The goal of FIRST 5’s High Risk Infant Follow-Up Program (Let’s Go! Let’s Grow!) is to improve developmental, emotional and social outcomes for at risk infants and their families in Santa Clara County, with particular focus on very low birth weight and medically fragile infants.

Through an intensive public health nursing home visitation program that includes multiple assessments and screenings, problems will be identified early and interventions applied or referrals made. Using a family centered, strength based model, nursing interventions will focus on parents ability to read infant clues, meet infant needs, problem solve and access appropriate care. Nurses will also support parents with their adaptation to parenthood. Assistance with coordination of care and linkage to needed services that will assure timely follow-up will also be provided.

Let’s Go! Let’s Grow! will utilize “best practices” and generate outcome-based data on 75 infants/toddlers and their families that:

1. Reside in Santa Clara County
2. Are graduates of Valley Medical Center Neo-Natal Intensive Care Unit (NICU) and meet the criteria for High Risk Infant Follow-Up (HRIF) Program
3. Demonstrate a level of need that would benefit from Public Health Nursing assessments and interventions and need case management and follow-up services.
4. Require coordination and communication across systems of care (i.e. health, mental health, drug and alcohol, social services)

The infant must also meet one or more of the following medical criteria to qualify for participation in this pilot project:

1. Weigh under 1500 grams at birth
2. Be born at a gestational age under 32 weeks
3. Have severe respiratory and/or cardiac problems
4. Have neurological complications
5. Have an Apgar score of 3 or less at 5 minutes after birth

Those infants who meet the above criteria will be reviewed by the NICU Multi-Disciplinary Team to review the social risk factors for each child/family and determine which infants qualify as the highest risk. Social risk factors may include one or more of the following:

1. Lack of social support for the family
2. Single parent family
3. Parent under 18 years of age
4. Non-involved father
5. Non-English speaking
6. Less than 8th grade education
7. Drug/alcohol issues in the family
8. Domestic violence in the family

All infants will be seen in the Santa Clara Valley Health and Hospital System High-Risk Infant Follow-up Program (HRIF), as with any infant graduating from the NICU and meeting High-Risk Infant criteria. The first visit to the HRIF program will be three (3 months) following discharge from the NICU. The remaining visits are regularly scheduled until the child turns three (3) years of age or is discharged from the program because he/she is developmentally on target. Additionally visits may be augmented when necessary during the time the child is eligible for the HRIF program.

What distinguishes the Let’s Go! Let’s Grow! Pilot Project from the other HRIF services is the addition of a home visitation component. 2.5 full-time equivalent Public Health Nurses (PHN) will be assigned to provide home visitation services to the 75 infants and their families in the Let’s Go! Let’s Grow! pilot project.

Nurses will conduct a range of screenings and assessments in the home that include but are not limited to: home safety, infant development, and maternal depression. In addition the nurse will provide an array of education, anticipatory guidance, support and case management, consultation, and referral and linkages to other needed services.

Coordination, planning and data sharing will occur between the PHN and the HRIF program, with the HRIF program serving as the Medical Home for these infants/toddlers. When the child is no longer eligible for this program, the PHN will work with the HRIF program, the child’s family, and the appropriate FIRST 5 Family Partner agency to develop a transition plan and ensure the child and family continue to receive appropriate and necessary services.