Critical Path Network-Parent to Parent Program paths minimize OB complications

By Christie Peck

Nurse Coordinator

Parent to Parent Program

Janice Schriefer, RN, MSN, MBA

Clinical Systems Improvement Specialist

Spectrum Health

Grand Rapids, MI

The Healthier Communities Department of Spectrum Health in Grand Rapids, MI, is home to several parent support projects. One of the initiatives, the OB (obstetrics) Special Care Parent to Parent Program (PPP), is designed to offer intensive in-home care to mothers and families who have pregnancies complicated by preterm labor, diabetes, hypertension, multiple pregnancy, history of pregnancy loss, and/or hyperemesis gravidarum. In addition, the program helps families who express concerns about housing, finances, adequate nutrition, transportation, child care, domestic violence, and substance abuse.

Intervention is delivered by a team consisting of an RN, a community health advocate, and a volunteer support parent (peer mentor) in collaboration with the mother's primary care provider, medical social worker, dietitian, and other members of the health care team. Intervention begins as soon as possible in pregnancy and continues until the infant's first birthday (or 12 months corrected age). Mothers generally enroll during the second trimester of pregnancy and receive an average of 19.2 weeks of prenatal intervention. (See chart detailing demographics of plan participants, below.)

Demographic information on Parent to Parent Program participants

<19 20-25 26-35 >36
8.4% 28.9% 54.2% 8.4%
Marital Status:
Never married Divorced Married Widowed Separated
27.6% 2.3% 66.7% 1.1% 2.3%
White/Caucasian African-American Hispanic Other
77.9% 16.3% 4.7% 1.2%
Commercial Medicaid
67.5% 32.5%
Years of Education:
<12 years 12 years >12 years
10.5% 41.9% 47.7%

Education ensures healthy pregnancies

Comprehensive care of the family requires physical and psychosocial assessments as well as assessment of mother and family strengths and abilities to participate in self-care. Educa tion surrounding issues of pregnancy, complications, understanding medications and treatment modal i ties, and accessing appropriate resources that enable families to be compliant with a multidisciplinary plan of care is vital to positive pregnancy outcomes. For this reason, intervention must be specific, consistent, and high-quality. A plan was designed to measure the program outcomes based on the following six goals:

1. to reduce the adverse psychosocial effects of pregnancy complications for pregnant women;

2. to provide women with education about pregnancy and their pregnancy complications;

3. to have a mutually determined plan of care;

4. to assist in the identification of infants at risk for, or experiencing, developmental delay and provide appropriate referrals when needed;

5. to provide pregnant women with parenting education and support;

6. to provide women with services during and after their pregnancy that are helpful and meet their needs.

Outcome measures include:

• standardized assessments of depression, perceived stress, mastery, and social support at four time points (two prenatal and two postnatal);

• documentation of ongoing progress toward educational goals on a prenatal and postnatal education record;

• completion of a needs assessment by mothers at enrollment and their inclusion in the written mutual plan of care;

• developmental assessments of all infants at 4, 8, and 12 months (corrected) of age and numbers of referrals made for developmental follow-up;

• completion of a satisfaction survey.

Results from the standardized measures of depression, perceived stress, personal mastery, and social support scales show positive progress. For example, results from the Center for Epi demiolo gical Studies depression scale are shown below. Scores above 16 indicate the presence of depressive symptoms. Of note is the change from 55.8% of mothers showing depressive symptoms at enrollment to 31.7% and 35.3% at times 2 and 3, and, finally, only 10% at discharge from the program.

In order to ensure that consistent, individualized, high-quality care is given to each family, clinical paths were developed to guide the program services to mothers with the most common pregnancy complications — premature labor, diabetes (IDDM and gestational), hypertension, and multiple pregnancy. Clinical paths have become a vital part of quality because they ensure that all team members are aware of the services needed by each population. The clinical paths are used by all members of the PPP team; volunteer parents have even written a modified version for their use. The care paths address consultations with health team members, nursing assessments based on independent and interdependent guidelines for care, non-licensed assessments, intervention, and education, and provide an opportunity to document any variances in the clinical care that may affect outcomes.

The paths do not replace a mutually determined, individualized plan of care, but do provide a mechanism to help decrease cost and increase efficiency. They help us determine what variances to the path will affect outcomes. And their use frees time to focus on patients' individual needs and helps to match services to those needs at the point of care. Quality care begins with qualified caregivers working together to meet the unique needs of each individual family.