Before 48-hour hospital stays for mothers and their newborns became an election-year issue, St. Joseph Hospital in Orange, Calif., was looking to address an issue of growing concern.
Because insurers typically don't pay for maternal hospital stays of longer than 24 hours, St. Joseph developed a Mother-Baby Assessment Center designed to evaluate mothers and infants on the third or fourth day after delivery. The program, launched in November 1995, provides a free outpatient return visit to examine mothers and their babies.
"We found the additional 24-hour hospital stay still doesn't meet the patients' needs," said Cheryl Purvis, manager of women's services at St. Joseph, who took the lead in planning and implementing the program. "You're listening to all of this talk about 24-hour stays, and you're saying, `Wait a minute, the extra day in the hospital doesn't necessarily prevent most problems."'
With more than 5,400 births annually, St. Joseph has the largest obstetrics program in Orange County. "We were concerned about 24-hour stays because managed care is so predominant in Southern California. So we began a three-month phone assessment last summer of 421 patients about a week after they delivered," Purvis said. "The things we found led us to believe we needed some kind of follow-up."
St. Joseph successfully capitalized on an important concern of clinicians and consumers worried about mothers and babies being released too soon from the hospital. Senior management at St. Joseph approved the project in less than a month, using existing space in an outpatient area.
In Southern California, most payers will only cover 24 hours for a vaginal birth and 48 hours for a Caesarean section. Only 15% of payers cover home health visits, St. Joseph said. "Breast-feeding is a common problem, and many home health agencies don't offer lactation consultants," said Elizabeth Porter, assistant manager for women's services at St. Joseph. "All of our nurses are lactation consultants. A lot of the questions that come in are (from) moms asking questions about breast-feeding, which they've never done before."
Most problems arise for mothers and babies three or four days after a birth. For mothers, problems include breast or urinary-tract infections and infections from C-section stitches. For babies, dehydration, jaundice and significant heart murmurs can be detected three or four days after birth, even though they're not usually apparent during the first 48 hours.
"We're doing preventive care and acting as a safety net for patients who might develop problems," Purvis said.
The assessment includes a complete physical for mother and baby, observation of feeding and an educational briefing. The exams are conducted by nurses; physician referral is available if complications are diagnosed.
From November 1995 when the center opened through the end of August, 3,739, or 84%, of the 4,437 mothers and babies discharged from the hospital were evaluated. "Of the moms that don't come, we call them and try to reschedule or at least do the same assessment over the phone," Purvis said.
If a phone assessment is made, a follow-up visit is arranged within three or four days of the birth so a physician can see the mother and infant.
Although the program is less than a year old, St. Joseph is already curbing some of the potentially high-risk and litigious problems common in obstetrics cases. In the first nine months of the program, fewer than 5% of patients required additional evaluations or treatments. Fewer than 0.5% of patients were readmitted to the hospital.
It cost $18,000 to start up the center and equip the examination room with supplies. The ER is staffed with two registered nurses and one clerk. The center's budget is $140,000. By comparison, an extra inpatient hospital stay for St. Joseph's 5,400 deliveries would cost about $2 million. But cost saving is not the program's main goal.
"It was primarily driven more by our health system mission than by risk management," said Larry Ainsworth, St. Joseph president and chief executive officer. "We just kept hearing from our patient feedback surveys. Patients basically defined it for us."