By Kristin Rothwell, associate editor
(Originally published in Oct. 2004)
Scheduling home nursing visits just a few days after a mother gives birth has shown to be a cost-effective method of preventing hospital care for infants who might otherwise suffer from jaundice and dehydration, according to a recent Penn State Children’s Hospital study.
The study cited that 92 percent of the 2,641 infants who were not visited by a nurse returned to the hospital emergency department in the first 10 days of life compared with none of those who received a nurse visit.
The study, “Cost Effectiveness of Postnatal Home Nursing Visits for Prevention of Hospital Care for Jaundice and Dehydration” was published in the journal of Pediatrics, Oct. 4.
“Our study suggests that a low-cost home nurse visit can significantly reduce the need for comparatively expensive hospital and ED services for jaundice and dehydration and, most importantly, prevent babies from getting sick,” said Ian Paul, M.D., assistant professor of pediatrics at Penn State Children’s Hospital part of the Penn State Milton S. Hershey Medical Center.
During his residency at a hospital in Durham, North Carolina, Paul noticed that several infants weren’t being brought to their first follow-up appointments—when infants are most at-risk following birth—and that some of the infants were being readmitted to the hospital due to dehydration and jaundice. Additionally, he noticed that many mothers, particularly first-time mothers, were overwhelmed with caring for a new baby.
“When combining these problems, I wanted to investigate,” Paul said. “I didn’t go into this with an agenda, but I’m convinced [home nurse visits] is a model of care.”
While more than 4 million births taking place each year in the United States—making childbirth one of the most common causes of hospitalizations—many hospitals have reduced the postpartum length of stay due to the high cost of care, according to a National Hospital Discharge Survey published in 2002.
“Many pediatricians don’t recognize or don’t address the need for close follow up during the initial post discharge period so many practices will discharge at less than 48 hours [with] no follow up for two weeks,” Paul said. “That’s flat out not acceptable and not accepted by the American Academy of Pediatrics or recommended by U.S. Congress.”
The Newborns’ and Mothers’ Health Protection Act of 1996 mandates insurance coverage of a minimum of 48 hour hospital stay after childbirth. The American Academy of Pediatrics also has stated that a newborn should be in the hospital at least 48 hours after birth and, in most cases, should be reassessed by a physician 48 hours to 72 hours after discharge. However, many babies are discharged before 48 hours and less than one-half of all infants are taken to a follow up appointment in the recommended timeframe.
“Minorities and Medicaid patients tend to get the poorest follow up and they’re the populations most at risk, so compliance is even worse for them,” Paul said.
The study found that the average cost of a home nurse visit to insurers is about $85 while the cost of an emergency department visit and readmission is about $400 and $4,000, respectively.
In the current study, after nursery discharge, the average cost per child who received a home health visit was $109.80 compared to $118.70 for each newborn who did not receive a visit. When totaled, the data suggest that insurance payers will save $181.82 for every additional child who does not use hospital services (emergency department or inpatient) in the first 10 days of life.
“This data demonstrates that home nurse visitation is less costly and affords a significant reduction in the need for subsequent hospital and ED visits due to jaundice and dehydration,” Paul said. “These data also show that a program in which each infant receives a home visit may be less expensive to payers as a result of the reduction in the need for more expensive hospital-based services.”
In addition to the study’s goal of reducing or eliminating jaundice and dehydration by assessing infants through home nurse visits, the study also found that the visits provided needed support to mothers.
Paul said that nurses who visited patients’ homes didn’t have time pressures so they were able to help mothers with breastfeeding problems by sitting with the mother during a feeding, assessing the home environment and evaluating the mother’s physical and mental health.
Ann Schwoebel, a neonatal nurse practitioner at Pennsylvania Hospital in Philadelphia, Pennsylvania, and a member of the Association of Women’s Health, Obstetrics and Neonatal Nursing, agreed that home nurse visits provide a more relaxed environment for nurses to educate mothers.
“People hear things differently in the hospital,” Schwoebel said. “I think [patients] listen better in their own homes.”
Plus, Schwoebel said that it’s often difficult for nurses to cover everything mothers need to know in the 24 to 48 hours before they’re discharged.
She added that the more relaxed home environment makes it easier to reinforce information, to go over any questions or concerns a mother might have and makes it possible for nurses to more aptly notice any signs of postpartum depression.
“With postpartum depression, we can get clues but you often don’t see it in the first 48 hours of a mom being in the hospital,” Schwoebel said. “We can get a gut feeling, but it’s better to see it in the [home environment] because that’s where you get a better idea of the problem.”
Donna Walker, RN, MS, a nurse supervisor of the Southeast Colorado Family Partnership, has seen first-hand the importance of providing home nurse visits.
The organization, which has been serving first-time mothers in Prowers, Bent, Baca and Kiowa counties in Colorado since July 2001, provides support to mothers at their homes throughout their pregnancy—from as early as 28 weeks into the pregnancy until the child is 2-years-old.
Walker with two other nurses serve about 50 family case loads in all four counties with the goal of helping new mothers accomplish three main goals: improve pregnancy by helping women improve health-related behaviors such as reducing or ending the use of cigarettes, alcohol or illegal drugs, improve child health and help develop parents’ parenting skills to provide responsible competent care for their children.
Based on the organization’s philosophy of “Whatever her heart desires,” Walker said the program is not about making mothers do anything but to help them set their own goals and to provide them with any education or resources they might need to be an advocate for their child.
By providing home nurse visits, Walker said the mothers are more likely to get prenatal care, they tend to visit the emergency department less, they have less accidents, they are breastfeeding their babies longer and they’re vaccinating their children as needed.
“It’s a really good program,” Walker said. “We’re helping moms be good mom[s].”
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