VON for Health Equity

Potentially Better Practices for Follow Through

As neonatal care providers, we play critical roles in the lives of small and sick newborns and their families and therefore are uniquely positioned to address social determinants of health. Our responsibility to infants and families extends beyond the hospital or clinic walls. We must follow through. Follow through is different from the more typical neonatal practice of “follow up.” It is a comprehensive approach that begins before birth and continues into childhood. Health professionals, families, and communities must partner to meet the social as well as medical needs of infants and families to achieve health equity.

These Potentially Better Practices for Follow Through are intended as a starting point for individuals and teams. They vary greatly in ease of implementation and potential cost and we encourage you to start with change ideas that make the most sense for your unit. We refer to improvement ideas as Potentially Better Practices (PBPs) rather than “better” or “best” practices to indicate that no practice is better or best until adapted, tested and shown to work in the local context.

The PBPs are divided into six main categories:

I. Promote a culture of equity
II. Identify social risks of families and provide interventions to prevent and mitigate those risks
III. Take action to assist families after discharge (transition to home)
IV. Maintain support for families through infancy
V. Develop robust quality improvement efforts to ensure equitable, high-quality hospital and follow through care to all newborns by eliminating modifiable disparities
VI. Advocate for social justice at the local, state, and national levels

Health Equity and Follow Through in VON Programs


I. Promote a culture of equity

  1. Provide training and education in the social determinants of health to staff1,2
  2. Provide cultural sensitivity training to staff3–7
  3. Acknowledge and manage implicit and explicit personal bias8–14
  4. Promote a culture of equity15–17
  5. Create a disparities dashboard18–20
  6. Create a culture committed to follow through18,21


II. Identify social risks of families and provide interventions to prevent and mitigate those risks

  1. Screen all families for social risks and social support using a standardized tool22–29
  2. Use electronic health records to identify patterns and inform clinical decisions27,30–32
  3. Include a social worker or other social health professional on the team33,34
  4. Create alliances with community organizations (clinical-community partnerships)35–44
  5. Include a paralegal or attorney on the team45–47
  6. Provide parenting and family support tailored to individual family strengths and needs48–51
  7. Provide mental health services for families during the hospital stay52–57
  8. Provide referrals for drugs, alcohol, and smoking cessation counselling and treatment58–63
  9. Provide housing, meals, and transportation vouchers for families64–70
  10. Provide back to sleep education71–80
  11. Provide sibling care for families81,82
  12. Practice family integrated care tailored to the capabilities and needs of families51,83–85
  13. Provide trauma-informed care51,86,87
  14. Provide lactation support using peer counsellors and other approaches88–99
  15. Assess eligibility for SSI, WIC, early intervention, and other public benefits100–103
  16. Provide language support and culturally appropriate translation services for families104–107


III. Take action to assist to families after discharge (transition to home)

  1. Provide discharge education and planning tailored to each family’s needs51,106,108–112
  2. Begin discharge planning and teaching at admission113
  3. Estimate discharge date at admission and revise regularly during the stay114–116
  4. Implement a medical home model for patients and families117–121
  5. Establish effective communications with the primary care provider121
  6. Create a health coach program122
  7. Connect families with appropriate community organizations and services18,103,123–127
  8. Screen for developmental risk128
  9. Provide high risk infant follow up128–135
  10. Conduct home visits before discharge and at intervals after discharge51,136–142
  11. Facilitate parent support groups and peer counselling that extend beyond the stay88,98
  12. Implement strategies to identify and minimize risk for readmission143–149
  13. Provide telehealth support after discharge150–155
  14. Use technology and social media to support families156–165
  15. Facilitate access to all necessary clinical specialists after discharge121,134
  16. Provide reminders to facilitate health behaviors and keeping of appointments79,166–169
  17. Provide mental health and addiction services for families after the stay54,57,170
  18. Provide family planning education and contraception referral171–176
  19. Develop meaningful clinical-community partnerships21


IV. Maintain support for families through infancy

  1. Use parent coaches to support families98,99
  2. Provide evidence based early intervention programs103,177–182
  3. Utilize innovative approaches to medical visits99,183–186
  4. Establish a reach out and read program for patients and siblings187–192
  5. Provide medical and developmental follow up128–135
  6. Provide resources regarding available public benefits at follow-up visits100
  7. Establish partnerships with pre-K programs for patients and siblings193,194
  8. Develop and support tools that utilize parent reported outcomes195
  9. Provide access to quality high risk obstetrical care196–204
  10. Launch a fruit and vegetable prescription program205–208


V. Develop robust quality improvement efforts to ensure equitable, high-quality hospital and follow through care to all newborns by eliminating modifiable disparities

  1. Establish measurable improvement aims related to social determinants of health209–211
  2. Adopt standardized measures for social determinants of health19,20,27,212
  3. Develop strategies to support QI participation by parents including economically challenged, non-traditional and racially and ethnically diverse families213,214</sup
  4. Include pediatricians and other primary care providers for children on QI teams215
  5. Establish a charter with organizational leaders setting goals and resources for family advisors216
  6. Provide salary support for family advisors216


VI. Advocate for social justice at the local, state, and national levels

  1. Conduct and disseminate research that identifies disparities in access and outcomes21,210
  2. Serve on committees and in leadership roles within the local health system and raise awareness of need for social justice in healthcare44,217–219
  3. Actively recruit a diverse workforce with respect to race, ethnicity, gender, age, religion, and sexual orientation220
  4. Educate organizational leaders about social determinants of health
  5. Engage organizational leaders with a social determinants of health charter
  6. Advocate for the protection and restoration of nature by forming alliances to prioritize access to green spaces, especially in minority neighborhoods221
  7. Advocate, organize, inform and lobby to change policy at the local, state and national levels222–225
  8. Play a role in addressing global health inequities217,226,227
  9. Advocate for environmental health and justice228–231
  10. Name racism and ask, “How is racism operating here?”223,232
  11. Engage local, state, and federal agencies with responsibilities for infants and families
  12. Advocate to include population health and social justice in the organizational mission233,234
  13. Support the establishment of a national commission to explore restitution and atonement for historical and ongoing injustices inflicted on African Americans and Native Americans.235–238
  14. Speak out!

References

  1. Sharma M, Pinto A, Kumagai A. Teaching the social determinants of health: A path to equity or a road to nowhere? Acad Med. 2018;93(1):25-30.
  2. Lewis JH, Whelihan K, Roy D. Teaching students to identify and document social determinants of health. Adv Med Educ Pract. 2019;10:653-665.
  3. McGowan EC, Abdulla LS, Hawes KK, Tucker R, Vohr BR. Maternal immigrant status and readiness to transition to home from the NICU. Pediatrics. 2019;143(5).
  4. Horvat L, Horey D, Romios P, Kis-Rigo J. Cultural competence education for health professionals. Cochrane Database Syst Rev. 2014;(5):CD009405.
  5. Butler M, McCreedy E, Schwer N, et al. Improving Cultural Competence to Reduce Health Disparities. Agency for Healthcare Research and Quality (US); 2016. Accessed November 8, 2019. http://www.ncbi.nlm.nih.gov/books/NBK361126/
  6. Brottman MR, Char DM, Hattori RA, Heeb R, Taff SD. Toward cultural competency in health care: A scoping review of the diversity and inclusion education literature. Acad Med. Published online September 17, 2019.
  7. Ogbolu Y, Scrandis DA, Fitzpatrick G, Newhouse R. Leading organizational cultural competency: Nurse leader rounds and care for diverse patients. J Nurs Adm. 2016;46(12):627-629.
  8. Zeidan AJ, Khatri UG, Aysola J, et al. Implicit bias education and emergency medicine training: Step one? Awareness. AEM Educ Train. 2019;3(1):81-85.
  9. Sherman MD, Ricco J, Nelson SC, Nezhad SJ, Prasad S. Implicit bias training in a residency program: Aiming for enduring effects. Fam Med. 2019;51(8):677-681.
  10. Oliver MN, Wells KM, Joy-Gaba JA, Hawkins CB, Nosek BA. Do physicians’ implicit views of African Americans affect clinical decision making? J Am Board Fam Med. 2014;27(2):177-188.
  11. Maina IW, Belton TD, Ginzberg S, Singh A, Johnson TJ. A decade of studying implicit racial/ethnic bias in healthcare providers using the implicit association test. Soc Sci Med 1982. 2018;199:219-229.
  12. Hall WJ, Chapman MV, Lee KM, et al. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: A systematic review. Am J Public Health. 2015;105(12):e60-76.
  13. FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics. 2017;18(1):19.
  14. Dehon E, Weiss N, Jones J, Faulconer W, Hinton E, Sterling S. A systematic review of the impact of physician implicit racial bias on clinical decision making. Acad Emerg Med. 2017;24(8):895-904.
  15. Purnell TS, Calhoun EA, Golden SH, et al. Achieving health equity: Closing the gaps in health care disparities, interventions, and research. Health Aff (Millwood). 2016;35(8):1410-1415.
  16. National Quality Forum. A roadmap for promoting health equity and eliminating disparities: The four I’s for health equity. Published online September 2017. Accessed February 5, 2020. https://www.qualityforum.org/Publications/2017/09/A_Roadmap_for_Promoting_Health_Equity_and_Eliminating_Disparities__The_Four_I_s_for_Health_Equity.aspx
  17. American Hospital Association, Association of American Medical Colleges, American College of Healthcare Executives, Catholic Health Association of the United States, National Association of Public Hospitals and Health Systems. Eliminating Health Care Disparities: Implementing the National Call to Action Using Lessons Learned. Published online February 2012. http://www.hpoe.org/Reports-HPOE/eliminating_health_care_disparities.pdf
  18. Stevenson DK, Wong RJ, Profit J, Shaw GM, Wang CJ, Lee HC. “Following through”: addressing the racial inequality for preterm infants and their families. Pediatr Res. Published online October 3, 2019:1-2.
  19. Profit J, Gould JB, Bennett M, et al. Racial/ethnic disparity in NICU quality of care delivery. Pediatrics. 2017;140(3).
  20. Health Research and Educational Trust. Improving Health Equity Through Data Collection AND Use: A Guide for Hospital Leaders. Published online 2011. http://www.hpoe.org/Reports-HPOE/improvinghealthequity3.2011.pdf
  21. Beck AF, Edwards EM, Horbar JD, Howell EA, McCormick MC, Pursley DM. The color of health: how racism, segregation, and inequality affect the health and well-being of preterm infants and their families. Pediatr Res. Published online July 29, 2019:1-8.
  22. Sokol R, Austin A, Chandler C, et al. Screening children for social determinants of health: A systematic review. Pediatrics. 2019;144(4).
  23. Fuller MG, Vaucher YE, Bann CM, Das A, Vohr BR, NICHD Neonatal Research Network. Lack of social support as measured by the Family Resource Scale screening tool is associated with early adverse cognitive outcome in extremely low birth weight children. J Perinatol. 2019;39(11):1546-1554.
  24. Fierman AH, Beck AF, Chung EK, et al. Redesigning health care practices to address childhood poverty. Acad Pediatr. 2016;16(3 Suppl):S136-146.
  25. Dworkin PH, Garg A. Considering approaches to screening for social determinants of health. Pediatrics. 2019;144(4).
  26. Chung EK, Siegel BS, Garg A, et al. Screening for social determinants of health among children and families living in poverty: A guide for clinicians. Curr Probl Pediatr Adolesc Health Care. 2016;46(5):135-153.
  27. Adler NE, Stead WW. Patients in context — EHR capture of social and behavioral determinants of health. N Engl J Med. 2015;372(8):698-701.
  28. Beck AF, Klein MD, Schaffzin JK, Tallent V, Gillam M, Kahn RS. Identifying and treating a substandard housing cluster using a medical-legal partnership. Pediatrics. 2012;130(5):831-838.
  29. Beck AF, Tschudy MM, Coker TR, et al. Determinants of health and pediatric primary care practices. Pediatrics. 2016;137(3):e20153673.
  30. Beck AF, Sandel MT, Ryan PH, Kahn RS. Mapping neighborhood health geomarkers to clinical care decisions to promote equity in child health. Health Aff (Millwood). 2017;36(6):999-1005.
  31. Miranda ML, Ferranti J, Strauss B, Neelon B, Califf RM. Geographic health information systems: A platform to support the ‘Triple Aim.’ Health Aff (Millwood). 2013;32(9):1608-1615.
  32. Hardt NS, Muhamed S, Das R, Estrella R, Roth J. Neighborhood-level hot spot maps to inform delivery of primary care and allocation of social resources. Perm J. 2013;17(1):4-9.
  33. Standards for Social Work Services in the Newborn Intensive Care Unit. Accessed December 19, 2019. https://www.napsw.org/assets/docs/NICU-standards.pdf
  34. Hynan MT, Steinberg Z, Baker L, et al. Recommendations for mental health professionals in the NICU. J Perinatol. 2015;35 Suppl 1:S14-18. doi:10.1038/jp.2015.144
  35. Clinical-Community Linkages. Accessed December 30, 2019. http://www.ahrq.gov/ncepcr/tools/community/index.html
  36. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff Proj Hope. 2008;27(3):759-769.
  37. Baum FE, Bégin M, Houweling TAJ, Taylor S. Changes not for the fainthearted: reorienting health care systems toward health equity through action on the social determinants of health. Am J Public Health. 2009;99(11):1967-1974.
  38. Wesson DE, Kitzman HE. How academic health systems can achieve population health in vulnerable populations through value-based care: The critical importance of establishing trusted agency. Acad Med J Assoc Am Med Coll. 2018;93(6):839-842.
  39. Wilkins CH, Alberti PM. Shifting academic health centers from a culture of community service to community engagement and integration. Acad Med J Assoc Am Med Coll. 2019;94(6):763-767.
  40. Smitherman HC, Baker RS, Wilson MR. Socially accountable academic health centers: Pursuing a quadripartite mission. Acad Med J Assoc Am Med Coll. 2019;94(2):176-181.
  41. Kahn RS, Iyer SB, Kotagal UR. Development of a child health learning network to improve population health outcomes; Presented in Honor of Dr Robert Haggerty. Acad Pediatr. 2017;17(6):607-613.
  42. Henize AW, Beck AF, Klein MD, Adams M, Kahn RS. A road map to address the social determinants of health through community collaboration. Pediatrics. 2015;136(4):e993-1001.
  43. Carroll-Scott A, Henson RM, Kolker J, Purtle J. The role of nonprofit hospitals in identifying and addressing health inequities in cities. Health Aff (Millwood). 2017;36(6):1102-1109.
  44. Alberti PM, Sutton KM, Cooper LA, Lane WG, Stephens S, Gourdine MA. Communities, social justice, and academic health centers. Acad Med. 2018;93(1):20-24.
  45. Klein MD, Beck AF, Henize AW, Parrish DS, Fink EE, Kahn RS. Doctors and lawyers collaborating to HeLP children–outcomes from a successful partnership between professions. J Health Care Poor Underserved. 2013;24(3):1063-1073.
  46. Regenstein M, Trott J, Williamson A, Theiss J. Addressing social determinants of health through medical-legal partnerships. Health Aff (Millwood). 2018;37(3):378-385.
  47. Sandel M, Hansen M, Kahn R, et al. Medical-legal partnerships: transforming primary care by addressing the legal needs of vulnerable populations. Health Aff (Millwood). 2010;29(9):1697-1705.
  48. Treyvaud K, Spittle A, Anderson PJ, O’Brien K. A multilayered approach is needed in the NICU to support parents after the preterm birth of their infant. Early Hum Dev. Published online August 27, 2019:104838.
  49. Davidson JE, Aslakson RA, Long AC, et al. Guidelines for family-centered care in the neonatal, pediatric, and adult ICU. Crit Care Med. 2017;45(1):103-128.
  50. Brett J, Staniszewska S, Newburn M, Jones N, Taylor L. A systematic mapping review of effective interventions for communicating with, supporting and providing information to parents of preterm infants. BMJ Open. 2011;1(1).
  51. Haroz EE, Ingalls A, Wadlin J, et al. Utilizing broad-based partnerships to design a precision approach to implementing evidence-based home visiting. J Community Psychol. 48(4):1100-1113.
  52. Shaw RJ, St John N, Lilo E, et al. Prevention of traumatic stress in mothers of preterms: 6-month outcomes. Pediatrics. 2014;134(2):e481-488.
  53. Shaw RJ, Bernard RS, Deblois T, Ikuta LM, Ginzburg K, Koopman C. The relationship between acute stress disorder and posttraumatic stress disorder in the neonatal intensive care unit. Psychosomatics. 2009;50(2):131-137.
  54. Roque ATF, Lasiuk GC, Radünz V, Hegadoren K. Scoping review of the mental health of parents of infants in the NICU. J Obstet Gynecol Neonatal Nurs. 2017;46(4):576-587.
  55. Hatters Friedman S, Kessler A, Nagle Yang S, Parsons S, Friedman H, Martin RJ. Delivering perinatal psychiatric services in the neonatal intensive care unit. Acta Paediatr. 2013;102(9):e392-397.
  56. Greene MM, Rossman B, Patra K, Kratovil AL, Janes JE, Meier PP. Depression, anxiety, and perinatal-specific posttraumatic distress in mothers of very low birth weight infants in the neonatal intensive care unit. J Dev Behav Pediatr JDBP. 2015;36(5):362-370.
  57. Walsh TB, Davis RN, Garfield C. A call to action: Screening fathers for perinatal depression. Pediatrics. 2020;145(1).
  58. Smoking: stopping in pregnancy and after childbirth. Accessed November 6, 2019. https://www.nice.org.uk/guidance/ph26
  59. Phillips RM, Merritt TA, Goldstein MR, Deming DD, Slater LE, Angeles DM. Prevention of postpartum smoking relapse in mothers of infants in the neonatal intensive care unit. J Perinatol. 2012;32(5):374-380.
  60. Nichols A, Clarke P, Notley C. Parental smoking and support in the NICU. Arch Dis Child – Fetal Neonatal Ed. 2019;104(3):F342-F342.
  61. Stotts AL, Green C, Northrup TF, et al. Feasibility and efficacy of an intervention to reduce secondhand smoke exposure among infants discharged from a neonatal intensive care unit. J Perinatol. 2013;33(10):811-816.
  62. Maguire DJ. Mothers on methadone: care in the NICU. Neonatal Netw. 2013;32(6):409-415.
  63. Stotts AL, Klawans MR, Northrup TF, Villarreal Y, Hovell MF. Understanding motivation to implement smoking bans among mothers with a hospitalized infant. Addict Behav. 2016;58:60-67.
  64. Pollack CE, Blackford AL, Du S, Deluca S, Thornton RLJ, Herring B. Association of receipt of a housing voucher with subsequent hospital utilization and spending. JAMA. 2019;322(21):2115-2124.
  65. Zupancic JAF. Societal Costs of Preterm Birth. In: Preterm Birth: Causes, Consequences, and Prevention. National Academies Press; 2019.
  66. Pineda R, Bender J, Hall B, Shabosky L, Annecca A, Smith J. Parent participation in the neonatal intensive care unit: Predictors and relationships to neurobehavior and developmental outcomes. Early Hum Dev. 2018;117:32-38.
  67. Klawetter S, Greenfield JC, Speer SR, Brown K, Hwang SS. An integrative review: maternal engagement in the neonatal intensive care unit and health outcomes for U.S.-born preterm infants and their parents. AIMS Public Health. 2019;6(2):160-183.
  68. Hodek J-M, von der Schulenburg J-M, Mittendorf T. Measuring economic consequences of preterm birth – Methodological recommendations for the evaluation of personal burden on children and their caregivers. Health Econ Rev. 2011;1:6.
  69. Franck LS, Ferguson D, Fryda S, Rubin N. The child and family hospital experience: Is it influenced by family accommodation? Med Care Res Rev. 2015;72(4):419-437.
  70. Beck AF, Klein MD, Schaffzin JK, Tallent V, Gillam M, Kahn RS. Identifying and treating a substandard housing cluster using a medical-legal partnership. Pediatrics. 2012;130(5):831-838.
  71. Babies Sleep Safest on Their Backs: A Resource Kit for Reducing the Risk of Sudden Infant Death Syndrome in African American Communities. Accessed December 19, 2019. https://www.nichd.nih.gov/sites/default/files/publications/pubs/documents/SIDS_resourcekit_rev.pdf
  72. Salm Ward TC, Balfour GM. Infant safe sleep interventions, 1990–2015: A review. J Community Health. 2016;41(1):180-196.
  73. Naugler MR, DiCarlo K. Barriers to and interventions that increase nurses’ and parents’ compliance with safe sleep recommendations for preterm infants. Nurs Womens Health. 2018;22(1):24-39.
  74. Moon RY, Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: Evidence base for 2016 updated recommendations for a safe infant sleeping environment. Pediatrics. 2016;138(5).
  75. Mathews AA, Joyner BL, Oden RP, Alamo I, Moon RY. Comparison of infant sleep practices in African-American and U.S Hispanic families: Implications for sleep-related infant death. J Immigr Minor Health Cent Minor Public Health. 2015;17(3):834-842.
  76. Leong T, Billaud M, Agarwal M, et al. As easy as ABC: evaluation of safe sleep initiative on safe sleep compliance in a freestanding pediatric hospital. Inj Epidemiol. 2019;6(Suppl 1).
  77. Hwang SS, Smith RA, Barfield WD, Smith VC, McCormick MC, Williams MA. Supine sleep positioning in preterm and term infants after hospital discharge from 2000 to 2011. J Perinatol. 2016;36(9):787-793.
  78. Hirai AH, Kortsmit K, Kaplan L, et al. Prevalence and factors associated with safe infant sleep practices. Pediatrics. 2019;144(5).
  79. Gelfer P, Cameron R, Masters K, Kennedy KA. Integrating “Back to Sleep” recommendations into neonatal ICU practice. Pediatrics. 2013;131(4):e1264-1270.
  80. Bombard JM. Vital Signs: Trends and disparities in infant safe sleep practices — United States, 2009–2015. MMWR Morb Mortal Wkly Rep. 2018;67.
  81. Peluso AM, Harnish BA, Miller NS, Cooper ER, Fujii AM. Effect of young sibling visitation on respiratory syncytial virus activity in a NICU. J Perinatol. 2015;35(8):627-630.
  82. Horikoshi Y, Okazaki K, Miyokawa S, et al. Sibling visits and viral infection in the neonatal intensive care unit. Pediatr Int Off J Jpn Pediatr Soc. 2018;60(2):153-156.
  83. O’Brien K, Robson K, Bracht M, et al. Effectiveness of Family Integrated Care in neonatal intensive care units on infant and parent outcomes: a multicentre, multinational, cluster-randomised controlled trial. Lancet Child Adolesc Health. 2018;2(4):245-254.
  84. Franck LS, O’Brien K. The evolution of family-centered care: From supporting parent-delivered interventions to a model of family integrated care. Birth Defects Res. 2019;111(15):1044-1059.
  85. Cheng C, Franck LS, Ye XY, Hutchinson SA, Lee SK, O’Brien K. Evaluating the effect of Family Integrated Care on maternal stress and anxiety in neonatal intensive care units. J Reprod Infant Psychol. Published online September 10, 2019:1-14.
  86. Sanders MR, Hall SL. Trauma-informed care in the newborn intensive care unit: promoting safety, security and connectedness. J Perinatol. 2018;38(1):3-10.
  87. Marcellus L. Supporting women with substance use issues: trauma-informed care as a foundation for practice in the NICU. Neonatal Netw. 2014;33(6):307-314.
  88. Thomson G, Balaam M-C. International insights into peer support in a neonatal context: A mixed-methods study. PLoS ONE. 2019;14(7).
  89. Rossman B, Greene MM, Meier PP. The role of peer support in the development of maternal identity for “NICU Moms.” J Obstet Gynecol Neonatal Nurs. 2015;44(1):3-16.
  90. Rossman B, Engstrom JL, Meier PP. Healthcare providers’ perceptions of breastfeeding peer counselors in the neonatal intensive care unit. Res Nurs Health. 2012;35(5):460-474.
  91. Rossman B, Engstrom JL, Meier PP, Vonderheid SC, Norr KF, Hill PD. “They’ve walked in my shoes”: mothers of very low birth weight infants and their experiences with breastfeeding peer counselors in the neonatal intensive care unit. J Hum Lact Off J Int Lact Consult Assoc. 2011;27(1):14-24.
  92. Parker MG, Greenberg LT, Edwards EM, Ehret D, Belfort MB, Horbar JD. National trends in the provision of human milk at hospital discharge among very low-birth-weight infants. JAMA Pediatr. 2019;173(10):961-968.
  93. Oza-Frank R, Bhatia A, Smith C. Impact of peer counselors on breastfeeding outcomes in a nondelivery NICU setting. Adv Neonatal Care Off J Natl Assoc Neonatal Nurses. 2014;14(4):E1-8.
  94. Merewood A, Chamberlain LB, Cook JT, Philipp BL, Malone K, Bauchner H. The effect of peer counselors on breastfeeding rates in the neonatal intensive care unit: results of a randomized controlled trial. Arch Pediatr Adolesc Med.
  95. Meier PP, Patel AL, Bigger HR, Rossman B, Engstrom JL. Supporting breastfeeding in the neonatal intensive care unit: Rush Mother’s Milk Club as a case study of evidence-based care. Pediatr Clin North Am. 2013;60(1):209-226.
  96. Meier PP, Engstrom JL, Rossman B. Breastfeeding peer counselors as direct lactation care providers in the neonatal intensive care unit. J Hum Lact Off J Int Lact Consult Assoc. 2013;29(3):313-322.
  97. Hilditch C, Howes A, Dempster N, Keir A. What evidence-based strategies have been shown to improve breastfeeding rates in preterm infants? J Paediatr Child Health. 2019;55(8):907-914.
  98. Hall SL, Ryan DJ, Beatty J, Grubbs L. Recommendations for peer-to-peer support for NICU parents. J Perinatol. 2015;35(Suppl 1):S9-S13.
  99. Coker TR, Chacon S, Elliott MN, et al. A parent coach model for well-child care among low-income children: A randomized controlled trial. Pediatrics. 2016;137(3):e20153013.
  100. Benefits For Children With Disabilities. Accessed December 19, 2019. https://www.ssa.gov/pubs/EN-05-10026.pdf
  101. Soneji S, Beltrán-Sánchez H. Association of Special Supplemental Nutrition Program for women, infants, and children with preterm birth and infant mortality. JAMA Netw Open. 2019;2(12):e1916722-e1916722.
  102. Hamad R, Collin DF, Baer RJ, Jelliffe-Pawlowski LL. Association of revised WIC food package with perinatal and birth outcomes: A quasi-experimental study. JAMA Pediatr. 2019;173(9):845-852.
  103. Centers for Disease Control and Prevention. What is “Early Intervention”? Accessed January 28, 2020. https://www.cdc.gov/ncbddd/actearly/parents/states.html
  104. Miquel-Verges F, Donohue PK, Boss RD. Discharge of infants from NICU to Latino families with limited English proficiency. J Immigr Minor Health. 2011;13(2):309-314.
  105. Enlow E, Herbert SL, Jovel IJ, Lorch SA, Anderson C, Chamberlain LJ. Neonatal intensive care unit to home: the transition from parent and pediatrician perspectives, a prospective cohort study. J Perinatol. 2014;34(10):761-766
  106. Dunn MS, Reilly MC, Johnston AM, Hoopes RD, Abraham MR. Development and dissemination of potentially better practices for the provision of family-centered care in neonatology: The family-centered care map. Pediatrics. 2006;118(Supplement 2):S95-S107.
  107. DeCamp LR, Choi H, Davis MM. Medical home disparities for Latino children by parental language of interview. J Health Care Poor Underserved. 2011;22(4):1151-1166.
  108. Welch CD, Check J, O’Shea TM. Improving care collaboration for NICU patients to decrease length of stay and readmission rate. BMJ Open Qual. 2017;6(2):e000130.
  109. Sims DC, Jacob J, Mills MM, Fett PA, Novak G. Evaluation and development of potentially better practices to improve the discharge process in the neonatal intensive care unit. Pediatrics. 2006;118(Supplement 2):S115-S123
  110. Mills MM, Sims DC, Jacob J. Implementation and case-study results of potentially better practices to improve the discharge process in the neonatal intensive care unit. Pediatrics. 2006;118 Suppl 2:S124-133.
  111. Enlow E, Gray MM, Wallace-Keeshen S, D’Agostino JA, Abbasi S, Lorch SA. Health literacy of parents of very preterm infants at NICU admission and discharge: a prospective cohort study. J Perinatol. 2019;39(6):866-875.
  112. Lakshmanan A, Kubicek K, Williams R, et al. Viewpoints from families for improving transition from NICU-to-home for infants with medical complexity at a safety net hospital: a qualitative study. BMC Pediatr. 2019;19(1):223.
  113. VON Quality Improvement Kit: Improving Discharge Management. Published online January 2009.
  114. Seaton SE, Barker L, Jenkins D, Draper ES, Abrams KR, Manktelow BN. What factors predict length of stay in a neonatal unit: a systematic review. BMJ Open. 2016;6(10).
  115. Seaton SE, Barker L, Draper ES, Abrams KR, Modi N, Manktelow BN. Estimating neonatal length of stay for babies born very preterm. Arch Dis Child Fetal Neonatal Ed. 2019;104(2):F182-F186.
  116. Fleming PJ, Ingram J, Johnson D, Blair PS. Estimating discharge dates using routinely collected data: improving the preparedness of parents of preterm infants for discharge home. Arch Dis Child Fetal Neonatal Ed. 2017;102(2):F170-F172.
  117. Van Cleave J, Boudreau AA, McAllister J, Cooley WC, Maxwell A, Kuhlthau K. Care coordination over time in medical homes for children with special health care needs. Pediatrics. 2015;135(6):1018-1026. doi:10.1542/peds.2014-1067
  118. Litt JS, McCormick MC. Preterm infants are less likely to have a family-centered medical home than term-born peers. J Perinatol. 2018;38(10):1391-1397.
  119. Litt JS, McCormick MC. Care coordination, the family-centered medical home, and functional disability among children with special health care needs. Acad Pediatr. 2015;15(2):185-190.
  120. Homer CJ, Klatka K, Romm D, et al. A review of the evidence for the medical home for children with special health care needs. Pediatrics. 2008;122(4):e922-e937.
  121. Medical Home Initiatives for Children With Special Needs Project Advisory. Policy Statement: Organizational principles to guide and define the child health care system and/or improve the health of all children. Pediatrics. 2004;113(Supplement 4):1545-1547.
  122. Transitioning Newborns from NICU to Home. Published November 11, 2019. Accessed November 11, 2019. http://www.ahrq.gov/patient-safety/settings/hospital/resource/nicu/index.html
  123. Smith VC, Hwang SS, Dukhovny D, Young S, Pursley DM. Neonatal intensive care unit discharge preparation, family readiness and infant outcomes: connecting the dots. J Perinatol. 2013;33(6):415-421
  124. Purdy IB, Craig JW, Zeanah P. NICU discharge planning and beyond: recommendations for parent psychosocial support. J Perinatol. 2015;35(Suppl 1):S24-S28.
  125. Committee on Fetus and Newborn. Hospital discharge of the high-risk neonate. Pediatrics. 2008;122(5):1119-1126.
  126. Murch TN, Smith VC. Supporting families as they transition home. Newborn Infant Nurs Rev. 2016;16(4):298-302.
  127. Gottlieb LM, Hessler D, Long D, et al. Effects of social needs screening and in-person service navigation on child health: A randomized clinical trial. JAMA Pediatr. 2016;170(11):e162521-e162521.
  128. Lester BM, Andreozzi-Fontaine L, Tronick E, Bigsby R. Assessment and evaluation of the high risk neonate: The NICU Network Neurobehavioral Scale. J Vis Exp. 2014;(90).
  129. Sigurdson K, Mitchell B, Liu J, et al. Racial/ethnic disparities in neonatal intensive care: A systematic review. Pediatrics. 2019;144(2).
  130. Pursley DM, McCormick MC. Bending the arc for the extremely low gestational age newborn. Pediatr Res. 2018;83(4):751-753.
  131. Pai VV, Kan P, Bennett M, Carmichael SL, Lee HC, Hintz SR. Improved referral of very low birthweight infants to high-risk infant follow-up in California. J Pediatr. 2019;0(0).
  132. McCormick MC, Litt JS. The outcomes of very preterm infants: Is it time to ask different questions? Pediatrics. 2017;139(1).
  133. Hintz SR, Gould JB, Bennett MV, et al. Referral of very low birth weight infants to high-risk follow-up at neonatal intensive care unit discharge varies widely across California. J Pediatr. 2015;166(2):289-295.
  134. Chorna O, Baldwin HS, Neumaier J, et al. Feasibility of a team approach to complex congenital heart defect neurodevelopmental follow-up: Early experience of a combined cardiology/neonatal intensive care unit follow-up program. Circ Cardiovasc Qual Outcomes. 2016;9(4):432-440.
  135. American Academy of Pediatrics. Follow-up care of high-risk infants. Pediatrics. 2004;114(Supplement 5):1377-1397.
  136. Patel R, Nudelman M, Olarewaju A, et al. Homecare and healthcare utilization errors post–neonatal intensive care unit discharge. Adv Neonatal Care. 2017;17(4):258-264.
  137. Olds DL, Kitzman H, Anson E, et al. Prenatal and infancy nurse home visiting effects on mothers: 18-year follow-up of a randomized trial. Pediatrics. Published online November 1, 2019.
  138. Liu Y, McGowan E, Tucker R, Glasgow L, Kluckman M, Vohr B. Transition home plus program reduces Medicaid spending and health care use for high-risk infants admitted to the Neonatal intensive care unit for 5 or more days. J Pediatr. 2018;200:91-97.e3.
  139. Kitzman H, Olds DL, Knudtson MD, et al. Prenatal and/or infancy nurse home visiting and 18-year outcomes of a randomized trial. Pediatrics. Published online November 1, 2019./li>
  140. Hobbs JE, Tschudy MM, Hussey-Gardner B, Jennings JM, Boss RD. “I don’t know what I was expecting”: Home visits by neonatology fellows for infants discharged from the NICU. Birth Berkeley Calif. 2017;44(4):331-336.
  141. Hamline MY, Speier RL, Vu PD, et al. Hospital-to-home interventions, use, and satisfaction: A meta-analysis. Pediatrics. 2018;142(5).
  142. Awindaogo F, Smith VC, Litt JS. Predictors of caregiver satisfaction with visiting nurse home visits after NICU discharge. J Perinatol. 2016;36(4):325-328.
  143. Schell S, Kase JS, Parvez B, et al. Maturational, comorbid, maternal and discharge domain impact on preterm rehospitalizations: a comparison of planned and unplanned rehospitalizations. J Perinatol. 2016;36(4):317-324.
  144. MacMillan KDL, Rendon CP, Verma K, Riblet N, Washer DB, Volpe Holmes A. Association of rooming-in with outcomes for neonatal abstinence syndrome: A systematic review and meta-analysis. JAMA Pediatr. 2018;172(4):345-351.
  145. Lundberg B, Lindgren C, Palme-Kilander C, Örtenstrand A, Bonamy A-KE, Sarman I. Hospital-assisted home care after early discharge from a Swedish neonatal intensive care unit was safe and readmissions were rare. Acta Paediatr Oslo Nor 1992. 2016;105(8):895-901.
  146. Laugier O, Garcia P, Boucékine M, et al. Influence of socioeconomic context on the rehospitalization rates of infants born preterm. J Pediatr. 2017;190:174-179.e1. doi:10.1016/j.jpeds.2017.08.001
  147. Kuo DZ, Berry JG, Hall M, Lyle RE, Stille CJ. Health-care spending and utilization for children discharged from a neonatal intensive care unit. J Perinatol. 2018;38(6):734-741. doi:10.1038/s41372-018-0055-5
  148. Erdeve O, Arsan S, Yigit S, Armangil D, Atasay B, Korkmaz A. The impact of individual room on rehospitalization and health service utilization in preterms after discharge. Acta Paediatr Oslo Nor 1992. 2008;97(10):1351-1357. doi:10.1111/j.1651-2227.2008.00889.x
  149. Aykanat Girgin B, Cimete G. Rehospitalization of preterm infants according to the discharge risk level. J Spec Pediatr Nurs JSPN. 2017;22(1).
  150. Willard A, Brown E, Masten M, et al. Complex surgical infants benefit from postdischarge telemedicine visits. Adv Neonatal Care Off J Natl Assoc Neonatal Nurses. 2018;18(1):22-30.
  151. Robinson C, Gund A, Sjöqvist B-A, Bry K. Using telemedicine in the care of newborn infants after discharge from a neonatal intensive care unit reduced the need of hospital visits. Acta Paediatr Oslo Nor 1992. 2016;105(8):902-909.
  152. Rasmussen MK, Clemensen J, Zachariassen G, et al. Cost analysis of neonatal tele-homecare for preterm infants compared to hospital-based care. J Telemed Telecare. Published online May 2, 2019:1357633X19843753.
  153. Holm KG, Clemensen J, Brødsgaard A, Smith AC, Maastrup R, Zachariassen G. Growth and breastfeeding of preterm infants receiving neonatal tele-homecare compared to hospital-based care. J Neonatal-Perinat Med. 2019;12(3):277-284.
  154. Hägi-Pedersen M-B, Norlyk A, Dessau R, Stanchev H, Kronborg H. Multicentre randomised study of the effect and experience of an early inhome programme (PreHomeCare) for preterm infants using video consultation and smartphone applications compared with inhospital consultations: protocol of the PreHomeCare study. BMJ Open. 2017;7(3):e013024.
  155. Garne Holm K, Brødsgaard A, Zachariassen G, Smith AC, Clemensen J. Parent perspectives of neonatal tele-homecare: A qualitative study. J Telemed Telecare. 2019;25(4):221-229.
  156. Robinson A, Lauckner C, Davis M, Hall J, Anderson AK. Facebook support for breastfeeding mothers: A comparison to offline support and associations with breastfeeding outcomes. Digit Health. 2019;5:2055207619853397.
  157. Robinson A, Davis M, Hall J, Lauckner C, Anderson AK. It takes an e-village: Supporting African American mothers in sustaining breastfeeding through Facebook communities. J Hum Lact Off J Int Lact Consult Assoc. 2019;35(3):569-582.
  158. Niela-Vilén H, Axelin A, Melender H-L, Löyttyniemi E, Salanterä S. Breastfeeding preterm infants – a randomized controlled trial of the effectiveness of an Internet-based peer-support group. J Adv Nurs. 2016;72(10):2495-2507.
  159. Niela-Vilén H, Axelin A, Melender H-L, Salanterä S. Aiming to be a breastfeeding mother in a neonatal intensive care unit and at home: a thematic analysis of peer-support group discussion in social media. Matern Child Nutr. 2015;11(4):712-726.
  160. Litt JS, Agni M, Jacobi-Polishook T, et al. The acceptability and feasibility of emailed parent questionnaires for medical and developmental surveillance after NICU discharge. J Perinatol. 2018;38(4):392-401. doi:10.1038/s41372-017-0022-6
  161. Lakshmanan A, Santo E, McCormick MC, Belfort M. Parental preference and ability to participate in web-based developmental screening and surveillance: preliminary evidence for preterm infants after NICU discharge. Clin Pediatr (Phila). 2014;53(13):1278-1284.
  162. Kim HN, Wyatt TH, Li X, Gaylord M. Use of social media by fathers of premature infants. J Perinat Neonatal Nurs. 2016;30(4):359-366.
  163. Johnston DC, Mathews WD, Maus A, Gustafson DH. Using smartphones to improve treatment retention among impoverished substance-using Appalachian women: A naturalistic study. Subst Abuse Res Treat. 2019;13:1178221819861377.
  164. Gabbert TI, Metze B, Bührer C, Garten L. Use of social networking sites by parents of very low birth weight infants: experiences and the potential of a dedicated site. Eur J Pediatr. 2013;172(12):1671-1677.
  165. Dol J, Delahunty-Pike A, Anwar Siani S, Campbell-Yeo M. eHealth interventions for parents in neonatal intensive care units: a systematic review. JBI Database Syst Rev Implement Rep. 2017;15(12):2981-3005.
  166. Zallman L, Bearse A, West C, Bor D, McCormick D. Patient preferences and access to text messaging for health care reminders in a safety-net setting. Inform Health Soc Care. 2017;42(1):32-42.
  167. Perron NJ, Dao MD, Kossovsky MP, et al. Reduction of missed appointments at an urban primary care clinic: a randomised controlled study. BMC Fam Pract. 2010;11:79.
  168. Patel S, Hemmige V, Street RL, Viswanath K, Arya M. Activating racial and ethnic minorities to engage in preventive health: Patient preferences for health reminders. J Particip Med. 2017;9.
  169. Jacobson Vann JC, Jacobson RM, Coyne-Beasley T, Asafu-Adjei JK, Szilagyi PG. Patient reminder and recall interventions to improve immunization rates. Cochrane Database Syst Rev. 2018;1:CD003941.
  170. Earls MF, Yogman MW, Mattson G, Rafferty J, Committee on Psychosocial Aspects of Child and Family Health. Incorporating recognition and management of perinatal depression Into pediatric practice. Pediatrics. 2019;143(1).
  171. Verbiest S, McClain E, Stuebe A, Menard MK. Postpartum health services requested by mothers with newborns receiving intensive care. Matern Child Health J. 2016;20(Suppl 1):125-131.
  172. Rossman B, Asiodu I, Hoban R, et al. Priorities for contraception and lactation among breast pump-dependent mothers of premature infants in the neonatal intensive care unit. Breastfeed Med Off J Acad Breastfeed Med. 2019;14(7):448-455.
  173. Leaverton A, Lopes V, Vohr B, Dailey T, Phipps MG, Allen RH. Postpartum contraception needs of women with preterm infants in the neonatal intensive care unit. J Perinatol. 2016;36(3):186-189.
  174. Kroelinger CD, Morgan IA, DeSisto CL, et al. State-identified implementation strategies to increase uptake of immediate postpartum long-acting reversible contraception policies. J Womens Health 2002. 2019;28(3):346-356.
  175. Hogue CJ, Menon R, Dunlop AL, Kramer MR. Racial disparities in preterm birth rates and short inter-pregnancy interval: an overview. Acta Obstet Gynecol Scand. 2011;90(12):1317-1324.
  176. Okoroh EM, Kane DJ, Gee RE, et al. Policy change is not enough: engaging provider champions on immediate postpartum contraception. Am J Obstet Gynecol. 2018;218(6):590.e1-590.e7.
  177. Enhancing the outcomes of low-birth-weight, premature infants: A multisite, randomized trial. JAMA. 1990;263(22):3035-3042.
  178. Spittle A, Orton J, Anderson PJ, Boyd R, Doyle LW. Early developmental intervention programmes provided post hospital discharge to prevent motor and cognitive impairment in preterm infants. Cochrane Database Syst Rev. 2015;(11):CD005495.
  179. McManus B, McCormick MC, Acevedo-Garcia D, Ganz M, Hauser-Cram P. The effect of state early intervention eligibility policy on participation among a cohort of young CSHCN. Pediatrics. 2009;124 Suppl 4:S368-374. doi:10.1542/peds.2009-1255G
  180. McCormick MC, McCarton C, Tonascia J, Brooks-Gunn J. Early educational intervention for very low birth weight infants: results from the Infant Health and Development Program. J Pediatr. 1993;123(4):527-533.
  181. Litt JS, Glymour MM, Hauser-Cram P, Hehir T, McCormick MC. Early intervention services improve school-age functional outcome among neonatal intensive care unit graduates. Acad Pediatr. 2018;18(4):468-474.
  182. Peacock-Chambers E, Feinberg E, Senn-McNally M, et al. Engagement in early intervention services among mothers in recovery from opioid use disorders. Pediatrics. 2020;145(1):e20191957.
  183. Coker TR, Windon A, Moreno C, Schuster MA, Chung PJ. Well-child care clinical practice redesign for young children: a systematic review of strategies and tools. Pediatrics. 2013;131 Suppl 1:S5-25. doi:10.1542/peds.2012-1427c
  184. Coker TR, Moreno C, Shekelle PG, Schuster MA, Chung PJ. Well-child care clinical practice redesign for serving low-income children. Pediatrics. 2014;134(1):e229-239. doi:10.1542/peds.2013-3775
  185. Upadhya KK, Psoter KJ, Connor KA, Mistry KB, Levy DJ, Cheng TL. Cluster randomized trial of a pre/interconception health intervention for mothers in pediatric visits. Acad Pediatr. Published online October 17, 2019.
  186. Williams DR, Costa MV, Odunlami AO, Mohammed SA. Moving upstream: how interventions that address the social determinants of health can improve health and reduce disparities. J Public Health Manag Pract JPHMP. 2008;14 Suppl(Suppl):S8-S17.
  187. Zuckerman B, Khandekar A. Reach Out and Read: evidence based approach to promoting early child development. Curr Opin Pediatr. 2010;22(4):539-544.
  188. Webb AR, Heller HT, Benson CB, Lahav A. Mother’s voice and heartbeat sounds elicit auditory plasticity in the human brain before full gestation. Proc Natl Acad Sci U S A. 2015;112(10):3152-3157.
  189. Levesque BM, Tran A, Levesque E, et al. Implementation of a pilot program of Reach Out and Read® in the neonatal intensive care unit: a quality improvement initiative. J Perinatol. 2018;38(6):759-766.
  190. Lariviere J, Rennick JE. Parent picture-book reading to infants in the neonatal intensive care unit as an intervention supporting parent-infant interaction and later book reading. J Dev Behav Pediatr JDBP. 2011;32(2):146-152.
  191. Caskey M, Stephens B, Tucker R, Vohr B. Adult talk in the NICU with preterm infants and developmental outcomes. Pediatrics. 2014;133(3):e578-584. doi:10.1542/peds.2013-0104
  192. Braid S, Bernstein J. Improved cognitive development in preterm infants with shared book reading. Neonatal Netw. 2015;34(1):10-17.
  193. Phillips DA, Lipsey MW, Dodge KA, et al. Puzzling it out: The current state of scientific knowledge on pre-kindergarten effects. Brookings. Published April 17, 2017. Accessed November 12, 2019. https://www.brookings.edu/research/puzzling-it-out-the-current-state-of-scientific-knowledge-on-pre-kindergarten-effects/
  194. Meloy B, Gardner M, Darling-Hammond L. Untangling the Evidence on Preschool Effectiveness: Insights for Policymakers. Learning Policy Institute; 2019.
  195. Grunberg VA, Geller PA, Bonacquisti A, Patterson CA. NICU infant health severity and family outcomes: a systematic review of assessments and findings in psychosocial research. J Perinatol. 2019;39(2):156-172.
  196. Zeitlin J, Egorova NN, Janevic T, et al. The impact of severe maternal morbidity on very preterm infant outcomes. J Pediatr. Published online September 10, 2019.
  197. Roman LA, Raffo JE, Dertz K, et al. Understanding perspectives of African American Medicaid-insured women on the process of perinatal care: An opportunity for systems improvement. Matern Child Health J. 2017;21(Suppl 1):81-92.
  198. Petersen EE, Davis NL, Goodman D, et al. Racial/ethnic disparities in pregnancy-related deaths — United States, 2007–2016. Morb Mortal Wkly Rep. 2019;68(35):762-765.
  199. Johnson PD, Duzyj CM, Howell EA, Janevic T. Patient and hospital characteristics associated with severe maternal morbidity among postpartum readmissions. J Perinatol. 2019;39(9):1204-1212.
  200. Janevic T, Zeitlin J, Auger N, et al. Association of race/ethnicity with very preterm neonatal morbidities. JAMA Pediatr. 2018;172(11):1061-1069.
  201. Howell EA, Brown H, Brumley J, et al. Reduction of peripartum racial and ethnic disparities: A conceptual framework and maternal safety consensus bundle. Obstet Gynecol. 2018;131(5):770-782.
  202. Howell EA, Ahmed ZN. Eight steps for narrowing the maternal health disparity gap. Contemp Obgyn. 2019;64(1):30-36.
  203. Bingham D, Jones DK, Howell EA. Quality improvement approach to eliminate disparities in perinatal morbidity and mortality. Obstet Gynecol Clin North Am. 2019;46(2):227-238.
  204. Aziz A, Gyamfi-Bannerman C, Siddiq Z, et al. Maternal outcomes by race during postpartum readmissions. Am J Obstet Gynecol. 2019;220(5):484.e1-484.e10.
  205. Wholesome Wave. The Fruit and Vegetable Prescription Program (FVRx). https://snaped.fns.usda.gov/library/materials/fruit-and-vegetable-prescription-programr-fvrxr
  206. Sundberg MA, Warren AC, VanWassenhove-Paetzold J, et al. Implementaton of the Navajo Fruit and Vegetable Prescription Program to improve access to healthy foods in a rural food desert. Public Health Nutr. Published online May 13, 2020.
  207. Esquivel MK, Higa A, Hitchens M, Shelton C, Okihiro M. Keiki Produce Prescription (KPRx) Program feasibility study to reduce food insecurity and obesity risk. Hawaii J Health Soc Welf. 2020;79(5 Suppl 1):44-49.
  208. Forbes JM, Forbes CR, Lehman E, George DR. “Prevention Produce”: Integrating medical school mentorship into a fruit and vegetable prescription program for at-risk patients. Perm J. 2019;23:18-238.
  209. McPheeters ML, Kripalani S, Peterson NB, et al. Closing the quality gap: revisiting the state of the science (vol. 3: quality improvement interventions to address health disparities). Evid ReportTechnology Assess. 2012;(208.3):1-475.
  210. Lion KC, Raphael JL. Partnering health disparities research with quality improvement science in pediatrics. Pediatrics. 2015;135(2):354-361.
  211. Chin MH, Alexander-Young M, Burnet DL. Health care quality-improvement approaches to reducing child health disparities. Pediatrics. 2009;124 Suppl 3:S224-236.
  212. Hatef E, Rouhizadeh M, Tia I, et al. Assessing the availability of data on social and behavioral determinants in structured and unstructured electronic health records: A retrospective analysis of a multilevel health care system. JMIR Med Inform. 2019;7(3).
  213. Celenza JF, Zayack D, Buus-Frank ME, Horbar JD. Family involvement in quality improvement: From bedside advocate to system advisor. Clin Perinatol. 2017;44(3):553-566.
  214. Improving FCC for Diverse NICU Families Tip Sheet. https://www.cpqcc.org/tip-sheet-health-equity
  215. Gerson WT. In search of better practice. Curr Probl Pediatr Adolesc Health Care. 2018;48(7):191-192.
  216. Advancing the Practice of Patient- and Family-Centered Care in Hospitals: How to Get Started. Accessed December 19, 2019. https://ipfcc.org/resources/getting_started.pdf
  217. Spencer N, Raman S, O’Hare B, Tamburlini G. Addressing inequities in child health and development: towards social justice. BMJ Paediatr Open. 2019;3(1).
  218. Matwick AL, Woodgate RL. Social justice: A concept analysis. Public Health Nurs Boston Mass. 2017;34(2):176-184.
  219. Thurman W, Pfitzinger-Lippe M. Returning to the profession’s roots: Social justice in nursing education for the 21st Century. ANS Adv Nurs Sci. 2017;40(2):184-193.
  220. Jackson CS, Gracia JN. Addressing health and health-care disparities: the role of a diverse workforce and the social determinants of health. Public Health Rep Wash DC 1974. 2014;129 Suppl 2(Suppl 2):57-61.
  221. American Public Health Association. APHA Policy Statement: Improving Health and Wellness through Access to Nature. Published online November 5, 2013. Accessed September 2, 2020.
  222. Farrer L, Marinetti C, Cavaco YK, Costongs C. Advocacy for health equity: A synthesis review. Milbank Q. 2015;93(2):392-437. doi:10.1111/1468-0009.12112
  223. Task Force on the Social Determinants of Health in Baltimore City. Accessed January 3, 2020. https://msa.maryland.gov/msa/mdmanual/26excom/html/04bcitysocial.html
  224. Kendi, Ibram X. How to Be an Antiracist. One World; 2019.
  225. Berwick DM. The moral determinants of health. JAMA. Published online June 12, 2020.
  226. Marmot M, Friel S, Bell R, Houweling TA, Taylor S. Closing the gap in a generation: health equity through action on the social determinants of health. Lancet. 2008;372(9650):1661-1669.
  227. Blas E, Gilson L, Kelly MP, et al. Addressing social determinants of health inequities: what can the state and civil society do? Lancet. 2008;372(9650):1684-1689. doi:10.1016/S0140-6736(08)61693-1
  228. Health Care Without Harm. Accessed December 30, 2019. https://noharm.org/
  229. Bennett H, Macmillan A, Jones R, Blaiklock A, McMillan J. Should health professionals participate in civil disobedience in response to the climate change health emergency? The Lancet. 2019;0(0).
  230. Solomon CG, LaRocque RC. Climate change – a health emergency. N Engl J Med. 2019;380(3):209-211.
  231. Haines A, Ebi K. The imperative for climate action to protect health. N Engl J Med. 2019;380(3):263-273.
  232. Jones CP. Toward the science and practice of anti-racism: Launching a national campaign against racism. Ethn Dis. 2018;28(Suppl 1):231-234.
  233. Kelleher K, Reece J, Sandel M. The Healthy Neighborhood, Healthy Families Initiative. Pediatrics. 2018;142(3):e20180261.
  234. U.S. Department of Housing and Urban Development. Stamford Hospital anchors the Vita Health and Wellness District. Accessed February 4, 2020. https://www.huduser.gov/portal/casestudies/study-041618.html
  235. Coates T-N. The case for reparations. The Atlantic. Published online June 2014.
  236. Brooks D. The case for reparations: A slow convert to the cause. The New York Times. March 7, 2019.
  237. Hannah-Jones N. What is owed. The New York Times. June 30, 2020.
  238. Darity, Jr. WA, Mullen AK. From Here to Equality: Reparations for Black Americans in the Twenty-First Century. The University of North Carolina Press, 2020.

The Potentially Better Practices are revised and annotated from a list first published with the permission of Vermont Oxford Network as an appendix in: Beck AF, Edwards EM, Horbar JD, Howell EA, McCormick MC, Pursley DM. The color of health: how racism, segregation, and inequality affect the health and well-being of preterm infants and their families. Pediatr Res. July 2019:1-8.

They also appears as a Supplement in: Horbar JD, Edwards EM, Ogbolu Y.  Our responsibility to “follow through” for NICU infants and their families.  Pediatrics. 2020:10.1542/peds.2020-0360.

This work is licensed by Vermont Oxford Network under a Creative Commons Attribution-NonCommercial 4.0 International License

Under the following terms:

  • Attribution — You must give appropriate credit, provide a link to the license, and indicate if changes were made. You must indicate if you modified the material and retain an indication of previous modifications. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use.
  • NonCommercial — You may not use the material for commercial purposes.
  • No additional restrictions — You may not apply legal terms or technological measures that legally restrict others from doing anything the license permits.

https://creativecommons.org/licenses/by-nc-sa/4.0

Creative Commons