbury, VT, United States; Zoe S. Nicozisin, The University of Vermont Children's Hospital, Burlington, VT, United States; Michelle Shepard, The University of Vermont Children's Hospital, Fairfax, VT, United States; Melinda Pariser-Schmidt, The University of Vermont Children's Hospital, Essex Junction, VT, United States; Andrea Corley, The University of Vermont Children's Hospital, Burlington, VT, United States; Keith Robinson, The University of Vermont Children's Hospital, Burlington, VT, United States; Molly Rideout, Robert Larner, M.D., College of Medicine at the University of Vermont, Burlington, VT, United States; Adrienne Pahl, University of Vermont, Burlington, VT, United States

Background: Infants with in-utero opioid exposure are at high risk for postnatal complications including feeding and growth difficulties and developmental delays. Birth parents are also at risk for relapse and overdose death. Affected families benefit from additional support postnatally; recommendations are to provide families with wrap-around community services at discharge including home health referrals. At baseline, our institution referred an average of 27% of families with in-utero opioid exposure to home health at discharge (median 20%).

Objective: We aimed to increase the rate of home health referrals for all infants monitored for in-utero opioid exposure and discharged from the University of Vermont Children's Hospital newborn nursery (NBN) or NICU to 90% by Jan 31, 2026.

Design/Methods: A multidisciplinary team including outpatient and inpatient pediatricians, social workers (SW), family advisors, and representatives from nursing and home visiting leadership began meeting in Sept 2023. The main outcome measure was the percent of opioid-exposed infants with home health referrals placed at discharge. Process measures included percent of charts with documentation of home health discussion by SW and/or nursing, including documentation method. Balancing measures included SW documentation burden, the potential for exceeding the capacity of the home health system, and the potential to negatively influence family opinions of home health. The project was IRB exempt. A key driver diagram (figure 1) identified opportunities to develop a standardized referral process, improve understanding regarding the home health services among providers and families, and promote documentation in the medical record. Thus, our successive PDSA cycles included 1) focused education for stakeholders and pediatric providers on home health services and benefits, 2) improving documentation of the Family Care Plan within the EMR, 3) focused education on home health benefits and referral process for all NICU and NBN staff, including a transition to opt out language, and 4) launch of new patient education materials, which were developed with family advisor guidance, and standardization of the referral process using medical orders in the EMR for referral placement. We used quality improvement methodology to track changes with run charts with one data point for every five sequential infants with 20 data points (100 infants) of background data (figures 2 and 3). Run charts will continue to be developed through project end date in Jan 2026.

Figure 1
Key driver diagram for home health referral process.

Figure 2
Percent of infants with home health referral placed at time of discharge, grouped in sequential cohorts of 5 patients. Four PDSA cycles have been completed including 1) focused education for stakeholders and pediatric providers on home health services and benefits, 2) improving documentation of home health discussions and the Family Care Plan within the EMR, 3) focused education on home health benefits and referral process for all NICU and NBN staff, including a transition to using opt out language, and 4) launch of new patient education materials, which were developed with family advisor guidance, and standardization of the referral process by using medical orders in the EMR for referral placement.

Figure 3
Percent of infants with documented discussion of home health by social workers, grouped in sequential cohorts of 5 patients. Four PDSA cycles have been completed including 1) focused education for stakeholders and pediatric providers on home health services and benefits, 2) improving documentation of home health discussions and the Family Care Plan within the EMR, 3) focused education on home health benefits and referral process for all NICU and NBN staff, including a transition to using opt out language, and 4) launch of new patient education materials, which were developed with family advisor guidance, and standardization of the referral process by using medical orders in the EMR for referral placement.