Feb 01, 2012
A new model of care for low-risk postpartum families
Public health nurses at the Middlesex-London Health Unit (MLHU) in London, Ont., have offered home visits after the birth of a child to all families as part of the Healthy Babies Healthy Children (HBHC) program introduced across the province by the Ontario government in 1998. The program is administered through local health units. Its components include screening and assessments at various stages of prenatal and early childhood development as well as home visiting services, which take place primarily in the postpartum period. Some components are available to all families, and others are available only to more vulnerable families facing parenting challenges. New mothers are offered an HBHC postpartum screen before discharge from the hospital to determine their level of risk (low, moderate or high); those who decline the screen do not receive followup. Those who consent receive a further screening by telephone with a PHN within 48 hours of hospital discharge. After this assessment, families are offered a home visit. At this visit, PHNs determine whether long-term followup is required.
Financial and human resources constraints necessitated a review of the delivery of MLHU’s postpartum home visiting services. In April 2009, a committee of 25 PHNs and three managers was formed to review workloads and resources within the HBHC program. Committee members identified a number of problems, including the high volume of referrals received and the management of workloads related to the handling of low-risk referrals. One of the committee’s recommendations was to explore a new model of care in which community visits would be offered to low-risk families as an alternative to home visits.
Decisions about the new model of care were influenced by a new approach to integrating the provision of children’s services in our community, research evidence, available resources, the activities of other health units, and program monitoring and evaluation data.
A NEW MODEL
The review committee tasked a working group of six keen HBHC PHNs who volunteered to participate and two managers to develop and pilot a new model for providing client care over a nine-month period beginning in March 2010. The model involves offering low-risk postpartum parents and their infants an appointment with a PHN at a community site (e.g., library, community centre, Ontario Early Years Centre) in their neighbourhood after a PHN conducts a telephone assessment. If the PHN determines during this assessment that low-risk families face barriers to attending a community visit, such as transportation, the need for a translator, or complicated breastfeeding issues, the families are offered a home visit instead. Parents have an opportunity to schedule an appointment anytime within six weeks of the birth of their infants. Other than their location, home and community visits are identical.
Our goals were as follows: to provide an effective and efficient service to families, to deliver the HBHC program cost-effectively, to streamline staff workloads through effective use of the PHNs’ time, to maintain client-centred care and to maintain the HBHC principle of a telephone contact and offer of a visit for every family after the birth of a child. Middlesex County and London have a combined population of about 450,000, and approximately 5,000 babies are born each year. The low-risk visits completed in previous years in different regions of the city were mapped. Five sites that families could easily access were selected within the city in the areas with the highest numbers of births. Two sites were established outside the city to accommodate families living in the surrounding county. Prospective sites had to meet strict criteria:
- located on a bus route
- space for parking
- main floor access to street (no stairs)
- Internet access
- telephone access via a land line
- provide the space to MLHU at no cost
- offer other parenting programs
- provide washroom facilities
- ensure room is private
Community visits were scheduled to accommodate three appointments in each half day at each site. This allowed the PHN to spend 45 minutes with a family, followed by 15 minutes for electronic note-taking. One hour is also allocated for home visits, but the PHN needs to spend some of this time setting up for the appointment in the family’s home. One or two half days per week at each site were allotted to community visits; this time allocation was determined by examining both the number of low-risk families referred to the health unit through the hospital screen in that area and the number of home visits completed in that area in the previous year. Each of the PHNs on three home visiting teams chose a site at which to work; this allowed nurses to work in their own neighbourhood.
Weekly debriefing sessions for PHNs were held throughout the pilot to discuss successes and challenges and to review weekly statistics (number of families referred to MLHU by hospital staff through postpartum HBHC screening, number of families declining a community visit and their reasons for this decision, number of families accepting a community visit, number of no-shows, number of cancellations). Notes and actions recommended at the sessions were distributed by e-mail to all staff involved in the pilot. Voice mail, e-mail, team meetings and debriefing meetings were used to keep HBHC program staff informed of progress. The debriefing sessions provided a rich source of dialogue between team members and management. Community visit guidelines were drafted by the working group and then disseminated to team members at a debriefing session and via e-mail. The guidelines were developed to facilitate orientation and education and support consistent delivery of the pilot and the daily functioning of the sites. Communication with our community partners (including Ontario Early Years Centres, Parent-Child Resource Centres, churches and libraries) and hospital partners was ongoing throughout the process.
A process evaluation was conducted with the assistance of an evaluator from the MLHU Research and Evaluation Program. HBHC computer data provided us with information on the number of families that accepted an appointment for a community visit at the various sites. Demographic data were collected from these clients, who completed a short questionnaire at the end of their visit and were contacted by phone for additional feedback about six months later.
Of the 167 families we contacted, 92 per cent were satisfied or very satisfied with the service they received. Sixty-one per cent of the PHNs in the pilot who responded to a survey were dissatisfied with operational efficiency. Among the issues mentioned were the need to streamline the telephone scripts used when offering a home visit, the need for the HBHC team and the team responsible for community well-baby breastfeeding clinics to find better ways to work together, the need for protocols to determine which breastfeeding service would be best for the client and the need for decision trees. Preliminary data indicated substantial cost savings for the HBHC program in the area of travel and mileage and no compromising of client care; the new model allowed MLHU to see clients more quickly than before.
The working group modified the pilot to improve uptake of appointments and communication between teams and to facilitate the development of a breastfeeding protocol and decision trees. The new model continues to be used, and a second evaluation was conducted in the fall of 2011 that confirmed that we were on the right track and that the addition of a breastfeeding protocol had assisted PHNs in providing appropriate services.
From the feedback we received from staff members who attended the debriefing sessions and what we observed of the practices of those who did not attend, we learned that staff commitment to the pilot would have been enhanced had the sessions been mandatory. It was not sufficient to communicate recommendations coming out of these sessions by e-mail; staff members who missed the debriefings did not incorporate the recommendations into their practice. Technical support should have been on board from the pilot’s inception to ensure remote access via the Internet to MLHU’s electronic documentation program, an essential component of client assessment. We did not have access to an evaluator for the first two months of the pilot because the Research and Evaluation Program was undergoing change during that time. This meant we needed to revise some evaluation elements at a later date. It would also have been beneficial if the new model had been explained to parents on the MLHU website and if the website had been updated to reflect changes that were made after the pilot was launched.
Public health services continue to be challenged by the need to introduce innovative nursing practices to address system constraints while ensuring the effective delivery of services. Followup of low-risk postpartum families at community sites is a reasonable strategy to address resource limitations.
The authors thank Diane Bewick, director of Family Health Services and MLHU senior nurse leader, the working committees and the staff of MLHU for their continued support in moving this model forward.