Transitions of Care and Developmental Follow-Up

We aim to evaluate and improve discharge and follow-up processes for medically complex NICU infants through multicenter collaboration.


We have a great multidisciplinary group of nurses, physicians, data abstracters, case managers,  therapists, and parents representing 15 – 20 CHNC centers. We were the first CHNC focus group to establish a Parent Advisory Board, who are active participants in our meetings and work. With this team, we are a collaborative forum for exchange of ideas and shared experiences across the CHNC network. Our group is engaged in multicenter quality improvement and research projects surrounding discharge and neurodevelopmental follow-up.

Mission & Goals
  • Improve transition processes and education for medically complex NICU infants through multicenter collaboration
  • Evaluate long-term neurodevelopmental outcomes among infants with rare diagnoses within the CHNC network
  • To develop a long-term outcomes database platform within CHNC for key diagnoses
  • Establish best practices that impact neurodevelopmental outcomes among infants with rare diagnoses


We will establish best practices that optimize discharge and neurodevelopmental outcomes and follow-up for medically complex NICU infants.


Abstract Presentations:

Bourque S, Machut K, Chuo J, Cohen S, Johnson Y, Nanda S, Rubinos L, Ponzek R on behalf of The Children’s Hospitals Neonatal Consortium Transitions of Care Focus Group. Establishing Potential Best Practices for Discharge from Regional Children’s Hospital NICUs: A Modified Delphi Study. Pediatric Academic Societies/Society for Pediatric Research Annual Meeting, Denver, CO, 04/2022.

Nanda S, Machut K, Rubinos L, Johnson Y, Ponzek R. Evolution of Key Driver Diagram to Improve Discharge Readiness and Caregiver Education Using Parental Perspectives. Children’s Hospitals Neonatal Consortium Annual Symposium, Houston, TX, 11/2021.

Nanda S, Ponzek R, Machut K. Factors Contributing to Discharge Delays of Complex Neonates: Development and Evolution of Key Drivers Diagram using Quality Improvement Methodology in the Multicenter CHNC Collaborative. Graven’s Conference, Clearwater, FL/virtual, 03/2021.

Focus Group Leaders

Karen Clark

Autumn Whiteman

Yvette Johnson

Rachel Ponzek

Meeting Schedule

First Friday of each month at 8:00 a.m. PT / 9:00 a.m. MT / 10:00 a.m. CT / 11:00 a.m. ET (Transitions) & Third Friday of each month at 11:00 a.m. PT / 12:00 p.m. MT / 1:00 p.m. CT / 2:00 p.m. ET (Follow-up)

Transitions of Care and Developmental Follow-Up


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