Have you ever had to turn away perinatal patients?
Have you ever had to turn away perinatal patients?
Specialty program can make you competitive
Not long ago, St. Mary’s Hospital Home Health found itself in an untenable situation. Its perinatal specialty program was a good one, but it wasn’t comprehensive. The Athens, GA-based provider was forced to discharge some of its high-risk pregnancy patients to competitors who could provide services St. Mary’s couldn’t, such as uterine activity monitoring, or reglan therapy for hyperemesis. These therapies, which once required admission to a hospital, now are routinely delivered at home. Any hospital-affiliated home health provider that doesn’t offer one-stop shopping runs the risk of losing physician referrals.
"That’s what happened to us," says Jeannine Richardson, RN, manager of specialized services at St. Mary’s, whose agency serves 13 mostly rural counties about 60 miles east of Atlanta. "We had one [preterm labor] patient on our service for a while and her condition worsened, and her doctor wanted her [fetal-] monitored. But we couldn’t provide that. We had to transfer her to an agency that could monitor her, so we discharged her."
In fact, continues Richardson, St. Mary’s "had three referrals in the last year from doctors who needed monitors for patients, but we had to say, We can’t do that.’"
But that was then, and this is now. Thanks to St. Mary’s decision to expand the perinatal program, Richardson doesn’t have to lose high-risk pregnancy patients any more.
Spurred by requests from local physicians, and by a market study from two years ago predicting the need for the service, St. Mary’s began shopping for a uterine monitoring system. The market research showed that the local competition would be Apria and Hand-n-Hand Home Health Care, so St. Mary’s entered into an agreement with Secure Care of Savannah, GA, a subsidiary of Contemporary Medical Resources.
Secure Care trained St. Mary’s nurses and provides staff at the remote monitoring center in Savannah. The agency uses care plans that it developed in conjunction with Secure Care, says Hill.
Meeting any need
"Uterine monitoring has been done heavily in Savannah," says Richardson, "so we decided to use the monitoring center there at Secure Care. They helped us get the program started."
Between January 1996 and February 1997, St. Mary’s had handled 10 high-risk pregnancy cases with the agency’s three OB nurses, but so far, the agency hasn’t had a uterine monitoring case.
While it may be too soon to tell how referrals or lengths of stay will be affected, or how much money the program will save the hospital, Hill and Richardson expect the new service to have a positive impact. St. Mary’s officials say the cost avoidance figures supplied by Secure Care should be close to the agency’s own savings.
The monitoring capability completes the perinatal picture. "We have a comprehensive perinatal program," Richardson says. "We handle high-risk pregnancies, and offer uterine telemetry monitoring plus phototherapy, plus pediatric nurses who follow up on preemies. We provide apnea monitoring, oxygen therapy, and education to make sure parents know what to do.
"We want to be an agency that can take a patient who needs all this and provide it under one umbrella. We want to meet any need a new mother, pregnant woman, or baby can have."
To educate doctors about their monitoring service, Richardson and her nurses took a slide presentation to the hospital. They followed up with one-on-one meetings with the physicians or their office managers.
The uterine monitoring device is worn like a belt, explains Richardson. It connects to a monitor through a regular telephone line, allowing nurses at a remote location to detect even the slightest of contractions. "It’s like a fax, and nurses can see if a patient is having contractions even before the patient feels it sometimes. Patients can be on terbutaline therapy, too, and they can be told over the phone how to give themselves another dose to get over a bout of abnormal activity."
St. Mary’s had a specialized services department before adding the uterine monitoring component, and offered only limited perinatal services. However, St. Mary’s OB/GYN program has since evolved into a comprehensive delivery model, now offering:
• heparin infusion therapy for deep vein thrombosis;
• reglan infusion therapy for hyperemesis;
• uterine activity monitoring;
• terbutaline infusion therapy;
• NST (Non Stress Testing);
• phototherapy;
• antibiotic infusion therapy;
• PIH (Pregnancy Induced Hypertension) therapy;
• gestational diabetes;
• management of post C-section wound complications;
• new mom/baby care for Medicaid patients.
Although some studies have said uterine monitoring doesn’t help, St. Mary’s disagrees. "The stats we have seen indicate it does help," says Hill. "It is a cost-effective means to detect abnormal activity."
The same is true of the controversy over terbutaline, Hill says. "It has been used a number of years for pregnancy. The subcutaneous method requires less of the medicine and is more effective."
Patients call agency, not the docs
Physicians have been mostly positive in their responses to the comprehensive perinatal program, Richardson says. "A few doctors think it’s a great idea, but you know how that goes. Some have really loved it because their patients don’t call them up in the middle of the night and say, I’m throwing up and can’t stop. What are you going to do about it?’ Now the patients call us."
One of the strongest selling points of the OB/GYN program, Richardson says, is the staff itself. It is made up of eight nurses with specialties in pediatrics, obstetrics, and infusion. "And they are all cross-trained," adds Richardson.
"It’s just a matter of education," she says. "The doctors have to come to trust us. That’s why the only nurses doing this are my most experienced OB nurses. I want physicians to know I’m not going to put just any home care nurse out there."
Although the program offers patients and doctors a lot, the cost of its development was a bargain, says Marilyn Hill, RN, MS, vice president of the hospital and director of all home care services.
"It was implemented at little cost because we already had nurses on staff who could do the work," says Hill. "It saves the hospital and the patient money, and it facilitates recuperation, because patients are in their own environment. Moms don’t have to be taken away from their other kids, or husbands, if this is a first child.
"We spent about $11,000 for manuals, consulting time, marketing analysis, and demographic information," recalls Hill. Working with Secure Care proved to be less expensive than going it alone, Hill says, although she says she does not know the cost of the monitor center set-up.
Keeping staff where they’re needed most
While its high-risk pregnancy patients have enjoyed the choice of home care over a hospital stay, the program also has benefited hospital nurses, Richardson says.
"It really is to the hospital’s advantage. If we have a patient on reglan therapy, for example, then our head nurse in OB doesn’t have to pull staff from women in labor to start IV fluids and medicate someone pregnant and vomiting. This can be a problem for the hospital and doctor’s office as well. They have to take time from scheduled patients. It saves money and the busy OB floor from having to deal with someone who is vomiting."
In the past, says Richardson, women with uncontrolled vomiting were put in the hospital and "tanked up on IV fluids, but we’ve begun reglan therapy at home. We put them on a hand pump with a subcutaneous needle, and they are on fluids for 24 to 48 hours. It cuts out all those trips to the doctor and the hospital. We teach them how to manage the pump, how to change the pump, how to load the medicine, and how to rotate the site on the body where the needle goes in to avoid irritation. Most become really independent with it."
According to figures provided by Secure Care, the average hospital cost per day for perinatal IV hydration is $800, based on an average length of stay (LOS) of 2 days, excluding the bed cost. The average daily home care cost is $125. (See perinatal cost avoidance programs chart, above.)
"None of these figures are counting the cost of a hospital bed," Richardson notes.
Preterm labor is even more expensive. The average hospital cost per day is $900, excluding bed, based on an average length of stay (LOS) of 4 days. The average daily home care cost is $360.
Throw in a bed, and the price really jumps. Quoting the Secure Care figures, Richardson points out that the average cost of one preterm delivery, based on an 18-day LOS at $3,000 a day, including bed costs, runs to $54,000.
"When I have a preterm labor case, I charge around $420 a day, including the uterine monitor, all supplies, unlimited nursing visits, monitoring, the whole thing," Richardson says. "Why wouldn’t hospitals jump at this?" St. Mary’s is considering marketing the new service to managed care organizations and insurers as well.
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