AN EVALUATION OF REFERRAL AND FOLLOW-UP CARE FOR POSTPARTUM
HOME VISITATION RECIPIENTS
by
Lindsay E. Caddell
A Senior Honors Project Presented to the
Honors College
East Carolina University
In Partial Fulfillment of the
Requirements for
Graduation with Honors
by
Lindsay E. Caddell
Greenville, NC
May 2015
Approved by:
Kim Larson, PhD, RN, MPH
Undergraduate Department of Nursing Science, College of Nursing
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INTRODUCTION
This senior honors project was conducted in conjunction with the core community health
course in a baccalaureate nursing program. Senior nursing students complete this course during
the final semester of the senior year and are assigned to work with a registered nurse (RN)
preceptor in a community-based health care setting. This university nursing program
collaborated with community health agencies, such as health departments, in eastern North
Carolina (NC) for clinical practicum experiences. This project fulfilled a community service
learning project (CSLP) course requirement, an evidence based project that provides students
with an opportunity to apply the nursing process to health issues for an aggregate in the
community. The CSLP involves collaboration with a community partner/agency, a targeted
community health assessment, determination of a priority health need, plan of action,
implementation and program evaluation.
REVIEW OF LITERATURE
The infant mortality rate (IMR) is defined as the number of infant deaths during the first
year of life and is the indicator of the overall health of a population (Murphy, Xu & Kochanek,
2013). Maternal and infant risk factors such as, low socioeconomic status, single motherhood,
alcohol or drug use, multiple gestation, geographic residence, and public insurance coverage
contribute to infant mortality (Ballantyne, Stevens, Guttmann, Willan & Rosenbaum, 2014).
Public health outreach, such as home visitation programs, are an evidence-based intervention that
address these risk factors and have been shown to decrease adverse infant outcomes (Broyles et
al., 2000). Some home visit programs begin before delivery and follow the infant for two years
while others are shorter in duration and make one routine home visit.
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As a whole, infant outcomes have been shown to improve in conjunction with follow-up
care programs in the home. Two year home visit follow-up programs show decreased infant and
childhood mortality for infants enrolled, improved intellectual performance, and fewer
behavioral problems (Broyles et al., 2000; Kitzman et al., 2000; Kitzman et al., 1997; Olds et al.,
2004; Olds et al., 2007; Spencer-Smith et al., 2012; Spittle et al., 2010). Olds et al. (2014) found
that there were lower rates of child deaths among those receiving post-partum home visits
compared to infants receiving standard care and no home visits. Intellectual performance of
children who received postpartum home visits as infants was increased while behavioral
problems observed in children decreased (Olds et al., 2004; Spencer-Smith et al., 2012; Spittle et
al., 2010).
Mothers also benefit significantly from postpartum home visits. A number of studies
have demonstrated a marked decrease in second pregnancies and an increased interval between
the first and second pregnancies (Kitzman et al., 1997; Olds et al., 2014; Olds et al., 2004; Olds
et al., 2007). In addition, these families used fewer months of welfare and food stamps. Kitzman
(1997) recorded a decrease in maternal cigarette, alcohol and marijuana use. These mothers and
caregivers were found to have fewer anxiety symptoms and reduced overall rates of anxiety
along with reduced episodes of depression (Spittle et al., 2010). Dellenmark-Blow & Wigert
(2014) found that being a part of a post-partum program helped caregivers establish independent
parenthood, mature as parents, and process experiences successfully.
In spring 2015, a collaborative partnership was developed with a local Health
Department, specifically the Postpartum Home Visitation (PPHV) program in the county and a
senior nursing student at East Carolina University College of Nursing. The goal of the county
PPHV program is to assess both mother and infant within two weeks following delivery. This
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PPHV program is a one time home visit to mothers and infants. Public health nurses complete
assessments and make referrals to essential community resources during this visit. Clients who
receive prenatal care at the health department automatically are invited to participate in the
PPHV program. Postpartum home visits often result in referrals to health department services or
other community resources. Public health nurses, social workers, case managers and interpreters
work together on referral and follow-up. There was no current comprehensive tracking system to
monitor client progression through the referral and follow-up process. Therefore, the overall goal
of this project was to evaluate the referral and follow-up process to community resources for the
recipients of the PPHV program.
METHOD
Setting
This project took place in a county in eastern North Carolina with an agricultural
economy. The ethnic/racial demographics are predominantly White (54.7%), African American
(32%) and Hispanic/Latino (10.7%). The county has a community hospital, local health
department, department of social services and other health and social service providers to serve
the community. The average per capita income is $21,557 with 22.1% of persons living below
the poverty level. The five major health problems are teen pregnancy, infant mortality, chronic
disease, sexually transmitted infections, and obesity (Wayne County Community Assessment,
2011). Health disparities are disturbingly apparent in the county. The infant mortality rate (IMR)
for Whites is 4.1/ 1,000 while the rates for minorities is 17.1/1,000 (Wayne County Health
Department, 2011).
Program Evaluation
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The program evaluation was designed to obtain information regarding the effectiveness
of the PPHV program referral and follow-up process. The project objectives were to a) obtain
data on infant and maternal referrals to health department and community resources; b) analyze
and interpret this data and; c) identify program and service characteristics regarding effective
community resources.
When the health department is notified of a client delivery, a staff member from the
Maternity Department calls the client two or more days ahead of time to confirm a PPHV
appointment. During each PPHV, the RN preceptor and senior nursing student completed a
comprehensive maternal and child assessment that included physical, mental, social and
environmental components. Two separate assessment forms, one for the mother and the other for
the infant, were completed during each PPHV, through observation and interview. The
Edinburgh Postnatal Depression Scale was also completed with the mother. A score of 10 or
higher indicates possible depression and subsequent referral to a mental health agency. Each
PPHV took approximately one hour. During each PPHV, the nurse determined the need for
referral and follow-up resources for each client. Depending on the need, clients can be referred to
Care Coordination for Children (CC4C), Pregnancy Care Management (PCM) or mental health
services (MH). The first two services, CC4C and PCM, are located within the health department.
Care Coordination for Children ensures children receive the support needed to thrive and is
specifically for children with special health care needs, children in foster care, fragile infants
from the NICU or a child exposed to toxic stress. According to the CC4C referral form, toxic
stress includes domestic violence, caregiver unable to meet infant health and safety needs,
history of parental rights termination, active substance abuse by caregiver, unstable home, unsafe
environment, parental mental health condition and homelessness. Pregnancy Care Management
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works to improve the health of mothers and infants by coordinating medical care for mothers
who qualify such as those facing preterm birth, chronic illness, substance abuse and other
concerns. A local MH agency is used as the referral source and upon receipt of referral staff
establish contact with the client and make appointments with a MH provider in the area.
The RN files paperwork in the medical record after each PPHV to begin the referral
process to the appropriate resource. The PPHV program utilizes individual-level and populationlevel public health nursing interventions including case finding, case management, referral and
follow-up, health teaching, counseling, and collaboration (Maurer & Smith, 2013).
To identify trends, data was organized to include race, type of home visit, type of referral,
and whether the community resources were utilized. Three key informant interviews were
completed to further inform the referral and follow-up process. Community partners involved in
this project included the Maternity Department nurse manager, the RN preceptor, social workers
and interpreters. Each of these community partners were crucial to the successful completion of
this project.
FINDINGS
For this program evaluation, we evaluated 24 PPHV completed during a 7-week period.
During this period, four scheduled home visits clients were not completed as a result of the
mother not being at home. Of the 24 PPHV, 14 were made to African American clients, seven to
Hispanic/Latino clients and three to White clients. Racial and ethnic minority clients made up
87.5% of users of the program during this time period. One third of the PPHV clients visited
were referred to community resources. Table 1 shows the type and number of referrals made by
race.
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Table 1. Type and Number of Referrals by Race (n=8)
Of the referred clients, all except one were African American clients. One referral was
made for a White client and no referrals were made for the Latino clients. The top three referral
resources were CC4C, PCM and MH. Two of the clients who were referred to MH were also
referred to CC4C and PCM. Every client who was referred to an outside resource was followedup with in some capacity including phone calls, health department appointments or home visits.
The nurses completing PPHVs received an email when a client they referred to an agency was
accepted into or denied from the recommended follow-up program. After the client is approved,
social workers and staff from CC4C, PCM or MH follow up with clients through phone calls,
home visits, health department or mental health office appointments.
Limitations
The main limitation in this project was the small number of clients receiving home visits
during the short program evaluation time period.
IMPLICATIONS FOR PRACTICE AND POLICY
This project met the goal of evaluating one aspect of the PPHV in a rural county health
department. The most vulnerable, at risk population, was the African American families. Though
all clients who were referred to community resources were followed-up in some capacity, there
were variations in type of follow-up, communication and timing. For MH referrals, the nurse
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calls the MH agency at the time of the PPHV, reports risk factors and then the mother schedules
an appointment with the MH provider. For PCM referrals, the nurse may call or see the PCM
social worker at a later time to make the referral. In one to two weeks, the nurse would contact
the PCM social worker to determine the outcome of the referral. For CC4C referrals, the nurse
completes a referral form and submits it manually to the CC4C office. The CC4C program would
send an email one to two weeks after the initial referral informing the PPHV nurse if the client
had been accepted into or denied from the program.
As a result of variations in type of follow-up, communication and timing, a
comprehensive monitoring system for the tracking of referrals and follow-up would be
beneficial. A comprehensive monitoring system could track the type of follow-up received by the
client. It could also improve communication between PPHV nurses and the staff of community
agencies to help ensure clients are being followed-up within timely manner. The development of
a comprehensive monitoring system to provide accurate data to staff regarding the referral and
follow-up process in collaboration with CC4C, PCM and MH programs would increase
communication between the agencies and prevent gaps in care for the postpartum clients.
The health department implemented an electronic health record (EHR) system in
February 2015. Nurses and social workers will have computer accessibility to accurate client
information at their desk. This immediate access to clients’ EHR will make it easier to track
PPHV recipients during the referral and follow-up process. The implementation of EHRs would
create the ability for a comprehensive tracking system for referrals and follow-up.
There is evidence to suggest that outreach to leaders in the African American
communities, such as churches, to train Lay Health Advisors would also be beneficial (Arvey &
Fernandez, 2012). Lay Health Advisors can provide skills, knowledge and advocacy to new
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mothers in collaboration with official health educators and public health nurses. The training
might include the most prevalent issues identified during home visits such as breastfeeding,
postpartum complications, infant safety and common illness recognition and management. The
trainers of the lay health advisors could include health department staff and baccalaureate
nursing students.
Referral and follow-up are essential interventions of public health nursing that require a
comprehensive tracking approach. This project provided an evaluation of the referral and followup process of the PPHV program and recommendations for future program development. This
health department has initiated an EHR that could lead to the development of a comprehensive
tracking system for PPHV referral and follow-up. A new outreach endeavor could be the
implementation of a Lay Health Advisor training program in collaboration with the local school
of nursing.
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