How Cleveland Clinic Is Transforming the Transition From NICU to Home

The first month after discharge from the Neonatal Intensive Care Unit (NICU) can be challenging for families, especially when an infant has ongoing medical needs. Patients and families lose the daily support of NICU providers and transition to outpatient support, where clinicians may be less familiar with the infant’s NICU course.

This vulnerable time began to stand out to Cleveland Clinic neonatologist Anirudha Das, MD, as a gap in care, ultimately motivating the creation of the NICU Transition of Care Program. “Families felt kind of left alone to fend for themselves,” Dr. Das says. “We thought it would be a great opportunity for us to improve our care by focusing on transition of care from NICU to home.”

Dr. Das developed a pilot project in 2018 alongside Ajith Mathew, MD, to conduct virtual follow-up with NICU graduates five to seven days after discharge. The telemedicine visit was created to complement, not replace, pediatrician care by giving families early access to NICU-specific expertise. The team found many early post-discharge concerns could be addressed virtually without an in-person exam.

Since its launch in 2018, the Cleveland Clinic NICU Transition of Care Program has grown from a pilot telehealth initiative seeing about 200 patients into one of the country's largest neonatal transition programs, caring for approximately 1,400 infants annually. As the program has grown, it has evolved beyond a virtual check-in to include lactation support for mother-infant dyads.

Emerging institutional data suggest this model may reduce healthcare utilization in this high-risk population.

Expanding breastfeeding support after NICU discharge

Because mothers are already present for the virtual transition-of-care visit, the team saw an opportunity to expand support to the dyad, during a time when breastfeeding challenges often emerge.

Neonatal nurse practitioner Erin Sweigart describes these challenges: “We know that NICU hospitalization disrupts breastfeeding. Mothers and babies are separated, skin-to-skin time is limited due to clinical illness, and early latching opportunities are lost due to illness or prematurity,” she says. “Understandably, these issues can impact mothers’ long-term breastmilk production and feeding plan.”

During virtual transition-of-care visits, mothers most often ask about milk supply and how to incorporate direct breastfeeding, especially as pumping routines are disrupted during the transition home.

“Without regular milk removal by either pumping or breastfeeding, milk supply starts to decrease. We discuss how to find a balance between maintaining frequent milk expression and caring for their baby or babies,” Sweigart says.

Even a small change in routine can make a big difference, she stresses. Some mothers stop pumping between NICU discharge and the first virtual appointment because of the new overwhelm of pumping and caring for their baby. Others wish to transition from bottle to direct breastfeeding, which requires time and an incremental, strategic approach.

Sweigart hopes mothers leave the appointment feeling confident about their next steps—and many do—but she also notes that the appointment serves as a screening tool to determine if in-person support is needed. This might mean a referral to the Breastfeeding Medicine Clinic or other outpatient resources, such as lactation support groups.

Several neonatology providers have completed a lactation certification, including two neonatal nurse practitioners who became International Board-Certified Lactation Consultants (IBCLCs), through a rigorous, time-intensive certification process.

Addressing common post-discharge concerns

Each virtual transition-of-care visit is tailored to the family’s needs, but feeding support is one of the most common concerns after NICU discharge. Dr. Das says the top questions they address in the clinic are related to feeding, especially because many NICU babies are discharged with nasogastric tube feeding and parents are eager to support and wean them off.

Additional concerns include breathing, growth and gastrointestinal issues.

“In many cases, these are normal, straightforward problems,” notes Dr. Das. “But parents are rightfully anxious and need guidance or reassurance about how to deal with them.”

Early data suggest lower healthcare utilization

Institutional data suggest the clinic may reduce healthcare utilization. The team analyzed electronic health records of 145 infants born on or before 32 weeks’ gestation who attended the virtual transition-of-care visit within one week of discharge. None of these patients had subsequent emergency department (ED) visits, hospital readmissions, or ICU admission within one month of their NICU discharge.

“Neonates with prolonged NICU stays are a high-risk population for increased healthcare utilization following discharge,” explains Dr. Das. “National data indicate that up to 8% of these infants are readmitted within 30 days of discharge.”

Telehealth may also support developmental follow-up

The research team also studied whether this type of visit may improve adherence to neurodevelopmental follow-up. In an analysis of very preterm infants, those who attended the telehealth visit were more likely to complete Bayley developmental testing, a standardized assessment tool used to diagnose developmental delays.

This is important, according to Dr. Das, because very preterm infants are at increased risk for neurodevelopmental disorders, and earlier identification can connect families with identification and support services sooner.

The Cleveland Clinic team is continuing to study whether structured transition-of-care models can improve long-term outcomes, reduce healthcare utilization, strengthen breastfeeding success, and provide a framework for post-NICU care nationwide.