For more than a decade now, a Yale School of Medicine program has provided long-term follow-up care to children who have spent time in the neonatal intensive care unit (NICU) or are at risk for medical or developmental difficulties resulting from medical conditions during the newborn period.
Dubbed NICU GRAD (Great Results After Discharge), the program has helped thousands of patients since it was created in 2013.
Angela Montgomery
Dr. Angela Montgomery, associate professor of pediatrics at Yale School of Medicine and director of NICU GRAD, recently spoke with Yale News about the program, how it has changed over the years, and its latest expansion. Here are five takeaways.
GRAD offers comprehensive care for infants who might be vulnerable after hospital discharge.
GRAD provides medical and developmental follow-up care for infants who are born preterm or have conditions — such as chronic lung disease or cardiac defects, for example — that might place them at increased risk after hospital discharge.
During each visit, GRAD patients are seen by a neonatologist or pediatric medical provider, a nutritionist, and an occupational or physical therapist.
“That’s the general makeup of what we call our medical visits,” said Montgomery. “In those visits the GRAD team focuses on any ongoing medical concerns, how infants are feeding and growing, and a review of developmental milestones. If concerns arise, we make recommendations to help optimize outcomes.”
Appointments also incorporate standardized developmental assessment. Through a collaboration with the Yale Child Study Center, GRAD embeds child psychologists within its program. And at particular points during the course of their care, patients are offered developmental assessments to determine how they’re doing from a long-term developmental perspective.
Care teams also include physician associates specializing in premature and high-risk infants, medical trainees (medical students, pediatric residents, and neonatal fellows), and a dedicated nurse coordinator. Speech therapists and social workers are also available as needed.
“It’s truly multidisciplinary,” said Montgomery.
The program cares for more than 400 additional infants every year.
The number of patients treated by the GRAD program has increased over recent years. For the past few years, the team has seen between 400 and 450 new patients annually.
“And as we continue to expand GRAD sites across the state, we expect these numbers to grow,” said Montgomery.
GRAD focuses on the whole family.
“We’ve tried to develop GRAD so that it supports what the family needs after an infant’s hospital discharge,” said Montgomery. “So often these families are taking home infants with medical complexities and face many follow-up visits with different types of providers. We support those families in that transition from hospital to home.”
Part of that involves helping families understand the many different kinds of medical visits that will be required and why they’re important. The GRAD nurse coordinator helps families navigate these visits and also provides families with necessary referrals, keeping appointments as close to the family’s home as possible.
“We try to understand what families need in terms of support,” said Montgomery. “How are the parents adapting to their parental role outside the NICU? What are they worried about in terms of their infant’s outcome? How can we support them at home? And if we identify additional concerns, making sure we get the parents set up with the right types of services to support them and their infant.”
The program has been caring for infants in the New Haven area for more than 10 years.
Established in 2013 by Yale neonatologist Richard Ehrenkranz, GRAD has since expanded the services it offers and the types of patients it serves. Montgomery joined the program in 2015 as its associate medical director at a time when GRAD was caring for patients who had, for the most part, spent time in the NICU.
“But a couple of years in, we recognized the need to follow infants from other areas of the hospital long term as well,” she said. “For example, infants requiring cardiac surgery or infants with opiate exposure in utero who are typically cared for outside the NICU.”
Similarly, as GRAD team members treated more patients, they identified additional services that would benefit them. Subsequent collaborations with the Yale Child Study Center, pediatric orthopedics, and audiology allowed GRAD to incorporate additional developmental assessments, screening for cerebral palsy, and hearing screenings within scheduled GRAD visits rather than requiring additional appointments in other departments.
GRAD now has three Connecticut locations.
The original GRAD clinic continues to operate out of its center located on Long Wharf Drive in New Haven. The team opened a second location in Old Saybrook, Connecticut in 2017. Then, in October 2023, a third location opened in Greenwich.
Opening new clinics requires more than just physical space. As Montgomery explains, locations also need to have adequate access to all of the many specialists incorporated into its program.
“We’ve been focused these past few years on expanding to Greenwich Hospital in order to meet the needs of patients coming out of the Greenwich NICU and to better serve patients discharged from New Haven who reside near Greenwich,” said Montgomery. “The goal is to continue expanding the GRAD program to provide comprehensive services to infants and children across the state in a way that is easily accessible to families.”
