NICU Specialty Program

Newborns admitted to a neonatal intensive care unit (NICU¹) or a transitional nursery unit (TNU) are potential candidates for early case management² evaluation and assessment. Newborns are identified for referral to the Aetna Health Connections^SM Case Management Program in two ways: 1) during the newborn's inpatient stay as part of the concurrent review and discharge planning process, and 2) through follow-up calls to the newborn’s parent/legal guardian after discharge home.

• The concurrent review process provides for an exchange of information with appropriate facility staff, practitioners and providers³ regarding the newborn’s clinical status, progress and care during the inpatient stay. The information gathered assists with early identification of the newborn’s specific continuing care needs upon discharge to home.

Discharge planning focuses on the gathering of clinical information to complete the discharge plan and includes:

• Evaluation of the readiness of the parent/legal guardian and home environment
• Evaluation and identification of:
  • The need for home health care (HHC) services
  • The need for durable medical equipment (DME)
  • The need for future surgical treatment (for example, repair of a congenital heart defect)
  • The need for specialty infant formula
  • The need for community-based early intervention services
• Identification of primary care physician (PCP), specialist and community resources as applicable, and parent/legal guardian acknowledgement of these contacts
• Whether the newborn has received Synagis^® 
• Any changes in the infant’s eligibility status
• Whether a hearing test has been completed
• Whether an eye exam has been completed (may be applicable for infants who have received oxygen therapy)

Follow-up telephone calls are made to the newborn’s parent/legal guardian following the newborn’s discharge to home. The goals of the follow-up call(s) include:

• Determining the parent’s/legal guardian’s understanding of and compliance with the treating provider’s discharge plan of care (for example, medication regimen, scheduled Synagis doses and appropriate use of DME)
• Confirming that the post-discharge plan has been implemented (for example, physician appointments, initiation of and/or delivery of services [HHC, DME])
• Identifying infant needs, including feeding or elimination difficulties, breathing problems, and/or sleep/wake activity  
• Continuing to assess for case management needs
  
  
  

¹For purposes of this policy, the term NICU refers to all admissions to either a neonatal intensive care unit (NICU) or a transitional nursery unit (TNU) after birth.

²Case management is defined by the Case Management Society of America (CMSA) as a “collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s health needs through communication and available resources to promote quality, cost-effective outcomes.

³The term “provider,” as defined in the Aetna Care Management Program description and National Care Management policy/procedure, is used collectively to mean a practitioner/professional who provides health care services and is usually required to be licensed, as defined by applicable law or regulation, and/or an organizational provider, an institutional provider and/or supplier of health care services, including behavioral health care organizations. Organizational providers include, but are not limited to, hospitals, nursing homes, skilled nursing facilities (SNFs), home care agencies and freestanding surgical centers (including freestanding abortion centers). Behavioral health organizations include, but are not limited to, mental health and chemical dependency hospitals, residential treatment facilities, and ambulatory settings, including partial hospital programs, intensive outpatient programs, crisis stabilization centers, clinics and community mental health centers. Behavioral health organizations can be freestanding or hospital based. Additionally, in networks where the Medicare Advantage products are offered, the organizational providers include laboratories, rehabilitation agencies (comprehensive outpatient rehabilitation facilities, outpatient physical therapy and speech pathology providers), renal disease services, outpatient diabetes self-management training providers, portable X-ray suppliers, rural health clinics and federally qualified health centers.