Bridging the Gap for Underdeveloped Preterm Infants from the Hospital to the Home Iris Luanne De La Calzada, OTR/L Valley Regional Medical Center December 2009 The Rainbow Occupational Therapy Program for the NICU
Underdeveloped babies as a result of preterm birth in young mothers who have had Caesarian section
Health Care cost: $7.4 billion a year – 15 times greater than full term babies in their first year of life
Average cost: $41,610 for premature babies vs. $2,830 for a healthy, full term baby
Reference: P.R. Newswire. (2005, March 28). March of Dimes analysis finds direct health care costs for preemies nearly 15 times greater than full term babies. Retrieved on November 9, 2009 at website: http://wwwmarchofdimes.comaboutus/14458_15365.asp
In 2006, 12.3% of births in the United States are preterm(<37 weeks of gestation)
31% increase in the preterm birth rate since 1981 [Raju, et al. (2006)]
Largest contribution to this increase was from births between 34 and 36 completed weeks of gestation
In Texas, there were 54,621 preterm births – 13.7% of total number of births documented
63.1 teen births per 1000 residents
References: Raju, T., Higgins, R., Stark, A., Leveno, K. (2006). Optimizing care and outcome for late-preterm (near-term) infants: A summary of the workshop sponsored by the National Institutes of Child Health and Human Development. Pediatrics, 118(3), 1207-1214. The Henry J. Kaiser Foundation. Texas Births in 2006. Retrieved online on November 11, 2009 from website: http://www.statehealthfacts.org/profileind.isp?cat=2&sub=11&rgn=45
Brownsville, TX Profile based on 2000 U.S. Census
Unemployment rates – only 52.4% in the labor force
High-school drop-out rates – only 17.2% with high school education, 10% with higher education
Socio-economic status – average of $24,468 per household, $9,762 per capita income
Age of population – median age of 27.7 years
Reference: United States Census for Brownsville, Texas. (n.d.). 2000 Brownsville, TX Demographics. Retrieved online on November 2, 2009 from website: http://brownsville.texas.com/demographics.html
Why is it a problem?
Late preterm infants have higher frequencies of:
rates of hospitalization
High correlation between high rates of elective and non-elective Caesarian sections and premature births and mental retardation
Changing obstetric practices in the U.S.
Need to develop primary, secondary and tertiary prevention
Lack of well-structured NICU Occupational Therapy Programs
References: Aucott, S., Donohue, P., Atkins, S., Allen, M. (2002). Neurodedvelopmental care in the NICU. Mental Retardation and Developmental Research Reviews, 8(4), 298-308. Fuchs, K. and Wapner, R. (2006). Elective cesarian section and induction and their impact on late preterm births. Clinics in Perinatology, 33(4), 793-801. Weiss, S. (2006). Origins of tactile vulnerability in high-risk infants. Advances in Neonatal Care, 6(1), 25-36.
Analysis of Determinants of the Health Problem
Early exposure and engagement in sexual activity of female teenagers in the region
Low socio-economic status of households in the region
Lack of prenatal care and informed consent on risks involved in C-section
High immigrant population, unemployment and high school drop-out rates in the region
Lack of awareness among health professionals and the general public of existing well-structured NICU Occupational Therapy Programs
Lack of good communication among medical, allied health professionals and parents affecting smooth transition to the home
New Hospital Initiative: The Rainbow Occupational Therapy Program
Using the PRECEDE-PROCEED Model, the goal of this
health promotion program is to improve client
satisfaction and quality of care for underdeveloped
preterm infants and their families through seamless
hospital-home transition through occupational therapy
intervention in the NICU by May 2010. The objectives of
this program therefore are as follows, to be realistically
implemented in 2-3 months:
Consistent staff documentation
Streamlined protocol for referral for occupational therapy services
Regular family case conferences
Creation of printed educational material
Formal classes to focus on the empowerment of women and first-time parents
Transtheoretical Model of Change
Chosen to address the lack of communication at the individual level
Designed to instill intentional change
Focuses on decision-making
Relies on self-report
References: Velicer, W., Prochaska, J., Fava, J. Norman, G., Redding, C. (1998). Smoking cessation and stress management: Applications of the transtheroretical model of behavioral change. Homeostasis, 38, 216-233.
Diffusion of Innovations Theory
Chosen to address the problem at the community level
ATTRIBUTE EXAMPLE RELATIVE ADVANTAGE The degree to which an innovation is perceived as better than the previous idea The Rainbow program would facilitate better lines of communication among medical and allied health professionals, as well as with parents of underdeveloped babies. COMPATIBILITY The degree to which an innovation is consistent with existing values, experiences and needs of the adopters The Rainbow Program is consistent with the needs of this underserved population in communities challenged by educational, health-related, and socio-economic needs. COMPLEXITY The degree to which an innovation is perceived to be difficult to understand or use The Rainbow Program will provide the necessary service (Occupational Therapy) to improve the process of discharge planning. There is already an existing discharge planning committee that exists within this facility where OT is also a part. The addition of patients from the NICU during this weekly meeting would be a minor adjustment.
Diffusion of Innovations Reference: U.S. Department of Health and Human Services. National Cancer Institute. Theory at a glance: A guide for health promotion practice. Retrieved on November 20, 2009 from website: http://moodle.embanet.com/ot/mod/assignment/view.php?id=17018 ATTRIBUTE EXAMPLE TRIALABILITY The degree to which an innovation may be tested or experimented with on a limited basis The Rainbow Program can be pilot tested for 2-3 months or one quarter of a year. Program will consist of staff in-services, hosting of continuing education courses in the facility, formal letters to administrative, medical and allied health personnel. OBSERVABILITY The degree to which the outcomes of an innovation is visible to others Outcomes are measured through increase in patient satisfaction scores, increase in the perceived improvement in the quality of service based on a needs assessment survey among teenage mothers, as well as parents of NICU babies, and increase in staff satisfaction scores in the NICU and Women’s Department. Scores would be posted in the hospital intranet system.
Language barriers between service receptors and a culturally diverse staff
Communication barriers typical of a paternalistic biomedical model of patient intervention
Limited staffing, time and budget
Better organized discharge planning and referral system
Smoother (faster) lines of communication
Improved quality of patient care
Increased patient satisfaction and quality of life
The Rainbow Occupational Therapy Program Valley Regional Medical Center Brownsville, TX “ I am putting my bow in the clouds. It will be the sign of my covenant with the world.” – Genesis 9:13
Althabe F. & Belizan J. (2006). Caesarean section: The paradox. The Lancet, 368, 1472-1473.
Aita, M., and Snider, L. (2003). The art of developmental care in the NICU: A concept analysis. Journal of Advanced Nursing, 41, 223-232.
American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Occupational Therapy, 62, 625-683.
American Occupational Therapy Association. (2007). Specialized knowledge and skills in feeding, eating, and swallowing for occupational therapy practice. American Journal of Occupational Therapy, 61, 686-700.
Aucott, S., Donohue, P., Atkins, S., Allen, M. (2002). Neurodedvelopmental care in the NICU. Mental Retardation and Developmental Research Reviews, 8(4), 298-308.
Bigsby, R., Vergara, E. (2004). Developmental and therapeutic interventions in the NICU. Baltimore, MD: Paul H. Brookes Publishing Co.
Carvajal, S. (2005). Standard of Care for the NICU Infant. Retrieved on November 7, 2009, from Brigham and Women’s Hospital, A Teaching Affiliate of Harvard Medical School at website: http://www.brighamandwomens.org/GlobalFiles/search.aspx?st=0&site=BWH_CI&qt=NICU+protocol&submitButton.x=0&submitButton.y=0&submitButton=Go
Chen, X., Wen, S., Fleming, N. Demissie, K., Rhoads, G., Walker, M. (2007). Teenage pregnancy and adverse birth outcomes: a large population based retrospective cohort study. International Journal of Epidemiology, 36(2), 368-73.
Childbirth Connection, Inc. (2008, July). Why does the national U.S. cesarian section rate keep going up? Retrieved on November 2, 2009 from website: http://www.childbirthconnection.org/article.asp?ck=10456
Clark, G., Cox, B., Ward, S., Webber, H. (2009, June). Occupational therapy feeding challenges in early intervention. Early Intervention and School Special Interest Section Quarterly, 16(2), 1-3.
Davis, D., Sweeney, J., Turnage-Carrier, C., Graves, C., Rector L. (2004). Early intervention beyond the newborn period. In C. Kenner & J.M. McGrath (Eds.), Developmental care of newborns and infants: A guide for health professionals (pp. 373-410). St. Louis, MO: Mosby.
Fuchs, K. and Wapner, R. (2006). Elective cesarian section and induction and their impact on late preterm births. Clinics in Perinatology, 33(4), 793-801.
Galvan Gonzales, F., Mirchandani, G., McDonald, J., Ruiz, M., Echegollen Guzman, A., Castrucci, B., et al. (2008) Characteristics of young women who gave birth in the US-Mexico border region: The Brownsville-Matamoros sister city project for women’s health. Preventing Chronic Disease, 5(4), 1-14.
Gorga, D. (1994). Nationally Speaking – The evolution of occupational therapy practice for infants in the neonatal intensive care unit. American Journal of Occupational Therapy, 48, 487-489.
Holloway, E. (1994). Parent and occupational therapist collaboration in the neonatal intensive care unit. American Journal of Occupational Therapy, 48, 535-538.
Hunter, J.G. (2001). Neonatal intensive care unit. In J. Case-Smith (Ed.), Occupational therapy for children (4 th ed., 636-689). St. Louis, MO: Mosby.
Malacova, E., Li, J., Leonard, H., Klerk, N., Stanley, F. (2008). Association of birth outcomes and maternal, school, and neighborhood characteristics with subsequent numeracy achievement. American Journal of Epidemiology, 168(1), 21-29.
Oldham, A. (2008, September). Trends of occupational therapy in the neonatal intensive care unit. School System Special Interest Section Quarterly, 15(3), 1-3.
Primary caesarian section: Risk-adjusted utilization rates. (n.d.). Texas Health Care Information Collection: Texas Hospital Inpatient Discharge Public Use Data File 2004, Indicators of Inpatient Care in Texas Hospitals (2004). Retrieved online on November 2, 2009 from website: http://www.dshs.state.tx.us/THCIC/publications/hospitals/IQIReport2004/Chart33.pdf
P.R. Newswire. (2005, March 28). March of Dimes analysis finds direct health care costs for preemies nearly 15 times greater than full term babies. Retrieved online on November 9, 2009 at website: http://www.marchofdimes.com/aboutus/14458_15365.asp
Raju, T., Higgins, R., Stark, A., Leveno, K. (2006). Optimizing care and outcome for late-preterm (near-term) infants: A summary of the workshop sponsored by the National Institute of Child Health and Human Development. Pediatrics 118(3), 1207-1214.
The Henry J. Kaiser Foundation. Texas Births in 2006. Retrieved online on November 11, 2009 from website: http://www.statehealthfacts.org/profileind.jsp?cat=2&sub=11&rgn=45
U.S. Department of Health and Human Services. National Cancer Institute. Theory at a glance: A guide for health promotion practice. Retrieved on November 20, 2009 from website: http://moodle.embanet.com/ot/mod/assignment/view.php?id=17018
United States Census for Brownsville, Texas. (n.d.). 2000 Brownsville, TX Demographics. Retrieved online on November 2, 2009 from website: http://brownsville.texas.com/demographics.html
Velicer, W., Prochaska, J., Fava, J. Norman, G., Redding, C. (1998). Smoking cessation and stress management: Applications of the transtheroretical model of behavioral change. Homeostasis, 38, 216-233.
Weiss, S. (2006). Origins of tactile vulnerability in high-risk infants. Advances in Neonatal Care, 6(1), 25-36.