# Presentation: 559262

## Home Visiting New Hampshire Best Practices Project

- Lisa Bujno				Betsey Eltonhead
- Administrator			Senior Consultant
- Maternal and Child Health Section	HealthMETRICS
- Division of Public Health Services	Bedford, MA
- NH DHHS				(781) 687-9500
- (603) 271-4516		         beltonhead@healthmetricspartners.com lbujno@dhhs.state.nh.us

## Home Visiting New Hampshire

**Home Visiting New Hampshire (HVNH) **is a preventive program that provides health, education, support and linkages to other community services to Medicaid-eligible pregnant women and their families in their homes.

## Who Provides HVNH Services?

- The NH Department of Health and Human Services, Division of Public Health Services, Maternal and Child Health Section contracts with 18 community based agencies across the state
- VNA’s
- Community Heath Centers
- Family Resource Centers
- Hospitals

## Unique Qualities of HVNH

- HVNH has adapted successful models of home visiting to the unique needs of New Hampshire families
- A nurse and parent educator team regularly visits a woman at her home from early in her pregnancy until her child’s first birthday
- Families, home visitors and healthcare providers form a team to ensure that families can address concerns such as smoking cessation, depression and access to reproductive
-      healthcare.

## Best Practice Strategy

- Identify the Best Practice for providing home visiting services:
- Episode of care (from enrollment in the program until graduation from the program)
- Visits which make up episode of care
- Systematically measure and evaluate across sites:
- Clinical Quality
- Unit Costs
- Participant Satisfaction
- Staff Satisfaction

## HVNH Best Practice Project Results

- Very high participant satisfaction.
- Good clinical outcomes.
- High staff satisfaction
- By implementing appropriate components of the Best Practice Process, there is opportunity to:
- Reduce unit costs on average by 19%.
- Maintain or enhance satisfaction and clinical outcomes

## Summary of Variation in Process

|  | Range | Average |
| --- | --- | --- |
| Number of Visits per Episode | 24.7 – 50.2 | 38.1 |
| Visit Prep Time (min) | 8 – 30 | 17 |
| Visit Length Time (min) | 25 – 86 | 61 |
| Visit Follow Up Time (min) | 15 – 60 | 26 |
| % Visits by Home Visitors | 49% - 88% | 77% |
| No Show Rate | 2% - 13% | 8% |
| Non-Direct Clinical Time | 7% - 59% | 29% |
| Management/Supervisor FTE | .15 – 1.16 |            .47 |

## Variation in Overall Participant Satisfaction

- Average = 7.0

- Average = 6.89

- Average = 6.84

**Average = 6.76**

- Average = 6.63

- Average = 6.39

-  = 6.78

## Drivers of Participant Satisfaction

## Variation in Overall Staff Satisfaction

**= 5.90**

- Average = 6.30

**Average = 6.20**

- Average = 6.10

- Average = 5.80

- Average = 5.80

- Average = 5.14

## Drivers of Staff Satisfaction

## Clinical Indicators

| Delivery Outcomes |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- |
|   | Best Practice | Site 2 | Site 3 | Site 4 | Site 5 | Site 6 | Total |
| Total charts reviewed | 50 | 50 | 34 | 28 | 46 | 25 | 233 |
| % of low risk clients with adverse outcomes | 3% | 19% | 12% | 14% | 31% | 50% | 22% |
| % of high risk clients with adverse outcomes | 7% | 12% | 31% | 36% | 30% | 26% | 24% |
| % of clients with adverse outcomes using weighted average | 5% | 16% | 22% | 25% | 31% | 38% | 23% |
| Adverse outcomes found in this study include: miscarriage, complications during delivery, birth weight <2,500g >4,500g, gestational 
age <37 weeks, NICU admission>24 hours, hospital readmission of mother after delivery, hospital readmission of baby after delivery |  |  |  |  |  |  |  |

## Clinical Indicators Ranking

| Rankings for Clinical Indicators |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- |
|   | Best Practice | Site 2 | Site 3 | Site 4 | Site 5 | Site 6 |
| Delivery Outcomes | 1 | 5 | 6 | 3 | 2 | 4 |
| WIC Enrollment (% change from Intake to Birth Interview) | 2 | 4 | 1 | 6 | 5 | 3 |
| Health Insurance for Mom (% change from Intake to Birth Interview) | 3 | 2 | 1 | 5 | 4 | 5 |
| Health Insurance for Baby (Exit Interview) | 6 | 1 | 4 | 5 | 1 | 1 |
| Healthcare Provider for Mom (% change from Intake to Exit Interview) | 3 | 2 | 1 | 6 | 4 | 5 |
| Healthcare Provider for Baby (% change from Birth to Exit Interview) | 1 | 2 | 4 | 3 | 4 | 4 |
| Depression Screening (average across episode) | 3 | 4 | 1 | 2 | 6 | 5 |
| Smoking (greatest % decrease from Intake to Birth Interview) | 2 | 4 | 6 | 1 | 3 | 5 |
| Breastfeeding (Birth Interview) | 1 | 3 | 6 | 2 | 5 | 4 |
| Total score | 22 | 27 | 30 | 33 | 34 | 36 |

## Episode Costs (Adjusted)

## Best Practice Model

**Percentage of non-direct clinical time: <20%**
**Time spent on the visit and associated functions**
- 		Home Visitor
- 			Prep: 15 minutes
- 			Visit: 60 minutes
- 			Follow-up: 20 minutes
- 		Registered Nurse
- 			Prep: 7.5 minutes
- 			Visit: 64 minutes
- 			Follow-up: 15 minutes

## Best Practice Model

**Staff mix**
- 88/ 12% (Home Visitor/ Registered Nurse)
- RNs provide one visit per trimester of a client’s pregnancy, and 3 visits postpartum. The first RN visit post delivery occurs soon after the birth, the second visit around six months postpartum and the last at the time of program exit.
- HVs visit every other week except the month prior to the birth of the baby when they visit every week. They also visit weekly for the month after the baby is born, and then resume biweekly visits.
** ****Supervision**
-  .52 FTE or less