Neonatal home program saves money, helps babies

NICU-experienced nurses manage babies’ care

By sending prematurely born babies home an average of 3.5 weeks earlier than the average preemie, Carolinas Medical Center’s nursery staff and home care agency was able to save more than $3.3 million in the first 18 months of a neonatal home management program.

"In addition to the shortened length of stay and cost savings, we discovered that the babies gain an average of 32 g to 37 g per day as compared to premature babies in the hospital who gain an average of 20 g per day," says Martha J. Whitecotton, RN, MSN, vice president and chief nursing executive of Carolinas Medical Center in Charlotte, NC.

The program was implemented in 1998 after a two-year period of development, Whitecotton says. "We needed to reduce the length of stay in our neonatal intensive-care unit [NICU] in order to handle the number of babies we get, and we also learned through research that babies do better in the home," she says.

The long period of development was needed for several reasons, not least of which was changing a long-term practice of defining when the babies were ready to go home.

"To go home, a premature baby has always needed to be able to maintain a stable body temperature in an open crib and eat and gain weight," Whitecotton says.

However, the NICU nurses typically didn’t even put a baby in an open crib until he or she weighed 4 lbs., she explains.

Now, the practice is to evaluate each baby on an individual basis, and if the baby is stable in the isolette and has no other condition that precludes being in an open crib, he or she is moved, even if the baby weighs as little as 3 or 3.5 lbs., Whitecotton says.

"By weaning the babies from the isolette earlier, we are able to consider more babies for the home care program," she adds.

Expert staff essential

One of the key hurdles to overcome was pediatricians’ acceptance of the program, Whitecotton says.

"The community-based pediatricians follow the babies once they move to home care, so we needed to reassure them that the nurses were experienced in caring for these tiny babies and that the pediatrician would not see an increased number of calls from these parents," she says.

Hiring experienced NICU nurses and training them for home care overcame everyone’s objections. Not only are the pediatricians not seeing an increase in the number of calls they receive, they also have fewer office follow-up visits because the nurses are taking care of many things in the home, Whitecotton says.

"I don’t get many calls from parents because we provide excellent patient education when we make our visits," says Barbara Samartino, RN, a field nurse for the neonatal nurse management program.

"We see the babies within 24 hours of their discharge to home, then call the parents every day for the first week," Samartino explains.

"The average number of visits is two per week for two weeks," she adds.

At the beginning of the program, eight visits were planned, then dropped to an average of five to seven and now the number of visits averages four, Samartino says.

"Most insurers easily pay four visits, but we re-evaluate the baby at the two-week point to see if there are any reasons to justify more visits," she says. If there is a need for more visits, the home health agency handles the contact with the payer, she adds.

Neonatal nurses are instrumental

The neonatal nurses also are instrumental in identifying babies that qualify for the program. In addition to making sure the baby can main-tain body temperature, eat, and gain weight, the nurses look for motivated parents who are able to learn and are willing to accept responsibility for the baby’s care, Samartino says.

Hiring the right nurses was a challenge for the home health agency, says Dianne Wingate, RN, BSN, assistant vice president of Carolinas Home Care.

In addition to having experience with preemies, Wingate says she looked for nurses with excellent communication skills, good assessment skills, and the ability to make sound judgments on their own in the home care environment.

"Home care nurses don’t have the backup that hospital NICU nurses [have], so we wanted people who could work on their own and inspire confidence in the parents and pediatricians," she explains.

Home care training required

After choosing the nurses for the neonatal home management program, the home health staff provided an intensive education in regulations, paperwork, Medicare and Medicaid coverage issues, safety, and information on community resources, Wingate says.

The neonatal nurses also accompanied home health staff on home visits and experienced home health nurses accompanied the neonatal nurses on the first several visits until everyone was comfortable, she adds.

"I definitely had to handle things I never encountered in the NICU," Samartino says. Upon arrival at one home, she discovered that the baby was ice-cold even though it was a warm July day and there was no air conditioning in the apartment. "The teen-age mother could not drive, and her mother was at work and couldn’t be reached," she says.

The baby and mother needed transportation to the clinic but did not require an ambulance, and Samartino knew that she could not assume the risk of taking the baby in her car. "I called the clinic, explained the situation, and the clinic nurse sent a cab," she adds.

Another unexpected obstacle for parents taking their babies home was a medication that most of the babies are taking, Whitecotton says.

"We discovered that local pharmacies did not know how to mix a caffeine compound we prescribed, so our parents were having to drive back to the hospital pharmacy to get the medication," she explains. Once this was discovered, a hospital pharmacist developed instructions for local pharmacists to use for both the caffeine compound and a diuretic commonly prescribed for premature infants.

Everyone involved in the Carolinas Medical Neonatal Home Management Program agrees that the secret to success is the close collaboration between hospital and home health personnel. Wingate, however, adds one more piece of advice: "Don’t try to utilize existing home health nurses in this program. This is such a different population for home health that you must tap into the clinical expertise of the NICU to ensure the safety of these babies and good outcomes for everyone."

[For more information about Carolinas Medical’s Neonatal Home Management Program, contact:

Dianne Wingate, RN, BSN, Assistant Vice President, Carolinas Home Care, P.O. Box 32861, Charlotte, NC 28232. Telephone: (704) 561-8500.]