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Service Delivery Innovation Profile

Nurse Home Visitation Program Reduces Readmissions, Emergency Department Visits, Child Abuse, and Foster Home Placements for Medically Fragile Infants


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Snapshot

Summary

Bridge to the Future provides nurse home visits to low-income families with medically fragile infants who have been discharged from the neonatal intensive care unit, thus ensuring a smooth transition to long-term care in the home. Specially trained nurses proactively identify potential problems in the home and provide intensive training and support to parents of very low birth weight or special needs infants. Infants served by the program are less likely to experience readmissions, inappropriate emergency department visits, child abuse, and placement in a foster home, and are more likely to have up-to-date immunizations and access to medical resources.

Evidence Rating (What is this?)

Moderate: The evidence consists of nonrandomized comparisons of program participants with matched control groups.
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Developing Organizations

Missouri Bureau of Special Healthcare Needs; Nurses for Newborns Foundation; St. Louis Children’s Hospital
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Date First Implemented

1991
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Patient Population

Age > Infant (1-23 months); Vulnerable Populations > Medically or socially complex; Age > Newborn (0-1 month)end pp

Problem Addressed

Many medically fragile infants who are discharged from the neonatal intensive care unit (NICU) are rehospitalized and/or come to the emergency department (ED) for a variety of reasons, including neglect and other preventable conditions. In the absence of support and education, parents often lack the physical, mental, and financial resources to adequately care for these children.
  • Increased potential for maltreatment and child abuse: Neonatal status is an important predictor of child maltreatment early in life among low-income families. Parents of these infants typically see NICU nurses as experts in their babies’ care and doubt their abilities to serve as the sole caregiver for the child after discharge. Caring for these infants puts physical, emotional, and financial strains on the parents, leading to increased potential for neglect and maltreatment.1,2
  • High incidence of preventable conditions: Parents of medically fragile infants often lack the experience to observe the warning signs of infections and weight loss, which are common in medically fragile infants. These otherwise preventable conditions can often lead to unnecessary and costly rehospitalizations and/or ED visits.

What They Did

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Description of the Innovative Activity

Bridge to the Future is a safety net program in which specially trained nurses provide in-home services to the families of medically fragile infants, thereby bridging the gap between the NICU and the homes by supporting families of infants who are most at risk of abuse and neglect. The program aims to prevent child abuse, neglect, and developmental disability by creating a supportive and nurturing environment and by increasing parents’ understanding of their infant’s needs and confidence in their ability to effectively support their infant’s development. Key program elements include:
  • Early identification: Through various partnerships with area NICUs and community-based organizations, the program receives referrals from social workers, nurses, abuse shelters, and others who identify families that are at high risk. Infants who are eligible for the program are NICU graduates with very low birth weight and one or more of several risk factors, including an Apgar score of 6 or less at 5 minutes, ventilator dependency for 72 hours or more, intracranial bleeds, asphyxiation, and genetic conditions known to be associated with mental retardation or another developmental disability.
  • Early action by empathetic nurses: Nurses from Nurses For Newborns Foundation, a community agency, contact parents over the phone. During this call, parents have the opportunity to identify any fears that they have about taking the infant home and being responsible for care. The program matches families with nurses who live nearby and who are of the same ethnic background, with the intention that nurses will understand the dynamic of the specific community and the unique challenges that a resident of that area faces.
  • Followup home visits and telephone contact: Within 2 or 3 days of hospital discharge, the assigned nurse provides the first of a series of free visits to the infant’s home. Because many clients move frequently or may have their telephone services disconnected at times, it is important that nurses make contact with families quickly after discharge, before they “fall through the cracks.” Each nurse has a cell phone to facilitate communication with families and to allow them to call for support and/or immediate assistance if necessary during the home visit. Communication and home visits continue for as long as the nurse deems necessary for up to 2 years.
  • Home visit protocol focused on infant health, parental education: Home visits and other contacts focus on assessing the infant’s health and educating and supporting parents. The nurse completes a full physical evaluation of the infant and notes any abnormal findings at every visit. In addition, the nurse teaches parenting and coping skills specific to each infant, points out parenting strengths and addresses family stresses, and leaves educational handouts that can be posted on the refrigerator for babysitters and other relatives, empowering families to deal with emergencies. Parents also learn infant cardiopulmonary resuscitation and how to deal with an obstructed airway, central nervous system compromise, chronic illness, drug withdrawal, or other situations that may arise.
  • Resource referrals: The nurses provide families with information about existing government and private community resources for which they may be eligible. The nurses help the families fill out various forms, often using their cell phones to help client connect with resources while in the home, and follow up to ensure that they receive the assistance available to them.
  • Proprietary database to support nurses: Nurses carry laptop computers that provide access to a proprietary database offering age-specific developmental teaching for each family as well as information on local community resources.
  • Electronic documentation: Each nurse uses the laptop computer to complete a full report during or after each visit, thus enhancing the accuracy of data collection and eliminating the need for additional data entry personnel. The nurse uses the computer to note any abnormal findings and to track the infant’s chronic or preexisting diseases, height and weight, immunization status, visit history, and other health indicators.
  • Monthly nurse meetings: Nurses hold monthly meetings to discuss the difficulties and challenges they encounter, and to share strategies for overcoming these obstacles.

Context of the Innovation

Nurses For Newborns’ Bridge to the Future Program was founded in 1991 by Sharon Rohrbach, RN, a former NICU nurse who became alarmed after realizing that infants who left the NICU often returned to the hospital within a month of discharge, and that many of these readmissions were caused by easily preventable conditions. At the same time St. Louis Children's Hospital received a Newborn Individualized Developmental Care and Assessment Program grant to create a followup care program for these infants that focused on the creation of a home environment where they could thrive. As the terms of the grant mandated that they choose a community partner, Children’s Hospital selected Nurses For Newborns, a local nonprofit nurse home visitation organization, to conduct training for the program.

Did It Work?

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Results

An analysis of 16 years of data from nurse home visits shows that medically fragile infants served by the program are less likely than matched control cases to be rehospitalized or have inappropriate ED visits and are more likely to receive appropriate care. A separate independent analysis found that the program reduced the likelihood of child abuse or placement into a foster home, as compared with a matched group of infants.
  • Reduced readmissions and ED visits: Infants receiving six or more postpartum visits are less likely to be rehospitalized for preventable causes (2 percent) or have preventable ED visits (98 percent).
  • More appropriate, up-to-date care: Infants receiving six or more postpartum visits are more likely to be up to date on immunizations (90 percent for program participants vs. 77 percent national average), use community resources (86 percent), and have access to a medical home (99 vs. 46 percent).
  • Reduced likelihood of child abuse and foster home placement: An independent analysis of data from 2003 to 2006 found that infants served by the program were less likely to experience child abuse and placement into foster homes than were infants in a matched control group.

Evidence Rating (What is this?)

Moderate: The evidence consists of nonrandomized comparisons of program participants with matched control groups.

How They Did It

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Planning and Development Process

Key steps in the planning and development process include the following:
  • Training the nurses: Nurses For Newborns worked with Children’s Hospital and Missouri First Steps program, a state-mandated program that provides services to developmentally delayed newborns, to train the nurses performing home visits. Nurses for Newborns adapted its training program from the University of Washington NICU Follow-Through Project, which has been used to train 1,127 professionals in 20 NICUs and 32 community development service agencies in 9 states. Training included 4 full days of home visits in areas where the nurses would be working. The nurses also received specialized training in early intervention under a grant provided by St. Louis Children’s Hospital. Hospital-employed nurses at Children’s Hospital also received training, thus allowing both the hospital and community-based nurses to work together on behalf of the infants and their families. After the nurses were trained, St. Louis Children’s and Barnes Hospital began referring their NICU babies to Nurses for Newborns, which assigned an appropriate nurse to each case.
  • Community donations: The program called upon the community to donate cribs, formula, diapers, and money to pay for electricity, water, gas, and in some cases telephone services (so that parents of medically fragile infants could reach medical help quickly).
  • Building infrastructure: Program developers purchased and arranged for cell phone service for visiting nurses. The program also invested in laptop computers to allow for results tracking and nurse access to other support tools, such as a proprietary smart database.

Resources Used and Skills Needed

  • Staffing: The program currently employs 46 nurses, each of whom has a minimum of 3 years of experience in a NICU or 5 years experience in a newborn nursery. Many of these nurses are concurrently employed at local hospital NICUs.
  • Training: Initial training is conducted by two directors of nursing over a 2-week timeframe, including the 4 days of training visits to the home.
  • Costs: The program currently operates in two sites (Nashville and St. Louis) and has an annual budget of approximately $1 million per year across both sites. Each nurse receives a laptop computer that costs roughly $1,000 along with approximately $500 in additional equipment.
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Funding Sources

Missouri Children’s Trust Fund; Dana Brown Foundation; Enterprise Rent-a-Car Foundation; Express Scripts Foundation; St. Anthony’s Medical Center Foundation; St. Louis Variety Club; United Way; Premier Cares
The program is funded through contracts and grants from the state and a variety of foundations and charitable organizations.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Set measurable goals and objectives, and track progress toward them: It is important to determine desired program outcomes, and how and when progress will be measured.
  • Invest in and monitor the ongoing need for technology: The cell phones and laptop computers were important to the program’s success. Any organization implementing the program should assess technology needs on an ongoing basis to ensure that organizational funding is available and can be distributed efficiently to meet these needs.
  • Address clients’ basic needs first: A major goal of the program is to create a safe and nourishing home environment for special needs babies. However, many homes lack basic necessities, including furniture, electricity, phone service, and sometimes even running water. Program staff must address these needs before teaching parenting skills.

Sustaining This Innovation

  • Give nurses flexibility in scheduling home visits: Program leadership allowed nurses to make as many visits as they thought necessary to produce the desired outcomes. The consistently strong results produced by the program over many years support the wisdom of allowing nurses to tailor program to individual families’ needs rather than prescribing visits at specific intervals.
  • Encourage the formation of a bond between nurse and client: These strong bonds are critical to the program’s success, as they allow the nurse to learn things about the home environment that would otherwise go unnoticed.

More Information

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Contact the Innovator

Melinda M. Ohlemiller, MA
Chief Executive Officer
Nurses for Newborns Foundation
7259 Lansdowne, Suite 100
St. Louis, MO 63119
(314) 544-3433
E-mail: melinda.ohlemiller@nfnf.org

Innovator Disclosures

Ms. Ohlemiller has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Nurses for Newborns Foundation. Bridge to the Future Program. Available at: http://www.nfnf.org/services/bridge-to-the-future.php.

Nurses for Newborns Foundation. Success Stories. (A “success story” of an individual patient/family served by the program.) Available at: http://www.nfnf.org/services/success-stories.php

Footnotes

1 Bugental DB, Happaney K. Predicting infant maltreatment in low-income families: the interactive effects of maternal attributions and child status at birth. Dev Psychol. 2004;40(2):234-43. [PubMed]
2 Sullivan PM, Knutson JF. Maltreatment and disabilities: a population-based epidemiological study. Child Abuse Negl. 2000;24(10):1257-73. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: April 14, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: August 27, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: February 18, 2009.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.