High-Risk Pediatrics Management

AMAXX’s high-risk pediatric care management includes patients in the NICU and other premature infants and the parents of these high-risk patients. Intensive care coordination and follow-up for the newborns begins with admission on the NICU or identification of late preterm during OB hospital postpartum rounds, as well as, children’s hospital round visits and continues throughout the first year of life.

Services include:

  • Comprehensive NICU Graduate Program
  • Late Preterm Pregnancy Program
  • Nutritional management (WIC and the Breastfeeding Initiative)
  • RSV follow-up
  • Early Intervention Management Program
  • “Medical Home” selection and first appointment scheduling
  • Collaboration and follow-up on adherence to treatment plans and EPSDT, as appropriate
  • Evaluation of maternal attachment
  • Parental education and evaluation concerning neuro-development
  • Three-day post-discharge follow-up clinic where:
    • Pediatrician assesses physical condition
    • Lactation specialist addressing feeding issues
    • Social workers assesses biopsychosocial and economic issues and mood disorders
    • Evaluation of mood disorders (postpartum depression).

NICU Graduate Interventions:

While the newborn is in the NICU, AMAXX’s multidisciplinary team of care coordinators work collaboratively with the NICU care team to provide the following:
  • Support for the family
  • Identification and preparation of in-home caregivers
  • Daily hospital rounds to assess any opportunity to further support the family
  • Environmental assessments of homes prior to discharge
  • Collaboration with NICU staff on treatment plans
  • Assistance with the education, identification and selection of a “Medical Home”
  • Follow-up to ensure compliance (Home visitation programs and telephone follow-up)
  • Parental counseling and crisis intervention
  • Assistance with screening criteria for early intervention programs
  • Advocacy and emotional support for the family
  • Promotion of mother’s breast milk use in the NICU and afterwards
  • Kangaroo care/ NIDCAP for neuro development.
Care coordination and psychosocial support continues through the infants first year of life. The level and intensity of care depends upon severity of the infant’s medical condition and the intensity of the psychosocial issues affecting the parents/caregivers.