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!


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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.

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