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Rapid change is best — sometimes. But some practices need time to evolve, and to push them is a waste of energy. Such is the experience with the comprehensive follow-up care project for high-risk babies born at Parkland Memorial Hospital in Dallas. Affiliated with the University of Texas Southwestern Medical Center, the program has evolved over 21 years. It is designed especially for young, inner-city mothers.
According to one of the founders, physician’s assistant Elizabeth Heyne, MS, PA-C, the key distinctions between the comprehensive follow-up and standard routine care for this population include:
• home visits;
• 24-hour access to clinicians;
• Spanish-speaking clinicians;
• acute care.
While standard programs provide well-baby care and treatment for chronic conditions, the extra component of acute care helps reduce pediatric intensive care admissions by 57%. In a recent article, the comprehensive follow-up team write: "Without prompt, effective treatment, minor illnesses or complications may quickly become life-threatening in these vulnerable infants."1
Heyne credits the program’s success to the art and skill plied by nurses, the physicians’ assistant, physicians, and volunteers, who value each other’s competence.
Despite rapport based on her fluency in Spanish, "a middle-class, Caucasian clinician could never have the same acceptance as somebody of their own ethnic background," Heyne says. That gap is covered by Hispanic and African-American foster grandmothers.
Former clients sometimes become volunteers, hoping to guide others through hardships similar to those they remember so well. Among the most dedicated volunteers is a father who "graduated" 12 years ago. As an Hispanic male, he has a good deal of influence within the community of teen moms who are culturally programmed to look up to males, Heyne explains. Like a respected uncle, he often can persuade the hesitant to use services that will improve their lives as well as their children. (For a discussion of the effect of a mother’s frame of mind on her infant’s well-being, see "Mom’s outlook influences newborn’s health," p. 19.)
Experience shows that frequent interventions are critical to prevent crises in fragile infants. Compared to the routine follow-up group, the comprehensive group averages 3.1 more visits to hospital clinics and 6.7 more telephone contacts with clinicians during an infant’s first year. Those in the routine follow-up group used local clinics or emergency departments (EDs) for acute care.
Compared to their peers enrolled in the routine follow-up of two prescheduled interventions a year, babies in comprehensive care were more likely to remain in the program for a year. In fact, tenures of two to three years are typical.
Sally Adams, MS, RN, CPNP, nurse practitioner on the comprehensive follow-up team observes, "A regular medical practice couldn’t afford us, but the hospital’s cost savings in emergency and ICU [intensive care unit] services pays for our salaries. Each visit takes an hour because each one is comprehensive." Besides routine immunization or checkups, providers assess the child’s developmental progress. They check the mother’s skill in encouraging normal development and review her familiarity with signs of health problems in the child.
Then there’s the mom’s state of mind. Is she depressed? Is she pursuing her academic or vocational training?
Other contributing factors to success in comprehensive follow-up include:
• Early contact with the family. The team enrolls its clients from the ranks of uninsured mothers who give birth at Parkland Memorial, Dallas County’s public hospital. "Though we like to initiate contact before the infant leaves the hospital, we walk a tightrope," explains R. Sue Broyles, MD, neonatologist with the comprehensive follow-up team. "If the baby isn’t going to make it out of the unit, and the intensivist is talking with the mother about how ill the baby is, [the mother] can get mixed messages if we start talking about when she’ll take the baby home." Infants can spend up to the first two months in neonatal intensive care. If the home care will be complicated or if the mother appears to need help, clinicians prepare her for the home transition by starting the educational process several days prior to discharge.
• Continuity and ease of access. A long-term relationship with the same clinician and 24-hour availability of advice and acute care are critical to sustain contact with this population, which is prone to using organized medical services only for emergencies.
• Affiliation with tertiary care services. Many of Parkland Memorial’s ED staff are experienced nurse practitioners who, Adams observes, "know better than to fluff off . . . these high-risk kids when they come in with a runny nose."
• Clinic location. A site close to inner-city clientele facilitates access. Many of the mothers depend on public transportation or rides from family and friends.
Two glitches could derail an otherwise elegant program. Broyles advises other groups to complete two pieces of groundwork before the first client is enrolled:
• Address bureaucratic inflexibility. While she describes it as a technical hitch, Broyles warns that such inflexibility could bar infants from timely access to care or cause providers to lose their Medicaid reimbursements. "It’s critical for HMOs to recognize specialists like neonatologists as primary care providers in view of the needs of this population," she explains.
• Shared fiscal responsibility. From a resource utilization standpoint, it’s appropriate to concentrate comprehensive follow-up services at one hospital within a geographic region. "But it’s not fair for all the hospitals to refer their high-risk babies to the program without supporting it," Broyles warns. "This kind of a program should get community-level support with each referring hospital paying a portion of the salary costs."
1. Broyles RS, Tyson JE, Heyne ET, et al. Comprehensive follow-up care and life-threatening illnesses among high-risk infants: A randomized controlled trial. JAMA 2000; 284:2,070-2,076.
For more on designing and delivering follow-up services to high-risk infants and their families, contact:
- Sally Adams, MS, RN, CPNP, Low Birthweight Clinic/ARCH Center, Children’s Medical Center of Dallas. Telephone: (214) 456-6500.
- Elizabeth Heyne, MS, PA-C, Low Birthweight Clinic/ARCH Center, Children’s Medical Center of Dallas. E-mail: email@example.com. tx.us.
- R. Sue Broyles, MD, Low Birthweight Clinic/ ARCH Center, Children’s Medical Center of Dallas. Telephone: (214) 648-3753.