top of page
Family + Home Needs Assessment
SETTING FAMILIES UP for SUCCESS
This section discusses how to use a family and home needs assessment to inform discharge planning.
Develop a process for assessing families’ needs and connecting them with appropriate community resources.
A transition plan must include the medical, physical, psychosocial, and mental health needs of both the family and infant.
All families should be screened upon admission to NICU for social determinates of health and risk factors.
Address risk factors early through referral to community partnerships and social work services for needed services (i.e., housing, finance, etc.).
Each NICU should have a readily available, easily accessible community referral guide with information about programs and agencies supporting families. This should be a living document; new resources should be added as they are made known.
​
READ: Who Should Do the Assessment with the Family and How to Start a Conversation
​
Where are they living? Are their housing needs met?
Does the family have what they need to care for their baby?
Does the family have safe, adequate housing?
Can the family get where they need to be reliably?
Who are the members of their caregiving team?
Does the family need help getting the food they need?
Who is a part of their community? Where do they find help?
How do they handle stressors? Do they need more support?
Do they have the mental health support they need?
What do they need for them and their baby to be safe?
WHO SHOULD DO the ASSESSMENT with the FAMILY
The NICU staff who conducts the family and home needs assessment may vary due to NICU personnel composition.
In general, social workers are in the best position to have conversations with families about their perceived strengths, challenges, and unmet needs.
Other appropriate staff include case managers, discharge coordinators, psychologists, child life specialists, etc.)
Any NICU staff with the appropriate skills or training may conduct the family needs assessment during the first few days of admission and prior to discharge, with a potential reassessment as needed.
It is preferred to use a multidisciplinary team (that includes nursing, social work, case management) to assess the family’s needs.
​
IMPORTANT: The family and home needs assessment must be a collaborative process with the family and one where the family is the driver and owner of the assessment process.
Prior to the assessment, discuss with the family:
-
what they are being assessed for
-
what the process will entail
-
how the information will be used
The person doing the assessment needs to be aware of their own explicit and implicit biases and respect the family’s right to disclose or not disclose information during the assessment process.
​
HOW to START a CONVERSATION
Always start by asking for permission and explaining the purpose of doing an assessment or screening.
A sample introduction could be, “I‘d like to ask you more about your family and who’s helping you already so that we can plan next steps together.”
Some other open-end questions include:
-
Where are you currently living? Is this where you will be living after discharge or will you be moving?
-
Who lives in the home with you? Who stays with you regularly? Who visits?
-
Are there any family members (e.g., extended family) or other support people who live near you?
-
Who are the support people that your family relies on?
-
Is there anything that the NICU staff should understand about your family to better serve you?
-
Are other children in the family receiving any services or supports? Do they have any unmet needs?
-
Who contributes to your family financially and economically? Who helps meet your needs?
-
How is your family’s health care covered and paid for?
start conversation
bottom of page