You're on VON's public site. To go to our logged in area, click here

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 counseling 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 Supplemental Security Income, Supplemental Nutrition Program for Women, Infants, and Children, early intervention, and other public benefits100–103
  16. Provide language support and culturally appropriate translation services for families104–107


III. Take Action to Assist Families After Discharge (Transition to Home)

  1. Provide discharge education and planning tailored to each family’s needs51,106,108–113
  2. Begin discharge planning and teaching at admission114
  3. Estimate discharge date at admission and revise regularly during the stay115–117
  4. Implement a medical home model for patients and families118–123
  5. Establish effective communications with the primary care provider122
  6. Create a health coach program124
  7. Connect families with appropriate community organizations and services18,103,125–129
  8. Screen for developmental risk130
  9. Provide high-risk infant follow up130–137
  10. Conduct home visits before discharge and at intervals after discharge51,138–144
  11. Facilitate parent support groups and peer counseling that extend beyond the stay88,98
  12. Implement strategies to identify and minimize risk for readmission145–151
  13. Provide telehealth support after discharge152–157
  14. Use technology and social media to support families158–167
  15. Facilitate access to all necessary clinical specialists after discharge122,136
  16. Provide reminders to facilitate health behaviors and keeping of appointments79,168–171
  17. Provide mental health and addiction services for families after the stay54,57,172
  18. Provide family planning education and contraception referral173–178
  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 programs103,179–184
  3. Use innovative approaches to medical visits99,185–188
  4. Establish a reach out and read program for patients and siblings189–194
  5. Provide medical and developmental follow-up130–137
  6. Provide resources regarding available public benefits at follow-up visits100
  7. Establish partnerships with pre-K programs for patients and siblings195,196
  8. Develop and support tools that use parent-reported outcomes197
  9. Provide access to quality high risk obstetrical care198–206
  10. Launch a fruit and vegetable prescription program207–210


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 health211–213
  2. Adopt standardized measures for social determinants of health19,20,27,214
  3. Develop strategies to support QI participation by parents including economically challenged, nontraditional, and racially and ethnically diverse families215,216</sup
  4. Include pediatricians and other primary care providers for children on QI teams217
  5. Establish a charter with organizational leaders setting goals and resources for family advisors218
  6. Provide salary support for family advisors218


VI. Advocate for Social Justice at the Local, State, and National Levels

  1. Conduct and disseminate research that identifies disparities in access and outcomes21,212
  2. Serve on committees and in leadership roles within the local health system and raise awareness of need for social justice in healthcare44,219–221
  3. Actively recruit a diverse workforce with respect to race, ethnicity, gender, age, religion, and sexual orientation222
  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 neighborhoods223,224
  7. Advocate, organize, inform and lobby to change policy at the local, state, and national levels225–228
  8. Play a role in addressing global health inequities219,229,230
  9. Advocate for environmental health and justice231–234
  10. Name racism and ask, “How is racism operating here?”227,235
  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 mission236,237
  13. Support the establishment of a national commission to explore restitution and atonement for historical and ongoing injustices inflicted on African Americans and Native Americans238–241
  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):e20182657
  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.
  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. 2020;95(5):803–813
  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. 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–e76
  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. Staats C, Capatosto K, Tenny L, Mamo S. Implicit bias review: race and ethnicity: views from inside the unconscious mind. Available at: https://edubirdie.com/blog/understanding-implicit-bias. Accessed March 7, 2020
  16. Purnell TS, Calhoun EA, Golden SH, et al. Achieving health equity: closing the gaps in health care disparities, interventions, and research. Health Aff (Milwood). 2016;35(8):1410–1415
  17. National Quality Forum. A roadmap for promoting health equity and eliminating disparities: the four I’s for health equity. Available at: https://www.qualityforum.org/Publications/2017/09/A_Roadmap_for_Promoting_Health_Equity_and_Eliminating_Disparities__The_Four_I_s_for_Health_Equity.aspx. Accessed February 5, 2020
  18. 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. Available at: http://www.hpoe.org/Reports-HPOE/eliminating_health_care_disparities.pdf. Accessed October 21, 2020
  19. 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. 2020;87(2):192–193
  20. Profit J, Gould JB, Bennett M, et al. Racial/ethnic disparity in NICU quality of care delivery. Pediatrics. 2017;140(3):e20170918
  21. Health Research and Educational Trust. Improving health equity through data collection and use: a guide for hospital leaders. Available at: http://www.hpoe.org/Reports-HPOE/improvinghealthequity3.2011.pdf. Accessed October 21, 2020
  22. 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. 2020;87(2):227–234. Available at: https://www.nature.com/articles/s41390-019-0513-6
  23. Sokol R, Austin A, Chandler C, et al. Screening children for social determinants of health: a systematic review. Pediatrics. 2019;144(4) :e20191622
  24. 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
  25. Fierman AH, Beck AF, Chung EK, et al. Redesigning health care practices to address childhood poverty. Acad Pediatr. 2016;16(3 Suppl):S136–146
  26. Dworkin PH, Garg A. Considering approaches to screening for social determinants of health. Pediatrics. 2019;144(4):e20192395
  27. 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
  28. 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
  29. 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
  30. Beck AF, Tschudy MM, Coker TR, et al. Determinants of health and pediatric primary care practices. Pediatrics. 2016;137(3):e20153673
  31. 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
  32. 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
  33. 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
  34. National Association of Perinatal Social Workers. Standards for social work services in the newborn intensive care unit. Available at: https://www.napsw.org/assets/docs/NICU-standards.pdf. Accessed December 19, 2019
  35. Hynan MT, Steinberg Z, Baker L, et al. Recommendations for mental health professionals in the NICU. J Perinatol. 2015;35(Suppl 1):S14–18
  36. Agency for Healthcare Research and Quality. Clinical-community linkages. Available at: http://www.ahrq.gov/ncepcr/tools/community/index.html. Accessed December 30, 2019
  37. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27(3):759–769
  38. 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
  39. 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. 2018;93(6):839–842
  40. Wilkins CH, Alberti PM. Shifting academic health centers from a culture of community service to community engagement and integration. Acad Med. 2019;94(6):763–767
  41. Smitherman HC, Baker RS, Wilson MR. Socially accountable academic health centers: pursuing a quadripartite mission. Acad Med. 2019;94(2):176–181
  42. 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
  43. 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). Available at: www.pediatrics.org/cgi/content/full/136/e993
  44. 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
  45. 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
  46. 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
  47. 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
  48. 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
  49. 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. 2019;139:104838
  50. 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
  51. 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):e000023
  52. 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. 2020;48(4):1100–1113
  53. Shaw RJ, St John N, Lilo E, et al. Prevention of traumatic stress in mothers of preterms: 6-month outcomes. Pediatrics. 2014;134(2). Available at: www.pediatrics.org/cgi/content/full/134/2/e481
  54. 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
  55. 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
  56. 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
  57. 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. 2015;36(5):362-370
  58. Walsh TB, Davis RN, Garfield C. A call to action: screening fathers for perinatal depression. Pediatrics. 2020;145(1):e20191193
  59. National Institute for Health and Care Excellence. Smoking: stopping in pregnancy and after childbirth. Available at: https://www.nice.org.uk/guidance/ph26. Accessed November 6, 2019
  60. 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
  61. Nichols A, Clarke P, Notley C. Parental smoking and support in the NICU. Arch Dis Child Fetal Neonatal Ed. 2019;104(3):F342–F342
  62. 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
  63. Maguire DJ. Mothers on methadone: care in the NICU. Neonatal Netw. 2013;32(6):409–415
  64. 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
  65. 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
  66. Zupancic JAF. Societal costs of preterm birth. In: Preterm Birth: Causes, Consequences, and Prevention. Washington, DC: National Academies Press; 2019:389-429
  67. 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
  68. 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
  69. 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
  70. 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
  71. 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
  72. US Department of Health and Human Services; National Institutes of Health; Eunice Kennedy Shriver National Institute of Child Health and Human Development. Babies sleep safest on their backs: a resource kit for reducing the risk of sudden infant death syndrome in African American communities. Available at: https://www.nichd.nih.gov/sites/default/files/publications/pubs/documents/SIDS_resourcekit_rev.pdf. Accessed December 19, 2019
  73. Salm Ward TC, Balfour GM. Infant safe sleep interventions, 1990–2015: a review. J Community Health. 2016;41(1):180–196
  74. 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
  75. 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):e20162940
  76. Mathews AA, Joyner BL, Oden RP, Alamo I, Moon RY. Comparison of infant sleep practices in African-American and US Hispanic families: implications for sleep-related infant death. J Immigr Minor Health. 2015;17(3):834–842
  77. 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):26
  78. 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
  79. Hirai AH, Kortsmit K, Kaplan L, et al. Prevalence and factors associated with safe infant sleep practices. Pediatrics. 2019;144(5):e20191286
  80. Gelfer P, Cameron R, Masters K, Kennedy KA. Integrating “Back to Sleep” recommendations into neonatal ICU practice. Pediatrics. 2013;131(4). Available at: www.pediatrics.org/cgi/content/full/131/4/e1264
  81. Bombard JM. Vital Signs: Trends and disparities in infant safe sleep practices — United States, 2009–2015. MMWR Morb Mortal Wkly Rep. 2018;67(1):39–46
  82. 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
  83. Horikoshi Y, Okazaki K, Miyokawa S, et al. Sibling visits and viral infection in the neonatal intensive care unit. Pediatr Int (Roma). 2018;60(2):153–156
  84. O’Brien K, Robson K, Bracht M, et al.;FICare Study Group and FICare Parent Advisory Board. Effectiveness of Family Integrated Care in neonatal intensive care units on infant and parent outcomes: a multicentre, multinational, cluster-randomised controlled trial. [published correction appears in Lancet Child Adolesc Health. 2018;2(8):e20]. Lancet Child Adolesc Health. 2018;2(4):245–254
  85. 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
  86. 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 [published online ahead of print September 10, 2019]. J Reprod Infant Psychol. doi:10.1080/02646838.2019.1659940
  87. 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
  88. 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
  89. Thomson G, Balaam M-C. International insights into peer support in a neonatal context: a mixed-methods study. PLoS ONE. 2019;14(7):e0219743
  90. 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
  91. 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
  92. 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. 2011;27(1):14–24
  93. 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
  94. Oza-Frank R, Bhatia A, Smith C. Impact of peer counselors on breastfeeding outcomes in a nondelivery NICU setting. Adv Neonatal Care. 2014;14(4):E1–E8
  95. 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. 2006;160(7):681–685
  96. 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
  97. Meier PP, Engstrom JL, Rossman B. Breastfeeding peer counselors as direct lactation care providers in the neonatal intensive care unit. J Hum Lact. 2013;29(3):313–322
  98. 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
  99. 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
  100. 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
  101. Social Security Administration. Benefits For children With disabilities. Available at: https://www.ssa.gov/pubs/EN-05-10026.pdf. Accessed December 19, 2019
  102. 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
  103. 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
  104. Centers for Disease Control and Prevention. What is “early intervention”? Available at: https://www.cdc.gov/ncbddd/actearly/parents/states.html. Accessed January 28, 2020
  105. 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
  106. 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
  107. 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(suppl 2):S95–S107
  108. 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
  109. 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
  110. 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(suppl 2):S115–S123
  111. 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
  112. 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
  113. 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
  114. Kahn A, Yin HS, Brach C, et al. Association between parent comfort with English and adverse events among hospitalized children published online ahead of print October 19, 2020]. JAMA Pediatr. doi:10.1001/jamapediatrics.2020.3215
  115. Pfister RH, ed. Quality Improvement Kit: improving Discharge Management. Burlington, VT: Vermont Oxford Network, 2009
  116. 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):e010466
  117. 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
  118. 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
  119. 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
  120. 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
  121. 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
  122. 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
  123. American Academy of Pediatrics 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(5, suppl):1545–1547
  124. Gupta M, Pursley DM, Smith VC. Preparing for discharge from the neonatal intensive care unit. Pediatrics. 2019;143(6):e20182915. doi:10.1542/peds.2018-2915
  125. Agency for Healthcare Research and Quality. Transitioning newborns from NICU to home. Available at: http://www.ahrq.gov/patient-safety/settings/hospital/resource/nicu/index.html. Accessed November 11, 2019
  126. 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
  127. Purdy IB, Craig JW, Zeanah P. NICU discharge planning and beyond: recommendations for parent psychosocial support. J Perinatol. 2015;35(suppl 1):S24–S28
  128. American Academy of Pediatrics Committee on Fetus and Newborn. Hospital discharge of the high-risk neonate. Pediatrics. 2008;122(5):1119–1126
  129. Murch TN, Smith VC. Supporting families as they transition home. Newborn Infant Nurs Rev. 2016;16(4):298–302
  130. 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
  131. 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):3368
  132. Sigurdson K, Mitchell B, Liu J, et al. Racial/ethnic disparities in neonatal intensive care: A systematic review. Pediatrics. 2019;144(2):e20183114
  133. Pursley DM, McCormick MC. Bending the arc for the extremely low gestational age newborn. Pediatr Res. 2018;83(4):751–753
  134. 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;216:101.e1–108.e1
  135. McCormick MC, Litt JS. The outcomes of very preterm infants: Is it time to ask different questions? Pediatrics. 2017;139(1):e20161694
  136. 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
  137. 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
  138. American Academy of Pediatrics. Follow-up care of high-risk infants. Pediatrics. 2004;114(supplement 5):1377–1397
  139. 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
  140. 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. 2019:144(6):e20183889.
  141. 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
  142. Kitzman H, Olds DL, Knudtson MD, et al. Prenatal and/or infancy nurse home visiting and 18-year outcomes of a randomized trial. Pediatrics. 2019;144(6):e20183876
  143. 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. 2017;44(4):331–336
  144. Hamline MY, Speier RL, Vu PD, et al. Hospital-to-home interventions, use, and satisfaction: a meta-analysis. Pediatrics. 2018;142(5):e20180442
  145. 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
  146. 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
  147. 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
  148. 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. 2016;105(8):895–901
  149. 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
  150. 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
  151. 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. 2008;97(10):1351–1357
  152. Aykanat Girgin B, Cimete G. Rehospitalization of preterm infants according to the discharge risk level. J Spec Pediatr Nurs. 2017;22(1):e12165
  153. Willard A, Brown E, Masten M, et al. Complex surgical infants benefit from postdischarge telemedicine visits. Adv Neonatal Care. 2018;18(1):22–30
  154. 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. 2016;105(8):902–909
  155. 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. 2020;26(7-8):474–481
  156. 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
  157. 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 in hospital consultations: protocol of the PreHomeCare study. BMJ Open. 2017;7(3):e013024
  158. 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
  159. 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. –. 2019;5:2055207619853397
  160. 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. 2019;35(3):569–582
  161. 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
  162. 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
  163. 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
  164. 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
  165. 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
  166. 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
  167. 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
  168. 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
  169. 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
  170. 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
  171. 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:e8.
  172. 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(1):CD003941
  173. 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):e20183259
  174. 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
  175. 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. 2019;14(7):448–455
  176. 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
  177. 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 (Larchmt). 2019;28(3):346–356
  178. 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
  179. 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
  180. Infant Health and Development Program. Enhancing the outcomes of low-birth-weight, premature infants: A multisite, randomized trial. JAMA. 1990;263(22):3035–3042
  181. 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
  182. 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–S374
  183. 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
  184. 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
  185. 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
  186. 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–S25
  187. 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). Available at: www.pediatrics.org/cgi/content/full/134/1/e229
  188. 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. 2020;20(5):660–669
  189. 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. 2008;14(suppl):S8–S17
  190. Zuckerman B, Khandekar A. Reach Out and Read: evidence based approach to promoting early child development. Curr Opin Pediatr. 2010;22(4):539–544
  191. 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
  192. 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
  193. 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. 2011;32(2):146–152
  194. Caskey M, Stephens B, Tucker R, Vohr B. Adult talk in the NICU with preterm infants and developmental outcomes. Pediatrics. 2014;133(3). Available at: www.pediatrics.org/cgi/content/full/133/3/e578
  195. Braid S, Bernstein J. Improved cognitive development in preterm infants with shared book reading. Neonatal Netw. 2015;34(1):10–17
  196. Phillips DA, Lipsey MW, Dodge KA, et al. Puzzling it out: The current state of scientific knowledge on pre-kindergarten effects. Brookings. Available at: https://www.brookings.edu/research/puzzling-it-out-the-current-state-of-scientific-knowledge-on-pre-kindergarten-effects/. Accessed November 12, 2019
  197. Meloy B, Gardner M, Darling-Hammond L. Untangling the Evidence on Preschool Effectiveness: Insights for Policymakers. Palo Alto, CA: Learning Policy Institute; 2019.
  198. 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
  199. Zeitlin J, Egorova NN, Janevic T, et al. The impact of severe maternal morbidity on very preterm infant outcomes. J Pediatr. 2019;215:56.e1–63.e1
  200. 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
  201. Petersen EE, Davis NL, Goodman D, et al. Racial/ethnic disparities in pregnancy-related deaths — United States, 2007–2016. MMWR Morb Mortal Wkly Rep. 2019;68(35):762–765
  202. 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
  203. Janevic T, Zeitlin J, Auger N, et al. Association of race/ethnicity with very preterm neonatal morbidities. JAMA Pediatr. 2018;172(11):1061–1069
  204. Howell EA, Brown H, Brumley J, et al. Reduction of peripartum racial and ethnic disparities: A conceptual framework and maternal safety consensus bundle. [published correction appears in Obstet Gynecol. 2019;133(6):1287]. Obstet Gynecol. 2018;131(5):770–782
  205. Howell EA, Ahmed ZN. Eight steps for narrowing the maternal health disparity gap. Contemp Obgyn. 2019;64(1):30–36
  206. 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
  207. 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
  208. Wholesome Wave. The fruit and vegetable prescription program (FVRx). Available at: https://snaped.fns.usda.gov/library/materials/fruit-and-vegetable-prescription-programr-fvrxr. Accessed October 21, 2020.
  209. Sundberg MA, Warren AC, VanWassenhove-Paetzold J, et al. Implementation of the Navajo Fruit and Vegetable Prescription Program to improve access to healthy foods in a rural food desert. Public Health Nutr. 2020;23(12):2199–2210
  210. 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.
  211. 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
  212. 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 Report Technol Assess (Full Rep). 2012;(208.3):1–475
  213. Lion KC, Raphael JL. Partnering health disparities research with quality improvement science in pediatrics. Pediatrics. 2015;135(2):354–361
  214. Chin MH, Alexander-Young M, Burnet DL. Health care quality-improvement approaches to reducing child health disparities. Pediatrics. 2009;124(suppl 3):S224–S236
  215. 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):e13802
  216. 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
  217. California Perinatal Quality Care Collaborative. Health equity tip sheet. Available at: https://www.cpqcc.org/tip-sheet-health-equity. Accessed December 19, 2019
  218. Gerson WT. In search of better practice. Curr Probl Pediatr Adolesc Health Care. 2018;48(7):191–192.
  219. Institute for Patient- and Family-Centered Care. Advancing the practice of patient- and family-centered care in hospitals: how to get started. Available at: https://ipfcc.org/resources/getting_started.pdf. Accessed December 19, 2019
  220. 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):e000503
  221. Matwick AL, Woodgate RL. Social justice: a concept analysis. Public Health Nurs. 2017;34(2):176–184
  222. 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
  223. 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. 2014;129(suppl 2):57–61
  224. American Public Health Association. APHA policy statement: improving health and wellness through access to nature. Available at: https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/08/09/18/improving-health-and-wellness-through-access-to-nature. Accessed September 2, 2020
  225. Schell CJ, Dyson K, Fuentes TL, et al. The ecological and evolutionary consequences of systemic racism in urban environments. Science. 2020;369(6510):eaay4497
  226. Farrer L, Marinetti C, Cavaco YK, Costongs C. Advocacy for health equity: A synthesis review. Milbank Q. 2015;93(2):392–437
  227. Maryland State Archives. Task force on the social determinants of health in Baltimore City. Available at: https://msa.maryland.gov/msa/mdmanual/26excom/html/04bcitysocial.html. Accessed January 3, 2020
  228. Kendi IX. How to Be an Antiracist. London, United Kingdom: One World; 2019
  229. Berwick DM. The moral determinants of health. JAMA. 2020;324(3):225–226
  230. 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
  231. 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
  232. Health Care Without Harm. Leading the global movement for environmentally responsible health care. Available at: https://noharm.org/. Accessed December 30, 2019
  233. 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? [published correction appears in Lancet. 2020;395(10228):e53]. Lancet. 2020;395(10220):304–308
  234. Solomon CG, LaRocque RC. Climate change – a health emergency. N Engl J Med. 2019;380(3):209–211
  235. Haines A, Ebi K. The imperative for climate action to protect health. N Engl J Med. 2019;380(3):263–273
  236. Jones CP. Toward the science and practice of anti-racism: Launching a national campaign against racism. Ethn Dis. 2018;28(suppl 1):231–234
  237. Kelleher K, Reece J, Sandel M. The Healthy Neighborhood, Healthy Families initiative. Pediatrics. 2018;142(3):e20180261
  238. S. Department of Housing and Urban Development. Stamford Hospital anchors the Vita Health and Wellness District. Available at: https://www.huduser.gov/portal/casestudies/study-041618.html. Accessed February 4, 2020
  239. Coates T. The case for reparations. The Atlantic. Available online at: https://www.theatlantic.com/magazine/archive/2014/06/the-case-for-reparations/361631/. Accessed October 21, 2020
  240. Brooks D. The case for reparations: A slow convert to the cause. The New York Times. Available online at: https://www.nytimes.com/2019/03/07/opinion/case-for-reparations.html. Accessed October 21, 2020
  241. Hannah-Jones N. What is owed. The New York Times. Available online at: https://www.nytimes.com/interactive/2020/06/24/magazine/reparations-slavery.html. Accessed October 21, 2020
  242. Darity Jr. WA, Mullen AK. From Here to Equality: Reparations for Black Americans in the Twenty-First Century. Chapel Hill, NC: The University of North Carolina Press; 2020

Last updated: November 1, 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

Links

Follow Us