Effects of Home Visiting and Maternal Mental Health on Use of the Emergency Department


Objective: To describe use of the emergency department (ED) among late preterm versus term infants enrolled in a home visiting program and to determine whether home visiting frequency was associated with outcome differences.

Design: Retrospective, cohort study.

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Setting: Regional home visiting program in southwest Ohio from 2007–2010.

Participants: Late preterm and term infants born to mothers enrolled in home visiting. Program eligibility requires � one of four characteristics: unmarried, low income, < 18 years, or suboptimal prenatal care.

Methods: Data were derived from vital statistics, hospital discharges, and home visiting records. Negative binomial regression was used to determine association of ED visits in the first year with late preterm birth and home visit

frequency, adjusting for maternal and infant characteristics.

Results: Of 1,804 infants, 9.2% were born during the late preterm period. Thirty-eight percent of all infants had at least one ED visit, 15.6% had three or more. No significant difference was found between the number of ED visits for late

preterm and term infants (39.4% vs. 37.8% with at least one ED visit, p = .69). In multivariable analysis, late preterm birth combined with a maternal mental health diagnosis was associated with an ED incident rate ratio (IRR) of 1.26,

p = .03; high frequency of home visits was not significant (IRR = .92, p = .42). Conclusions: Frequency of home visiting service over the first year of life is not significantly associated with reduced ED visits for infants with at-risk attributes and born during the late preterm period. Research on how home visiting can

address ED use, particularly for those with prematurity and maternal mental health conditions, may strengthen program

impact and cost benefits.

JOGNN, 44, 135-144; 2015. DOI: 10.1111/1552-6909.12538 Accepted July 2014

Neera K. Goyal, MD, is an assistant professor in the Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.

Alonzo T. Folger, PhD, is a senior epidemiologist in the Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.


The elevated risk of mortality and morbidity for late preterm infants (LPIs) born at 34 weeks 0 days to 36 weeks 6 days gestation, who represent more than 70% of all preterm infants, has been increas- ingly well described (Bird et al., 2010; Engle, Tomashek, & Wallman, 2007; Martin, Kirmeyer, Osterman, & Shepherd, 2009; Raju, Higgins, Stark, & Leveno, 2006). Compared with infants born full term (� 37 weeks), LPIs have higher rates of hospitalization and emergency depart- ment (ED) use in the neonatal period and through the first year of life (Escobar et al., 2005; Jain & Cheng, 2006; McLaurin, Hall, Jackson, Owens, & Mahadevia, 2009). Importantly, for certain condi- tions like neonatal jaundice, risk of hospitalization for LPIs is higher compared with full-term infants as well as infants born at earlier gestational ages (Ray & Lorch, 2013), suggesting an interplay of

immature physiology and current systems of care for this population. In contrast to very preterm infants, LPIs are often discharged home from the hospital without a prolonged period of observation (Goyal, Fager, & Lorch, 2011), and many are not seen by any health care professional during the first week home (Hwang et al., 2013). Moreover, the majority of these infants are not enrolled in systematic, high-risk infant follow-up programs, which generally focus on very early preterm in- fants (Walker, Holland, Halliday, & Badawi, 2012). For LPIs, therefore, further research is needed to develop models of follow up care that can improve outcomes (National Perinatal Association, 2012; Premji, Young, Rogers, & Reilly, 2012).

One potential strategy to address these concerns is home visiting, a voluntary service delivered

The authors report no con- flict of interest or relevant financial relationships.

http://jognn.awhonn.org C© 2014 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses 135

I N F O C U S Effects of Home Visiting and Maternal Mental Health on Use of the Emergency Department Among Late Preterm Infants

Given the late preterm birth rate among at-risk infants, practices and policies related to their care have the potential for a large

public health impact.

in a family’s home to provide care coordination, parenting education, and social support for at-risk child-bearing women and their children (American Academy of Pediatrics Council on Child and Adolescent Health, 1998; Kitzman et al., 1997; Sweet & Appelbaum, 2004). Several national models of home visiting, including Nurse Family Partnership and Healthy Families America, have developed specific program curricula and protocols; qualifications of home visitors range from nurses to social workers to paraprofessionals (U.S. Department of Health and Human Services, 2013). Currently, an estimated 400 publicly and privately funded home visiting programs serve at least 500,000 families in the United States, and an additional $1.5 billion was allocated through the Patient Protection and Affordable Care Act to expand these services (Astuto & Allen, 2009; Health Resources and Services Administration, 2010). Despite significant public investment in this intervention, to date, a paucity of literature on out- comes such as ED use for preterm infants enrolled in such programs (Goyal, Teeters, & Ammerman, 2013).

Eric S. Hall, PhD, is an assistant professor in the Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.

Robert T. Ammerman, PhD, is a professor in the Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.

Judith B. Van Ginkel, PhD, is a professor in the Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.

Rita S. Pickler, RN, PhD, is a professor of nursing in the Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.

The study objectives were to characterize ED use over the first year of life among late preterm and full-term infants enrolled in home visiting and to determine whether increased frequency of home visiting participation is associated with improvement in this outcome. Our logic model for this study was based on the social-ecological model of child health that underpins the role of home visiting for at-risk families. A strong body of literature has linked social and environmental risk factors with adverse child health outcomes, including avoidable hospitalizations and ED visits, that may be mitigated through early detec- tion, parental education, and care coordination (McLaren & Hawe, 2005; Paul, Phillips, Widome, & Hollenbeak, 2004; Shanley, Mittal, & Flores, 2013; Shonkoff & Garner, 2012). Given the known con- tribution of LPIs to pediatric morbidity and health care costs and the fact that preterm birth is likely to disproportionately affect at-risk mothers eligible for home visiting, a more detailed understanding of program effectiveness for LPIs may be critical to addressing gaps in care for this important population.

Methods Setting and Participants In this retrospective, cohort study we examined ED use among late preterm and term infants born to at-risk, first-time mothers enrolled in a well- established, regional home visiting program serv- ing southwest Ohio. This community-based home visiting program, which has to date served more than 19,000 families, comprises 11 local home vis- iting agencies which adhere to program, training, and evaluation standards established by a cen- tral office at Cincinnati Children’s Hospital Medi- cal Center (CCHMC). To track and document pro- cess and outcome measures within and across agencies, the program uses rigorous continuous quality improvement procedures under the super- vision of CCHMC quality improvement staff and is facilitated by a web-based data entry system (Ammerman et al., 2007).

In addition to being first- time mothers, women eligible for this program must have at least one of four risk characteristics: unmarried, low income (up to 300% of poverty level, receipt of Medicaid, or reported concerns about finances), < 18 years of age, or suboptimal prenatal care. Participants may be enrolled during pregnancy or postde- livery, before their child reaches age 3 months. Referrals to the program may be self-initiated or come from clinics, hospitals, and other commu- nity sources. Home visits are provided by social workers, child development specialists, or other professionals who employ a core program curricu- lum that is based on the Healthy Families America model of home visiting. The overall goals of the program are to (a) provide nutrition education and substance use reduction during pregnancy; (b) support parents in providing children with a safe, nurturing, and stimulating home environment; (c) optimize child health and development; (d) link families to health care and other services; and (e) promote economic self-sufficiency. To achieve these goals as outlined within the curriculum, the home provider offers printed materials for fami- lies but primarily focuses on interactive sessions with parents that may address curriculum content as well other issues or concerns specific to the family. Screening inventories for home safety, par- enting stress, substance use, and other items are also performed at scheduled intervals to identify and address risks and to generate appropriate service referrals. Expected visit frequency consis- tent with the curriculum is weekly through the first 3 months of infancy, tapering to biweekly through the remainder of the first year.

136 JOGNN, 44, 135-144; 2015. DOI: 10.1111/1552-6909.12538 http://jognn.awhonn.org

Goyal, N. K. et al. I N F O C U S

For this analysis, infants born prior to 34 weeks gestation were excluded, resulting in 1,852 late preterm and term infants born during the years 2007 to –2010 whose mothers enrolled in home visiting either prenatally or within 3 months af- ter delivery. Of these infants, 43 additional infants were excluded from analysis due to major congen- ital anomalies, as their patterns of health care use were expected to vary significantly from otherwise healthy infants. For similar reasons, six infants who died of any cause before their first birthdays were also excluded from analysis.

Data Sources Home visiting data were abstracted from the pro- gram’s web-based data entry system described above. This system contains detailed information on each participant including enrollment timing, home visit history, and maternal demographic and psychosocial screening information. Enrolled par- ticipants consented to data being used for the purpose of quality improvement benchmarking and research. These data were linked to Ohio vi- tal statistics, available from the Ohio Department of Health, and birth-related hospital discharge records of mother and infant, available from the Ohio Hospital Association. Because no common unique identifier across data sources was avail- able, record linkage was accomplished using LINKS (University of Manitoba), a SAS-based probabilistic and deterministic matching program. Selected variables used for linking included ma- ternal and infant dates of birth, hospital of birth, de- livery method, sex, and maternal address. Further details of linkage for these data sources has been previously described (Hall et al., 2014). The result- ing data set contained information regarding ma- ternal/child health including demographics, social factors, pregnancy-related conditions, and infant characteristics. Lastly, this data core was linked to electronic health record data at CCHMC for outcome measures of hospital service use. The Ohio Department of Health and CCHMC Institu- tional Review Boards approved this study.

Covariates and Key Predictors As described previously, data for maternal co- variates were obtained through a combination of linked vital statistics, hospital discharge records, and home visiting data (Hall et al., 2014). These variables included race, ethnicity, payer source, maternal age, education level, marital status, substance use, household membership, and paternal involvement. Indicator variables for relevant clinical factors were constructed using

International Classification of Diseases, 9th Revi- sion, Clinical Modification (ICD-9-CM) codes and vital statistics data (Centers for Disease Control and Prevention, 2014). The ICD-9-CM codes used to derive a composite maternal mental health diagnosis were obtained from the maternal birth hospitalization record.

Late preterm birth was defined as infant birth from 34 weeks 0 days to 36 weeks 6 days gestation; gestational age measures were obtained from vi- tal statistics and represented the best clinical es- timates. Additionally, as a sensitivity analysis we repeated analyses using a combined gestational age estimate from vital statistics rather than the clinical gestational age estimate, as prior studies have demonstrated discordance between these measures (Wingate, Alexander, Buekens, & Vahra- tian, 2007). To measure home visiting service in- tensity, we adapted a prior approach from Duggan et al. (2004), counting the number of home visits conducted over the first year of life and then di- viding this by the number of expected home visits over the infant’s first year per the program cur- riculum to calculate a percentage of expected vis- its. Mother/infant pairs were classified as receiving a high dose of service if they received �75% of expected visits, a commonly used cutoff for ser- vice evaluation in home visiting programs (Healthy Families New York, 2014). Timing of program en- rollment was dichotomized as enrollment prena- tally or after birth of the infant.

Analysis Bivariate analyses using chi-squared or t tests were used to identify covariates associated with any ED use and number of unique ED visits over the first year after birth. Factors deemed to be empirically or statistically important (p values less than 0.25) were considered and tested using step-wise multivariable modeling to derive parsi- monious models. To account for overdispersion of the ED visit data due to excess zeros, we used a random-effects negative binomial regression model as an alternative to standard Poisson regression, adjusting for clustering by individual home visiting agency. Models were tested for goodness of fit using Akaike Information Criterion values and link tests for model specification. Multicollinearity was also assessed, with variance inflation factors for all retained variables < 10 (O’brien, 2007).