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One way to improve health and hold down medical costs for low-birth-weight babies is to put a complete package of services within easy reach of their parents.
So promising are the results that Joy Basu, PhD, economist with the Agency for Healthcare Research and Quality (AHRQ) in Rockville, MD, says the approach should be regarded as a national prototype.
Her comments are based on findings from a randomized, controlled trial partially funded by AHRQ. The trial compared outcomes from comprehensive and routine follow-up models. "The project team found dramatic results, and providers should be able to replicate them in other places. The study shows that comprehensive care nets better infant health outcomes and better service utilization," notes Basu. Compared to babies in routine follow-up care, for example, those in the service-rich comprehensive model suffered 48% fewer life-threatening illnesses.
A clinical team based at Children’s Medical Center in Dallas conducted the trial in which the same staff provided routine and comprehensive follow-up care to groups of 441 and 446 infants, respectively. Team members included two pediatric nurse practitioners, a physician’s assistant, a pediatrician, and a neonatologist. They had an average of 11 years of experience in the medical center’s very low-birth-weight clinic. The nurses and the physician’s assistant were the clients’ primary points of contact. Caseloads from both groups averaged 20 to 30 infants.
Routine follow-up care included:
• clinic hours two mornings a week;
• treatment for chronic illnesses plus standard well-baby care, including immunizations, basic parenting education, social services, and child development assessments;
• education for mothers in recognition of signs of illness in the infant and instruction in appropriate use of local clinics and the emergency department (ED).
Comprehensive follow-up care included:
• contact with mothers prior to the infant’s discharge from nursery;
• initial home visits unless the home environment is deemed dangerous due to drug use or other circumstances;
• clinic hours five days a week until infants reach age three.
Services included all the components of routine follow-up as well as treatment of acute illnesses. The primary care clinician was available 24 hours a day to address acute problems either by phone or pager. When an infant needed acute care outside of clinic hours, the clinician notified the physician supervisor and, if necessary, authorized a taxi ride to the emergency department. The next morning, she contacted the mother to assess the need for further treatment and to review home care instructions.
• Foster grandmothers of similar ethnic and socio-economic background were assigned to mothers who needed better parenting skills or emotional support.
Grandmothers visited families three to four times a week, teaching moms how to bathe, feed, and nurture the babies. "For some, it’s a godsend, especially when they have twins or triplets," says team member R. Sue Broyles, MD, neonatologist and assistant professor at the University of Texas Southwestern Medical Center in Dallas.
Some families develop close bonds with the grandmothers that flourish for several years. But others consider the presence of a foster grandmother an invasion of privacy and consent to a few visits only.
Elizabeth Heyne, MS, PA-C, the team’s physician’s assistant, observes that the grandmothers are most effective with mothers who need a moderate amount of teaching and support in order to mature into successful parents. "At first, we placed grandmothers with the hardest cases, but too often they didn’t succeed," she notes.
Grandmothers are not assigned to homes where drug use or other dangers exist, such as domestic violence. Sadly, says Heyne, there are more drugs involved today than when she helped to create the comprehensive follow-up program 21 years ago.
Foster grandmothers also serve as another pair of eyes for the clinicians. They often alert them to signs of depression, which runs high among the mothers; many are younger than 17. Besides compromising the young woman’s effectiveness as a parent, untreated depression increases the likelihood of repeat pregnancy.
• Educational opportunities for the moms include "school" for the babies in which professionals demonstrate techniques for promoting the child’s physical and emotional development.
A "Mothers’ Day In" program offers supportive contacts with peers, field trips for personal enrichment, and opportunities to complete high school training through GED programs. Some of the young women complete their GEDs by the time their children graduate from the comprehensive follow-up program.
As Heyne puts it, comprehensive follow-up includes "everything we could possibly think of to help the mothers become successful parents."