Grow With Me

Program overview

The Grow with Me program is a care coordination service and outpatient clinic designed to serve at-risk children who have experienced intrauterine drug exposure or were diagnosed and treated for Neonatal Abstinence Syndrome (NAS). The focus of the Grow with Me program is to address the medical, developmental and emotional needs of a child during the first five years of life. Grow with Me will provide a care coordinator to serve as the child’s advocate or as a healthcare coach to the child’s parent or caregiver. The care coordinator will help families and caregivers with access to services and will be a partner to ensure each child has the foundation needed to shape their future in a positive way. Children enrolled in the Grow with Me program will receive:

• Five home health visits between the time of discharge from the hospital and the first clinic visit
• Ongoing developmental and behavioral assessments
• Nutritional assessment and support
• Education for parents and community providers to help your child develop best
• Referrals for other services as needed (specialized screenings, behavioral health, physiatry, occupational, physical and/or speech therapies, pediatric cardiology, gastroenterology, and pulmonology)
• A care coordinator to partner with and assist parents/caregivers navigate all aspects of the child’s medical, developmental and emotional needs.

The program

The first three months

The first month of life for an infant diagnosed with NAS is usually spent in the Neonatal Intensive Care Unit (NICU) weaning from drug exposure. The first two months after the baby is discharged are critical. Each baby will have an appointment scheduled with their primary care provider (PCP) or pediatrician within 48 hours after leaving the hospital. This initial visit is vital so that the baby’s medical home can be established with a physician who will follow them during their first years of life. As part of Grow with Me, the completion of this visit will be verified and that information will be shared with the care coordinator.

Eligible patients will have five Grow with Me home visits conducted by Children’s Hospital Home Health. These visits will begin following the baby’s discharge from the NICU and will be complete before the first scheduled Grow with Me Clinic visit. The home health visits will be conducted by home health nurses and social workers. Three of these visits will be with a nurse and two of these visits with a home health social worker. At each step of the way, the care coordinator will be informed of the child’s progress and any concerns shared during these visits.

The first Grow with Me clinic visit

The first Grow with Me clinic visit will be at three months of age. The clinic will be held at Children’s Hospital’s main campus, South Tower, second floor.

The clinic team is made up of professionals who are experts in caring for at-risk infants. The team includes:

• Care coordinator
• Pediatric nurse practitioner
• Psychologist
• Pediatric dietitian
• Occupational therapist
• Speech-language therapist
• Social worker

At each visit, your child may receive the following:

• Standardized developmental assessment screening
• Nutrition assessment
• Occupational/speech assessment
• Nursing assessment
• Behavioral health assessment

If any issues are identified, treatment options will be discussed with the parent/ caregiver. Appointments for follow-up with needed subspecialties or other disciplines will be scheduled. All recommendations and appointments will be shared with the child’s primary care provider.

Each child will receive screenings at each clinic visit. The visits will be at 3-months, 6-months, 9-months, 12-months, 18-months, 24-months, 30-months, 36-months, 42-months, 48-months, 54-months and 60-months. These visit intervals will allow vital evaluations to be completed.

The care coordinator will be involved in each clinic visit and will work with the family on a monthly basis to ensure that the parent/caregiver has the support they need and to ensure the child’s development is progressing.

Referral criteria

The Grow with Me program at Children’s Hospital will enroll infants through the following sources:

• Obstetricians
• Drug treatment centers
• Agencies caring for expectant mothers whose babies are at risk for NAS
• Newborns with a history of intrauterine drug exposure
• NICU admissions with a history of neonatal abstinence syndrome
• Pediatricians and family care providers

Criteria for Enrollment

• The baby's gestionational birth age must be 35 weeks or older
• There is drug exposure to AT LEAST opioids
• No involvement with UT’s developmental follow-up clinic, Dr. Trainer, or Dr. Weinstein

Mothers of infants with NAS admitted to Children’s Hospital who have not been referred to Grow with Me Prior to birth will be offered enrollment when their babies are admitted for treatment of NAS.