Perinatologists and Advanced Practice Nurses Collaborate to Provide High Risk Prenatal Care in Rural Virginia Communities
Title: Perinatologists and Advanced Practice Nurses Collaborate to Provide High Risk Prenatal Care in Rural Virginia Communities
- Cite two associated outcomes supporting improved access to high risk care for low income women in rural communities.
- Describe how nurse practitioners and perinatologists worked collaboratively to provide high risk prenatal care in rural communities.
- Debate the effectiveness of the use of telemedicine and collaborative care to provide high risk prenatal care in rural communities.
Proposed change: Adequate and early access to risk appropriate prenatal care can reduce the incidence of adverse outcomes. Access disproportionately affects women of low socioeconomic status and limited English in rural communities. Distance and costs associated with frequent travel, and the limited number of perinatologists are barriers to high risk care. Telemedicine can reduce barriers through collaboration of perinatologists and Advanced Practice Nurses. Telemedicine has shown favorable results in a variety of clinical disciplines. Prenatal care is a relative newcomer to the spectrum of health care provided via telemedicine.
Implementation, outcomes and evaluation: Collaborative High Risk OB Telemedicine clinics were implemented in five rural locations between 2009 and 2013. Local clinics serving the targeted population were solicited as partners. Hands-on prenatal care and exams at the local site were provided by nurse practitioners. Video Telemedicine visits were in real time with the patient, local practitioner, and remote perinatologist. The telemedicine clinics served 374 patients. With IRB approval, charts were reviewed to compare patient access measures and pregnancy outcomes before and after initiation of telemedicine. The comparison group consisted of 181 patients. Demographic, patient access, and pregnancy outcome data for women referred before and after the initiation of the telemedicine clinics were compared using two-sample t-tests and chi-square.
Women receiving care before telemedicine had a higher rate of missing one or more prenatal visits compared to the telemedicine group (57.1% vs 21.3%, p-value 0.000). The overall missed visit rate decreased from 0.71 to 0.53 per patient (p=0.086). There was no difference in the groups for gestational age at first visit (13.6 vs 14.0 weeks). Deliveries after 37 weeks were similar (84% pretelemed vs 83% telemed). The telemedicine group had higher mean birth weight (3226 vs 3137 grams, p=NS). There was no difference in NICU admission rate (12.0% vs 10.8%); mean NICU days were reduced in the telemedicine group (22.11 to 13.42, p less than 0.01). Aggregate saved patient travel was 162,126 miles in 3 years.
Implications for nursing practice: Collaborative care through telemedicine is an effective method for providing high risk prenatal care to women living in rural communities. When compared to traditional care, telemedicine was associated with improved access to care and similar rates of important outcomes.
Keywords: telemedicine, collaborative care, rural health care, advanced practice nurse, high risk prenatal care