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Keywords:

  • advanced nurse practitioners;
  • interventions;
  • low income mothers;
  • telenursing;
  • nursing;
  • nurses

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Contributions
  9. Conflict of interest
  10. References

Aims and objectives.  To examine the effects of a low cost advanced practice nurse telephone intervention for 2 months postbirth in low-income first time mothers with healthy full term infants.

Background.  Currently women with non-complicated, healthy full term newborn deliveries receive little to no routine postpartum support. This is problematic if mothers are first time mothers, poor, have problems accessing health care, have language barriers and sparse social support.

Design.  A two group randomised clinical trial. This study was conducted in an inner city South Florida county hospital.

Methods.  A control group (n = 69) received routine hospital discharge care. An intervention group (n = 70) received routine hospital discharge care plus APN follow up telephone calls for week 8 postdischarge. Comparison of outcomes included maternal health (stress, social support, physical health), infant health (routine medical visits, immunisations, weight gain), morbidity (urgent care visits, emergency room visits, re-hospitalisations), and health care charges (urgent care visits, emergency room visits, re-hospitalisations). Data were analysed using descriptive statistics and two-sample t-tests.

Results.  Intervention group mothers had significantly lower perceived stress, significantly greater perceived maternal health and social support; infants had healthier weight gain, fewer emergency room visits; significantly lower total health care charges ($14,333 vs. $70,834) compared to controls.

Conclusion.  Study results indicate that APN follow up telephone calls to low-income first time mothers with healthy full term infants is an effective, safe, low cost, easy to apply intervention that improved mothers’ and infants’ health outcomes and reduced healthcare charges.

Relevance to clinical practice.  APNs are uniquely positioned to conduct follow up interventions aimed at providing continuity of care including APN telephone follow up. This is imperative for vulnerable populations especially during times of major budget cuts that affect health care services.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Contributions
  9. Conflict of interest
  10. References

Low income, first time mothers represent one of the largest groups living below the poverty level (U.S. Census Bureau 2010) having no health insurance (Nightingale & Fix 2004), difficulty accessing the health care system due to language, financial and transportation problems (Trivedi et al. 2008, Kaiser Family Foundation 2006), low social support, increased stress and unmet learning needs (Sword et al. 2006, Loprest et al. 2007). And when compared with mothers who deliver a preterm infant, mothers with a full term infant experience early postpartum hospital discharge (within 24–48 hours) (Landy et al. 2008).

Additionally, reductions in federal reimbursements for health care are forcing elimination of many community maternal child health services (Ferrara & Hunter 2010, Abraham 2011) creating major delays in low income mothers and their newborns receiving routine and acute health care (Pear 2006, Zhang 2009). Results are demonstrating deterioration in maternal and infant health and increased health care costs (Pear 2007) including increased re-hospitalisation and increased mortality rates for infants (Abdullah et al. 2010).

Background

Interventions to improve maternal and infant health outcomes and reduce health care costs following delivery and hospital discharge, have included nurse home visits with or without telephone follow up, follow-up visits using lay community workers and telephone follow up for maternal depression (Norr 2003, Hartford 2005, Peck 2005, Ugarriza & Schmidt 2006). Most interventions have been targeted to preterm and low birthweight infants and mothers who have had complicated deliveries (Brooten et al. 2002). Few have targeted culturally diverse populations of low income first time mothers of healthy full term infants. In addition, interventions tested have often been costly and difficult to sustain in clinical practice. Follow up telephone calls by APNs to newly delivered low income first time mothers many of whom have no health insurance, difficulty accessing the health care system, with financial and transportation problems are a simple yet effective way to potentially improve care while reducing adverse outcomes and controlling costs. More recently, interventions using mobile technology with cell phone use and text messaging are increasing in the adult population with chronic probrems (Menon-Johansson 2006, Hurling 2007, Kim 2008). However, published research on follow up telephone calls by APNs to low income first time mothers is limited. Research with APN follow up interventions using mobile technology with low income minority mothers is almost non-existent. Therefore, the purpose of this randomised clinical trial was to examine the effects of a low cost telephone intervention provided by APNs for the first 2 months post birth in low-income first time mothers and their healthy full term infants.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Contributions
  9. Conflict of interest
  10. References

Using a randomised clinical trial, maternal health (perceived stress, social support and perceived physical health), infant health (routine medical follow up visits immunisations, weight gain), infant morbidity (urgent care visits, emergency room visits, re-hospitalisations) and health care charges (urgent care visits, emergency room visits, re-hospitalisations) were compared between two groups of mothers and newborns. A control group received routine post hospital discharge care; an intervention group received routine post discharge care plus follow up telephone calls by masters prepared pediatric APNs on days 3, 7, 14, 21, 28 and week 8 post discharge. The APNs were masters educated Pediatric Nurse Practitioners with a minimum of 10 years experience as PNPs. Data on outcomes and health care charges were collected for 12 weeks post hospital discharge on both groups.

Sample

A total sample of 146 first time low income mothers 18 years or older, in good health, who delivered a singleton healthy full term infant, were recruited from the mother baby unit at Jackson Memorial Hospital in Miami. Seven mothers were unable to be contacted post discharge due to disconnected telephones. Power Analysis for the sample size was determined based on a significance level of p = 0·05 and acceptable power of 80% and above. For maternal outcomes with a medium effect, a sample of 128 (i.e. 64 in each group) was necessary to provide 80% power with two sample t-tests. For infant outcomes with a medium effect, a sample of 88 (i.e. 44 in each group) provided 80% power for the 2 × 2 chi-square tests. For health care cost outcomes, a sample of 128 (i.e. 64 in each group) provided 80% power with two sample t-tests. The planned sample size (n = 154), accounting for 20% attrition, was sufficient to provide 80% power with a significance level of 0·05 for the analyses. The final sample consisted of 139 first time mothers: 70 in the intervention group and 69 controls.

Mothers ranged in age from 18–36 with a mean age of 24·1 years (SD = 4·0). Most were married (n = 72, 51·8%), in their current relationship a mean of 2·9 years (SD = 3·0) with a range of less than a year to 14 years. Most mothers spoke English (n = 94, 67·6%), were of Hispanic nationality (n = 84, 60·4%), not US born (n = 70, 50·4%) high school education (n = 96, 69·1%) and had an annual income of less than $20,000/year (n = 100, 71·9%). Most mothers were not employed (n = 76, 55·5%) and most were Medicaid recipients or awaiting coverage by Medicaid (n = 120, 76·3%). There were no significant differences demographically between the groups. More infants were female (n = 76, 54·6%). Infant birth weight ranged from 5·12–9·4 pounds with a mean of 7·2 pounds (SD = 0·94). The mean gestational age was 37·8 weeks (SD = 2·9) with a range of 36–40·2 weeks. There were no significant difference between the intervention and control groups mothers infants.

Data collection procedure

The study was approved by the IRBs of Florida International University and the Jackson Health System. Eligible mother and infant pairs were identified by the attending physician or the nurse practitioner on the mother baby unit at Jackson Memorial Hospital. Following explanation of the study to mothers willing to participate, informed consent was obtained and mothers were randomised to control or intervention groups using a table of random numbers by the research assistant (RA).

A bilingual (English & Spanish) RA, a nursing master’s student, trained by the PI in the procedures of recruitment, consent and data collection, obtained demographic data and reviewed data collection points with the mother in her preferred language. The RA collected data on maternal health outcomes on post hospital discharge day 3, months 1 and 2, infant health outcomes and health care charges for both groups on months 1 and 2. Data collection points were determined based on times of common infant morbidities within the first 2 months of life and times of routine infant follow up. Infants are recommended to have their first pediatrician appointment for immunisations and well child assessment by 8 weeks (American Academy of Pediatrics 2004).

Control group

Mothers received routine hospital discharge care consisting of: 1–2 hours of maternal and infant care instructions on feeding, bathing, sleep positions, signs and symptoms of urgent health conditions prior to discharge by the nursery nurse; written instructions on infant care to take home; and a pediatrician appointment in 2 months’ time.

Intervention group

Mothers received routine hospital care plus follow up telephone calls by an APN on posthospital discharge days 3, 7, 14, 21, months 1 and 2. The APN contacted the mothers by telephone and asked about any infant health concerns. When mothers voiced an infant health concern, the APN followed the AAP Pediatric Telephone Protocols established by the American Academy of Pediatrics to implement care (Schmitt 2009). The mothers infant health concerns and resulting care were documented in a log. A backup pediatric physician was available to the APN for consultation. If there was an urgent complaint such as fever, vomiting, diarrhoea, lethargy, or seizure like activity, the mother was directed to use the 911 emergency systems. For any urgent maternal health concerns, the mother was instructed to contact her physician. The APN was trained in the study protocol and telephone techniques including AAP Pediatric Telephone Protocols by the PI.

Measures

Maternal health (stress, social support, physical health) was measured using the Perceived Stress Scale, Multidimensional Scale of Perceived Social Support (MSPSS) and the Maternal Perception of Health Scale by telephone on post hospital discharge day 3, months 1 and 2.

Perceived maternal stress was measured using the Perceived Stress Scale (PSS) which measures which situations of life are appraised as stressful (Cohen et al. 1983). Scale questions ask about thoughts and feelings experienced and how often they were experienced within the last month. Mothers rated each of the PSS’s 10 items on a 5-point rating scale ranging from 0 ‘never’–4 ‘very often. Higher summative scores indicated greater perceived stress.

Social support was measured using the MSPSS, which measures perceptions about support from family, friends and significant others (Zimet et al. 1988). The MSPSS is a 12-item instrument with a 7-point Likert scale ranging from ‘very strongly disagree’ to ‘very strongly agree’. Higher summative scores indicate higher levels of perceived support.

Perceived maternal physical health was measured using a Rating Scale (RS). Mothers were asked to rank their perception of their health and to rate their overall perception of their health at present and compared with others by choosing a number from 1–10. A score of 1 indicates a perception of poor health and score of 10, indicates a perception of perfect health.

Infant health

Infant health was measured by contacting mothers on month 2 to document acute care visits (urgent care, emergency department visits), hospitalisations and routine infant health visit for immunisations and weight gain results.

Health care charges

Total charges billed for infants’ emergency room visits, acute care visits, or rehospitalisations were obtained from infants’ medical records from the medical care facility or from the mothers at two months posthospital discharge. Charges for APN services were determined by adding the total APN time spent on the telephone follow up care to the intervention group including all telephone call time, charting, filing, administrative time and any consultation with physicians. A charge was then calculated for the total APN time based on the average fulltime salary plus benefits for nurse practitioners (Family or Pediatric) working in South Florida as reported by the Florida Area Health Education Centers (AHEC 2009) data base. An hourly rate was calculated by dividing annual salary and benefits by 52 weeks and again by dividing by 40 hours per week. Realising that charges do not equal actual costs, the intent was to provide a comparison of charges between the control and intervention groups.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Contributions
  9. Conflict of interest
  10. References

Effects of the APN intervention on maternal health outcomes

Perceived maternal stress

Results of the PSS are presented in Table 1. At post hospital discharge day 3 mothers overall mean score was relatively low (mean =15·99, SD = 6·12) indicating that mothers perceived their stress at a level slightly lower than the total scale’s midpoint. The PSS means for the intervention group (mean = 16·25, SD = 6·56) and the control group (mean = 15·70, SD = 5·84) indicated no statistically significant differences, t(133) = 0·52, p = 0. 604. At 1-month post hospital discharge, the mean scores of perceived stress increased (mean = 19·4, SD = 5·86) compared with 3 days post hospital discharge. The intervention group mean and the control group mean scores (meanI = 19·13, SD = 5·93 vs. meanC = 19·50, SD = 5·71) indicated no significant differences in perceived stress, t(137) = -0·36, p = 0 .719, between groups. At 2 months post hospital discharge the overall mean maternal PSS (mean = 19·65, SD = 6·54) was higher than at day 3 and 1-month post discharge, indicating increasing perceived maternal stress. The differences between groups were statistically significant, t(137) = -13·6, p < 0·0001, indicating the intervention group perceived lower stress (meanI = 14·71, SD = 3·95 vs. meanC = 24·64, SD = 4·61).

Table 1. Maternal health outcomes
 Total sample (n = 139), M/SDIntervention (n = 70), M/SDControl (n = 69), M/SDStatistics
Perceived stress scale
 Time point 115.99/6.1216.25/6.5615.70/5.84 = 0.52
 Time point 219.40/5.8619.13/5.9319.50/5.71 = −0.36*
 Time point 319.65/6.5414.71/ 3.9524.64/4.61 = −13.6
Multidimensional scale of perceived social support
 Time point 171.77/10.2571.77/9.8971.77/10.72 = 0.002
 Time point 271.76/10.3672.93/9.7870.58/10.86 = 1.34
 Time point 372.29/9.4573.74/7.9570.83/10.61 = 1.83
Maternal perception of health rating scale total
 Time point 118.0/2.6018.0/2.6018.2/2.2 = 0.48
 Time point 217.7/2.5218.3/2.2417.1/2.67 = 2.8*
 Time point 317.9/2.3118.6/1.7417.2/2.69 = 3.6*
Maternal perception of health Item 1
 Time point 18.36/1.428.73/1.538.99/1.33 = 0.22
 Time point 28.79/1.309.06/1.098.52/1.43 = 0 02
 Time point 38.83/1.269.14/0.928.52/1.43 < 0.001
Maternal perception of health compared to other mothers her age item 2
 Time point 19.29/1.159.30/1.209.29/1.11 = 0.68
 Time point 29.04/1.259.39/1.058.71/1.35 = 0.00
 Time point 39.09/1.209.46/0.9128.71/1.35 = 0.00
 Total Charge N/T$/M$Intervention n/T$/M$Control n/T$/M$Group difference p
  1. *p value < 0.05.

  2. Wilcoxon rank sum test.

APN intervention: effects on health care charges
 Emergency26/$24,255/$93210/$7,306/$10416/$16,949/$245$9,643 = 0.13
Urgent care8/$2,937/$3675/$1,882/$273/$1,055/$15$827 = 0.47
Hospitalisation4/$56,377/$14,0941/$3,547/$513/$52,830/$764$49,283 = 0.29
APN$1,598/$7.61$1,598/$7.61N/A$1,598 
Totals$85,167/$637$14,333/$497$70,834/$1068$56,501 < 0.05
Perceived social support

At post hospital discharge day 3 the overall mean (mean = 71·77, SD = 10·25) of perceived social support from family, friends and significant others (MSPSS 3 sub scales) indicated that the mothers perceived themselves as having a high level of social support. Mothers scores ranged from 36 (n = 1, 0·7%)–84 (n = 28, 20·1%) with the majority at the high end of the scale. The intervention group mean and the control group mean scores (meanI = 71·77, SD = 9·89 vs. meanC = 71·77, SD = 10·72) indicated perceived social support was equivalent between groups with no statistically significant differences, t(137) = 0·02, p = 0·98.

The mothers’ overall mean score at 1-month post discharge (mean = 71·76, SD = 10·36) did not fluctuate much from post discharge day 3. Scores ranged from 39 (n = 1, 0·7%)–84 (n = 26, 18·7%). The intervention group mean was higher than the control group mean (meanI = 72·93, SD = 9·78 vs. meanC = 70·58, SD = 10·86), although not statistically significant t(137) = 1·34, p = 0·182.

Mothers in the total sample perceived themselves as having greater social support at the second month posthospital discharge (mean = 72·29, SD = 9·45) than at 3 days or 1-month post discharge. The mean for the intervention group was significantly higher (meanI = 73·74, SD = 7·95 vs. meanC = 70·83, SD = 10·61) indicating intervention group mothers had a greater perception of social support than control group mothers t(137) = 1·83, p = 0 .069.

Maternal perception of health

The overall mean for the Maternal Perception of Health Rating Scale (MPHRS) for themselves and compared with others were relatively high (mean = 18·0, SD = 2·6) at post discharge day 3 Table 1. Overall, mothers perceived themselves to be in ‘good health’ (n = 80, 29·4%) –‘excellent health’ (n = 68, 50%); and ‘average health’ (n = 8, 6%). The overall mean for perception of health compared with other mothers their age was higher (mean = 9·29, SD= 1·15) than their perception of their own health although the differences were not statistically significant (Z = -1·2, p = 0·22). The majority of mothers rated their perception of their health compared with mothers their age as excellent (n = 89, 65%), good (n = 34, 25%); average health (n = 4, 3%). At 3 days post discharge, there were no statistically significant differences between groups in health perception of themselves compared with the health of other mothers (Z = -0·406, p = 0·685).

At 1-month post discharge, the overall mean score for the MPHRS (meanI = 18·3, SD = 2·24 vs. meanC = 17·1, SD = 2·67) was higher for the intervention group indicating these mothers perceived themselves to have significantly better health t(137) = 2·86, p = 0·005 and better health compared with mothers her age (meanI = 9·39, SD = 1·05 vs. meanC = 8·71, SD = 1·35, p = 0·001) compared with control group mothers.

At 2 months posthospital discharge, the overall mean score for the MPHRS for both groups was lower (mean = 17·9, SD = 2·31) compared with day 3 and 1 month post discharge indicating mothers perceived their overall health lower (t(137) = 3·63, < 0·0004) than 2 months previously. Scores ranged from 10 (average health) (n = 2, 1·4%) –20 (perfect health) (n = 57, 41%). The intervention group MPHRS scores were higher (meanI = 18·61, SD = 1·74 vs. meanC = 17·2, SD = 2·69) indicating these mothers perceived themselves to be in better health and perceived their health to be better compared with mothers her age (t(137) = 3·63, < 0·0004) compared with control group mothers.

Effects of the APN intervention on infant health outcomes

Routine medical follow up visits

The majority of newborns received a well baby clinic visit within 48–72 hours posthospital discharge (n = 105, 75%), a 1 month well baby clinic visit (n = 103, 74·1%) and a 2 month well baby clinic visit (n = 124, 89·2%) as recommended by the AAP. Routine medical follow up visits between groups were statistically similar for the 48–72 hour follow up and at the 1 and 2 month follow up visit.

Immunisations

The majority of infants received their immunisations (n = 122, 87·8%) at the 2-month follow up visit. Fifteen infants who had not attended their 2-month visit were contacted by the RA (control) and APN (intervention) and had appointments for their 2-month follow up visit. Two infants did attend their 2 month visit but did not receive their immunisations due to an illness. They were rescheduled to receive immunisations at a later date. The intervention group had a greater number of infants vaccinated at the end of the second month post hospital discharge compared with the control group (n = 65, 92·8% vs. n = 58, 84·1%) although this was not statistically significant x2 = 1·75, = 0·186.

Weight gain

At the end of the second month posthospital discharge, the overall mean infant weight gain was 5·27 pounds (SD = 1·88). The minimum weight gain was 1·2 pounds (n = 1, 0·7%) with a maximum weight gain of 9·7 pounds (n = 1, 0·7%). A healthy weight gain for a newborn as recommended by the American Academy of Pediatrics (2000) is 1–2 pounds a month for the first two months of life. Weight gain lower than 2 pounds per month or more than 2 pounds per month may be indicative of health problems. The mean infant weight gain for the intervention group was lower than the control group at 2 months posthospital discharge (meanI = 5·06 pounds, SD = 1·63 vs. meanC = 5·50 pounds, SD = 2·11). The intervention group had more infant weight gains in the mid range. The control group had greater weight gains in the lowest weight gain range 1·2–1·5 pounds (n = 3, 2·1%) and the highest weight gain range 8·5–9·7 pounds (n = 4, 2·8%). Intervention group infants had a healthier weight gain than controls.

Morbidity

By the end of 2 months post discharge, infants had 26 emergency room visits (18·7%), 8 urgent care visits (5·8%) and 4 hospitalisations (2·9%). Intervention group infants had fewer emergency room visits (n = 10, 7·2% vs. n = 16, 11·5%) and hospitalisations (n = 1, 0·7% vs. n = 3, 2·2%) but more urgent care visits compared with controls (n = 5, 3·6% vs. n = 3, 2·2%). The number of emergency room visits (x2 = 1·81, = 0·179), urgent care visits x2 = 0·50, p = 0·48 and hospitalisations (x2 = 1·06, p = 0·30) between the groups was not statically significant.

Effects of the APN intervention on health care charges

Thirty-eight infants received urgent health services (emergency room, n = 26, urgent care visits, n = 8, rehospitalisations, n = 4) (Table 1). The mean health care charge for the intervention group was significantly lower (meanI = $211, SD $499 vs. meanC = $1,068, SD = $3,896), compared with the control group (< 0·0001). The intervention group also had a lower mean emergency room visit charge (meanI = $104, SD $267, range $365 - $ 1·080 vs. meanC = $245, SD = $538, range $298–$ 2,410) and a lower mean hospitalisation charge (meanI$51 SD = $423, range $3,547 vs. meanC = $764, SD = $3,847; range $9,153–$24,012). However, the control group had lower mean charges for urgent care visits (meanI = $351, SD = $15, range $267–$402 vs. meanC = $376, SD = $27, range $294-$482) compared with the intervention group.

The intervention group received additional charges for the APN service. The APN time was calculated to cost $40·21 per hour ($83,646/year) based on the average fulltime salary plus benefits for nurse practitioners (Family or Pediatric) working in South Florida as reported by AHEC data base. Hourly rate was calculated by dividing annual salary and benefits by 52 weeks and again by dividing by 40 hours per week. Total mean charge for APN telephone calls for the intervention group was $23·83 per mother with a total charge of $1,598 (SD = $7·61). The total mean charge for APN telephone calls for the intervention group was $23·83 per mother with a total charge of $1,598 (SD = $7·61). Total intervention group charges of $14,333 were significant lower ( 0·0001) compared with the control group’s total health care charges of $70,834, a difference of $56,056, or a 79% charge savings for the APN group.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Contributions
  9. Conflict of interest
  10. References

Studies using telephone follow up are heavily concentrated in adult populations (Rose et al. 2006, Carroll et al., 2007) including studies using mobile technology (Menon-Johansson 2006, Hurling, 2007, Kim, 2008). Studies examining maternal and newborn outcomes and health care charges postdelivery in first time low-income mothers are very limited. Despite concerns about the lack of newborn follow up, this study sample did receive timely and appropriate newborn follow up care, were immunised and had relatively few rehospitalisations, emergency room visits and acute care visits posthospital discharge. Unlike reports of Ronsaville and Hakim (2000) and the National Healthcare Disparities Report, AHRQ (2009) where many minority infants lack newborn follow up care, in this sample of low-income mothers, infants were receiving their health care.

Maternal postpartum health

Study findings indicate that the APN telephone intervention with this sample of first time low income mothers improved maternal postpartum health. At posthospital discharge day 3, mothers’ postpartum stress was relatively low with high social support and health rating scores. After the second month posthospital discharge mothers’ had increased perceived maternal stress and social support and decreased perceived health. Britton (2007) reported similar findings with postpartum mothers indicating that financial strains, low social support, poor marital relationships, low education and day-to-day struggles of motherhood with only minimal resources resulted in maternal stress higher at 1 month compared with before discharge in a group of mainly Caucasian low-income mothers. Ryan et al. (2005) reported low-income postpartum mothers having poorer maternal health and well-being compared with advantaged postpartum mothers. Gennaro and Rosen Bloch (2005) also found that in predominately poor, postpartum mothers the reported average number of days feeling ill was much higher compared with the number of days reported in more middle class postpartum mothers.

When comparing APN intervention mothers with control group mothers, intervention group mothers had a significantly lower mean stress score and a significantly higher perception of health at 2 months postpartum. These study results are consistent with the findings of others using APN interventions with postpartum mothers (Brooten et al. 2002). By the second postpartum month, mothers in the intervention group perceived themselves as having greater social support compared with the control group mothers. Leahy-Warren (2005) conducted a descriptive, correlational study to explore social support with a sample of 135 first-time mothers using a 28-item questionnaire. The majority of the mothers were Caucasian, college graduates and employed. The author concluded that social support provided to low-income mothers by nurse practitioners using follow up interventions, was in itself a form of social support.

The APN intervention, in comparison to other studies, used only telephone follow up. Brooten et al. (2002) and Norr et al. (2003) provided home follow up services including home visits and telephone follow up using APNs and community peers with low-income mothers and their infants. These interventions were costly to maintain in clinical practice. The telephone intervention used in this study was low cost, easy to use, safe, provided mothers with access to health care and was effective in improving health outcomes. To date, little has been reported testing APN telephone follow up interventions alone in samples with characteristics as those in this study.

Infant outcomes

Overall, the majority of infants in this study received their health care follow up visits in the AAP (2004) recommended time of 48–72 hours, immunisations and had relatively few hospitalisations or emergency room visits and acute care visits. However, intervention group infants had more immunisations and lower morbidity compared with control group infants.

Health care charges

Health care charges are difficult to compare with other research findings because medical facilities in different states have different charges for the same services. In addition, facilities in the same state have different charges for the same services. Paul et al. (2006) reported health care charges for an infant emergency department visit and rehospitalisation as $423 and $3,722 respectively. Medicaid reports indicate the average newborn rehospitalisation charge is approximately $2,100/day and the total hospitalisation charge averages $11,300 (Owens et al. 2003).

In this study, the mean emergency room charge was $104 and the mean rehospitalisation charge was $51. The intervention group had a lower mean emergency room visit charge and a lower mean hospitalisation charge compared with the control group. The intervention group had only one infant rehospitalisation compared with three in the control group. Charges reported in previous studies (Brooten et al. 2002, Gagnon et al. 2002) are comparable to this study’s findings especially when the increased costs of health care over the ensuing years are taken into consideration.

APN charges

In the present study, the intervention group had significantly lower healthcare charges (Total: $14,333, mean = $497), compared with the control group (Total: $70,834, mean = $1,068). These findings are similar to those in the series of studies by Brooten et al. (2002) using APN home health visits and follow up telephone calls, where intervention group total charges were consistently lower compared with controls. Similarly, Melzer and Poole (1999) using survey methods, examined a computerised pediatric telephone triage and advice program at 32 children’s hospitals. The average charge per call was $12·50. In the reported charges for telephone follow up, Brooten and teams reported APN follow up telephone calls averaged $4·42 to $9·14/ per patient call based on APN telephone time and total telephone charges (Brooten et al. 2002).

The average APN telephone call charge in the present study was $7·61 per call with a total charge of $1,598 for the intervention group mothers. Study findings are consistent with those of Brooten et al. (2002) and Melzer and Poole (1999) where the mean charge per telephone call was similar. Study results indicate that APN telephone follow up care is an effective and less expensive alternative to home visits in providing follow up care to low income first time mothers of healthy full term newborns after hospital discharge.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Contributions
  9. Conflict of interest
  10. References

Low income women have difficulty accessing the health care system due to language, financial and transportation problems. This is especially problematic for mothers of full term infants who are discharge within 24–48 hours with little to no postpartum follow up. Current reductions in federal reimbursements for health care are resulting in elimination of community maternal child health services creating major delays in low income mothers and their newborns receiving routine and acute health care. Future studies could include interventions such as mobile technology using cell phones and texting.

Studies using such interventions have reported improved communication between providers and patients by facilitating quick and direct access regardless of physical location and increased patient compliance. APNs are in pivotal positions to provide such interventions to vulnerable groups that may otherwise not have access to care.

Relevance to clinical practice

APNs are uniquely positioned to initiate and conduct follow up interventions aimed at providing continuity of care including APN telephone follow up and the use of mobile technology with cell phone and text messaging. This is imperative for vulnerable populations especially during times of major budget cuts that affect health care services.

Contributions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Contributions
  9. Conflict of interest
  10. References

Study design: JH; data collection and analysis: JH and manuscript preparation: JH.

Conflict of interest

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Contributions
  9. Conflict of interest
  10. References

I or family members, have no actual or potential conflict of interest in relation to this manuscript.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Contributions
  9. Conflict of interest
  10. References

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