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Warning: If you haven’t already been mandated by state law to offer a new mother an extra day in the hospital after the delivery of her baby, you will be a year from now when a federal law goes into effect. For some providers, the extra day will not be a problem and may even be seen as a guarantee of quality of care. But others tell Women’s Health Center Management that an extra day does not offer much in the way of clinical follow-up and education. For them, an early discharge program with follow-up home care may be the answer.
Although there are some guidelines and suggested discharge criteria (see references, p. 5), there are no set rules on how early discharge programs should be structured. Generally, they allow a new mother the option to leave the hospital earlier than is stipulated by her insurance carrier. For example, some birthing centers with early discharge programs allow mothers to leave within a few hours of giving birth. Most early discharge programs explored by WHCM consist of a 24-hour stay for a vaginal delivery (as opposed to a 48-hour stay) and a 48- to 72-hour stay for a cesarean delivery (as opposed to 96). Early discharge programs are usually used in tandem with home care as a clinical follow-up measure.
"It’s not the length of stay, but the quality of care that matters," asserts Julietta Appleton, MPA, CCE, project coordinator for the Early Postpartum Discharge Program at the Maternity Center Association in New York City. "If [new mothers] get education and breast-feeding advice [on the second day in the hospital], that’s great, if they retain the information. But usually the woman is just taking up space in a bed and not getting much attention."
Appleton says that because women learn better on a need-to-know basis and they don’t realize all they’ll need to know until they get home the Association has long been a proponent of early discharge programs with follow-up home care. During a Perinatal Home Care conference sponsored by the Washington, DC-based Association of Women’s Health, Obstetric, and Neonatal Nurses held Dec. 8-11, 1996, Appleton outlined the four components of successful early discharge programs:
• prenatal education, to prepare women to be new moms;
• clinical home follow-up, by a nurse;
• help at home, from family, friends, or a doula (an assistant who provides in-home support postpartum);
• a 24-hour telephone service, so women have access to support.
Lifestarts, an early discharge program for mothers and newborns offered by HIP (Health Insurance Plan) of New Jersey in New Brunswick, focuses on the educational opportunity afforded by home care, says Susan D. Emanuele, RN, BSN, manager and founder of the Lifestarts program.
Women are discharged early depending on certain factors that were decided upon collaboratively by the physicians and by HIP. The factors are the mother’s desire to go home, the type of delivery (vaginal or cesarean), the length and difficulty of her labor, the blood type of the mother and child, presence or absence of jaundice, and how well the baby is eating. Emanuele explains that each physician will make the determination on a case-by-case basis, depending on these factors.
Emanuele agrees that women don’t really learn until they need to and says hospital nurses have little time to devote to education.
"I used to be a nursery nurse, and I would give elevator classes,’" she says. "I would try to shove all this information at the new moms while taking them down in the elevator for discharge."
HIP worked with physicians to design the program and to determine criteria for who got discharged early and who didn’t. Emanuele says the pediatricians were "a little nervous," but because they were involved in determining what would be assessed, documented, and taught, they slowly warmed up to the idea. (To find out what happens during a home visit, see the related story, p. 3.)
The rate of readmission was the chosen outcome measure for Lifestarts. The staff looked at readmission rates for both moms and babies within the first week of discharge and found that the overall rate was less than the national average, Emanuele says.
Since 1991, Lifestarts has seen more than 7,000 patients who’ve given the program "nothing but glowing, glowing reviews," she says. HIP, a 206,000-member HMO, sees the program as a win-win-win situation for patients, providers, and the plan itself: Patients get education, providers save time, and the plan saves money by not having to pay for mom’s extra day in the hospital. And, it costs a mere 15 cents per member per month.
Emanuele says she is surprised when she hears that health plans aren’t interested in fostering home care programs, but that certainly is the case. Karen Waltenbaugh, MS, clinical nurse manager for the postpartum and antepartum department at Prentiss Women’s Hospital in Chicago, says managed care plans won’t pay for home care unless it’s ordered by a physician, which is a rare occurrence.
"I would love to see home care grow at our hospital," a facility that delivers more than 6,000 babies each year, she says.
Despite the lack of reimbursement, the John Muir Medical Center in Walnut Creek, CA, has sustained a successful home care program for eight years, says Meredith Pence, MBA, RN, CNAA, director of women’s and children’s services. Each woman who delivers there gets one home visit from a nurse at no extra charge.
"It’s probably one of the most valuable things we do, for a lot of reasons," she emphasizes. "We get a lot of good marketing mileage out of it, and I have stacks of letters from patients saying they think it was just one of the greatest things about their stay. The reason why, of course, is because it is so timely and it makes them feel so much better when the nurse has come to answer their questions."
The hospital receives a per diem rate or a per case rate from a woman’s insurer which Pence says usually covers only 50% to 60% of the hospital’s charges for maternity services and because it is less expensive to provide a day of home care as opposed to an extra day in the hospital, more of the per diem amount is retained, explains.
Pence and her colleagues have found that the third day after birth is the best time to visit a new mother. The home care nurse reinforces what the women learned before they were discharged after 24 hours, but most of the time the women don’t recall having heard the information.
"I think [the home visit] is really more beneficial than a second day here in the hospital," Pence says. "The parents go home and settle in, they’re comfortable, and then they get a clear idea of their educational deficits. Once you get home, the real world hits you and the baby’s crying, your breasts are filling up . . . those are the times you need to have someone come out. That’s when the questions occur to you, and that’s when you’re ready to listen."
At Women and Infants Hospital in Providence, RI, patients have a choice of home care or staying an extra day. Although surveys show patients are happy with the home care they received, once in awhile a postscript at the bottom of a follow-up questionnaire will indicate the patient wished she had chosen to stay an extra day instead, says Carol Dabek, MS, RNC, IBCLC, director of home care. They think they will get rest and be less exhausted, she explains. "People always imagine that what they didn’t get would have been a whole lot better."
Waltenbaugh agrees that women believe they will be more rested and get enough education to become a more competent parent if they stay the extra day. "The patients want to stay an extra day. It’s like an obsession," she says.
The 48-hour mandate has been "devastating" for the Women’s Center at Promina Cobb Hospital in Austell, GA, says Program Director Sally Rhoden, MA. Because the maternity ward is already overcrowded, a state law requiring insurers to pay for an extra day that was passed in July has meant moving patients to new rooms after the first 24 hours due to a lack of space in the obstetrics area, she laments. Although between half and two-thirds of all new mothers choose the extra day, Rhoden says she believes more women will begin choosing home care when they learn more about the benefits.
Brenda Toews, RN, director of the Circle of Caring Birth Place and Pediatrics at Goshen (IN) General Hospital, anticipates that many women will opt for home care rather than an extra day in the hospital when it becomes available at her facility early this year. The hospital currently offers an extra day of "hotel-like" stay at the hospital new moms get two meals, fresh linens, and use of the whirlpool, but no medical care at a cost of $75. The program has not been popular, says Toews, adding, "I’ve been surprised at how many women want to go home."
Providers who have experience in home care urge others to follow their example. Says Pence, "I believe if there is anything people can do to provide these services, they should definitely consider it because, in terms of the community’s well-being, there’s definitely a standard that the hospitals should strive for: to make sure that mothers and babies are well-cared-for in the community."