NICU Graduates

Preterm birth is the leading cause of infant mortality in Ohio. Babies born before 37 weeks of pregnancy are more likely to require lifelong medical care, including home caregivers and special education services. With improved life-saving measures and medical technology, increasing numbers of children with special health care needs transition home from NICUs with supportive technology. For newborns, the main types of technological support include nutritional support and respiratory support. As more babies with complex medical needs are transitioned to home, recent studies have shown that readmission rates of premature infants are on the rise, leading to increases in healthcare expenditures.

To more effectively promote the well-being of NICU graduates and their families, the NICU Grads Project will work to improve the transition from the NICU to home for infants with complex health care needs and/or technology dependence. Specifically, the project will target newborns with tracheostomies (with and without ventilators) and Gastrostomy Tubes (G-Tubes). Over a two year period, the NICU Grads initiative aims to identify best practices for a family-centered and more integrated care coordination approach among NICUs, families, care/case managers, and home health service, waiver and primary care providers.

Using an adaptation of the Institute for Healthcare Improvement (IHI) Breakthrough Series (BTS™) model, pilot and spread hospitals will participate in a learning network to test and share best practices, including rapid Plan-Do-Study-Act (PDSA) cycles. OPQC leadership and project staff will assist participants in testing changes to the process of care delivery using the “Key Driver” model. Key Components of the NICU Grads project will be developed into tools to ensure a coordinated, timely transition of care plan, shared decision making amongst neonatal providers, families and caregivers, and standardized discharge readiness assessments, with the goal of avoiding unnecessary delays with post discharge services.

NICU Graduates Key Driver Diagram

NICU Grads Change Package


The OPQC NICU Grads project is funded by the Medicaid Technical Assistance and Policy Program (MEDTAPP) and administered by the Ohio Colleges of Medicine Government Resource Center. The views expressed in this presentation are solely those of the authors and do not represent the views of state or federal Medicaid programs.​