A Pilot Study on Cost and Other Implementation Factors Comparing Telehealth and In-Person Therapy Service Delivery Following NICU Discharge
Phase: NA
Conditions: Prematurity Complications, NICU Infants, Early Intervention, Telehealth
Sponsor: University of Southern California

A Pilot Study on Cost and Other Implementation Factors Comparing Telehealth and In-
Person Therapy Service Delivery Following NICU Discharge  
NCT number not yet assigned 
March 7, 2025 
 
 

Study Protocol and Statistical Analysis Plan 
Participants and setting 
Participants included 20 high-risk parent-infant dyads hospitalized in an urban, level 
IV NICU. Consecutively eligible dyads from May 2023 to April 2024 were recruited if the 
infant was hospitalized in the NICU for > 7 days; received a referral for post-NICU physical 
therapy, occupational therapy, and/or speech-language pathology (or for the state-wide 
early intervention program) at NICU discharge; was referred to the Baby Bridge program at 
least 48 hours before NICU discharge; had a chronological age of < 6 months at the time of 
NICU discharge; and were from a family who spoke English. Infants who lived any distance 
away from the hospital were enrolled; however, infants who were not going to reside in the 
state of California following NICU discharge were excluded. Infants were deemed ‘high-risk’ 
for developmental challenges if they were recommended by the NICU medical team for 
therapy. Although we acknowledge that the term “high risk” can refer to high risk of medical 
complications or high risk of cerebral palsy, we use the term “high risk” to deﬁne the 
infant’s need for therapeutic interventions across a multitude of constructs including for 
language, cognition, self-regulation, sensory, motor, and feeding. A member of the 
research team attended weekly discharge rounds and reviewed the electronic medical 
record. Within discharge rounds, communication between the medical team and research 
team occurred, and the medical team referred infants to the Baby Bridge program through 
an online referral process in REDCap. The research team then screened and recruited 
those who were eligible.  

  
Enrolled infants and families were randomized to receive Baby Bridge services either 
through telehealth or in-person visits. Parent-infant dyads were enrolled at least 2 days 
before NICU discharge to enable rapport to be established (between the Baby Bridge 
therapist and family) through a visit to the NICU when possible and via telephone, text or 
email messaging when an in-person visit was not possible prior to discharge. This ﬁrst 
contact was attempted to be in-person in the NICU for both the telehealth and in-person 
groups. Enrolled infants and families then had a Baby Bridge telehealth or in-person visit 
scheduled within one week of discharge (depending on their group assignment). 
Subsequent individual weekly visits were adapted to in-person or telehealth (varying from 
assigned group) when needed or deemed appropriate (requested by the family or therapist 
or when an in-person visit was felt to improve the quality of the therapy session). Weekly 
Baby Bridge programming was conducted until other therapy through the state-wide early 
intervention program commenced, as in the infant was receiving therapy services as 
recommended. We also tracked rates of enrollment, rates and reasons for any 
cancellations, and completion of the program (deﬁned as being seen until community-
based early intervention services commenced). Infants were withdrawn if they were 
transferred to another hospital or if they were readmitted to the hospital and additional 
contact was not possible or feasible.  
Sociodemographic and medical data 
 
Sociodemographic and medical data were collected from the electronic medical 
record for each dyad enrolled to better understand diberences between groups as well as 
to deﬁne sample characteristics. Sociodemographic factors collected included: infant 

race, insurance type (public or private), maternal age, number of siblings, home distance 
from the hospital, and categorization of home residence (urban with <3,000 people per 
square mile, suburban with between 1,000 and 3,000 people per square mile, or rural with 
<1,000 people per square mile). Medical factors collected included: estimated gestational 
age at birth, the primary condition of the infant (congenital anomaly, preterm birth, or 
neurological condition not related to preterm birth or congenital anomaly), number of days 
of endotracheal intubation, number of days of hospitalization, and whether or not the 
infant was orally feeding at time of hospital discharge. 
In-person group assignment 
For those assigned to the in-person Baby Bridge group, the ﬁrst visit was scheduled 
in the home within one week of NICU discharge, and attempts were made to see the infant 
weekly in the home environment for a one-hour therapy session. Scheduled visits were 
conﬁrmed with families via text messaging the day before each visit. Visits were 
rescheduled to telehealth in the event of therapist illness, parent preference or parent/child 
illness, or distance or therapist schedule limitations. Changes of visits from in-person to 
telehealth were tracked along with their reasoning.  
Telehealth group assignment 
For those assigned to the telehealth Baby Bridge group, a ﬁrst telehealth visit was 
scheduled within one week of discharge, and weekly telehealth visits were scheduled 
therafter. However, parents were informed that in-person visits were an option when needs 
arise. Adapations from a telehealth visit to an in-person visit were made in the event of 
therapist clinical judgment due to the medical complexity or feeding/tonal abnormalities of 

the infant and parent preference or rapport building. Visit adapations were tracked along 
with the reasoning for them.  
Implementation outcomes 
We deﬁned measures for this study based on previous implementation research 
(Lewis et al., 2015; Proctor et al., 2011; Proctor et al., 2009). The primary outcome of 
interest for this study was cost diberence between telehealth and in-person visits of the 
Baby Bridge program. We also investigated implementation outcomes of adoptability, 
feasibility, adaptations, and acceptability. Many of the procedures here mirror a previous 
article on feasibility, which enrolled a diberent sample to assess the same outcomes in 
context of telehealth only, whereas this manuscript enables exploration of the diberences 
when comparing to an in-person model.  
Cost 
Cost is an important factor when determining feasibility of an intervention. When 
resources are limited, it can aid in choosing one intervention over another. For the 
purposes of this project, we estimated costs associated with each Baby Bridge visit. We did 
not assess cost across group assignment, due to the allowed adaptations to each visit 
type. Cost was deﬁned in relation to the organizational cost of providing Baby Bridge visits 
and included the time that the therapist spent conducting therapy sessions (billable time), 
administrative time (documentation, communication with families), driving (for in-person 
visits), and mileage reimbursement.  The total billable and non-billable time that the 
therapist spent (including therapy session time, administrative time, and drive time) was 

multiplied by $50 per hour, an hourly wage that matches typical rates across the United 
States and in California (29-1122 Occupational Therapists, 2024). Mileage reimbursement 
was calculated at the $.67 per mile, the California mileage reimbursement rate for 
employees (2024 Updated Mileage Reimbursement Rates for Use of Personal Vehicle and 
Private Aircraf, 2024). Further, the number of billable minutes (in evaluation, for therapeutic 
activities, or therapeutic exercises) were put in context of Current Procedural Terminology 
(CPT)/Healthcare Common Procedure Coding System (HCPCS) codes and reimbursement 
amounts for Fee For Service Medi-Cal (California Medicaid) (though we acknowledge this 
reimbursement rate could diber drastically depending on actual insurance type). This 
enabled a total amount of reimbursable potential in context of the total cost of 
programming, with the ability to explore diberences across telehealth and in person costs. 
Because many infants had some adaptations to their assigned type of therapy visit, rather 
than investigating across assigned groups, we analyzed cost based on actual visit type 
(telehealth or in person) rather than assigned group type.  
Adoptability 
Adoption refers to the uptake of Baby Bridge programming, measured at the 
organizational and provider level (Proctor et al., 2011). This can include health care 
professionals’ buy-in and support of the program that enables infants and families to 
receive Baby Bridge services. We tracked the number of infants referred, approached, and 
enrolled. Adoption was operationalized to include the total number of infants approached 
versus enrolled (enrollment rate).  

Feasibility 
Feasibility is deﬁned as the extent to which Baby Bridge programming can be 
successfully used or carried out within a given agency or setting (Proctor et al., 2011). To 
understand the feasibility of Baby Bridge telehealth programming, we captured timing (if 
the ﬁrst visit was conducted within one week of discharge); average time from NICU 
discharge to ﬁrst Baby Bridge visit); frequency of visits; rate and reasons for any therapy 
visit cancellations; the completion rates (percentage of enrolled infants who completed 
programming); and the timing of transition to community-based therapy. Feasibility was 
deﬁned a priori as all Baby Bridge visits attempted within the ﬁrst week, infants seen at 
least 3 visits per month while in the program, and that 80% would be successfully 
transitioned to early intervention programming.   
Adaptations 
Adaptations include intentional changes made to programming (from the way it was 
intended) in order to enable real-world uptake by aligning the intervention to the context it 
exists in (Moore et al., 2021). To aid in understanding speciﬁc adaptations made to 
telehealth versus in-person programming, we captured the proportion of visits conducted 
via telehealth in the telehealth group and proportion of visits that occurred in-person in the 
in-person group. Reasoning for such adaptations was tracked as described above in the 
telehealth and in-person assignment sections. 
Acceptability  

Acceptability is the perception among stakeholders, speciﬁcally the consumers or 
parents, that the Baby Bridge program is satisfactory. Using Proctor’s model (Proctor et al., 
2011) as a guide and through adaptation of a previously reported measure of acceptability 
(Karlsson & Bendtsen, 2005), the Baby Bridge Parent Survey was developed to determine if 
programming was acceptable to parents. The survey was developed, and ﬁve members of 
the research team added/revised queries to aid in comprehensive collection of 
perceptions as well as to aid clarity of each question’s wording. It went through an iterative 
process with multiple revisions until no further feedback from team members was received 
and there was consensus on the inclusion of and the wording of survey questions. The 
survey took < 5 minutes to complete.  
Upon completion of the Baby Bridge program, parents were asked to complete the 
Baby Bridge Parent Survey to query their perceptions about Baby Bridge programming. 
Survey questions were loaded into REDCap and administered electronically through a 
shared link to a REDCap survey. Parents received subject remuneration of $50 after 
completing the survey. Parent satisfaction was measured based on a sum (possible range 
of 0-10) of the following questions from the survey: 
1. Were therapy goals achieved through Baby Bridge programming (2=yes, 1=partially, 
0=no) 
2. How likely would you be to recommend the Baby Bridge program to other NICU 
parents? (3=definitely will, 2=probably will, 1=probably will not, 0=definitely will 
not) 

3. How likely would you be to use Baby Bridge programming again? (3=definitely will, 
2=probably will, 1=probably will not, 0=definitely will not) 
4. Was there anything about the Baby Bridge program that you found confusing or 
complicated? (0=yes, 1=no) 
5. Did you experience any challenges with he Baby Bridge program (0=yes, 1=no).  
 
Analysis 
A power analysis to determine sample size was not conducted, as this is a pilot 
study aimed at understanding initial diberences across groups while determining variance 
to aid in future sample size determination for a larger trial. Sociodemographic and medical 
factors are reported descriptively and diberences across groups were investigated using 
independent samples t-tests and chi-square analysis.  
Cost 
The cost of in-person visits vs. telehealth visits are reported descriptively. 
Diberences in costs across telehealth and in-person visits were investigated using 
independent samples t-tests and linear regression models.  
Adoptability 
Rates of enrollment are reported descriptively but not analyzed between groups, as 
enrollment occurred prior to group assignment.  
Feasibility 

We investigated diberences across groups (in-person versus telehealth) in whether 
the ﬁrst visit occurred within 1 week of NICU discharge, average number of days between 
NICU discharge until ﬁrst Baby Bridge visit, frequency of visits, number of therapy visit 
cancellations, and the completion rates using independent samples t-tests and chi-square 
analysis. 
Adaptations 
The proportion of visits conducted within the assigned group was investigated 
across groups using independent samples t-tests.  
Acceptability 
Satisfaction scores were compared across groups using independent samples t-
tests.