Addressing health equity through a telehealth maternal–newborn home visit for nurse practitioner students : Journal of the American Association of Nurse Practitioners

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Addressing health equity through a telehealth maternal–newborn home visit for nurse practitioner students

Doucette, Julianne A. DNP, MSN, APRN, CPNP-PC (Program Director and Assistant Professor)1; Rousseau, Jennifer DNP, WHNP-BC, CNE (Associate Professor)2; Vondracek, Hugh MSc (Data Analyst and Faculty Instructor)3

Author Information
Journal of the American Association of Nurse Practitioners 35(1):p 63-70, January 2023. | DOI: 10.1097/JXX.0000000000000810

Abstract

Is health equity achievable in maternal/newborn care? Implementing universal home visits in the early postpartum/newborn period to address disparities and access to care while providing needed community resources is a start (Handler et al., 2019). In 2019, the total maternal mortality rate nationally for Hispanic, non-Hispanic Black, and non-Hispanic White women was 20.1 maternal deaths per 100,000 live births (Hoyert, 2021). Notably, the rate for non-Hispanic Black women is nearly three times the rate for non-Hispanic White women at 44.0 and 17.9 maternal deaths per 100,000 live births, respectively (Hoyert, 2021). Despite the decrease in infant mortality from 1995 to 2019, similar racial disparities persist. The infant mortality rate for infants born to non-Hispanic Black women is consistently higher than other ethnic/racial groups (Ely & Driscoll, 2021). The reasons for these disparities are multifactorial and include the influence of systemic racism (Artiga et al., 2020). Furthermore, access to care in the early postpartum/neonatal period can affect the health outcomes of this population (Dodge et al., 2019).

The use of telehealth has the potential to improve access to care, especially for historically underserved populations, by removing barriers such as distance to care/time spent, transportation, and childcare issues (Franciosi et al., 2021). College of Nursing faculty can leverage current telehealth practices to meet population needs and address health equity, as well as student learning needs. Implementing telehealth opportunities with nurse practitioner (NP) students can address clinical course objectives and provide students with the skills and knowledge to use telehealth technology in practice. The purpose of the project was to implement and evaluate a unique telehealth maternal–newborn home visit experience for primary care Pediatric Nurse Practitioner (PNP) Doctor of Nursing Practice (DNP) students. This article describes how this innovative educational clinical experience prepared students to meet the needs of diverse patient populations in the early postpartum/newborn period and consider indicated community resources to improve health equity. Recommendations for how faculty can prepare community health nurse collaborators and students to improve the telehealth home visit experience are also discussed.

Background

The impetus for providing PNP students with the opportunity to participate in the early home visiting program was multifactorial. The students were beginning their advanced practice clinical rotations, which take place in outpatient pediatric clinics, schools, and federally qualified health centers. There was a desire of faculty for PNP students to learn more about the needs of early postpartum families in the local community, which is 75% non-White, 35% Hispanic or Latino, and majority Medicaid recipients (Chicago Department of Public Health, personal communication, July 21, 2022). Fifty-six percent of patients eligible for Family Connects at Rush live in economic hardship zip codes. Familiarizing PNP students with questions families have in these early days at home with a newborn, completing an assessment of social determinants and any barriers to accessing care, addressing the safety and well-being of the family, as well as, providing available community resource referrals could enhance the students' understanding of the population served from the advanced practice nursing perspective and address any needs of the family during this critical period.

Many clinical sites closed during the pandemic and were not available to nursing students. The College of Nursing at a private, midwestern university engages in many academic–practice partnerships, one of which is a program called Family Connects. The faculty of the PNP program leveraged this program to provide students with the opportunity to learn and use telehealth, continue clinical experiences, and meet clinical objectives. The Family Connects model provides home visits; however, due to Covid-19 restrictions, the students participated through phone, phone with video, or by telehealth visit. Telehealth has been a strategy to meet the needs of certain patient populations for decades but never to the degree that was needed during the Covid-19 pandemic. In fact, the use of telehealth in NP education programs is fairly new and often combines didactic and simulation opportunities for learning (Gibson et al., 2020; Rutledge et al., 2017; Smith et al., 2018). Simulation can be used before clinical experiences as preparation for telehealth clinical visits. Merritt et al. (2018) found that of the 26 master of nursing NP students participating in a telehealth simulation in their residency term, 81% believed that the experience improved their understanding of the Advanced Practice Nursing (APN) role in telehealth. Exposure to and practice with this modality helps the graduate to gain proficiency with this health care delivery strategy. Per Hawkins (2012), nurse practitioner faculty must explore innovative strategies to ensure that graduates can successfully practice in today's health care society.

Indications for implementation and description of the Family Connects model

In the fall of 2019, the Chicago Department of Public Health (CDPH) released its first Maternal Morbidity and Mortality in Chicago Report detailing the disparate rate at which Black women experience severe maternal morbidity and mortality, as well as the community areas most affected. These community areas also experience the highest racial disparity for preterm birth, low birth weight, and infant mortality (CDPH, 2019; Illinois Department of Public Health, 2022). In response, CDPH announced the launch of the Family Connects Chicago in partnership with four local hospitals to help impact the identified health disparities.

Family Connects is an evidence-based universal support service for families with newborns that seeks to support maternal–infant health, family well-being, and social needs within the first several weeks after a baby is born (Friedman & Gougler-Reeves, 2020). New mothers are typically scheduled for a home visit before discharge from the birth hospital and then receive an integrated home visit by a community health nurse between three and five weeks postpartum. During the visit, the nurse provides a physical assessment of the new mother and baby, discusses various aspects of psychosocial functioning, responds to concerns and questions, offers developmentally appropriate guidance, and provides connections to needed and desired community services for ongoing support (Friedman & Gougler-Reeves, 2020). The model concludes with a follow-up session one month later from a staff member to evaluate the use and perceived effectiveness of the given resources and referrals.

To evaluate a family's unique risks, the nurse assesses family needs and risks across four domains: child and family health, parenting/childcare, household and community safety, and parental well-being (Dodge & Goodman, 2019). The factors that are assessed across these domains include maternal and infant health, plans for health care, plans for childcare, parent and child relationship, management of infant crying, household safety and material supports, family and community safety, history of parenting difficulties, maternal well-being, substance abuse, and maternal emotional support (Dodge & Goodman, 2019). Each of these factors is rated on a Family Support Matrix. Based on the scores a family achieves for each factor, the nurse response can be no intervention, provide education, make a referral, or emergency intervention. Critical to the success of Family Connects is the assessment of social determinants of health, addressing specific needs of the family, and alignment with community resources so that families have access to local resources when they need them (Family Connects International, 2021).

The value of home visits during the postpartum period

Home visits in the postpartum period have been shown to have many benefits for infants and their families, with the potential to reduce disparities in maternal and infant outcomes (Dodge et al., 2014; Friedman & Gougler-Reeves, 2020; Handler et al., 2019). Dodge et al. (2014) found that families who had one to three nurse home visits and were connected to indicated community resources in the early postpartum period experienced 59% less infant visits to the emergency department during the first 12 months of the child's life. In addition, mothers chosen at random from this study reported more community connections, more positive parenting behaviors, sending their infant to higher-quality out-of-home childcare, and lower rates of anxiety than mothers in the control group (Dodge et al., 2014). Reaching women through home visits at three to five weeks after birth allows the opportunity for early intervention with maternal physical and mental health concerns and to offer breastfeeding support (Handler et al., 2019). In the pediatric population, home visits from NP students to children with asthma helped to identify new community-based resources, reduce barriers to care, and improve care continuity (McClure et al., 2021).

Connecting with women postpartum through virtual means presents some challenges such as technical and logistical difficulties, assisting with breastfeeding latch, and not being able to read body language or accurately assess infant growth (Schindler-Ruwisch & Phillips, 2021). Despite these challenges, virtual lactation support was found to be moderately effective compared with in-person support (Schindler-Ruwisch & Phillips, 2021). In an ongoing effort to address inequities related to accessing family support services, Rybinksa et al (2022) recommended that home visiting programs continue to offer virtual visits as an alternative to in-person visits to maximize program reach and program impact.

Supportive phone calls and modified home visits (telehealth)

When Covid-19 restrictions were in place, in-home visits were prohibited, and a new protocol was developed by Family Connects International including supportive phone calls or modified in-home visits (mIHV) using telehealth with families (Friedman & Gougler-Reeves, 2020). The supportive phone call was a brief patient guided check in to address essential questions and to ensure patient follow up with providers. The mIHV was a full visit delivered through telehealth or phone following the original model where the nurse would complete a verbal assessment in place of the physical assessment. The 12 matrix factors were still assessed and scored using the full screening tools. Despite the visits taking place virtually or by telephone during this time, follow-up to evaluate patient satisfaction revealed that 93% of patients found the time with the nurse helpful.

How virtual visits meet the essentials domains and competencies for education

Nursing education in the 21st century needs to incorporate contemporary trends and values to prepare graduates to coordinate resources and provide equitable nursing care to diverse populations. To guide this transition, the American Association of Colleges of Nursing (AACN) Essentials identify competencies and concepts that the future nursing workforce needs, specifically encompassing person-centered care, population health, interprofessional partnerships, and health care technologies (2021). In addition, care provided needs to move from expensive settings to primary care and community settings, which requires knowledge of system-based practice. One way to provide opportunities in the community setting is through academic–practice partnerships. Academic–practice partnerships foster new models of care delivery and integrate systems of health care to deliver equitable health care. The Family Connects program, an academic–practice partnership between a College of Nursing and a metropolitan Department of Public Health, considers personal, social, economic, and environmental factors to address the needs of the diverse population in Chicago. The impact of structural and social determinants of health are thoroughly assessed during the home visit and addressed through education during the visit, referrals to community resources, or through immediate care when indicated.

Clinical experience at the advanced level needs to integrate didactic learning, promote innovative thinking, and test new potential solutions to clinical practice or systems issues. The virtual postpartum home visit is a patient-centered learning opportunity, which meets these requirements. Per AACN (2021), clinical learning experiences may be accomplished through varied methodologies, including virtual technology. Competencies addressed by the Family Connects virtual clinical experience at the advanced level are presented below (see Appendix, Supplemental Digital Content 1, https://links.lww.com/JAANP/A180). Although this project did not evaluate individual attainment of competencies by student, the competencies were mapped for future evaluation.

Methodology

Preparation of student participation in telehealth visits

Pediatric Nurse Practitioner students were recruited from a DNP program at an urban, private graduate school of nursing. Students in two cohorts, summer of 2020 and spring of 2021, were all offered the Family Connects clinical experience including distance students because the visits were virtual, and 18 of 41 (44%) chose to participate. Institutional Review Board approval was obtained for the project. DNP faculty prepared the students for the telehealth visits through advanced primary care didactic, telehealth didactic, and simulated telehealth experiences. After the didactic and clinical preparation, students were provided with information and evidence supporting the Family Connects model, an overview of screening tools, contact information for the community health nurse collaborators, and a list of the modified home visits topics, which outlined areas the students would discuss and document during the visit.

Orientation to Family Connects

Before participating in the Family Connects Virtual Clinical Experience, the students were provided with Family Connects resources that described the history of Family Connects, components of the model, the community health nurse home visit template Modified Home Visit Topics, including the family support domains (Support for Health Care, Support for Infant Care, Support for a Safe Home, and Support for Parents), an overview of the mental health assessment, other screenings, and data collection and analysis procedures (Dodge & Goodman, 2019). They were also provided a copy of the journal article, Implementation and Randomized Controlled Trial Evaluation of Universal Postnatal Nurse Home Visiting (Dodge et al., 2014) to emphasize the benefits of the home visit program. The brochure, Do You Live in Chicago? Family Connects Chicago at Rush, was also provided to students for the review of the information new mothers received in the hospital related to the program after giving birth at Rush. The brochure provided the photographs and names of the community health nurse collaborators, a brief description of the program, and how to schedule an in-home visit, phone, or modified telehealth visit.

Didactic and telehealth preparation to meet course objectives and prepare for visits

The DNP faculty prepared students to participate in the visits through a pediatric advanced level didactic course, telehealth didactic, and preclinical telehealth scenarios. All students were enrolled in DNP Specialty Practicum clinical course and Advanced Primary Care of the Child 1, which provided the advanced level knowledge students needed to provide anticipatory guidance related to many primary care topics from the provider perspective during the Family Connects visits. The content covered initiation and duration of breastfeeding, including how to manage low supply, jaundice, over supply, pumping, hand expression, and mastitis among other primary care topics. Students were asked to retrieve articles about health disparities related to breastfeeding and discuss their findings in a discussion board assignment. They also watched the videos, “The African American Breastfeeding Project” (Bayne, 2014) and “Chocolate Milk: The Documentary Series” (Bayne, 2014), to gain a better understanding of challenges of breastfeeding and dispel myths about breastfeeding among Black women.

The didactic telehealth education included a four-hour session with a 3-minute description of telehealth from Johns Hopkins Medicine (2017), a 15-minute Telehealth 101 for NPs (University of Buffalo School of Nursing, nd) and 14 telehealth training videos created by Old Dominion University's Center for Telehealth Innovation, Education, & Research (C-TIER) (2019). Faculty reviewed the Center for Telehealth Innovation, Education & Research website for additional information on telehealth education for students (2020). The information provided to students included telehealth etiquette and adequate preparation for telehealth interactions, as well as how to troubleshoot issues with technology and privacy. Once the students completed the didactic component, they were instructed to contribute to a discussion post describing one clinical situation they had encountered during their Advanced Practice Registered Nurse (APRN) education that could have been conducted through telehealth. They were encouraged to think critically about how to deliver the visit through telehealth. Finally, the students were asked to pair with one other student and practice four faculty-devised telehealth scenarios through Zoom (depression/anxiety, epilepsy, asthma, and attention deficit disorder). Each APRN student participated in the role of the APRN for two scenarios and the patient/family for two scenarios to practice their newly acquired telehealth skills.

The goal of the clinical experience was for students to engage with families during the early postpartum period through several one- to two-hour telehealth visits. The experience familiarized students with questions that families have during the early newborn period. The objectives of the Family Connects Virtual Clinical Experience for PNP students included the following:

  • Provide newborn care advice (feeding, elimination, hydration, safe sleep, anticipatory guidance on development, car safety, household safety)
  • Evaluate social determinants of health
  • Evaluate access to primary care provider for follow-up pediatric visits
  • Provide community resource referrals based on need or screening results, and
  • Participate in telehealth visits.

Debriefing of student experience and evaluation

DNP/APRN faculty evaluated student didactic learning and telehealth preparation through graded course assignments and the clinical experience through a one-hour debriefing session to discuss the visits in more depth from the perspective of the advanced practice role. The session included a discussion of how the students assessed social determinants of health and access to primary care through discussions and assessment tools, areas of newborn care advice provided to families, and the types of community resource referrals provided to families. Many stated that they were able to address feeding questions, sleep questions, and car seat questions and provide needed community resource referrals.

The students were asked whether they participated in the modified home visits as mainly an observer or as an active participant. The amount of participation varied depending on which community health nurse collaborated with the student. Faculty discussed with the community health nurses that students were prepared to answer parent questions during the early postpartum period from the provider perspective and could participate more in the visits if offered. The next cohort reported being able to participate at a higher percentage. The community health nurses collaborated with the NP students during visits but did not serve in the role of evaluator.

In addition to the debriefing session, the Family Connects virtual clinical experience was evaluated by the Family Connects Student Survey, a 21-item yes/no and open-ended REDCap survey (Harris et al., 2009,2019) deployed to participating students after all students concluded the clinical experience. The Nurse Perspective Survey consisted of four yes/no and four open-ended items deployed through REDCap Survey to the community health nurse collaborators. An expert in survey development reviewed the surveys before deployment for face validity. Attainment of competencies was not evaluated.

Results

Despite potential complications of virtual visits, there were no reported issues with technology or access to the virtual platform with this population during the project. The Family Connects Student Survey was distributed to all 18 student participants, and 15 students completed the survey. The results (Table 1) showed that 93% (n = 14) of students felt prepared to participate in the visits, and 100% (n = 15) of the students were able to meet the clinical objectives of providing education on newborn care to families and evaluating social determinants, whereas 93% (n = 14) were able to evaluate access to primary care. The students learned how to assess the social needs of the families using the Family Connects Family Support Matrix and promote health and equity by providing referrals and resources (Family Connects International, 2021). Eighty-seven percent (n = 13) of the students provided a variety of community resources to address specific family needs. Data from the first two years of the service from March 2020 to December 2021 show that of the 1,570 visits that occurred, 81% (n = 1,272) of visits resulted in at least one referral for families. Nearly half of patients who were given referrals report contacting the referral agency with the majority using the services and finding them helpful. The most common referrals for families were for childcare, primary care for the mother and infant, help in managing a fussy baby, Supplemental Nutrition for Women, Infants, and Children (WIC), diapers, and a hotline for mental health postpartum. Social services were also frequently needed to arrange for longer-term nursing care and for situations such as intimate partner violence and home safety/property owner issues.

Table 1. - Family Connects student survey results
Questions (n = 15) n (%)
Provided newborn care advice (feeding, elimination, hydration, safe sleep, car safety, household safety) 15 (100%)
Evaluated social determinants of health of the family 15 (100%)
Evaluated access to primary care 14 (93%)
Felt prepared to participate as an APRN student in the visits 14 (93%)
Participated in a telehealth visit 13 (87%)
What percentage did you participate? (n = 13)
 >75 1 (8%)
 50–75 3 (23%)
 25–50 6 (46%)
 <25 1 (8%)
Role was limited to observation only 4 (27%)
Provided community resources to the family 13 (87%)
Would recommend the virtual experience for PNP students 12 (80%)
Counseled on breastfeeding or bottle-feeding practices (n = 14) 11 (79%)
Counseled on safe sleep practices (n = 13) 10 (77%)
Provided anticipatory guidance on infant development (n = 14) 10 (71%)
Counseled on breastfeeding issues (n = 14) 7 (50%)

Qualitative data showed that students enjoyed providing anticipatory guidance related to newborn care, learning about diverse cultures and parenting styles, and learning about the available community resources. When asked what they learned, students reported learning about breastfeeding, depression screening, and common concerns mothers have about their newborns. Students offered suggestions to improve the clinical experience, which included increased participation in the visit and a simulated Family Connects visit with the faculty before the telehealth visit.

The nurse collaborators reported that students participated in the visits, and only once did a parent decline having an APRN student. They reported feeling prepared to collaborate with students and that they benefited from having a student participate in the visit. One nurse collaborator reported that at times she learned from the education the students presented to the families.

Open-ended question responses

Other concerns of the family discussed included access to care, resources, consolability, taking a temperature, when to go to the emergency room, constipation concerns, appropriate dress for temperature, fussiness, soothing measures, importance of reading to child, maternal depression and anxiety, social and financial support.

Resources provided included Mom's Line for postpartum depression, social work consults, online new moms group, and WIC information. An email with additional resources was sent to each family at the end of every session.

Aspect of the experience the students liked the most was providing anticipatory guidance, assessing mother's primary concerns/needs and listening to the guidance of the nurses, hearing common new-mother concerns and important topics to cover, how different cultures or parenting styles lead to varied inquiries or areas of concern related to infant care, gaining knowledge and information on the resources/education provided, being able to support and educate mothers, enjoying answering all the questions during the visit, and to have input from the Family Connects community health nurse as needed.

What did students learn from the experience included breastfeeding and pumping (how to discuss, what mothers concerns were, and information provided), common educational topics for anticipatory guidance, conducting the Edinburgh Postnatal Depression Scale and providing appropriate resources and follow-up, helping families troubleshoot during early days at home with newborn, what things parents are most concerned about, how mothers are often stressed post delivery, words of reassurance or connecting with resources makes a huge positive impact, became more confident in ability to interview and educate, newborn care, and importance of speaking up and offering to counsel the family.

Discussion/recommendations

The Family Connects virtual clinical experience was found to be a valuable learning experience for students with a majority reporting that they would recommend it to other PNP students. In addition, the students reported that the simulation and telehealth modules prepared them to provide this modality of health care during clinical practicum. Similar to family nurse practitioner students who opted for a telehealth experience as described by Gibson et al., students in this study were able to demonstrate telehealth competence in a clinical experience (2020). As was found by McClure et al (2021), students identified new community-based resources, reduced barriers to care, and improved care continuity that is inherent to the model. Specifically, students addressed the safety and well-being of the family, provided advanced level newborn care advice, completed an assessment of social determinants and any barriers to accessing care, and provided available community resource referrals to address any needs of the family to enhance the delivery of equitable health care through the Family Connects virtual clinical experience. Referral to community resources is a responsibility of NPs, and familiarity with the local resources can enhance this referral process as providers. Feedback from both the students and community health nurse collaborators suggests that some changes could be implemented to enhance the overall experience.

Recommendations for how to prepare students

Suggestions to improve clinical experience included an orientation or simulation day to review what would happen during a typical visit, allowing students to ask questions and participate not just listen, assigning students to a nurse collaborator for a longer period to ensure participation despite some patient no shows, including APRN faculty preceptors during the visits, allowing access to community health nurse collaborators after the experience to be able to ask follow-up questions, streamlining scheduling and contact, allowing all telehealth visits rather than some phone, and allowing students to meet with the nurse collaborator before the visit to review each case.

Suggestions for how we could have prepared students for the visits included simulation experience with the community health nurse collaborators to review a sample patient chart and completing a mock visit through telehealth or phone of an actual Family Connects visit rather than a varied telehealth scenario. Students suggested a more formalized orientation or workshop to ensure a more consistent experience for students and allow students to participate more in the visits while maintaining a safe, evidence-based visit for the parents.

Recommendations for how to prepare community nurse collaborators

Although it is an expectation that Faculty Practice community health nurses participate in the education of students, additional preparation for how to engage students in the visit and stimulate their critical thinking is recommended. It would also be beneficial if the nurse collaborators were familiar with the course content taught to students so they would understand a student's advanced knowledge surrounding topics to be discussed during a visit.

Limitations

The project involved a small cohort of advanced practice students, DNP faculty, and community health nurses at one hospital system. No demographic data or the amount of previous experience with telehealth or caring for infants and postpartum women were collected at the time of the survey, which further limits the application of results. Participation in the experience and completion of the evaluation survey was voluntary. Perhaps those students who chose to not participate would have reported a different experience than those who self-selected to participate. Another limitation of the project was that individual student evaluation of competency attainment was not conducted by DNP faculty. A group debriefing session was used to discuss how students met the objectives of the experience and the AACN Essentials addressed through the experience, but formal evaluation of each individual student was not a component of the project. One recommendation for the future would be for DNP faculty to evaluate each student to determine whether they met the advanced level competencies and at what level of achievement.

Conclusion

This project supports the current literature about the value of incorporating telehealth clinical experiences into the DNP curriculum to meet clinical objectives. Nothing was found in the literature about this modality to provide maternal–newborn content. This unique clinical opportunity filled a gap in students learning about early maternal–newborn health at the advanced nursing level by assessing social determinants of health, access to care, and providing needed resource referrals to address health equity in the community setting. Nurse practitioners need to understand the barriers to care presented by social determinants of health to build a partnership between primary care providers and the community to ultimately improve health outcomes. In subsequent cohorts, an evaluation of advanced level competencies would provide a more robust evaluation of the experience. Overall, thorough preparation for both students and community health nurse collaborators is essential for students to participate fully in the telehealth format, meet clinical objectives, provide education and anticipatory guidance at the advanced level to families related to many pediatric primary care topics, and rate the experience positively.

Acknowledgments:J. Doucette contributed substantially to the conception and design of the work, drafting of the manuscript, editing of the manuscript, and final approval of the version to be published. J. Rousseau contributed substantially to the conception of the design of the work, drafting the manuscript, editing the manuscript, and final approval of the version to be published. H. Vondracek contributed substantially to the development of the evaluation survey, data analysis, editing the draft, and final approval of the version to be published.

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Keywords:

Access to care; health equity; maternal–newborn home visits; nurse practitioner education; nursing competencies; social determinants of health; telehealth

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