Problem stabilization: A metric for problem improvement in home visiting clients

Background: Public health nurse (PHN) home visiting programs have been widely employed to improve life course trajectories for high risk mothers. Home visiting programs are often lengthy, during which PHNs simultaneously address multiple problems using diverse interventions over several client encounters. To manage PHN caseloads it is critical to understand the trajectory of client improvement and the optimal duration or services. PHN documentation data enable intervention trajectory research for specific client problems. A new metric called problem stabilization is proposed for evaluating interim improvement during PHN home visiting. Problem stabilization is an intervention pattern for a client problem that is characterized by co-occurring actions (i.e. teaching, guidance, and counseling; treatments and procedures; case management; and/or surveillance) during a client encounter; followed by surveillance actions only for that problem during a subsequent client encounter. The purpose of the study was to investigate problem stabilization during home visiting services for high risk mothers. Methods: A retrospective cohort was created using family home visiting intervention documentation data from a local Midwest public health agency over a six year period (2000-2005). The data set consisted of Omaha System interventions for 720 high risk mothers. Analysis was conducted using descriptive statistics and Kaplan Meier curves. Results: On average 30.1% of the time, client problems stabilized before discharge. Stabilization patterns differed by problem. Time to stabilization was longest for Caretaking/parenting and Antepartum/ postpartum problems, and shortest for Residence and Mental health problems. Conclusions: Problem stabilization, a proposed intermediate outcome of PHN home visiting care, appears to be meaningful in describing client response to PHN intervention. This metric is an example of meaningful use of structured clinical electronic health record data for program evaluation and clinical decision support.