Home Care of High Risk Pregnant Women by Advanced Practice Nurses: Nurse Time Consumed

National strategies to control healthcare costs have resulted in decreased use of hospitalization and increased use of home care services for many high risk patient groups. Women at high risk of delivering low birthweight (LBW) infants represent such a group. LBW infants have high mortality and morbidity rates and healthcare costs among the highest of any patient group, stressing families financially and functionally (Guyer, Martin, Anderson & Strobino, 1997). Preventing birth of LBW infants is a national healthcare priority (Centers for Disease Control, 1990). Understanding of the basic causes of LBW (preterm labor and intrauterine growth retardation) remains limited (Mittendorf, Williams, Hibbard, Moawad, & Lee, 1994). However, a number of associated factors are known. These include: previous preterm birth; genital infection; abruptio placenta; placenta previa; and preeclampsia and multiple pregnancy. Through careful monitoring and early treatment of problems, gestation can be prolonged in women at high risk of preterm delivery. Nurse home visiting has been identified as one strategy to conduct such monitoring and maintain women with high risk pregnancies at home. Nurse home visiting is currently being conducted by a variety of providers including visiting nurse associations, independent home care agencies, and hospital based home care agencies. However, there are wide variations in home care services including the number, type, and length of the services. Although most home care services include home visits and telephone contacts, the number of home visits and telephone contacts patients receive are most often dictated by reimbursement plans, rather than provider judgment and patient need. Currently, there are limited reported data on nurse time required by various patient groups in need of discharge planning and home care services. Nurse time includes: inhospital time spent in discharge planning; total hours spent in the home; the number of contacts (home visits and telephone calls); and time per contact. In a recent study (Brooten, Knapp, Borucki, Jacobsen, Finkler, Arnold, & Mennuti, 1996) the mean advanced practice nurse (APN) inhospital time spent in discharge planning with women who delivered via an unplanned cesarean was 121 minutes. This was almost identical to the 124 minute mean reported by Naylor (1990) in a study of comprehensive discharge planning of elderly patients conducted by APNs. In work reporting on APN follow-up of low socioeconomic mothers of term infants, Norr, Nacion, & Abramson (1989) reported a mean of 1.6 hours of inhospital APN time consumed in this program. Work reported by Damato and colleagues (Damato, Dill, Gennaro, Brown, York, & Brooten, 1993) on APN early discharge and home follow-up of very low birthweight infants demonstrated a mean of 6.5 hours of APN time consumed during the inhospital portion of the program. There is limited information on the hours of care needed in the home. Payne and colleagues (1996) reported on home health nursing resource use in 12 nonproprietary home health agencies in Massachusetts. These investigators reporting on patients with AIDS, mothers and children (MCH), and medical surgical (MS) clients found differences in hours of total nurse time per completed episode of care. Patients with AIDS consumed an average of 27.4 hours of nurse time, MCH patients an average of 13 hours, and MS patients an average of 14.2 hours. In examining the number of visits per episode of care, Payne and colleagues (1996) reported patients with AIDS received an average of 33.3 visits, MCH patients an average of 25.1 visits, and MS patients an average of 8.1 visits. Again, these were dictated by reimbursement plan, not provider judgment and patient need. Maternal and child health visits included any visit to a child less than 18 years of age or to a woman for prenatal or postpartum services. No further breakdown of type of visit was reported. In the study by Payne and colleagues (1996), home visits to MS patients had a median length of 30 minutes while visits to patients with AIDS had a median length of 40 minutes. Length of MCH visits was not reported. Home health resource use for patients with AIDS was estimated to be 685 hours of nurse time per episode of care, twice that of either MCH or MS patients. Norr et al., working with mothers of term infants, reported a mean of 1.6 hours of total postdischarge time including one home visit and a clinic visit. One-hour postpartum home visits to women with term infants were reported in a study by Gagnon and colleagues (1997). Brooten and colleagues reported a mean of 189 minutes of APN time providing postdischarge home visits to women with unplanned cesarean birth. More than half of the women in the study required more than two post-discharge postpartum home visits. Mean time of home visits was 1 hour. In the Brooten et al. study of women with unplanned cesarean birth, women also received telephone follow-up. Mean telephone time was 13 minutes. In this same study, women with unplanned cesarean birth who experienced infections required a mean of 20 minutes more APN time during hospital visits and a mean of 40 more minutes of APN time during home visits when compared to women without infections. Damato et al. reported a mean of 20.88 hours of APN time postdischarge including one predischarge and 5 postdischarge home visits as well as a series of telephone calls and clinic visits. The literature on nurse time in home healthcare is sparse and uses various definitions for measurement of time, which makes comparisons between studies difficult at best. In addition, many of these studies relied on home care as dictated by the reimbursement plan versus patient need and provider judgment. It is not clear how differently home care would be provided without the constraints of the reimbursement plan. However, one way to evaluate this is to examine home care provided in the course of a research study, where the home care costs are subsumed under the study. Therefore, the purpose of this study was to examine the time APNs spent in providing care during home visits, telephone calls, and hospital visits to women with medically high-risk pregnancies when the number and type of contacts was determined by patient need and provider judgment rather than reimbursement plan.