Newborn home care can improve outcomes and expand services

Well-trained staff and resources for moms are key to success

A newborn is most at risk for jaundice and dehydration during the first 10 days of life, and these conditions mean increased risk for hospitalization and emergency department (ED) visits. Unless, as demonstrated by a Pennsylvania State University Children’s Hospital study, the mother and newborn are discharged with orders for a home visit within two days.1

"I was not surprised at the improved health outcomes for babies who received home health visits within 48 hours of discharge," says Ian M. Paul, MD, assistant professor of pediatrics at Pennsylvania State University Children’s Hospital in Hershey and co-author of the study.

"I was surprised, however, at the cost-effectiveness of home health visits when you compared the costs of hospitalization or emergency department visits for the group that did not receive home health visits to the costs of the group that received home health visits," he says.

Paul’s study shows 5.5% of newborns who did not receive home health visits required either a hospitalization or visit to the ED in the first 10 days of life. Only 0.6% of newborns who received a home health visit required additional hospital services, he points out.

Payers that cover a home health visit within two days of discharge can save as much as $181.82 for every child who does not require additional hospital services, he says. "These home health visits pay for themselves and produce much better outcomes for the newborn," Paul adds.

Home health visits are not just necessary for at-risk babies either, he says. "Any new parents can benefit from a home health nurse visiting the home to reinforce education about the care of newborn, offer breast-feeding support and tips, and evaluate the home for safety issues related to a young child," Paul explains.

"Home health nurses can answer questions the mother may have about postpartum care and can make sure that parents understand when the infant needs to see a pediatrician for well-visit checkups and immunizations," he adds.

The nurses at the Visiting Nurse Association (VNA) in Camp Hill, PA, always have visited new moms and infants, but there wasn’t a specific program for the service, says Nancy Alleman, RN, DPNP, CSN, maternal child health coordinator for the agency. "Some of the nurses said the work made them nervous because they didn’t always have the training to answer questions related to breast-feeding or newborn care," she continues.

In addition to Alleman, who is a pediatric nurse practitioner, the agency now has three other RNs who are experienced pediatric and prenatal nurses. "In addition to caring for the new moms and infants, we are all available by telephone for other agency nurses who may encounter a question related to infant or postpartum care, or breast-feeding," she says.

The VNA Maternal Child Health Project accepts a wide range of newborns and their mothers, Alleman notes. "We care for preemies, babies with gastric tubes, babies who are failing to thrive, and uncomplicated, healthy newborns," she says. If insurance does not cover the home visit or visits, Alleman has United Way funding to underwrite the project, she adds.

"Nutrition and sleep position are two areas in which nurses answer the most questions from new parents, and breast-feeding counseling is also important," Alleman explains.

Typically, one or two home health visits are made to infants who are not at-risk for other medical conditions, she says.

Educate referral sources

Marketing the program involves visits to obstetricians, family practitioners, and hospital social workers to make sure they understand the qualifications of the VNA staff and the benefits to the patients, Alleman notes.

In addition to reducing the need for hospital and ED visits, as demonstrated in Paul’s study, pediatricians benefit from the visits because new parents make fewer calls to the pediatricians’ offices with questions, she says.

A new mom and baby program proved so successful for HealthTouch, a private-duty home health agency in Wakefield, RI, that there was a waiting list before the program officially began.

"We knew there was a need for doulas in the area because one of the local hospitals had identified the need through their telephone hotline for new mothers," says Candace Sharkey, RN, MS, executive director of the agency. (Editor’s note: A doula, as defined by Klaus, Kennell, and Klaus, is "a woman experienced in childbirth who provides continuous physical, emotional, and informational support to the mother before, during, and just after childbirth.")

The hospital developed a course to train doulas, but the local health department would not recognize them as health care providers, she adds. "We chose 10 certified nursing assistants (CNA) for the new mom and baby program and sent them to the 30-hour doula training course developed by the hospital," Sharkey says. "They learned how to care for a newborn, how to recognize symptoms of postpartum depression, how to address sibling rivalry, and how to care for premature babies and multiple babies," she says.

The CNAs also learn how to offer support to a breast-feeding mother and answer general questions, but they are not lactation consultants, she says. If a mother needs a referral to a lactation consultant, the CNAs have a list of resources for this and other issues, she adds.

While the agency doesn’t require motherhood as a prerequisite for training as a doula, Sharkey does say that most CNAs in the program are mothers, and that gives them a special perspective on their patients’ situation. "They remember how tired they were when they had a newborn and how overwhelming newborns can be." In addition to the information doulas can provide, their main benefit is the calm reassurance they offer new mothers, she notes.

It is important to provide extra support for CNAs, Sharkey adds. "Be sure that they have a nurse to call for advice if they notice signs of jaundice, lack of weight gain, or other symptoms that might indicate a problem," she says.

That gives the agency a chance to step in with education or a recommendation that the infant be seen by a physician before he or she becomes too ill, Sharkey explains. "For example, in one home with twins, the CNA discovered that the mother was feeding cereal to the 1-week-olds so they might sleep through the night," she continues. "The CNA called an RN, who visited the mother to further educate her about nutrition and proper feeding for infants."

If you are considering a new mom and baby program for your agency, be sure to plan well, Sharkey suggests.

Staffing is tricky because this is not a program that generates a steady stream of patients on an ongoing basis, she explains. "You have to be flexible and have staff members who are willing to work with a variety of patients when you don’t have any new moms and babies," she says. "This is also not a program that generates a lot of revenue," Sharkey admits. "It does, however, create a positive image for your agency, and that new mom may have an aging parent who will need home health."

It is like any specialty program, she says. "If you plan well and provide a good service, referral sources will keep you in mind for a wide range of home health referrals."

Reference

1. Paul IM, Phillips RA, Widome MD, et al. Cost-effectiveness of postnatal home nursing visits for prevention of hospital care for jaundice and dehydration. Pediatrics. October 2004; 114:1,015-1,022.

For more information, contact:

  • Nancy Alleman, RN, CPNP, CSN, Maternal Child Health Coordinator, Visiting Nurse Association, 3315 Berry St., Harrisburg, PA 17111. Phone: (717) 233-1035 or (800) 995-8207. E-mail: nalleman@paonline.com.
  • Ian M. Paul, MD, Assistant Professor of Pediatrics, Penn State College of Medicine, Pediatrics, H085, P.O. Box 850, Hershey, PA 17033. E-mail: ipaul@psu.edu.
  • Candace Sharkey, RN, MS, Executive Director, HealthTouch, 49 S. County Commons Way, Wakefield, RI 02879. Phone: (401) 788-2400. E-mail: sharkeyc@kentri.org.