6
Providing for the Continuity of Nutritional Care

Delivering appropriate, coordinated nutrition services to cover the period beginning before conception and extending through infancy poses major challenges, especially because services typically are delivered at different sites and by different providers. For mothers or infants with special nutritional problems, continuity of care is especially important when a move is made from one site or level of care to another. Moreover, continuity of care may be especially difficult to achieve for the large numbers of women and families who do not have regular care providers, who experience shifts in their financial eligibility for services, who move between geographic areas (e.g., migrant workers), or who find it difficult to make the travel and child care arrangements necessary for acting on referrals or continuing with regular care.

Disadvantaged women have disproportionately high rates of preterm delivery, low-birth-weight infants, and other complications and adverse outcomes of pregnancy. Thus, efforts to overcome financial, cultural, language, and other barriers to effective communication and the continuity of nutritional care are especially valuable for such women and their families.

This chapter briefly reviews three approaches that have been proposed for improving communication and continuity of care:

  • efforts to implement coordinated services, including one-stop shopping ("any local service system of integrated service delivery, where



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 93
Nutrition Services in Perinatal Care 6 Providing for the Continuity of Nutritional Care Delivering appropriate, coordinated nutrition services to cover the period beginning before conception and extending through infancy poses major challenges, especially because services typically are delivered at different sites and by different providers. For mothers or infants with special nutritional problems, continuity of care is especially important when a move is made from one site or level of care to another. Moreover, continuity of care may be especially difficult to achieve for the large numbers of women and families who do not have regular care providers, who experience shifts in their financial eligibility for services, who move between geographic areas (e.g., migrant workers), or who find it difficult to make the travel and child care arrangements necessary for acting on referrals or continuing with regular care. Disadvantaged women have disproportionately high rates of preterm delivery, low-birth-weight infants, and other complications and adverse outcomes of pregnancy. Thus, efforts to overcome financial, cultural, language, and other barriers to effective communication and the continuity of nutritional care are especially valuable for such women and their families. This chapter briefly reviews three approaches that have been proposed for improving communication and continuity of care: efforts to implement coordinated services, including one-stop shopping ("any local service system of integrated service delivery, where

OCR for page 93
Nutrition Services in Perinatal Care women and children can receive multiple health and/or social services at one site" (p. 6),1 the integration of a well-designed, patient-carried health diary into the delivery of services, and the development and integration of computer-based patient records and systems.2 The second approach appears to be relatively easy to achieve; implementation of the other two would require greater commitment and effort, but it is reasonable to expect that such efforts would result in substantial improvements in care. Although these three approaches are intended to improve many aspects of overall health care, they may be especially useful in facilitating the improved delivery of nutrition services in support of maternal and infant health. COORDINATED SERVICES The coordination of health care services, food assistance, and social services can promote continuity of care and improve the integration of nutrition services into the care of pregnant and postpartum women. In 1986, the U.S. Departments of Health and Human Services (DHHS) and of Agriculture jointly sponsored a study of coordination between the Maternal and Child Health (MCH) Program of DHHS and the Special Supplemental Food Program for Women, Infants, and Children (WIC). The study concluded that coordinated care has the following objectives: a well developed referral system among the providers for each program the transfer of needed information between providers on an anticipatory basis avoidance of unnecessary duplication of functions between MCH and WIC programs, such as blood and anthropometric measurements the scheduling of services and different aspects of care such that they contribute to, rather than interfere with, the services and care being delivered in another program the design, content, and delivery of nutrition-related education components which do not contradict those delivered by another program serving the same patient improved case management, continuity of care and follow-up of shared clients (p. ii).3

OCR for page 93
Nutrition Services in Perinatal Care The report of the first Ross Roundtable on Current Issues in Public Health, The Role of MCH and WIC in the Delivery of Local Health Services ,4 continued the dialogue on this topic: ''The . . . greatest challenge is for all of us to realize that to meet needs, maternal and child health and nutrition must consist of more than WIC and more than Title V MCH nutrition services. We must be in collaboration—not in competition—with many other food, health, education, and welfare programs'' (p. 84).4 The scope of coordinated care is described in two publications of the National Governors' Association;5,6 the concept of one-stop shopping incorporates techniques for delivering such care. The three key elements of one-stop shopping7 are (1) location of several health and human services at the same site, and development of procedures to integrate those services or to schedule several appointments sequentially so that the number of trips for care can be minimized; (2) establishment of a uniform application process for programs (e.g., only one form need be completed to determine eligibility for Medicaid, WIC, and a state-funded health care program); and (3) provision for handling applications for assistance at the site of care delivery (which may include assigning workers to distant sites—sometimes called "outposting" or "outstationing"8). Many one-stop shoppping programs have been implemented. In Idaho, for example, a comprehensive prenatal health care model with one-stop shopping has led to expansion and improvement of WIC services; WIC, in turn, has helped attract and maintain participation in prenatal care.9 Watkins and colleagues10 describe a model program targeted to migrant women and their children that also emphasized coordinated services and follow-up. With appropriate case coordination, there is considerable potential for promoting continuity of nutritional care in the public sector, especially since Medicaid funds can be used for perinatal nutrition services in many states.11,12 In North Carolina, improved maternity care coordination for women on Medicaid has been associated with reductions in low birth weight, infant mortality, and medical care costs for newborns.13 PATIENT-CARRIED HEALTH DIARIES The Omnibus Budget Reconciliation Act of 1989 required the Secretary of Health and Human Services to develop a model national maternal and child health handbook. Under the leadership of the Maternal and Child Health Bureau, a handbook called Health Diary is being developed (I. Heyman, Maternal and Child Health Bureau, personal communication, 1992). The Health Diary covers the period from concep

OCR for page 93
Nutrition Services in Perinatal Care tion through the second year after birth, providing basic information that includes recommendations on weight gain during pregnancy, healthful diets, and breastfeeding. It allows both the provider and the woman to record items of importance: any questions the woman may have, weights (of mother or baby, or both), advice given during the visit, date of the next appointment, and other matters. The diary is intended to enable the woman to be an active participant in her own and her infant's health care, encourage the adoption and maintenance of healthy behaviors, encourage the seeking of care, and enhance communication between providers and patients. The functions described above for the health diary are similar to those suggested by Giglio and Papazian14 for specially designed patient-carried records. (These records, which the woman keeps, are sometimes called "passports," "handbooks," or cards, depending on the form they take.) Studies suggest that several types of patient-carried records can help to promote continuity of care—for example, family-carried growth records,15 antenatal cooperation cards,16 adverse drug reaction cards, 17 and reminder cards for health maintenance procedures.18 More elaborate patient-carried records have been reported to hold potential for improved care of migrants10 and of homeless men.19 In 1990,18 of the 54 states and territories reported the development of some type of patient-carried record,1 and 8 of these had at least one kind of form for pregnant women (see, e.g., Baby Your Baby Health Keepsake20 ). There is at least one large-scale example of patient-carried records in operation: U.S. military health care facilities give their patients (including dependents of military personnel) their health records to carry. Although this system is not without problems,21 its long history indicates that patient involvement can provide a useful means of improving continuity of care. The importance ascribed to patient-carried records by many in the public health field was highlighted in 1991: among the key actions in the Public Health Service's 1991 Plan to Strengthen Public Health in the United States22 is the development of "maternal and child health handbooks to provide a home-based health record and basic information on health and development for pregnant women and new families" (p. 81).22 If health diaries with a strong nutritional component become widely used in maternal and infant care, improvements can be expected in both communication with patients and the continuity of nutritional care. For maximum effectiveness, clinicians need to use the health diary to identify and record nutrition-related information during health care visits, encourage the woman to use it at home, and ask her to bring it to office visits. In this way, reasonable tracking of the woman's nutritional care and

OCR for page 93
Nutrition Services in Perinatal Care progress can occur even if the woman must see many different providers at different sites. COMPUTER-BASED PATIENT RECORDS AND SYSTEMS The Institute of Medicine Committee on Improving the Patient Record has recommended the following: "Health care professionals and organizations should adopt the computer-based patient record as the standard for medical and all other records related to patient care" (p. 6).2 That committee views the future patient record as offering broader functions than those provided by current record systems: The future patient record will be a computer-based, multimedia record . . . that offers access (availability, convenience, speed, reliability, and ease of use), quality, security, flexibility, connectivity, and efficiency. In addition, future patient records will provide new functions through links to other databases and decision support tools(p. 135).2 The committee's final report, The Computer-Based Patient Record: An Essential Technology for Health Care,2 contains a strategic implementation plan, advocates prompt development and implementation of the system (within the decade), and addresses measures to protect the patient's confidentiality. Such a system would have special utility for the maternal and child health population2 and would allow great strides to be made in nutritional care. Individualized nutritional care plans could be developed and updated readily for women and their infants—including those who require complex care because of health problems or disabilities. Only authorized care providers would have access to the information entered into the data base concerning the results of nutritional assessments, the setting of specific nutritional objectives, changes in the patient's status, and so forth. Transfer of information about the mother relevant to the care of the infant could be handled easily, and advanced features could facilitate decision making in complex situations, such as the nutritional care of very-low-birth-weight infants.

OCR for page 93
Nutrition Services in Perinatal Care SUMMARY Improved delivery of nutritional care in support of maternal and infant health requires concrete measures to improve communication and continuity of care. Promising approaches with widespread applicability include expansion of the one-stop shopping concept, development and widespread use of patient-carried health diaries that have a strong nutritional component, and development and implementation of computer-based patient record systems. Until such approaches become widely available, providers can use forms, referrals, supportive personnel (e.g., case managers and nurse home visitors), and other linkages to foster improved continuity of care. REFERENCES 1. Association of Maternal and Child Health Programs. 1990. Building on the Basics: Four Approaches to Enhancing MCH Service Delivery. Association of Maternal and Child Health Programs, Washington, D.C. 2. Institute of Medicine; Dick, R.S., and E.B. Steen, eds. 1991. The Computer-Based Patient Record: An Essential Technology for Health Care. National Academy Press, Washington, D.C. 3. Pindus, N., B. Duggar, and C. Schulz. 1986. Improving MCH/WIC Coordination: Final Report and Guide to Good Practices. Professional Management Associates, Inc., Rockville, Md. 4. Dwyer, J.T., ed. 1987. The Role of MCH and WIC in the Delivery of Local Health Services. Report of the First Ross Roundtable on Current Issues in Public Health. Ross Laboratories, Columbus, Ohio. 5. Hill, I.T., and Bennett, T. 1990. Enhancing the Scope of Prenatal Services: Strategies for Improving State Perinatal Programs. National Governors' Association, Washington, D.C. 6. Hill, I.T., and J. Breyel. 1989. Coordinating Prenatal Care. National Governors' Association, Washington, D.C. 7. Macro Systems, Inc. 1990. One-Stop Shopping for Perinatal Services. Identification and Assessment of Implementation Methodologies. National Center for Education in Maternal and Child Health, Washington, D.C. 8. Hill, I.T. 1988. Reaching Women Who Need Prenatal Care. National Governors' Association, Washington, D.C. 9. Machala, M., and M.W. Miner. 1991. Piecing together the crazy quilt of prenatal care. Public Health Rep. 106:353–360. 10. Watkins, E.L., K. Larson, C. Harlan, and S. Young. 1990. A model program for providing health services for migrant farmworker mothers and children. Public Health Rep. 105:567–575. 11. Caldwell, M. 1991. Financing nutrition programs. Pp. 289–302 in C. Sharbaugh, ed. Call to Action: Better Nutrition for Mothers, Children, and Families. National Center for Education in Maternal and Child Health, Washington, D.C. 12. Summer, L. 1991. Working Together. A Guide to Coordinating WIC and Medicaid Services. Center on Budget and Policy Priorities, Washington, D.C.

OCR for page 93
Nutrition Services in Perinatal Care 13. Buescher, P.A., M.S. Roth, D. Williams, and C.M. Goforth. 1991. An evaluation of the impact of maternity care coordination on Medicaid birth outcomes in North Carolina. Am. J. Public Health 81:1625–1629. 14. Giglio, R.J., and B. Papazian. 1986. Acceptance and use of patient-carried health records. Med. Care 24:1084–1092. 15. Young, S.A., M. Kaufman, K. Larson, and E.L. Watkins. 1990. Family-carried growth records: a tool for providing continuity of care for migrant children. Public Health Nurs. 7:209–214. 16. Draper, J., S. Field, H. Thomas, and M.J. Hare. 1986. Should women carry their antenatal records? Br. Med. J. 292:603. 17. Hannaford, P.D. 1986. Adverse drug reaction cards carried by patients. Br. Med. J. 292:1109–1112. 18. Turner, R.C., L.E. Waivers, and K. O'Brien. 1990. The effect of patient-carried reminder cards on the performance of health maintenance measures. Arch. Intern. Med. 150:645–647. 19. Reuler, J.B., and J.R. Balazs. 1991. Portable medical record for the homeless mentally ill. Br. Med. J. 303:446. 20. Utah Department of Health, Family Health Services Division. 1990. Baby Your Baby Health Keepsake. Utah Department of Health, Salt Lake City. 21. Curtis, M.R. 1989. The patient-carried medical record. J. Qual. Assurance 11(1):34. 22. Assistant Secretary for Health's Public Health Service Task Force to Strengthen Public Health in the United States. 1991. A plan to strengthen public health in the United States. Public Health Rep. 106 (Suppl. 1):1–86.

OCR for page 93
Nutrition Services in Perinatal Care This page in the original is blank.