Hospital to Home

The Hospital to Home (H2H) program supports high-risk babies after they are discharged from hospital. H2H was designed to improve newborn survival in resource-constrained settings and is being piloted in central Uganda. Through this grant, we will add technology to the program in the form of an adapted smartphone app to empower 100 H2H volunteer community health workers (CHWs) to provide accurate care and prompt follow-up to these high-risk newborns for six months after hospital discharge. By introducing this technology, we can ensure that babies are visited at the right time, receive the right care, and are referred when necessary. Technology will help the CHW identify when a child requires intervention and will provide decision support tools. Additionally, CHWs will be able to receive ongoing education remotely and will be able to consult with a newborn expert using telehealth. The addition of this technology will help reduce newborn mortality

There are 32,000 newborn deaths every year in Uganda. Newborns who are considered high-risk, particularly those born preterm, low birth weight (LBW), or who develop illnesses early in life, often face significant nutrition and/or developmental challenges compared to healthy newborns. While more high-risk infants are now surviving thanks in part to the increasing development of neonatal intensive care units (NICUs), very few follow-up programs exist to ensure these infants receive the ongoing care needed after discharge from hospital. Often, parents lack the finances to return to the hospital for follow-up care, leaving them with no clinical support for their high-risk infant. Many infants die after returning home because they don’t have the support needed to survive and thrive.

We developed H2H to support these high-risk infants and their families. While the program is already improving lives, by adding technology we can increase the capacity of CHWs to further expand the program’s reach. Currently, program data is collected on paper, which is labor-intensive, costly, and can be inaccurate. All supervision and training are also done in person, which is costly and inefficient. The addition of this technology will empower CHWs to care for high-risk newborns, therefore reducing newborn mortality.

To address the problem of newborn mortality and lack of follow-up, in 2019 we launched a program called Hospital to Home (H2H) to support high-risk babies after hospital discharge through home visits from volunteer community health workers (CHWs) until they are six months old.

We want to digitally empower these CHWs with an adapted smartphone app to help guide their clinical decision making, keep timely appointments, and eliminate labor-intensive, costly, and inaccurate paper-based data entry while increasing the scope of data available to improve performance.

The app will identify the correct visit schedule for each baby and send reminders to CHWs to ensure the babies are seen at the right time. The CHW will enter real-time data about the baby – such as their temperature, respiration rate, and weight – and will be alerted by the app when a baby exhibits any danger signs needing referral to the hospital. The app will also allow the CHWs to seek real-time consultation from a newborn expert and receive training and supportive supervision remotely. With real-time data, the program manager will also be able to monitor CHW performance and provide timely feedback. This technological addition will help reduce newborn mortality in resource-constrained settings. 

Our solution is designed to serve high-risk infants in resource-constrained settings like Uganda, by supporting the community health workers (CHWs) that provide care to these infants.

Through our pilot project we will initially reach ~800 babies and their families each year, and 100 CHWs.

The solution will positively impact the CHWs by equipping them with up to date knowledge, experience, and skills, and supporting them to make timely decisions. Research shows if CHWs feel adequately supported, they perform better, and are in a better position to mobilize the community and save more lives. The use of mobile technology will support CHWs to provide accurate care and prompt follow-up as they monitor the infants’ nutritional and neurodevelopmental outcomes, positively impacting high-risk infants and their families, by helping avert preventable newborn deaths through more timely intervention. Families will benefit from the education provided by CHWs on early childhood care and development as well as sanitation, nutrition, and family planning. This can be enhanced through the addition of this technology, with CHWs able to show educational videos.

We hope to make this app accessible to other health facilities or organizations that would like to use it to benefit more CHWs and high-risk infants.

High-risk newborns should receive regular follow-up after NICU discharge, but families in resource-constrained settings often struggle to return to the health facility due to financial and social factors. In Uganda there is stigma around premature babies, which also results in fewer families accessing care for these infants. This inability to access care can result in the infant’s poor health or even death. Our solution provides free follow-up visits for high-risk infants in their home, which directly expands access to care. 

Mobile software designed specifically for high risk babies in low resource settings to track health, growth and development is an innovative model that helps fill a gap in newborn care. While more neonatal intensive care units (NICU) are being established in low resource settings, no best practice, easily implemented and delivered, low cost program exists to follow-up newborns post discharge. Follow-up is either not done at all or is not done well. By adapting mobile software to support CHWs to deliver post-discharge care, we can provide neonatal units with a tested and easily implemented model to support newborns and their families.

H2H CHWs cover vast areas and this technology will help their coordination, support them with diagnostic decisions, facilitate training, and will allow the program to be closely monitored through real-time data. It will allow CHWs to follow specialized newborn protocols in a systematic and uniform fashion, ensuring newborns receive the highest levels of care and are referred where appropriate. It also gives CHWs the opportunity to utilise the expertise of clinicians based at the hospital, through video link up should they require assistance.

Currently, data on newborn survival is inadequate. According to a study by Lawn, Zupan, Begkoyian and Knippenberg, one of the reasons neonatal survival has received little attention relative to the huge number of deaths is the invisibility of those deaths. With more widespread adoption, this solution could help us better understand what happens to high-risk infants in resource-constrained settings after they are discharged from a hospital.

The care of high-risk newborns, especially in low resource settings is a very specialized field and has only really emerged in the last 20 years, with very little technology to support it.

Our solution will adapt an existing open source mobile health application that is being used by other frontline health workers. We are proposing to adapt this to include digital tools, protocols, and procedures to aid the specialized follow up required for small, sick, and preterm newborns to survive and thrive. These babies require a higher level of care and expertise and most CHWs are not trained or supported in this type of care. There is little room for error or inaccuracies.

The application will allow the following:

• Patient register and ability to schedule appointments
• A care guide, to guide CHWs through the different actions, activities and protocols required to screen, assess, or diagnose high-risk newborns
• Clinical decision support system with prompts based on data entered which provides instant information regarding next steps when abnormalities are detected.
• The ability to deliver training modules to CHWs
• The ability for video link up to the hospital for immediate clinical help with more complex cases
• The collection of real time data that can be used to inform decision making at local, national, and global levels.

As many of the CHWs do not have access to electricity, we are proposing using small solar panels as charging devices. 

One of the main technologies that is used in this space has been developed by Medic Mobile and is part of the community health toolkit. Medic Mobile currently supports over 25,000 CHWs in 23 countries. This provides the resources to design, build and deploy digital tools for community health and it would be this or something similar that we would adapt for the care of preterm high risk newborns. At present this technology supports the functionality of messaging, task schedules, decision support workflows and core protocols, person profiles and analytics.

There have been numerous research papers conducted on the benefit of mobile health in low resources settings including Manda and Hersted, who conducted a study on implementing mobile phone solutions for Health in Resource constrained areas. This highlighted the benefit of mobile technology for enhancing communication between medical personnel and CHWs, permitting better information exchange and work coordination and providing patients with urgent help when needed.  Hughes, Wasunna, Omedo and Rashid (2019) investigated a nurturing care application that supports CHWs in Kenya and the results were overwhelmingly positive. The CHWs appreciated the advantages over the hard copy registers and logbooks and valued the prompts the tool gave them to ensure all procedures were followed correctly. 

Over 90% of newborns born prematurely or with other life-threatening conditions are thought to reside in low-resource settings. These newborns are at higher risk and suffer higher mortality and morbidity than their full-term peers. Many spend time in a neonatal unit and are discharged home, only to face ongoing challenges with growth and development. A follow-up programme designed for high-risk newborns residing in low-resource settings is imperative to ensure these newborns receive the healthiest possible start.

Through Hospital to Home (H2H) eligible newborns are followed-up in their homes by specially trained, and digitally empowered community health workers (CHWs) until they reach six-months of age. During the home visits, CHWs provide parents with continuing education and support, monitor the infant’s growth and development, assess for danger signs, and refer for medical care when needed, assisted by a smartphone app.

H2H seeks to reduce preventable mortality of high-risk infants discharged from neonatal units in low-resource settings.

We believe that in the long term, H2H can ensure that every newborn has the potential to thrive.

H2H will help us reach these goals by achieving the following intermediate outcomes:

• Improved rates of exclusive breastfeeding at six months due to counselling from specially trained CHWs, enhanced by app-based prompts.
• Early identification of failure to thrive, through weight tracking in the app. allowing early intervention if babies are not following an appropriate growth curve.
• Early identification of developmental delay through milestones checklists in the app, allowing for the infant to be referred to early intervention.
• Identification of any newborn danger signs and prompt referral actions, enhanced by the apps clinical decision support system.
• Empowered and skilled CHWs, who receive regular training and skills assessments digitally to improve skills and knowledge.
• Empowered parents with improved knowledge on newborn care, nutrition, sanitation, and other key topics, enhanced by training videos in the app.
• Real-time data to monitor CHW performance against targets.
• Improved supportive supervision, using telehealth to connect to a neonatal health expert.
• Access to timely data on outcomes of high-risk infants in low resource settings that can be used to inform program development both locally and nationally.

In the pilot phase of Hospital to Home (H2H) we are currently serving 800 infants per year. These 800 infants receive home visits from CHWs for six months. In the first year of this project, as we introduce the technological component to H2H, we anticipate serving a similar number of infants. Depending on the outcomes of the project, in the next five years we would explore expanding the program to other sites in Uganda. We would select sites in consultation with the Ministry of Health. The Ministry of Health is already familiar with and supportive of H2H. We anticipate they would be highly interested in the rollout of the program to other regions that have neonatal intensive care units and thus high-risk infants that are discharged home. We would also explore partnerships with the Ministry of Health as well as other private companies, such as cell phone carriers, to determine the sustainability of supporting this program at a national level.

Another goal would be to provide the app to other neonatal intensive care units in resource-constrained settings. The establishment of follow-up programs for high-risk infants is an emerging trend, and we anticipate that health facilities would be eager for technology to assist these programs. By making the app more widely available, the global health field could also learn about the outcomes of high-risk infants after they are discharged from the hospital. The exact number of infants that could be reached depends dramatically on the adoption at district or national level.

The innovation will be implemented initially at Kiwoko Hospital, impacting the three main districts that make up Kiwoko Hospital’s catchment area – Luwero, Nakaseke, and Nakasongola. This area has a population of approximately one million.

Once established in Kiwoko the outcomes of using this technology will be documented and made readily available globally. We expect it could be easily adopted in other established Ugandan NICUs, such as International Hospital Kampala and Nsambya St Francis Hospital. It could also be implemented in other lower-level newborn units across the country, including at Nakaseke General Hospital where Adara is providing newborn training.

If successful it is a low-cost option that could be adopted by the MoH to catch high-risk infants before they fall through the cracks. There are huge economic and social benefits for governments to invest in this type of early intervention, with disruptions to early development causing setbacks that can result in massive economic losses for governments in lost productivity.

In 2014, the WHO estimated that there was a global deficit of about 7.2 million skilled health professionals, and projected that that number would rise to 12.9 million by 2035. Low resource settings (LRS) like Uganda often face the brunt of these deficits, and this, coupled with the challenge of having limited health facility infrastructure, lead many LRS to rely on CHW programs to deliver primary health care. As CHW programs are already established in most LRS across the globe, this training and technology could be easily integrated into NICUs. 

In the next year, we anticipate the biggest barrier to our goals will be COVID-19. The WHO predict that many African countries, including Uganda, may experience a more prolonged outbreak over a few years, rather than the exponential increase seen elsewhere.

COVID-19 has already impacted service delivery of H2H, as during lockdown, travel has been restricted, limiting CHW access to families. Social distancing restrictions have also affected group training and meetings of CHWs.

COVID-19 will likely impact the project goal of reducing neonatal mortality in other ways, as access to essential health services is disrupted, and food insecurity grows. Recent modelling from the Lancet estimates that we will see under-5 child deaths increase between 9.8% and 44.7%, depending on the extent that access to life-saving interventions is reduced.

In the next five years, one major potential barrier will be a loss of momentum nationally in tackling newborn morality. There was a significant political will to improve newborn health in Uganda, evidenced by government commitment to reaching the SDG targets and halving newborn deaths in health facilities within five years as part of the WHO Quality of Care network. However, COVID-19 and the mitigation of its impact is now the priority for the Ministry of Health in Uganda. This could impact widespread adoption of the program.

National security and financial instability are a potential risk but neither has caused significant difficulties in Adara’s work in the region in recent years. 

COVID-19 makes this a critical time for rolling out mobile technology, as the introduction of this technology will help address some of the barriers above, making it possible to use telehealth, digital training, and videoconferencing to deliver the H2H programme. The technology will also help us to monitor service delivery gaps, such as immunization rates, which will help us to encourage families to make sure they catch-up on any services disrupted during lockdown.

Uganda faces many economic challenges including lower than recommended health expenditure spending, and one of the lowest clinical health worker ratios. However, there is hope that this will improve, with Uganda increasing national health spending, and becoming a recipient of the Global Financing Fund (GFF) for newborn health.

Socially, there are some barriers that will need to be addressed, including giving increased hope and knowledge that LBW babies can survive and thrive once they leave the hospital.

CHW and NICU staff engagement, knowledge and retention risks will be mitigated against by comprehensive training, mentorship, supervision. CHWs will also be incentivized with bicycles and uniforms, with other community health worker studies demonstrating the impact these types of incentives have on engagement.

The solutions team fall under the international development organisation Adara Development. Adara Development is a non-profit that is part of the wider Adara Group. 

The first part of the Adara Group is Adara Development, which has expertise in maternal, newborn and child health, and remote community development. The second part of the Adara Group consists of two businesses, Adara Partners and Adara Advisors, which are ‘for purpose’ rather than for profit. Their sole objective is to fund Adara Development’s administration and emergency project costs. This allows 100% of donations received by Adara Development to go directly to project-related costs.

The solution team is made up of 16 staff members plus seven volunteers from Adara’s International Medical Volunteers. This includes seven people based in Uganda, four of our Global Health team based in Seattle and five support team based in our Global Support Office in Australia. These 16 staff members are part of Adara Development and work across many of Adara's programs.

The Adara team are a highly qualified Ugandan, American and Australian team with over 420+ years collective newborn, maternal, and public health experience, including 320+ years in the clinical care of small and sick newborns. This includes ten highly skilled and experienced NICU nurses who have been working on this specific topic for decades. They have developed the protocols that guide our Hospital to Home program and they will guide the content of the mobile application and ensure it will apply in a low resource setting.

The team also includes a Community Midwife with over 40 years’ experience delivering home-based care to mothers and babies in the H2H target community. This community midwife has managed and led the CHWs since H2H was implemented, and will be critical to the development and training of the app. overseeing this specific team of 100 for over a year.

The team will also have support from academics and program staff with expertise in Monitoring & Evaluation.

Critical to the deployment of the technology will be Adara's Head of Information Technology, who has over 20 years experience across all facets of Information Technology including operations, support, architecture, networking, project management, application development, IT transformation and IT Management.

Kiwoko Hospital, Uganda – Adara has worked in partnership for 22 years to deliver maternal, newborn and child health services.

Nakaseke Hospital, Uganda – This government district hospital in Uganda is our first location for newborn scale up work.

Ministry of Health, Uganda – Adara is a member of the National Newborn Steering Committee.

PATH – PATH is a well-known non-profit leader in global health innovation based in Seattle that creates innovative technological solutions for low-resource settings. Adara is collaborating with PATH to develop the Safe Bubble CPAP kit.

University of Washington/Seattle Children’s Hospital –This significant partnership gives us the opportunity to work closely with an expert clinical team, including neonatologists and NICU nurses. A key partner in training, research, and development of programmes in all our global health work.

Makerere University of Uganda: An important academic partner for our data collection and surveillance, research, connections to other NGOs, governments and multilaterals and scale up work. They house the country’s academic Centre of Excellence in Maternal, Newborn and Child Care.

London School of Hygiene and Tropical Medicine (LSHTM): We are working with them on early intervention of high-risk newborns.

The MRC/UVRI and LSHTM Uganda Research Unit – One of our partners for the early intervention of high-risk newborns. 

Saving Brains, Grand Challenges Canada – Adara is currently the grantee of a prestigious grant to develop and pilot a discharge and follow-up program to support high risk infants. This is the Hospital to Home program. 

Adara is unconventional in the way it works in partnership with communities over the long-term and in the way it is funded. We have worked in Ugandan communities for the past 22 years, establishing deep relationships with key leaders. Our work has been magnified in impact by its unique funding model, which ensures that 100% of donations and grants go to our projects.

The Adara Group comprises two different parts, the international development organization called Adara Development and two boutique corporate advisory businesses called Adara Advisors Pty Limited and Adara Partners (Australia) Pty Limited. The two corporate advisory businesses exist solely to fund Adara’s international development work. These BCorp®s deliver financial services expertise at the highest levels, with profits covering Adara’s core support and administration costs. Our approach to development is to ensure everything is led by the community and informed by best practice. 

We employ local people who live in and understand the communities, in addition to staff in the US and Australia. We have a range of professional staff – from health workers to an anthropologist and monitoring and evaluation experts – to make sure the work is ethical, effective, academically rigorous and is at the forefront of best practice.

Knowledge sharing is one of the key pillars to our strategy. We take our very best ideas and our biggest mistakes, distilled from two decades of working in the field, and share them locally, nationally, and globally to reach as many people as possible.

The Adara Group was founded in 1998 to bridge the worlds of business and international development and has a unique funding model. The Adara businesses - Adara Advisors Pty Limited and Adara Partners (Australia) Pty Limited provide independent and conflict free financial and strategic advice to leading Australian companies. The fees generated on transactions help support all Adara’s administrative and emergency project costs. The unique funding model The Adara Group operates ensures 100% of all donations to Adara Development are spent directly to project related costs.

Adara receives donations from a number of individuals, corporate partners and foundations and has developed many long term relationships that sustain its work.

We are applying to Solve to not only gain access to much needed funding but to learn from the insights and expertise of the MIT Solve community. Adara is a leading organization in the newborn health field and one of our areas of expertise is in caring for preterm and sick newborns in low resource settings. By working with the MIT Solve Community, it will give us the opportunity to harness this knowledge and magnify its reach through the power of technology and the brokering of new partnerships with like minded organizations and individuals.  

Our main partnership goal would be to gain an insight into how we can effectively apply this existing technology to the benefit of preterm and sick newborns to increase their survival rate, once discharged from hospital. If it is proven a successful aid for CHWs dealing with these more complex cases, we would look to partner with other organizations that have a strong network of CHWs to equip them with this application and the necessary specialized training to care for this high risk group. If other organizations choose to partner with us in this way, our experienced team can provide ongoing mentor-ship to ensure more babies can survive. 

We would like to use this opportunity to connect with other organisations who have an interest in reaching Sustainable Development Goal 3 and reducing maternal and newborn deaths. This would include Solve Members such as the Bill and Melinda Gates Foundation, Dubai Cares, Johnson and Johnson and MacArthur Foundation. Adara has expertise in newborn health and through MIT Solve Challenge we hope to identify appropriate implementation partners to enhance linkages between maternity and neonatal services. For example Save the Children could be a potential technical or implementation partner at scale.

Partnerships are essential for the success of this project but it is important to engage with the right partner that understands how the program needs to be implemented and therefore can develop a design intervention that meets the need.

Newborn mortality rates in Uganda are such that 20 newborns die for every 1,000 live births compared to high income country levels of 4 newborn deaths per 1,000 live births. We recognize that one of the most powerful levers to transform outcomes for women and newborns is the development of teams of skilled health workers who are both committed to the survival of small and sick newborns, and believe it is possible.

Training for nurses in newborn care has been limited in Uganda. Nursing Schools lack curriculum in the care of the newborn, especially those babies requiring more than basic care. Without adequately trained nurses, the support and referral pathways for Community Health Workers are very limited. This significant gap in newborn care training needs to be met in order to reduce newborn mortality.

We propose working with the Ministry of Health to select three key health facilities to receive newborn care training. We will conduct the training's and provide ongoing mentorship face to face and remotely with a skilled Ugandan neonatal nurse who has over 30 years’ experience, a component often missing in many training's. With our expertise, we can tailor training materials to the local setting, enhancing learning and comprehension. Adara will conduct needs assessments at each facility to determine the level of knowledge, understand processes in place, and to ascertain the availability of equipment, and will customize training's accordingly to meet trainees at the level they are at, rather than delivering a pre-packaged training.