1. Resident Home Visits in the First Month of Life Impact on Family Outcomes and Resident Education Mary Beth Sutter, MD Ashley Lakin, DO Susanna Magee, MD, MPH STFM National Conference 2013

2. Overview  Background on postpartum home visits and resident education  Methods and design  Results  Conclusions  Implications for future residency education

3. Literature Review- Meta-analysis 1  Home visits help families with young children Parental benefit: parenting behavior and attitudes Mothers return to school or seek education more often Cognitive and socio-emotional outcomes higher for children Actuality and possibility of abuse lower for children  Special populations outcomes: Low income families Low birth weight children Teen mothers 1. Sweet, M. & Appelbaum, M. (2004). Is Home Visiting an Effective Strategy? A Meta-Analytic Review of Home Visiting Programs for Families With Young Children. Child Development, 75, 1435-1456.

4. Literature Review- Composite  Maternal Outcomes Increased service satisfaction 2 Reduced rapid subsequent birth to teen mothers 3,4 Increased duration of breastfeeding 2 Shorter duration of usage of welfare and food stamp programs 4  Pediatric Outcomes Decreased utilization of emergency services for infants 2 Children demonstrated higher academic achievement 4 Lower rates of preventable mortality in children 4 2. Christie, J. & Bunting, B. (2011). The effect of health visitors’ postpartum home visit frequency on first time mothers: Cluster randomised trial. International Journal of Nursing Studies, 48, 689-702. 3. Barnet, B. et al. (2009). Motivational Intervention to Reduce Rapid Subsequent Births to Adolescent Mothers: A Community-Based Randomized Trial. Annals of Family Medicine, 7, 436-445. 4. Olds, D. et al. (2007). Effects of Nurse Home Visiting on Maternal and Child Functioning: Age-9 Follow-up of a Randomized Trial. Pediatrics, 120, 832-845.

5. Literature Review- Resident Education 5  Increased patient rapport: Patients found to be pleased, approving and trusting of visits  Increased resident knowledge of geriatrics across all fields: Performed more adequate patient assessments  Increased resident enthusiasm about home visits and intention of continuing them in future practice  Residents evaluated house calls as an important part of their residency training 5. Neale, A. et al. (1992). The Home Visit in Resident Education: Program Description and Evaluation. Family Medicine, 24, 36-40.

6. Methods- Study Design  June 2012-present  Patient population 18 resident clinic continuity pairs Predominately Medicaid insured, high risk population Age range 18-30; G1-G3  Pairs randomized and analyzed prospectively Controls- Well child checks in clinic usual schedule Cases- Two home visits replacing well checks

7. Methods- Visit Structure  1 week and 1 month of life  With continuity resident and one of the researchers  Overall content similar to usual clinic WCC  Anticipatory guidance tailored to Mom-baby pair

8. Methods  Home visit kit

9. Methods  Outcomes measurements  EMR review for maternal and child outcomes  Maternal quality of life 6 WHO QOL-BREF scale Validated in postpartum women  Patient satisfaction 7 Validated primary care scale  Maternal qualitative survey  Resident qualitative survey 6. Hill, P., et al. (2006). Maternal Postpartum Quality of Life Questionnaire. Journal of Nursing Measurement, 14, 205-217. 7. Hojat, M., et al. (2011). A Brief Instrument to Measure Patients’ Overall Satisfaction with Primary Care Physicians. Family Medicine, 43, 412-417.

10. Results  EMR Analysis- Pediatric Outcomes Majority in both groups adherent to AAP well child check schedule

11. Results  EMR Analysis- Maternal Outcomes  Majority in both groups Long acting reversible contraception Adhered to postpartum visit by 8 weeks  Postpartum depression equal in both groups (23.5%)  Breastfeeding 88% in home visit group attempted vs 38% in control Duration 1-15 weeks home, 3-8 weeks in control

12. Results  Post Intervention Quality of Life and Patient Satisfaction  Environment domain reached statistical significance

13. Results- Patient Survey  100% of participants would recommend to a friend  “Being able to be cared for in our own home gave us license to be truly authentic about our postpartum experience”  “By being in our home, the doctors were able to connect with us on a deeper level”  “Warm, supportive, and comforting”

14. Results- Provider Survey  “Best time of my day”  “It was a bonus to go with colleagues who were able to teach me along with the family”  “It gave me a better understanding of my patient and her baby by seeing the way they live”  “The home visit is an intimate space: it allowed me to spend more focused time and made me feel even more connected to my patient and her growing family”

15. Conclusions  Home visit group:  Lower usage of acute clinic resources  Higher rates of trial of breastfeeding and longer duration  Higher overall quality of life scores  Significant difference in Environment domain  No difference in:  Well care or contraception  Postpartum depression  Patient satisfaction

16. Conclusions  Limitations  Sample size not adequate to determine statistical significance for many measures  Logistical challenges (number of providers, time, grant funding)  Bias of already surprisingly high patient satisfaction and contraception use  Selection bias for resident participants  Future Directions  Repeat with higher sample size and more residents  Aim to incorporate into residency curriculum

17. Conclusions  Experiential learning  Added a new dimension to doctor patient relationships  Changing perceptions of patient support network  Created a unique space for honesty and vulnerability  Maternal child unit- rather than separate patients  Near misses in control patients

18. Acknowledgements  We would like to thank the Elise Coletta Educational Leadership Grant for their generous gift