Best Practices for Maternity Case Management
By Jeni Miller
In many ways, case management in the maternity and labor/delivery units is unlike other areas of the hospital. To start, there are two patients: the mother and the baby, both of whom need care and attention and who may have their own, separate discharge needs. There also is the reality that not every labor and delivery is a “medical event” that requires the use of conventional medicine. Often, the mothers and babies are healthy, and simply in need of support through the process. For that reason, it may even seem that case management is unnecessary. However, it is important to maintain a strong case management department that serves in labor and delivery as well as the postpartum units.
“A lot of people really don’t think you need a case manager for labor/delivery and mother/baby units,” explains Kimberly Anderson, RN, nurse care manager at Barbara Bush Children’s Hospital in Portland, ME. “I often go weeks without referrals from them, but when they need me, it’s often something complicated.”
Anderson, who serves as the maternity care manager at Barbara Bush, provides support like “walkers for patients with pubic symphyses separation, home health referrals for patients with baseline physical issues who are having difficulty with ambulation and ADLs [activities of daily living] during their pregnancy, and wound vacs for patients with surgical wound complications.”
Social work case managers meet with families who are new to the country and lack resources. The case managers also manage adoption/gestational carrier issues and develop plans for women experiencing opioid use disorder, domestic violence, or who are navigating other social concerns.
While these opportunities may be fewer and farther between, they are critical when they present, and case managers should be prepared to facilitate in these situations.
Anderson notes there are best practices case managers can employ when working on the maternity and labor/delivery units:
- Perform a chart review for every patient who delivers to determine social and medical issues that may need attention.
- Round with the maternal-fetal medicine physicians two to three days a week for a more in-depth view of the prenatal and postpartum floors, as well as a better sense of how long the prenatal patients are anticipated to remain admitted. Questions may include: Will they be here until delivery? How many weeks’ gestation is the goal for this patient?
- Work with the utilization review team if coverage issues arise, especially with long-term prenatal patients.
Long-Term Hospital Stays
In some cases, mothers will require a longer-term hospital stay either before or after delivery. These situations require extra attention.
“I usually review these cases at least weekly,” Anderson notes. “I like to get people connected with an insurance case manager, if possible, especially since many people have questions about their insurance coverage when their stay lasts weeks to months.”
Other issues that can arise during a long-term stay include:
- Childcare issues and other home absence stressors. Case managers do not necessarily have solutions, especially in the COVID-19 era. Anderson’s hospital used to partner with a group called Compassionate Homes. “People in the community would take in family members, help with childcare, but they have been understandably on hold since COVID,” she says.
- Insurance denials are more frequent. “We have been seeing more insurance agencies denying long stays in the past year or so,” Anderson says. “Our providers are very willing to do peer-to-peer calls and are usually able to overturn the denials.”
Babies in the NICU
Part of the difficulty of managing two patients at once in the labor/delivery and postpartum units is when either the mother or baby must stay while the other is discharged. This especially is the case when the baby requires time in the NICU. Some hospitals enacted policies to address this issue, and case managers can simply help carry out the proper procedure for the patients.
“One policy I really appreciate in our hospital is that we try to keep babies and moms united after delivery,” Anderson explains. “This means that when we receive a NICU baby from an outside hospital, we accept the mom as a transfer as well, as long as we have the bed space available. My understanding is that this is not a common practice because most insurance companies will not pay two different facilities for postpartum care. In this facility, however, we feel it is very important for bonding, initiating breastfeeding, [and more] that the dyad is not separated in the first two to three days.”
Anderson notes there are situations in which a baby who is not sick enough to need the NICU is not ready for discharge, yet the mother is. In these cases, the baby will be assigned to the mother/baby room and the parents have the freedom to room with the baby. When the parents leave, the baby is moved to the nursery space, but the room remains available for the parents to use.
When babies remain in the NICU after the mother is discharged, some hospitals provide private rooms for the parents to occupy around the clock, if desired.
“Often in the NICU, parents choose to go home at night, some parents go back to work right after delivery so that they can take a maternity leave when their baby goes home, or they don’t visit as often if they cannot hold or interact with their baby very much. It is more common to have parents in the room for longer hours in the continuing care nursery [CCN — the stepdown NICU] since babies are less sick and closer to going home.”
Anderson encourages the parents of babies in the CCN to spend as much time as they can to bond and learn how to care for their baby. Anderson, along with the medical team and social worker, recommends parents perform a full 48-hour block of caretaking before discharge to learn their baby’s patterns and ask any questions. The hospital’s social workers, physicians, and bedside nurses all encourage frequent visitation at this stage.
Many hospitals, including Barbara Bush, also offer access to a nearby Ronald McDonald House to most parents who live more than 30 minutes from the hospital. The social work case manager might help families determine their eligibility, as some exclusion criteria apply
Finally, when it comes to discharge planning for the baby, Anderson suggests not offering too many resources until the baby is within a couple weeks of discharge, unless there is a reason to start earlier.
“If a baby is going home with a trach and a vent, it likely needs to be set up well in advance of discharge because the durable medical equipment company will be involved in trialing the home vent in the hospital,” Anderson explains. “However, we find that if we offer services weeks before they are needed, the parents often don’t remember the discussion by the time their baby is discharging.”
Maternity and COVID-19
The COVID-19 pandemic led to some changes in the maternity and labor/delivery units, which has resulted in some changes in case management and care.
The biggest change at Barbara Bush is the number of prenatal women who have needed oxygen support at home for the remainder of their pregnancies. The difficulty for case management, Anderson says, “has been to get people home on oxygen — and impossible to get them CPAP — without a sleep study, which we have not been able to do on a pregnant woman because our maternal-fetal medicine physicians do not want them to desat below 95% during pregnancy for fear of fetal compromise.”
Many of the pre-COVID-19 policies are returning, such as allowing siblings to meet babies in the mother/baby and NICU units, and loosened visitor policies in general, she notes.
In many ways, case management in the maternity and labor/delivery units is unlike other areas of the hospital. Often, the mothers and babies are healthy, and simply in need of support through the process. For that reason, it may even seem that case management is unnecessary. However, it is important to maintain a strong case management department that serves in labor and delivery as well as the postpartum units.
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