Overview
Learning that your baby has complex medical needs can feel overwhelming. Managing care from multiple providers often adds to the stress. That’s why Rady Children’s offers the Continuing Care Coordination Program—a specialized service for a select group of babies in the NICU and their families.
Once enrolled, families receive personalized, expert support tailored to their child’s unique needs. Our care coordination continues throughout the NICU stay and extends beyond discharge, helping families navigate the transition home with confidence and compassion.
What to Expect
A dedicated inpatient care coordinator will work directly with your family throughout your stay at Rady Children’s NICU. Your care coordinator will do an intake assessment to get to know you and your infant. This assessment will help to identify ways we can help you navigate the health care system during your stay.
Your care coordinator will continue to meet with you regularly to provide your family with the following support:
- Acting as a central point of contact to help coordinate care for your child.
- Coordinating Family Care Conferences with the medical team to help you better understand the care your child is receiving.
- Providing education and guidance about navigating your child’s care while in the hospital.
- Setting weekly learning goals to help you stay on track with learning your child’s care.
- Monitoring the discharge planning process and remove barriers which may delay your child’s discharge.
Transition to Home
Approximately one month before discharge, you will be introduced to the outpatient nurse and social worker who will continue providing care coordination services to your family.
Some examples of what your coordinator may provide you with include:
- Completing a home visit.
- Helping you find a pediatrician who will manage your child’s needs.
- Attending pediatrician or subspecialty appointments.
- Maintaining frequent contact with you to monitor your child’s progress.
- Providing help with:
- Appointments
- Arranging transportation
- Connecting you with community resources
- Providing education
- Continuing to follow your child for 6-18 months after discharge from Rady Children’s.
Patient Story: A Beacon of Hope for Premature Infants
Amir was born at just over 24 weeks, marking the beginning of a long and challenging journey for both him and his family. Shortly after birth, he developed hydrocephalus, a condition where fluid builds up in the brain, leading to potentially severe complications.