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    FILE No. 234 09/24 '96 12:52 ID:AMER.ACADEMY PEDS. 1 202 393 6137 PAGE 1 American Academy of Pediatrics Department of Government Liaison Suite 400 North 601 13th Street, N.W. Washington, D.C. 20005 Phone: 800/336-5475 or 202/347-8600 Fax: 202/393-6137 To: Barbara Costello FAX 4562239 From: Todd Askew e-mail: [email protected] Date: September 24, 1996 Page 1 of 17 Re: States with early discharge requirements (descriptions attached) Alabama Oklahoma Alaska Pennsylvania Connecticut Rhode Island Florida South Carolina Georgia South Dakota Illinois Tennessee (by regulation) Indiana Virginia Iowa Washington Kansas Kentucky TOTAL: 29 as of 9/4/96 Maine Maryland Massachusetts Also, Delaware requests Minnesota voluntary adoption. Missouri New Hampshire New Jersey New Mexico (by regulation) New York North Carolina Ohio FILE No. 234 09/24 '96 12:52 ACADEMY PEDS. 1 202 393 6137 PAGE 2 002 09/04/96 WED 11:38 FAX 2286432 HPSA INSURANCE COVERAGE FOR POST-DELIVERY CARE 9/4/96 STATE BILL STATUS COVERAGE REQUIRED FOR COVERAGE OF POST COMMENTS NUMBER VAGINAL BIRTH/CESAREAN DISCHARGE CARE ALABAMA SB 535 Died in Com Requires coverage of medically Not addressed. HB 624 Bnacted necessary care as determined by 1996 OB, pediatrician or other physician & requires postpartum care to be consistent with Guidelines for Perinacel Care. ALASKA SB 193 Enacted Min. 48 hrs. inpatient care for Not addressed. 1996 vaginal birth; 96 hrs. cesarvan. ARIZONA SB 1262 Died in Com Min. 48 hrs. inpationt care for 1 visit within 48 hrs. of AZ Medical Society vaginal birth; 96 hrs. desarean. discharge. including par- & state's 8 HMO6 Permits earlier discharge after ent od., physical assess- agreed physicians olinioal observation and consulta- ment of newborn, breast/ would determine the tion with mother. bottle feeding, tests, & length of stay using assessment of home the Guidelines & support. physician-patient consultation. ARKANSAS CALIFORNIA AB 1841 Died in Com Coverage of stay as determined by Followup visit within 48 replaces physician pursuant to guidellnes hrs. of discharge if pres- AB 1978 adopted by insurer, based on AAP/ oribed by provider. ACOG Guidelines for Perinatal Care. Also applies to postpartum care for home births if home birth is covered benefit. AB 3005 Died in Com Requires insurers to cover medical standards of care including those of AAP and ACOG. COLORADO HB 1015 Withdrawd Min. of 48 hrs. inpatient care for Major insurers in vaginal birth, 96 hrs. cesarean. state agreed to pro- Permits carlier discharge if joint vide 48/96 hr. cover- depision by mother & physician. age & to follow AAP/ ACOG Guidelines. @ 1996, AMERICAN ACADEMY OF PEDIATRICS FILE No. 234 09/24 '96 12:53 ID:AMER. ACADEMY PEDS. 1 202 393 6137 PAGE 3 09/03/96 TUE 16:09 FAX 2286432 HPSA d 003 INSURANCE COVERAGE FOR POST-DELIVERY CARE Page 2 STATE BILL STATUS COVERAGE REQUIRED FOR COVERAGE OF POST COMMENTS NUMBER VAGINAL BIRTH/CESAREAN DISCHARGE CARE CONNECTICUT HB 5313/ Died in Com Min. 48 hrs. inpatient care for vag- 1 visit within 48 hrs. of SB 330 Enacted inal birth; 96 hrs. cesarean. Per discharge; 1 within 7 days 1996 mile shorter stay if decision made of discharge, including: by providers after conferring with parent ed., physical mother. assessment, assistation with breast/bottle feeding, home support, tests. DELAWARE HCR 30 Enauted Creates task force. 1995 HB 357 Died in Com Requires coverage of at least 48 Not addressed. hrs. impatient care if health CAFE provider prescribes it. HB 404 Died in Com Requires coverage of at least 48 Not addressed. hrs. inpatient care if health care provider prescribes it. HCR 61 Adopted Requests voluntary adoption of Guidelines for Perinatal Care by insurers. DISTRICT OF CB 598 In Comm Requires coverage of inpatient Visits prescribed by phy- COLUMBIA care in accordance with Guidclines sician in accordance with for Perinacal Care (AAP & ACOG) Guldelines/Standards, by or Standards for Obsterric-Gyne- RN, including: parent od., cologic Services (ACOG). Permits assistance with breast or shorter stay if physician finds baby bottle feeding, necessary meets medical stablity criteris of tests. either document. FLORIDA HB 103 Tabled Requires coverage of min. 48 hrs. Required to include infant SB 350 Died in Com for vaginal birth, 96 hrs. coserean. feeding education, physt- Permits earlier discharge if mother cian referral, assessment and infant meet guidelines of Agen- of mother and child, meta- cy for Health Care Administration bollie tests. or if coverage provided for home or office visit within 48 hrs. SB 1086 Died in Com Prohibits insurers from limiting FOV See left column. HB 2079 crage for inpatient stay/ follow-up care to less than that determined medically necessary by physician. Page 2 FILE No. 234 09/24 '96 12:53 ID:AMER. ACADEMY PEDS. 1 202 393 6137 PAGE 4 09/03/96 TUE 18:10 FAX 2286432 HPSA 004 INSURANCE COVERAGE FOR POST-DELIVERY CARE Page 3 STATE BILL STATUS COVERAGE REQUIRED FOR COVERAGE OF POST COMMENTS NUMBER VAGINAL BIRTH/CESAREAN DISCHARGE CARE FL, cont. SB 1860 Enacted Required to provide coverses of Requires coverage of 1996 period determined necessary by post-delivery care for pair provider in accordance with pre- 14 determined necessary valling standards. specifically the by provider in hospital. Guidelines for Perinatal Care. home/office: physical assessment. necessary ICHER, immunizations. GEORGIA HB 1114 Died in Com Requires coverage of min. 48 hrs. Requires coverage of 1 Defines "arrending for vaginal birth, 96 hrs. cesarean. follow-up visit if dis- provider" as OB, ped Requires decision on shorter stay charged in less than 48/96 iardejan, other to be made by attending provider hrs., including physical physician or nurse in consultation with mother. assessment, parent ed., midwife. breast/bottle feeding, home support assessment & necessary tests. SB 482 Enacted Requires coverage of min. 48 hrs. Min. 1 visit by within "Attending provider" 1996 for vaginal birth, 96 hrs. cosarean. 48 hrs. of discharge, by defined as pediatri- Requires decision on shorter stay physician, RN or PA inclu- cian, OB, other to be made by attending physician ding parent ed., breast or physician or certified in consultation with mother. bords feeding, necessary nurso midwife. clinical tests, home sup- port assessment. HB 1189 Died in Com Requires coverage of min. 48 hrs. Min. 2 visits, the lat within for vaginal birth, 96 hrs. casarean. 48 hrs. of discharge, in- Parmits shorter stay if decision cluding: physical авзеня- made by provider in consultation ment, parent ed., home with mother. support, assistance with breast/bottle fooding, necessary tosts. HAWAII HB 2530 Died in Com Min. 48 hrs. inpatient care for 1 visit. vaginal birth; 96 hrs. cesarean, excluding policies covering home visit, unless inpationt care deter- mined medically necessary by physician/ is requested by mother. Page 3 FILE No. 234 09/24 '96 12:54 ID:AMER. ACADEMY PEDS. 1 202 393 6137 PAGE 5 09/03/96 TUE 16:10 FAX 2288432 HPSA 0 005 INSURANCE COVERAGE FOR POST-DELIVERY CARE Page 4 STATE BILL STATUS COVERAGE REQUIRED FOR COVERAGE OF POST COMMENTS NUMBER VAGINAL BIRTH/CESAREAN DISCHARGE CARE HI, cont. SB 2318 Died in Com Min. 48 hrs. inpationt care for Not addressed. Defines "attending vaginal birth; 96 hrs cesarcan, physician" as OB, permitting shorter stay if decision pedistrician, certified made by physician In consultation midwife. with mother. SB 265B/SB Died in Com Min. 48 hrs. inpatient care for vag- Defines "attending 3088 ipal birth; 96 hrs. cesarean, ox- physician" MS OB, cluding policies covering home pediatrician, or other Visits unless physician determines physician. impatient care medically necessary or is requested by mother. SCR 135 Died in Com Requests study. IDAHO ILLINOIS HB 2514, Died in Com Requires coverage of min. 48 hrs. Min. 3 visits by RN within "Artending physician" SB 1221, for vaginal birth, 96 hrs. desarean. 24 hrs. of discharge, be defined an pediatri- SB 1222 Excludes policies covering home tween 25-48 hrs. & be cian, OH, or other visits unless hospital stay deter- twoen 96-120 hrs., inclu- physician. mined to be medically necessary ding parent ed., breast or by attending physician. bouls feeding, necessary olinioal tests. HB 2557 Enacted Requires coverage of min. 48 hrs. Requires coverago of 1 "Attending physician" 1996 for vaginal birth, 96 hrs. cesarean. visit if discharged prior to defined N.W OB, podi- Excludes policies covering home 48/96 hrs. or if prescribed atrician, or other visit unless hospital stay deter- by physician. Visit by RN physician mined to be medically necessary within 48 hrs. of discharge by accending physician. including physical assons- ment of baby, feeding assistance, assessment of home support system, & necessary care. HB 2558 Died in Com Requires health dept. to adopt rules requiring hospitals to comply with AAP/ACOG recommendations on duration of hospital stay. Adde right to such length of stay to Mod- ical Patient Rights Act. Page 4 FILE No. 234 09/24 '96 12:55 ID:AMER. ACADEMY PEDS. 1 202 393 6137 PAGE 6 09/03/96 TUE 18:11 FAX 2286432 HPSA 4. 006 INSURANCE COVERAGE FOR POST-DELIVERY CARE Puge S STATE BILL STATUS COVERAGE REQUIRED FOR COVERAGE OF POST COMMENTS NUMBER VAGINAL BIRTH/CESAREAN DISCHARGE CARE II., cont. HB 3298 Died in Com Min. 48 hrs. inpatient care for vage Visit by RN within 48 hrs. Defines "artending inal birth;96 hrs. cossion. exclu- of discharge if released physician" 28 OB, ding policies covering home visits early or if prescribed by pediatricisn, or other unless impatient care determined physician, including: par- physician. medically necessary by physician. ent al., physical ASSOSS- ment, assistance with breast/hoole feeding, etc. SB 1415 Died in Com Min. coverage of 48 hrs. inpasient Regardless of discharge Defines "attending cure for vaginal birth; 96 hrs. time, coverage of home physician" as OB, cesarean excluding policies cov- visit by RN within 48 hrs.: pediatrician, family ing home visits unless inpatient physical assessment, practice physician, care determined necessary by parent ed., assistance or other physician. physician. with breast/bottle feeding home support assessment necessary lests. INDIANA sa 59, SB Died in Com Requires coverage of 48 hrs. of 68, HB 1068 inpatient DATE for vaginal birth: 96 hrs. for occarean section. HB 1075 Eaacted Requires coverage of Inpatient Min. 1 visit within 48 hrs. 1996 careifor mothers and newborns as of discharge, including commended in most recent parent ccl., assistance Guidelines for Perinaral Care. Par- with breast/bottle feeding, nills earlier discharge if newborn necessary tests. maets oriteria for medical stability and followup visit is covered. SB 310 Died in Com Requires coverage of min. 48 hrs. Min. 1 visit by RN, inclu- inpatient care for vaginal birth, 96 ding parent ed., breast/ hrs. cesarean, excluding policies bottle feeding assistance, covering home visit unless physi- necessary cests within cian determines inpationt care to 24 hrs. of discharge. be medically necessary. IOWA SB 2038 Died in Com Requires coverage of min. 48 hrs. of inpationt care for vaginal birth; 96 hrs. for cesarean. Requires coverage of longer stay if believed necessary by physician or reques- tod by mother. Page 5 FILE No. 234 09/24 '96 12:55 ID:AMER. ACADEMY PEDS. 1 202 393 6137 PAGE 7 09/03/98 TUE 16:11 FAX 2286432 HPSA a 007 INSURANCE COVERAGE FOR POST-DELIVERY CARE Page 6 STATE BILL STATUS COVERAGE REQUIRED FOR COVERAGE OF POST COMMENTS NUMBER VAGINAL BIRTH/CESAREAN DISCHARGE CARE IA, cont. HB 2047 Died in Com Requires coverage of min. 48 hrs. Min. 1 visit within 48 hrs, of inpatient care for vaginal birth; including physical полоен 96 hrs. for ossarean. Permits ment of newborn, assis- earliar discharge If actending pro- tance with breast/bottle vider and mother agree. feeding, necessary tests, assessment of home support. HB 2057 Died in Com Requires coverage of min. 48 hrs. Min. 3 visits by RN, inclu- inpationt care for vaginal birth; 96 ding parent ad., assis- hrs. cessrean excluding policies tance with breast/bottle covering home visits unless provi- feeding, necessary tests der determines inpatient care is within 24 hrs., 25-48 hrs. necessary & 49-96 hrs. after dis- charge. SB 2162 Died in Com Prohibits insurers from terminating benefits or requiring discharge ear- lier than determined medically ap- propriate by physician after our sultation with mother & in accor- danos with Guidelines. HB 2369 Bnacted Requires coverage of length of stay 1 visit if discharged prior 1996 determined necessary by physician to 48/96 hrs. & determined in accordance with guidelines which necessary by physician. must be consistent with those of AAP/ACOG. KANSAS HCR 5030 Died in Com Urges insurers to cover 48/96 hrs. of Impatient care. HB 2738 Died in Com Min. 48 hrs. inparient care for 1 visit within 48 hrs. of vaginal birth; 96 hrs. Deserean, discharge, including par- exicuding policies covering home ent ed., assessment of cure unless physician feels inpa- child, assessment of tient care medically necessary. home support system, breast/bottle feeding, necessary tests. Page 6 FILE No. 234 09/24 '96 12:56 ACADEMY PEDS. 1 202 393 6137 PAGE 8 09/03/96 TUE 16:11 FAX 2286432 HPSA 4 008 INSURANCE COVERAGE FOR POST-DELIVERY CARE Page 7 STATE BILL STATUS COVERAGE REQUIRED FOR COVERAGE OF POST COMMENTS NUMBER VAGINAL BIRTH/CESAREAN DISCHARGE CARE KS, cont. SB 573 Enacted Min. 48 hrs. impadent care after See left column. No 1996 vaginal birth; 96 hrs. cosarean, 6x- specifies included in bill. cluding policies covering home visits unless physician dotermines inpatient care medically necessary Parmite shorter stay if decision made(by physician. KENTUCKY HIR 3 Died in Com Urgeninsurers to cover at least 72 hrs. of inpationt care. SB 19 Died in Com Requires ocverage of at least 48 hrs. inparient DATE. Permits carlier discharge if physician and mother agree on shorter stay, mother and nowborn meet AAP/ACOG Guide- lines for Perinatal Care, and plan provides for Initial postpartum visit. HB 82 Died in Com Requires coverage of at least 72 hrs. inpatient care after birth SB 43 Died in Come Requires coverage of min. 48 hrs. Min. 3 visits by RN within Defines "affending finatient care for mother and child 24 hrs. of discharge, be- physician" an OB, following vaginal birth;96 hrs. after rween 25-48 hrs. & bo- pedjatrician, or other cesarean. Excludes policies cov- tween 96-120 hr., inclu- physician. aring home visits unless hospital ding parent ed., breast or stay determined to be medically bottle feeding assistance, necessary by provider. necessary tests. HB 186 Enacted Min. 48 hrs. inpatient CRIO for vag- Not addressed. 1996 inal birth; 96 hrs. cesaroan, exclu- ding policies covering home visit if mother and physician authorize shorter stay and pair meat medical stability criteria of Guidelines. LOUISIANA Page 7 FILE No. 234 09/24 '96 12:56 ID:AMER. ACADEMY PEDS. 1 202 393 6137 PAGE 9 09/03/98 TUB 18:12 FAX 2286432 HPSA 4 009 INSURANCE COVERAGE FOR POST-DELIVERY CARE Poge 8 STATE BILL STATUS COVERAGE REQUIRED FOR COVERAGE OF POST COMMENTS NUMBER VAGINAL BIRTH/CESAREAN DISCHARGE CARE MAINE SB 670 Enacted Requires insurer to provide cover Sec left column. Defines "attending 1996 age for mutarrity & newborn servi- physician" as OB, uss, including hospital stay, in pedistrician, or accordance with physician or other physician. certified nurse midwife's determi- nation in conjunction with mother, that pair most oriteria outlined In Guidelines for Perinatal Care. MARYLAND SB 677 Enacted Permits discharge of mother and Requires coverage of 1 in- 1995 infant If newborn meets AAP/ home visit if mother, child ACOG Outdelines for Perinatal discharged in less than 48 Care medical stability criteria. hrs. Visit must include collection of sample for hereditary and metabollic screening. HB 112 Died in Com Min. 48 hrs. inpatient card for vaginal birth; 96 hrs. cessican, excluding policies Govering home visit unless inpatient care deter- mined medically necessary by physician or requested by mother. SB 433 Enacted Min. 48 hrs. impatient care for vage 1 home visit by RN no Home visit exempt 1996 inal birth; 96 hrs. cesarean. Par- matter when discharged. from ocinsurance & mite shorter stay if decision made For those released early, acpayments. by mother in conference with provi- requires coverage of 2nd der & insurer covers home visite. visit if ordered by provider. SB 717/ Died in Com Min. 48 hrs. impationt card for vag- See left column and Establishes utiliza- HB 1271 inal birth; 96 hrs. cesarean, ex- current law. tion review process cluding policies covering follow-up appeal and expedi- visits unlcss physician determines ted decision process inpatient care necessary. Page B FILE No. 234 09/24 '96 12:57 ID:AMER. ACADEMY PEDS. 1 202 393 6137 PAGE 10 09/03/98 TUE 16:12 FAX 2286432 HPSA 11 010 INSURANCE COVERAGE FOR POST-DELIVERY CARE Page 9 STATE BILL STATUS COVERAGE REQUIRED FOR COVERAGE OF POST COMMENTS NUMBER VAGINAL BIRTH/CESAREAN DISCHARGE CARE MASSACHUSETTS SB 2057 Enacted Min. 48 hrs. inpatient care for Min. 1 home visit by RN "Attending physician" formerly 1995 veginal birth, 96 hrs. cesaresn. nurse midwife/ physician. defined ns obststri- SB 2000 Prohibits earlier discharge unless Includes: physical cian, pediatrician, in accordance with health dept. assessment, necessary nurse midwife, or remittions, thus applying to ERISA tests, parent od., usels- other physician. plant also, Barlier discharge must tance with breast/bottle do if consultation with mother. feeding, referrals. MICHIGAN HB $109, In Comm Requires HMOs to provide cover- Min. 3 visits by RN within HMO assoc. agreed to HB 5727. age of min. 48 hrs. inpatient care 24 hrs. of discharge, be- voluntarily follow the HB 5728, for vaginal delivery, 96 hrs. for eween 25-48 hrs. & be- Guidelines for Perina HB 5729 cesarean section. Excludes tween 96-120 hr., inclu- tal Care. policies covering home care unless ding parent ed., breast or mother requests inpatient care or bortle feeding assistance, physician determines it to be med- necessary tests. ically Decessary. MINNESOTA HB 2008 Enacted Requires coverage of min. 48 hrs. Min. 1 home visit by RN 1996 inpatient care for vaginal birth; 96 within 4 days of discharge hrs. occurean. Services to include: parent ed., assistance with breast/bottle feeding, necessary tests. SB 2022 Died in Com Mm, 48 hre. impadent care for Not addressed. unitinal birth; 96 hrs. cesarean. MISSISSIPPI HB 1143 Died in Com Min. 48 hrs. inpatient care for Vag- Min. 3 visits by RN within Defines provider an inal birth; 96 hrs. cosarean, exolu- 24 hrs., 25-48 hrs. and 96 physician, esteopath ding policies covering home visits to 120 hrs. after discharge certified nurso mid- unless provider determines inpa- wife or hospital. cient care medically necessary. MISSOURI SB 533 Diod in Com Requires coverage of min. 48 hrs. Coverage of one post- Defines "attending Replaces inpatient care for vaginal birth; 96 parform visit including physician" as OB, SB 512, SB hrs. for cesarean. Permits earlier collection of hereditary pediacrician, or other 581 discharge if: baby meets criteria of and metabollic samples physician. Guidelines for Perinatal Care; for testing. physician and mother approve dis- charge and insurer covers one postpartum visit. Page 9 FILE No. 234 09/24 '96 12:58 ID:AMER. ACADEMY PEDS. 1 202 393 6137 PAGE 11 09/03/96 TUE 16:12 FAX 2286432 HPSA / 011 INSURANCE COVERAGE FOR POST-DELIVERY CARE Page 10 STATE BILL STATUS COVERAGE REQUIRED FOR COVERAGE OF POST COMMENTS NUMBER VAGINAL BIRTH/CESAREAN DISCHARGE CARE MO, cont. SB 581 Died in Com Same as above. Same as above, but re- quires visit to OCCUT with- in 48 hrs. of discharge. HB 1069- Enacted Same as above, except insurer Requires home visits with- substitute 1996 transt cover min. 3 home visits if in 24 hrs., 25-48 hrs. and for house discharged early. 96-120 hrs., including bills 794, physical assessment of 807,936, newborn, patent ad., 1128,1153, assistance with brease/ 1202 bottle feeding, tosts. MONTANA NEBRASKA LB 1071 Died in Com Requires coverage of min. 48 hrs. Not addressed. inpatient oars for vaginal birth; 96 hrs. cesarean. Permits shorter stay if decision made by physician and child mests medical stability criteria of Guidelines for Perinatel Care. LB 1180 Died in Com Min. 48 hrs. impartent care for vag- Sce left column. No Defines "arrending inal births; 96 hrs. cesarean, ex- specifics included in bill. physician" as OB, cluding policies covering postdo- pediatrician, or livery care unless physician deter- other physician. mines inpatient care to be medical- ly necessary upon conferring with mother. NEVADA NEW HAMPSHIRE HB 1352 Enacted Requires coverage of inpatient 1 neonatal visit for genetic Prohibits insurer from 1996 care, postpartum visits as deter- and metabollic tests; 2 penalizing provider mined by provider; if shorter chan postpartum visits to in- for following bill's 48/96 hrs., must be at provider's clude: feeding, injury pre- provisions. recommendation in consultation vention, infant behavior, with mother, must over neonatal physical assessment & visit. infant & maternal health. Page 10 FILE No. 234 09/24 '96 12:58 ID:AMER. ACADEMY PEDS. 1 202 393 6137 PAGE 12 09/03/96 TUE 16:13 FAX 2286432 HPSA 1012 INSURANCE COVERAGE FOR POST-DELIVERY CARE Page 11 STATE BILL STATUS COVERAGE REQUIRED FOR COVERAGE OF POST COMMENTS NUMBER VAGINAL BIRTH/CESAREAN DISCHARGE CARE NH, cont. SB 627 Died in Com Requires coverage of min. 48 hrs. Min. 3 home visits by RN for vaginal birth, 96 hrs. cesarean. within 24 hrs., 25-48 hrs., Excludes policies covering home & 96-120 hrs. after dis- visits unless hospital stay deter- charge. Must include par- mined to be medically necessary ont ed., necessary tests, by physician or requested by assistance with breast or mother. bottle feeding. NEW JERSEY AB 2224 Enacted Requires coverage of min. 48 hrs. Min. 3 home visits by RN "Artending physician" 1995 for vaginal birth, 96 hrs. casarean. within 24 hrs., 25 to 48 hrs. defined as obstem- Excludes policies covering home & 96 to 120 hra. after dis- cian, pediatrician, or visits unless hospital stay deter- charge. Must include par- other physician. mined to be medically necessary ent educ., assistance with by attending physician or is 10- breast/bottle feeding, & quested by mother. necessary tests. NEW MEXICO Regulation Effective Requires coverage of 48 hrs. of Min. 3 visits by licensed 3/1/96 inpatient care for vaginal birth, 96 personnel for cesarean, unless earlier dis- charge in accordance with Guide- lines for Perinatal Care. NEW YORK SB 5322 Diad in Com Requires min. of 48 hrs. inpatient Not addressed. care for vaginal birth. 96 hrs. for occarean. SB 5742, Enacted Requires coverage of min. 48 hrs. Min. 1 home visit within 24 Home visit exempt AB 8125 1996 inpatient care for vaginal birth; 96 hrs of discharge, including from deducables, hrs. tesarean. Permits mother parent ed., assistance coinsurance and disoretion as to early discharge if with breast/bottle feeding, copayments. physician believes pair are ready. necessary tests. SB 6602 Died in Com Requires coverage of min. 48 hrs. Min. 1 home visit within 24 inpatient care for vaginal birth: 96 hrs of discharge, including Hrs. cesarean. Permite mother parent ed., assistance discretion as to carly discharge if with breast/boule feeding, physician believes pair are ready. necessary DOBIS. Page 11 FILE No. 234 09/24 '96 12:59 ID:AMER. ACADEMY PEDS. 1 202 393 6137 PAGE 13 08/03/96 TUE 16:13 FAX 2286432 HPSA @ 013 INSURANCE COVERAGE FOR POST-DELIVERY CARE Page 12 STATE BILL STATUS COVERAGE REQUIRED FOR COVERAGE OF POST COMMENTS NUMBER VAGINAL BIRTH/CESAREAN DISCHARGE CARE NORTH CAROLIN SB 345 Enacted Requires min. of 48 hre. inpatient Not addressed. 1995 ours for vaginal birth, 96 hrs. for cesarean. NORTH DAKOTA OHIO HB 458 Died in Com min. of 48 hrs. inparient Not addressed. HB 486 carefic vaginal birth, 96 hrs. for cosseran. SB 199 Enacted Requires min. of 48 hrs. inpatient Requires coverage of care 1996 care for vaginal birth, 96 hrs. for provided within 48 hrs. for cesarean. Applies to medical women and infants dischar- assistance, public employee plans. ged in less than 48/96 hrs. & Permits earlier discharge after provi- coverage of followup care der consultation with mother or prescribed by physician for person responsible for mother or those released after 48/96 hr. child. OKLAHOMA SB 684 Died in Com Requires coverage of min. 48 hrs inpatient care for vaginal birth, 96 hrs. for cesarean. HB 2302, Withdrawn Require* coverage of min. 48 hrs. Min. 3 home visits by RN Insurance commis- HB 2330 ant care for vaginal birth, 96 including assistance with sioner and health for cewarean, excluding policy breast/boure feeding, dept. to define medi- covering home visits, unless inpa- parent ed., necessary oally necessary. tignt chro determined medically tasts, Visito to occur with- necessary by provider/requested in 24 hrs., 25-48 hrs, and by mother. 96-120 hrs. HB 2655 Died in Com Requires coverage of inpatient Follow-up visit within 48 CATO sufficient to meet medical hrs. of early discharge, stability oritaria of Guidelines for including physical assess- Perinatal care & min. of 96 hrs. for ment of newborn, breast/ cosarean section. Permits carlier bouie feeding, parent ed., discharge when decision made by home support assessment provider in consultation with mo- and necessary tcats. ther. Page 12 FILE No. 234 09/24 '96 12:59 ID:AMER. ACADEMY PEDS. 1 202 393 6137 PAGE 14 08/03/96 TUE 16:14 FAX 2286432 HPSA 0 014 INSURANCE COVERAGE FOR POST-DELIVERY CARE Page 13 STATE BILL STATUS COVERAGE REQUIRED FOR COVERAGE OF POST COMMENTS NUMBER VAGINAL BIRTH/CESAREAN DISCHARGE CARE OK, cont. HB 2348 Enacted Min. 48 hrs. inpatient care for 1 visit within 48 hrs. of 1996 vaginal birth; 96 hrs. consrean. discharge including parent Permits shorter stay if pair meet ed., assistance with Guidelines oriteria & Insurer covers breast/bouie feeding, 1 home visit. physical assessments. Also requires above 00V- crage if birth occurs If home/birthing center. OREGON PENNSYLVANIA HB 1747, Died in Com Requires min. of 48 hrs. for vaginal If covered must consist of HB 2225 birth, 96 hrs. for cesarean. at least 3 visits conduc- ted: within 24 hrs, of dis- charge; within 25-48 hrs., and within 96-120 hrs. by RN & include breast feed- ing assistance & medical evaluation. HB 1977 Enasted Requries coverage of min. 48 hrs. Min. 1 visit within 48hrs. of 1996 of inpatient care. Permits coverage discharge, including parent of shorter stay if mother and child education, assistance with meet medical criteria like Guidlines breast/bottle feeding, neces- for Perinatal Care and if plan covers sary tests, in either home or initial postpartum visit. office. SB 1237 Died in Com Requires coverage of min. 48 hrs. Not addressed. of inpatient care for mother & baby PUERTO RICO RHODE ISLAND HB 5858-A Enacted Creates task force 1995 to study issue. SB 2074 Ensoted Requires coverage of min. 48 hrs. Not addressed. Defines "attending 1996 inpatient care for vaginal birth; 96 provider" as OB, hrs. for cesarean. Permits earlier pediatrician, family discharge in accordunce with practitioner, general Guidelines for Perinatal Care and practitioner or certi- in consultation with mother. fied nurse midwife. FILE No. 234 09/24 '96 13:00 ID:AMER ACADEMY PEDS. 1 202 393 6137 PAGE 15 09/03/98 TUE 16:14 FAX 2286432 HPSA J 015 INSURANCE COVERAGE FOR POST-DELIVERY CARL Page 14 STATE BILL STATUS COVERAGE REQUIRED FOR COVERAGE OF POST COMMENTS NUMBER VAGINAL BIRTH/CESAREAN DISCHARGE CARE RJ, cont. SB 2279 Died in Com Min. 48 hrs inpationt care for vag- 3 visits by RN within 24 Defines "strending inal birth; 96 hrs. cesarean, OX- hrs., 25-48 hra., & 96-120 physician" AS OB, cluding policies covering home hrs. after discharge, in- pediatrician, nurse visits unless inpatient care deter- cluding parent od., assis- midwife. or other mined necessary by physician in tance with breast/bottle physician. consultation with mother. feeding, necessary tests. HB 2018 Died In Com MA. 48 brs. inpationt care for vag- Not addressed. Inal birth; 96 hrs. cesarean. SOUTH CAROLINA HB 4396 Died in Com; Requires coverage of min. 48 hrs. Not addressed. SB 1043 Enected inpatient care for vaginal birth; 72 1996 hrs. becarean. SOUTH DAKOTA SB 192 Bnacted Min. 48 hrs. inpatient care for vag- Min. 1 visit within 48 hrs. 1996 mal birth; 96 hrs. cesarean. Per- of discharge. mics coverage of shorter stay if physician finds pair meet medical stability criteria of Guidelines. TENNESSEE HB 2410/ Died in Com At min. coverage of care ordered SB 2722 by provider in accordance with Guidelines for Perinatel Care. Applies to Medicaid and other pub- Sheally funded programs. SB 2455 Died in Com Min. 48 hrs. inpatient care for 1 followup visit within Defines "attending vaginal birth; 96 hrs. cesarean. 48 hrs., including parent provider" as OB, Permits earlier discharge if deci- od., breast/bonds feeding pediatrician, other sion by provider and mother. Ap- assistance, assessment physician or pertified plies to Medicaid and other publi- of home support and nurse midwife cally funded programs. necessary tests. SB 2834/H Died in Com Min. 48 hrs. inpatient care for vag- Min. 3 home visits by RN Defines "attending 2483 inal birth: 96 hrs. cesarean, exclu- including parent od., physician" as OB, ding policies covering home cure assistance with breast/ pediatrician or other unless inpatient care determined bottle feeding. necessary physician. medically necessary by physician tests within 24 hrs., 25-48 or requested by mother. and 96-120 hrs. after discharge. Page 14 FILE No. 234 09/24 '96 13:01 ID:AMER. ACADEMY PEDS. 1 202 393 6137 PAGE 16 08/03/96 TUE 16:14 FAX 2286432 HPSA 016 INSURANCE COVERAGE FOR POST-DELIVERY CARE Page 15 STATE BILL STATUS COVERAGE REQUIRED FOR COVERAGE OF POST COMMENTS NUMBER VAGINAL BIRTH/CESAREAN DISCHARGE CARE TN, cont. SB 2379 Died in Com Min. 48 hrs. inpatient care for vag- See left column. No Defines "attending inal birth; 96 hrs. Desarean exclu- specifies included in bill. provider" as OB, ding policies covering home visits padiatrician or other unless provider determines inpa- physician. dont part medically necessary or it inrequested by mother. Regulation Effective Recommends discharge decision Recommends followup 2/20/96 be made according to specific visit within 48-72 hrs. of medical oritorie; lists recommended discharge for those re- criteria. leased in 24-48 hrs. if deemed necessary by provider. HB 2364 Enacted Authorizes develop- 1996 ment of regulations setting minimum standards of cover- aga. TEXAS UTAH SB 138 Died in Com Min. 48 hrs. inpationt care for vag- Not addressed. Defines "attending inal birth; 96 hrs. cesarean. physician" ME OB, Permits shorter etay if decision pediatrician, or cer- made by mother in consultation tified nurse midwife. with physician. VERMONT HB 650 Died in Com Requires coverage of min. 48 hrs. Not addressed. SB 292 inpadent care for vaginal birth; 96 hrs. cesarean. VIRGINIA HB 87 Enacted Prohibits limitations on inpatient Min. 1 home visit. 1996 bare coverage of less than 48 hrs. after vaginal birth; 96 hrs. after cesarean. Permits shorter stay if: mother consents in writing; dis- charge in in accordance with Guide lines for Perinatal Care; coverage of one home visit. Page 15 FILE No. 234 09/24 '96 13:01 ID:AMER. ACADEMY PEDS. 1 202 393 6137 PAGE 17 09/03/06 TUE 16:15 FAX 2286432 HPSA 1017 INSURANCE COVERAGE FOR POST-DELIVERY CARE Page 16 TATE BILL STATUS COVERAGE REQUIRED FOR COVERAGE OF POST COMMENTS NUMBER VAGINAL BIRTH/CESAREAN DISCHARGE CARE VA, cont. SE 148 Enacted Applies above 5 1996 medical assistance. SB 242/ Died in Com Same as above. Min. 2 home visits. HB 447 WASHINGTON SB 6120 Enacted Prohibles denial of coverage for Prohibits denial of cover- Defines "provider" as 1996 covered eligible services for inpa- age of followup care as physicians, certified dont pasadelivery care as ordered ordered by provider in nurso midwives, by provider in consultation with the consultation with mother. midwives, advanced mother Requires insurers to permit registered nurse provider to make length of stay practitioners, PAs. decision. HB 2639 Died in Com Min. 24 hrs. inpatient care for vag- For those discharged in inal birth; 96 hrs. cesarean. Per- 24/96 hrs., requires cov- mits shorter stay if decision made erago of follow-up visit on by provider & mother, 3rd/4th day after birth. For those discharged earlior, requires coverage of min. 3 visits within 14 of discharge with 1st visit a) occur on 3rd/4th day. WEST VIRGINIA HB 4126 Died in Com Mid 48 hrs. inpationt OBTD for Min. 1 visit. vagin 1 birth; 96 hrs. cesarean, excluding policies covering home visit unless inpacient care deter imped medically necessary by physician or requested by mother. SB 486 Defeated Min. 48 hrs. Inpatient care for Min. 1 visit. vaginal birth; 96 hrs. cesarean. excluding policies covering home visit unless inpatient care deter- mined medically necessary by physician or requested by mother. Page 16 FILE No. 234 09/24 '96 13:02 ID:AMER ACADEMY PEDS. 1 202 393 6137 PAGE 18 09/03/98 TUE 18:15 FAX 2286432 HPSA 018 INSURANCE COVERAGE FOR POST-DELIVERYCARE Page 17 STATE BILL STATUS COVERAGE REQUIRED FOR COVERAGE OF POST COMMENTS NUMBER VAGINAL BIRTH/CESAREAN DISCHARGE CARE WV, cont. HB 4197 Died in Com Min. 48 hrs. Inpatient care for vag- To be addressed in rules. Defines "attending inal birth; 96 hrs. Per- physician" as OB, mits shorter stay decision to be pediatrician, other made by physician in consultation physician or nurse with mother & in accordance with midwife. rules developed by dept. of health WISCONSIN AB 573, SB Died in Cord Requires coverage of min. 48 hrs Requires health comnus- 463 after vaginal birth and 96 hrs. after sioner to develop rules on obsarcan section, of either inpa- home care, including who tient care or home care, or combi- may provide care, and its nation of both. Requires type of frequency and duration. care and duration to be at mother's discretion in consultation with provider. WYOMING TOTAL LAWS 28 Page 17 - FILE No. 081 07/12 '96 10:28 ID:AMER.ACADEMY PEDS. 1 202 393 6137 PAGE 1 VIA FAX TO: Jennifer Klein FROM: Todd Askew American Academy of Pediatrics FAX TO: 456-2878 2 Pages including this cover I If there are problems with this fax, call 202/347-8600 FILE No. 081 07/12 '96 10:28 ID:AMER.ACADEMY PEDS. 1 202 393 6137 PAGE 2 July 12, 1996 TO: Jennifer Klein FR: Todd Askew RE: EARLY DISCHARGE - STATE ACTIVITY As of January 1, 1996, six states had enacted legislation: DE, MD, MA, NJ, NC, RI As of late June, 1996, 22 additional states had enacted early discharge legislation or regulations: AI., AK. CT, FL. GA. IL, IN, IA, KS, KY, ME, MN, MO, NH, NM (Regulation), NY, OK, SC. SD. TN (Regulation), VA, WA Please call with any questions. Senate Bill 1860 1996 Legislature SB 1860, Second Engrossed An act relating to maternity care; amending SS. 627.6406, 627.6574, and 641.31, F.S.; prohibiting certain health insurance policies and health maintenance contracts from imposing certain limitations on coverage for hospital maternity stays or followup care outside of a hospital; requiring such policies and contracts to provide coverage for postdelivery care for a mother and her newborn infant; specifying services that must be included; requiring the Agency for Health Care Administration to conduct a study to evaluate the clinical effects of shorter stays in the hospital for maternity care; specifying the subject matter of the study; requiring a report; providing a description of state interests; providing an effective date. Be It Enacted by the Legislature of the State of Florida: Section 1. Section 627.6406, Florida Statutes, is amended to read: 627.6406 Maternity care (1) Any policy of health insurance that provides coverage for maternity care shall also cover the services of certified nurse-midwives and midwives licensed pursuant to chapter 467, and the services of birth centers licensed under SS. 383.30-383.335. (2) An insurer issuing a health insurance policy which provides maternity and newborn coverage may not limit coverage for the length of a maternity and newborn stay in a hospital or for followup care outside of a hospital to any time period that is less than that determined to be medically necessary, in accordance with prevailing medical standards and consistent with proposed 1996 guidelines for perinatal care of the American Academy of Pediatrics or the American College of Obstetricians and Gynecologists as proposed on May 1, 1996, by the treating obstetrical care provider or the pediatric care provider. (3) Nothing in this section affects any agreement between an insurer and a hospital or other health care provider with respect to reimbursement for health care services provided or prohibits appropriate utilization review by an insurer. (4) Any policy of health insurance that provides coverage, benefits, or services for maternity or newborn care must provide coverage for postdelivery care for a mother and her newborn infant. The postdelivery care must include a postpartum assessment and newborn assessment and may be provided at the hospital, at the attending physician's office, at an outpatient maternity center, or in the home by a qualified licensed health care professional trained in mother and baby care. The services must include physical assessment of the newborn and mother, and the performance of any medically necessary clinical tests and immunizations in keeping with prevailing medical standards. (5) An insurer subject to subsection (1) shall communicate active case questions and concerns regarding postdelivery care directly to the treating physician or hospital in written form, in addition to other forms of communication. Such insurers shall also use a process which includes a written protocol for utilization review and quality assurance. Section 2. Section 627.6574, Florida Statutes, is amended to read: 627.6574 Maternity care (1) Any group, blanket, or franchise policy of health insurance that provides coverage for maternity care shall also cover the services of certified nurse-midwives and midwives licensed pursuant to chapter 467, and the services of birth centers licensed under SS. 383.30-383.335. (2) Any group, blanket, or franchise policy of health insurance that provides maternity and newborn coverage may not limit coverage for the length of a maternity and newborn stay in a hospital or for followup care outside of a hospital to any time period that is less than that determined to be medically necessary, in accordance with prevailing medical standards and consistent with proposed 1996 guidelines for perinatal care of the American Academy of Pediatrics or the American College of Obstetricians and Gynecologists as proposed on May 1, 1996, by the treating obstetrical care provider or the pediatric care provider. (3) Nothing in this section affects any agreement between an insurer and a hospital or other health care provider with respect to reimbursement for health care services provided or prohibits appropriate utilization review by an insurer. (4) Any group, blanket, or franchise policy of health insurance that provides coverage, benefits, or services for maternity or newborn care must provide coverage for postdelivery care for a mother and her newborn infant. The postdelivery care must include a postpartum assessment and newborn assessment and may be provided at the hospital, at the attending physician's office, at an outpatient maternity center, or in the home by a qualified licensed health care professional trained in mother and baby care. The services must include physical assessment of the newborn and mother, and the performance of any medically necessary clinical tests and immunizations in keeping with prevailing medical standards. (5) An insurer subject to subsection (1) shall communicate active case questions and concerns regarding postdelivery care directly to the treating physician or hospital in written form, in addition to other forms of communication. Such insurers shall also use a process which includes a written protocol for utilization review and quality assurance. Section 3. Subsection (18) of section 641.31, Florida Statutes, is amended to read: 641.31 Health maintenance contracts. -- (18) (a) Health maintenance contracts which provide coverage, benefits, or services for maternity care shall provide, as an option to the subscriber, the services of nurse-midwives and midwives licensed pursuant to chapter 467, and the services of birth centers licensed pursuant to SS. 383.30-383.335, if such services are available within the service area. (b) Any health maintenance contract which provides maternity or newborn coverage may not limit coverage for the length of a maternity or newborn stay in a hospital or for followup care outside of a hospital to any time period that is less than that determined to be medically necessary, in accordance with prevailing medical standards and consistent with proposed 1996 guidelines for perinatal care of the American Academy of Pediatrics or the American College of Obstetricians and Gynecologists as proposed on May 1, 1996, by the treating obstetrical care provider or the pediatric care provider. (c) Nothing in this section affects any agreement between a health maintenance organization and a hospital or other health care provider with respect to reimbursement for health care services provided or prohibits appropriate utilization review by a health maintenance organization. (d) Any health maintenance contract that provides coverage, benefits, or services for maternity or newborn care must provide coverage for postdelivery care for a mother and her newborn infant. The postdelivery care must include a postpartum assessment and newborn assessment and may be provided at the hospital, at the attending physician's office, at an outpatient maternity center, or in the home by a qualified licensed health care professional trained in mother and baby care. The services must include physical assessment of the newborn and mother, and the performance of any medically necessary clinical tests and immunizations in keeping with prevailing medical standards. (e) A health maintenance organization subject to paragraph (b) shall communicate active case questions and concerns regarding postdelivery care directly to the treating physician or hospital in written form, in addition to other forms of communication. Such organization shall also use a process which includes a written protocol for utilization review and quality assurance. Section 4. The Agency for Health Care Administration, in collaboration with insurance, hospital, and physician providers, obstetrical care providers, pediatric care providers, and birth centers, shall conduct a study to evaluate the clinical effects of shorter stays in the hospital for maternity care and shall consider the data on actual volume of early discharge; payor policies; the health effect on and complication rates in the infants; the health effects, both physical and psychological, on the mother; the extent of opportunity for maternal and infant-care education; the physical and psychological effects on other family members; the extent of opportunity for maternal and child psychosocial assessment; the extent of followup care provided to mothers and newborns; the volume of readmissions and catastrophic readmissions; and the costs associated with early discharge. The report shall also assess the impact of this act on each of these factors and effects. The agency shall report its findings to the President of the Senate, the Speaker of the House of Representatives, and the chairmen of the Health Care Committees of the Senate and the House of Representatives by January 1, 1998. Section 5. The provisions of this act fulfill an important state interest. Section 6. This act shall take effect October 1, 1996, and shall apply to policies and contracts issued or renewed on or after that date. Postpartum Care of Mothers and Their Newborn Infants Delivered in the Hospital Setting MEDICAL PRACTICE GUIDELINES GREAT SEAL OF THE STATE A FLORIDA * * IN GOD WE TRUST STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION (AHCA) in consultation with the Maternal and Newborn Hospital Discharge Guideline Committee These guidelines are endorsed under the authority of the Florida Health Care and Insurance Reform Act of 1993, section 408.02, Chapter 93-129, Laws of Florida. Endorsed on March 22, 1996 Permission to duplicate and distribute granted Postpartum Care of Mothers and Their Newborn Infants Delivered in the Hospital Setting MEDICAL PRACTICE GUIDELINES OF THE GREAT SEAL * IN GOD STATE TRUST a * FLORIDA WE STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION (AHCA) in consultation with the Maternal and Newborn Hospital Discharge Guideline Committee These guidelines are endorsed under the authority of the Florida Health Care and Insurance Reform Act of 1993, section 408.02, Chapter 93-129, Laws of Florida. Endorsed on March 22, 1996 Permission to duplicate and distribute granted TABLE OF CONTENTS Page Notice of Endorsement 3 Committee on Maternal and Newborn Hospital Discharge Guidelines 4 Text guidelines Definitions 5 Practitioner skills for postpartum care 5 Maternal skills for postpartum care 5 Hospital and community resources 6 General criteria for hospital discharge 6 Criteria for very early and early discharge of mother and baby 7 Infant discharge in less than 24 hours postpartum 8 Infant discharge between 24 and 48 hours postpartum 8 Discharge follow up criteria 8 Algorithms Term delivery-Eligibility for maternal very early discharge 10 Newborn term-Very early discharge/Early discharge 11 Preventive Pediatric Health Care Chart (AAP) Recommendations for Preventive Pediatric Health Care, American Academy of Pediatrics, 1995 12 References 13-15 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION (AHCA) NOTICE ON PRACTICE PARAMETERS The practice guidelines listed below, produced in consultation with the Committee on Maternal and Newborn Hospital Discharge Guidelines, are endorsed by the Agency for Health Care Administration (AHCA) pursuant to the Florida Health Care and Insurance Reform Act of 1993, Chapter 93-129, section 408.02, Laws of Florida. These guidelines are endorsed for information, education, and review by the medical community, other professionals, and the public. These guidelines are not to be used as fixed protocols. They merely identify typical courses of intervention. There may be patients who require more or less treatment. However, those cases that exceed or fall below the guidelines may be subject to more careful scrutiny and may require documentation of the special circumstances. Treatment must be based on patient need as well as professional judgment. In summary, medical guidelines are patient management strategies, which are not entirely inclusive or exclusive of all methods of reasonable care that can obtain the same results, or of those which consider the particular needs of the patient and available resources. While standards are intended to be rigid and mandatory - making exceptions rare and difficult to justify - guidelines are more flexible, although they should be followed in most cases. Guidelines can be tailored to fit individual needs that are influenced by the patient, setting, resources, and other factors. Deviations can be justified by individual circumstances. Options are intended to be neutral. They merely note the interventions available to practitioners. Guidelines are revisited every three years or less. Review is based on valid scientific update. PRACTICE PARAMETER SUBJECT: PERINATAL CARE: POSTPARTUM CARE OF MOTHERS AND THEIR INFANTS REVIEW COMMENTS NUMBER GUIDELINE ORDER FROM: COST AND INFORMATION 1 Postpartum Care of For technical Agency for Health Care Free Mothers and Their information on these Administration (AHCA) copy Newborn Infants guidelines and to submit Dennis Halfhill, Delivered in the Hospital your scientifically-valid Coordinator Setting-Medical Practice review comments, please Medical Guidelines Guidelines; State of contact: Clearinghouse Florida's Agency for James T. Howell, M.D., 2727 E. Mahan Drive, Health Care Director, Division of Bldg. 3 Administration (AHCA); Health Policy and Cost Tallahassee, Florida 15 pages; March 22, 1996. Control, AHCA 32308-5403 Address at right (904) 488-1295, 921-5505, FAX (904) 488-1261 3 COMMITTEE ON MATERNAL AND NEWBORN HOSPITAL DISCHARGE GUIDELINES Jeane McCarthy, M.D., Ph.D., Neonatologist Doris Barnett, A.C.S.W., Support Advisor President, Florida Perinatal Association Florida Healthy Start Coalitions Ronald A. Chez, M.D., Obstetrician and Chairman, Carol Brady, Executive Director Committee for the Early Discharge of Maternity Patients Healthy Mothers Healthy Babies Florida Obstetric and Gynecologic Society Cindy Casuccio, President Gene Burkett, M.D. Florida Alliance of Birth Centers Committee for the Early Discharge of Maternity Patients Beth Swisher, President Florida Obstetric and Gynecologic Society Tallahassee Birth Center Charles Mahan, M.D., Obstetrician and Dean, Caryn Craddick, Director College of Public Health, USF Florida Medical Association - Tampa Office John Curran, M.D., Neonatologist and Chairman, Barbara Foley, Director, Council on Public Health, FMA Governmental Affairs Florida Hospital Association Les Beitsch, M.D., J.D. Assistant Health Officer for Family Health Services Belita Moreton, Vice President Office of the Secretary for Health, Florida League of Hospitals Department of HRS Teresa Nugent, Legislative Consultant Dan Lestage, M.D., Medical Director Association of Voluntary Hospitals of Florida Blue Cross and Blue Shield of Florida President, Florida Society for Preventive Medicine Tom Pear, Legislative Aide to Representative Mark Flanagan William E. Rush, M.D., Pediatric Endocrinologist Vice President, Regional Medical Director Blue Cross and Blue Shield of Florida Ex-officio: Rick Sheridan, M.D., Neonatologist Jim Howell, M.D. St. Joseph's Hospital Director, Division of Health Policy and Cost Control Richard Romeis, M.D., Medical Director Agency for Health Care Administration (AHCA) Humana Health Care Plans-Tampa Florida President, Nat. Assoc. of Managed Care Physicians Barbara Lumpkin, R.N. Christiane J. Guignard, R.N., M.S.N. Associate Director Coordinator, Medical Guidelines Development Florida Nurses Association (FNA) Agency for Health Care Administration (AHCA) Marie Gottfried, R.N. Director, Obstetrical Services Wellington Regional Medical Center AHCA Consultant: Lance Wyble, M.D., Neonatologist and President, Dee Jeffers, R.N., Project Director, Florida Society of Neonatal Perinatologists, Florida Health Start Systems Committee Chairman College of Public Health, USF Donna Barber, R.N. Chief, Family and Community Health Office AHCA Health Policy Analysts: Office of the Secretary for Health, HRS Debby Walters Taaffe Anderson, M.A. Katie Powers, R.N. Suzanne Suarez, R.N., J.D. Manatee Memorial Hospital Brenda Wesley, R.N. OB Services, St. Mary's Hospital Judy Woodworth, R.N. Associate Executive Director Humana Health Care Plans-Tampa Connie Smith, President Florida Healthy Start Coalitions 4 DEFINITIONS EARLY DISCHARGE (24-48 hours) means a discharge of a mother and/or a baby between 24 and 48 hours postpartum. VERY EARLY DISCHARGE (<24 hours) means a discharge of a mother and/or a baby at less than 24 hours postpartum. PRACTITIONER SKILLS FOR POSTPARTUM CARE The physicians and other licensed professionals and practitioners caring for the postpartum mother and child need the following information, knowledge and skills: a) mother's medical, pregnancy and perinatal history; b) criteria for normal transition from the antepartum and intrapartum states to the immediate postpartum state; c) criteria for normal transition from fetal to neonatal life; d) normal newborn behavior; and e) factors that warrant extended hospital and/or outpatient observation or assessment of either mother or baby. MATERNAL SKILLS FOR POSTPARTUM CARE The mother must learn relevant information and skills that enable her to care for herself and her baby. These include: a) the components of a healthy adult diet; b) her physical activity guidelines; c) advised timing for resuming coitus and birth control methods, if indicated; d) names, doses and side effects of prescribed drugs for herself or the baby; e) normal characteristics and care of vaginal discharge (lochia); f) breast care; g) perineal and abdominal wound care; h) timing for follow-up appointments for herself and for her infant; i) demonstrable skills and ability regarding care of her infant, such as: infant bathing, umbilical cord / circumcision care, and awareness of the appropriate sleeping position for her infant; j) ability to adequately feed her infant either by breast or bottle; k) knowledge of the signs of illness especially sepsis, hyperbilirubinemia, and dehydration; 1) knowledge of the importance of using infant car seats; and m) the importance of follow-up care. 5 HOSPITAL AND COMMUNITY RESOURCES The following hospital and community resources are needed: a) experienced, licensed maternal and newborn professionals to assess the mother during the immediate postpartum period, and the infant during the transition period; b) trained-licensed maternal and newborn professionals to educate and instruct the mother regarding normal child care, including the chosen infant feeding method (breast or bottle); c) medical staff to evaluate the mother and infant prior to discharge; d) home care follow up in the community by licensed maternal and newborn professionals with extensive postpartum mother-and-child-care experience or knowledge; e) medical physician follow-up after discharge; and f) information on hospital or available community resources for cases of emergency, postpartum and gynecologic care, child care, parenting, breastfeeding, social services, and other relevant subjects including community and hospital services. GENERAL CRITERIA FOR HOSPITAL DISCHARGE Early, very early or delayed discharge of the postpartum mother or infant from the hospital requires that they are both well, being discharged to a home prepared to meet their needs, and that timely follow-up medical care is available and accessible. It is preferable to discharge the mother and her infant together from the hospital whenever possible and medically appropriate. The following are general considerations relevant to a decision regarding discharge: a) identification of maternal medical and social risks factors prior to, during the pregnancy, at time of delivery, and postpartum that would place the mother and her infant at risk; b) identification of abnormalities in the immediate postpartum period placing the mother at risk; c) identification of abnormalities in the transition and immediate newborn period indicating that the infant is at risk; d) demonstration of the mother's ability to adequately care for herself and her infant based on prenatal and postpartum education and instruction; e) identification of medical physician and/or licensed maternal and newborn staff follow-up (within 24 to 48 hours for very early discharge and 48 to 72 hours for early discharge) and f) appropriate encouragement and support of breastfeeding available both in the hospital and after discharge. 6 CRITERIA FOR VERY EARLY AND EARLY DISCHARGE OF THE MOTHER AND BABY (algorithm follows) The mother should: a) be free of, or under active treatment for, medical problems, (i.e., diabetes mellitus, bleeding disorders, cardiovascular or pulmonary disease, hypertension, neurologic disease, psychiatric illness, immune disorders, local or systemic infection, and other disabling medical disorders that can hamper her ability to care for herself and her infant;) b) have received prenatal care relative to her needs; c) have demonstrated that she has the ability to care for her infant following prenatal guidance and postpartum instruction; d) have had an uncomplicated vaginal delivery; e) for Caesarean Delivery, have had a Pfannenstiel incision without wound complications, uncomplicated surgery, no febrile morbidity, stable normal vital signs, the ability to ambulate without assistance, the ability to urinate without assistance, auscultation of active bowel sounds, and the establishment of a regular diet (this for Early Discharge consideration only); f) have no difficulty voiding or ambulating; g) have a physical examination and stable vital signs that are normal for the postpartum setting; h) have no history or current active Group B streptococcus infection, TB, hepatitis, or sexually transmitted diseases where medical treatment of the infant is indicated; i) have no unresolved social factors such as young age, alcohol or drug abuse problems, mental illness, homelessness, history of victimization from domestic violence, or a high score on the Healthy Start screening without a purposeful care plan; j) have been assessed for appropriate bonding with her infant; k) have the ability and necessary skills and support to care for her infant in the home environment; I) understand instructions and how to get help in the event of depression, an upper respiratory tract infection, a urinary tract infection, anemia, weakness, problems with vaginal or perineal injuries, fever, chills, leg pains, increased vaginal bleeding, and other medical problems she may suffer; m) have current laboratory information on ABO blood group, Rh typing, and tests for hepatitis, syphilis, and rubella; n) have been administered the appropriate amount of RhIg and a rubella vaccine, if indicated; o) know the time at which coitus can be resumed; and p) know methods of contraception, if indicated. 7 INFANT DISCHARGE IN LESS THAN 24 HOURS POSTPARTUM (algorithm follows) The infant should: a) be assessed as term (38 to 42 weeks) and appropriate for gestational age (any neonate whose birth occurs from the beginning of the first day of the 38th week through the end of the last day of the 42nd week); b) have not demonstrated any neonatal problems during the transition period following birth; c) have stable, normal vital signs, and an acceptable physical examination performed by an appropriately trained medical or osteopathic physician; d) have normal blood glucose levels, if indicated; e) be able to maintain his/her temperature in a crib; f) demonstrate the ability to breast or bottle feed well, and the adequacy of feeds; g) have stooled and voided appropriately for postnatal age; h) have a negative maternal test for syphilis, hepatitis B, and HIV (if positive, the infant has received an appropriate evaluation); i) have an appropriate infant metabolic screening test drawn with a plan for confirmatory recollection; j) have no clinical or laboratory (if obtained) indication of jaundice; k) have had an APGAR of 7 or greater at 5 minutes; 1) have no major congenital anomalies; and m) have a mother or other acceptable caretaker who has an appropriate plan for follow-up on any abnormal laboratory tests known at discharge. INFANT DISCHARGE BETWEEN 24 and 48 HOURS POSTPARTUM (algorithm follows) a) The infant should be greater than 35 full weeks gestation and appropriate for gestational age by accepted estimation techniques b) The baby should meet all of the other above-listed criteria for very early discharge 24 hours), and any initial neonatal problems should have been resolved prior to discharge, or adequate follow-up should be arranged. DISCHARGE FOLLOW UP CRITERIA The primary clinical providers, after consultation with the family, and in accordance with the mother's and family's choice, may write an order to refer the mother and child for home post-discharge assessment and care, or may elect to provide the post discharge care in an office setting. If a "Very Early" discharge (<24 hours after birth) has been chosen, an initial assessment of the mother and infant should be performed within 24 to 48 hours of discharge, with follow up as needed. 8 If an "Early" discharge (24 to 48 hours after birth) has been chosen, an initial assessment of the infant should be performed within 48 to 72 hours with follow up of the mother and infant performed as needed Home Discharge Care for the Mother and Infant Should Include: a) licensed health care professionals experienced and skilled in the assessment of both postpartum mothers and newborn infants; b) special attention to the mother's functional status and vital signs; breast examination; uterine fundus tone, size and tenderness; abdominal and perineal wound healing, color, volume and smell of lochia, absence of calf and thigh tenderness; and other health, social or domestic problems that can hamper the mother's ability to care for her child; c) special attention to the adequacy of feeding and hydration of the infant, especially a breastfeeding infant; d) an appointment for metabolic screening of the infant, if required; e) the assistance of an individual who can serve as a consultant for a breast-feeding mother if difficulties with feeding arise; f) a primary clinical provider who is responsible and willing to assume all appropriate follow-up care for the mother; and g) an identified medical physician (pediatrics or family medicine) responsible and willing to assume all appropriate follow-up care for the infant, including office visits in accordance with the periodicity schedule recommended by the American Academy of Pediatrics (AAP). 9 TERM DELIVERY ELIGIBILITY FOR MATERNAL VERY EARLY DISCHARGE PRENATAL CARE No Yes UNCOMPLICATED NOT ELIGIBLE PREGNANCY No Yes MATERNAL NOT ELIGIBLE ILLNESS Yes No VAGINAL NOT ELIGIBLE DELIVERY No Yes STABLE, NORMAL NOT ELIGIBLE VITAL SIGNS No Yes NORMAL NOT ELIGIBLE PHYSICAL EXAM No Yes POSTPARTUM NOT ELIGIBLE INFECTION Yes No POSITIVE MATERNAL GROUP B NOT ELIGIBLE STREP INFECTION Yes No NOT ELIGIBLE LAB DATA OKAY No Yes UNRESOLVED NOT ELIGIBLE SOCIAL FACTORS Yes No DEMONSTRATES ABILITY NOT ELIGIBLE TO CARE FOR INFANT No Yes FOLLOW-UP CARE BY A LICENSED NOT ELIGIBLE MATERNITY AND NEWBORN HEALTH PROFESSIONAL No Yes NOT ELIGIBLE VERY EARLY DISCHARGE 10 NEWBORN TERM Yes No PRENATAL CARE NOT ELIGIBLE FOR VERY EARLY D/C > 35 FULL WEEKS GESTATION AND No Yes APPROPRIATE FOR GESTATIONAL AGE NOT ELIGIBLE UNCOMPLICATED No Yes (VED) PREGNANCY No Yes NOT ELIGIBLE FOR EARLY D/C (ED) NEONATAL D/C WHEN APNEA FREE X 1 WK. PROBLEMS NOT ELIGIBLE MATERNAL FEEDING BY NIPPLE, RESOLVED (VED) ILLNESS > 1800g. OTHER PROBLEMS RESOLVED OR Yes No STABLE. FOLLOW-UP AVAILABLE No Yes NOT ELIGIBLE POSITIVE MATERNAL GROUP B (VED) STREP INFECTION Yes No NOT ELIGIBLE STABLE VITAL SIGNS NOT ELIGIBLE VAGINAL FOR EARLY FEEDING WELL (VED) DELIVERY D/C (ED) STOOLING WELL, STOOLING, VOIDING, LABS WITHIN NORMAL No Yes LIMITS APGARS NOT ELIGIBLE > 7 AT 5 (VED) MINUTES No Yes No Yes DEMONSTRATE NOT ELIGIBLE FOLLOW-UP CARE BY A NOT ELIGIBLE ABILITY TO CARE FOR EARLY D/C LICENSED MATERNITY (VED) FOR CHILD (ED) AND NEWBORN HEALTH PROFESSIONAL No Yes (48-72 HRS) NOT ELIGIBLE INFANT FACTORS: (VED) STABLE TRANSITION No Yes PERIOD STABLE. NORMAL VITAL NOT ELIGIBLE SIGNS ELIGIBLE FOR FOR EARLY D/C FEEDING WELL, EARLY D/C (ED) (ED) STOOLING, VOIDING, NO MAJOR CONGENITAL ANOMALIES LABS NORMAL No Yes EARLY DISCHARGE FOLLOW-UP CARE BY A LICENSED NOT ELIGIBLE MATERNITY AND NEWBORN (VED) HEALTH PROFESSIONAL (24 to 48 HRS) No Yes NOT ELIGIBLE VERY EARLY D/C (VED) < 24 HOURS VERY EARLY DISCHARGE 11 Recommendations for Preventive Pediatric Health Care Committee on Practice and Ambulatory Medicine Each child and family is unique; therefore, these Recommendations for Preventive Pediatric Health Care are designed for the care of children who are receiving competent parenting, have no manifestations of any important health problems, and are growing and developing in satisfactory fashion. Additional visits may become necessary if cir- cumstances suggest variations from normal. These guidelines represent a consensus by the Committee on Practice and Ambulatory Medicine in consultation with national committees and sections of the Academy of Pediatrics. The Committee emphasizes the great importance of continuity of care in comprehensive health supervision and the need to avoid fragmentation of care. A prenatal visit is recommended for parents who are at high risk, for first time parents, and for those who request a conference. The prenatal visit should include anticipatory guidance and pertinent medical history. Every infant should have a newborn evaluation after birth. INFANCY3 EARLY CHILDHOOD' MIDDLE CHILDHOOD' ADOLESCENCE3 AGE Newbo 2-4 By 1 2 4 6 9 12 15 18 24 3 4 5 6 8 10 11 12 13 14 15 16 17 18 19 20 21 m¹ days2 month mos. mos mos mos mos mos mos mos yrs yrs yrs yrs yrs yrs. yrs yrs. yrs yrs yrs yrs yrs yrs yrs yrs yrs History Initial/Interval e e e e e e e e e 0 e e e e e e e Θ 0 Θ e 0 0 e e e 0 e Measurements Height and Weight e e e e e e e e e e e e e e e 0 e e e e e e 0 e e e e e Head Circumference e e e 0 e e e e e e e Blood Pressure e e e e e e e e e e e 0 e e 8 e e Sensory Screening Vision SSSSSSSSSSS000S S o S 0 S S o S S o S S S Hearing S/O S S S S S S S S S S o o o S S o S o S S o S S o S S S Developmental/ 0 e e e e e e e e e e e e e Behavioral Assessment Physical Examination 0 e e e e Θ e e e e e e e e e e e e Θ e e 0 e e e e e e 12 Procedures - General Hereditary/Metabolic e Screening Immunization" e e e Lead Screening¹² Hematocrit or Hemoglobin 13 e 14 Urinalysis Procedures - Patients at Risk Tuberculin Test's 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 Cholesterol Screening¹⁶ 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 STD Screening¹⁷ 3 3 3 3 3 3 3 3 3 3 3 18 Pelvic Exam" 3 3 3 3 3 3 3 3 3 3 3 Anticipatory Guidance" e e e e e e e e e 0 e e © e o 0 0 00000000000 Injury Prevention²⁰ e e e e e e e 0 e @ O e e e O O Θ Θ 0 e 0 e e 0 e o e e 1. Breastfeeding encouraged and instruction and support offered. 8. AI each visit, a complete physical examination IS essential, with infant totally unclothed. older 16. Cholesterol screening for high nsk patients per AAP "Statement on Cholesterol" (1992). If 2. For newborns discharged in less than 48 hours after delivery. child undressed and suitably draped. family history cannot be ascertained and other nsk factors are present, screening should be at 3. Developmental, psychosocial and chronic disease issues for children and adolescents may 9. These may be modified, depending upon entry point into schedule and individualized need. the discretion of the physician. require frequent counseling and treatment visits separate from preventive care visits. 10 Metabolic screening (e.g. thyroid. hernoglobinopathies, PKU, gallactoserial should be done 17 All sexually active patients should be screened for sexually transmitted diseases (STDs). 4. If a child comes under care for the first time at any point on the schedule, or if any items are according to state law. 18 All sexually active females should have a pelvic examination. A pelvic examination and rou- not accomplished at the suggested age. the schedule should be brought up to date at the earti- 11. Schedule(s) per the Committee on Infectious Diseases. published periodically in Pediatrics line pap smear should be offered as part of preventive health maintenance between the ages est possible time. Every visit should be an opportunity to update and complete a child's immunizations. of 18 and 21 years 5. If the patient is uncooperative, rescreen within SIX months. 12. Blood lead screen per AAP statement Lead Poisoning: From Screening to Primary Preven- 19. Appropriate discussion and counseling should be an integral part of each visit for care 6. Some experts recommend objective appraisal of hearing in the newborn period. The Joint tion" (1993) 20. From birth to age 12, refer to AAP's injury prevention program (TIPP") as described in "A Committee on Infant Hearing has identified patients at significant nsk for hearing loss. All chil- 13. All menstruating adolescents should be screened. Guide to Safety Counseling in Office Practice" (1994). dren meeting these criteria should be objectively screened. See the Joint Committee on Infant 14. Conduct dipstick urinalysis for leukocytes for male and female adolescents. 21 Earlier initial dental evaluations may be appropriate for some children. Subsequent exami- Hearing 1994 Position Statement 15 TB testing per AAP statement "Screening for Tuberculosis in Infants and Children" (1994) nations as prescribe by dentist 7 By history and appropriate physical examination, if suspicious, by specific objective develop- Testing should be done upon recognition of high risk factors If results are negative but high mental testing. nsk situation continues. testing should be repeated on an annual basis. e to be performed 3 - to be performed for patients at risk S a subjective, by history o . objective, by a standard testing method = the range during which a service may be provided, with the dot indicating the preferred age Special chemical, Immunologic, and endocrine testing is usually carried out upon specific indications. Testing other than newborn (e.g. inborn errors of metabolism, sickle disease, etc.) IS discretionary with the physician recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances. may be appropriate. 1995 American Academy of Pediatrics REFERENCES Not all references provide the mandated research-based evidence for the guidelines. 1) Guerrieu, W.F., A Maternal Welfare Program for New Orleans, Am J Obstet Gynecol, 46312, 1943. 2) Hellman, L.M., Kohl S.G., Palmer J., Early Hospital Discharge in Obstetrics. Lancet, 1227-232, 1962. 3) Day, G.A., Early Discharge of Maternity Patients, Nurs Outlook, 11825-827, 1963. 4) Hurt, H., M.D., Early Discharge for Newborns - When is it Safe? Contemp Ped, 1168-88, 1944. 5) Mehl, L.E., M.D., Peterson, G.H., B.A., Sokolosky, W., M.D., Whitt, M.C., M.D., Outcomes of Early Discharge After Normal Birth, Birth and The Family J, 3101-107, 1976 6) Yanover, M.J., M.D., Jones, D. R.N., M.S., Miller, M.D., M.D., Perinatal Care of Low-Risk Mothers and Infants (Early Discharge with Home Care). New Eng J MED, 294702-705, 1976. 7) Scupholme, A., C.N.M., Postpartum Early Discharge An Inner City Experience, J Nurse- Midwifery, 2619-22, 1981. 8) Britton, H.L., M.D., and Britton, J.R., M.D., Efficacy of Early Newborn Discharge in a Middle-Class Population, AJDC, 1381041-1046, 1984. 9) Waskerwitz, S., M.D., Fournier, L., R.N., Jones, P., R.N., Meier, W., M.D., A Comparative Analysis of Newborn Outcome in A Hospital-based Birthing Center, Clin Ped, 24273-277, 1985. 10) Lemmer, Sister C.M., R.N., M.S., Early Discharge Outcomes of Primiparas and Their Infants, JOGNN, 230-236, 1987. 11) Patterson, P.K., R.N., M.A., A Comparison of Postpartum Early and Traditional Discharge Groups, QRB, 365-371, 1987. 12) Pittard III, W.B., M.D., and Geddes, K.M., B.S.N., Newborn Hospitalization A Closer Look, J Ped 257-261, 1988. 13) Conrad, P.D., M.D., Wilkening, R.B., M.D., and Rosenberg, A.A., M.D., Safety of NewbornDischarge in Less Than 36 Hours in an Indigent Population, AJDC, 14398- 101,1989. 14) Norr, K.F., PhD, Nacion, K.W., C.N.M., PhD, Abramson, R., R.N., M.S., Early Discharge with Home Follow-up Impacts on Low-Income Mothers an Infants, JOGNN, 133-141,1989. 15) Berryman, M.A., J.G.K., U.S.A.F., M.C., and Rhodes, M.A., J.G.K., U.S.A.F., N.C., Early Dischargeof Mothers and Infants Following Vaginal Childbirth, Military Med, 15611583, 1991. 13 16) Welt SI M.D., Cole JS CR.N., C, Myers M.S., M.D., Sholes DM Jr. and M.D., and Jelovsek FR M.D., Feasibility of Postpartum Rapid Hospital Discharge, A Study From A Community Hospital Population, Amer J Perinatol, 105384-387. 17) Theobal, D., G.W., M.D., F.R.C.S., E.D., F.R.C.O.G., Home on the Second Day, The Bradford Experiment. Brit Med J, 1364-1367, 1959. 18) Pinker, G.D., M.B., F.R.C.S., E.D., M.R.C.O.G., and Fraser, A.C., M.B., M.R.C.O.G., Early Discharge of Maternity Patients, Brit Med J, 99-100, 1964. 19) Bradford Group of The College of General Practitioners*, A Survey of 100 Early Discharge Cases, The Lancet, 536-540, 1966. 20) Craig, G.A., M.B.E., F.R.C.S., F.R.C.O.G., and Muirhead, J., M.B., M.B., B.C.H., M.R.C.O.G., Obstetric Aspects of the Early Discharge of Maternity Patients, Brit Med J, 520-522, 1967. 21) Waldenstrom, U., Sundelin, C., and Lindmark, G., Early and Late Discharge after Hospital Birth Breastfeeding, Act A., Paediatr Scand, 76727-732, 1987. 22) Arborelius, E. and Lindell, D., Psychological Aspects of Early and Late Discharge after Hospital Delivery, Scand J Soc Med, 17103-107, 1989. 23) Carty, E.M., R.N., M.S.N., C.N.M., and Bradley, C.F., PhD., A Randomized, Controlled Evaluation of Early Postpartum Hospital Discharge, BIRTH 17:4, 199-204,1990. 24) Norr, K.F., PhD., and Nacion, K., B.S., C.N.M., M.S., Outcomes of Postpartum Early Discharge, 1960-1986, A Comparitive Review. BIRTH 143135-141, 1987. 25) Britton, J.R., M.D., PhD., Britton, H.L., M.D., and Beebe, S.A., M.D., Early Discharge of the Term Newborn: A Continued Dilemma, Ped, 943, 1994. 26) Desmond, M.M., M.D., Rudolph, A.J., M.B., and Phitaksphraiwan, P., M.D., The Transitional Care Nursery, A Mechanism for Preventive Medicine in the Newborn. From the Department of Pediatrics, Baylor University College of Medicine, and Jefferson Davis Hospital, Houston, Texas. Supported by the John A. Hartford Foundation, Inc. pp. 651-668. 27) Eidelman, A.I., M.D., Early Discharge - Early Trouble, J Perinatol, 122101-102, 1992. 28) Stern, T.E., M.S., R.N.C., An Early Discharge Program An Entrepreneurial Nursing Practice Becomes A Hospital-Affiliated Agency, J Perinat Neonatal Nurs, 511-8, 1991. 29) Gillerman, H., R.N.C.M.S., and Beckham, M.H., R.N., EdM, The Postpartum Early Discharge Dilemma. An Innovative Solution, J Perinat Neonatal Nurs, 519-17, 1991. 30) Avery, M.D., C.N.M., M.S.N., Fournier, L.C., R.N., B.S.N., Jones, P.L., R.N., B.S.N., and Sipovic, C.P., R.N., B.S.N., An Early Postpartum Hospital Discharge Program Implementation and Evaluation, J.O.G.N. Nursing, 233-235, 1982. 31) Jansson, P., Early Postpartum Discharge, Amer J Nursing, 547-550,1985. 14 32) Waldenstrom, U., Early and Late Discharge after Hospital Birth: Father's Involvement in Infant Care, Early Development ,1719-28, 1988. 33) McIntosh, I.D., M.D., Hospital Effects of Maternity Early Discharge, Medical Care, 227611- 619, 1984. 34) Waldenstrom, U., and Lindmark, G., Early and Late Discharge after Hospital Birth, A Comparison Study of Parental Background Characteristics, Scand J Soc Med, 15159-167, 1987. 35) Thurston, N.E., R.N., M.S.C., Dundas, J.B., M.D., C.M., F.R.P.C.(C), Evaluation of an Early Postpartum Discharge Program. Can J Pub Health, 76384-387,1985. 36) Guidelines of Early Hospital Discharge of Obstetrical Patients and Newborns, Wis Med J, 678-679, 1993. 37) American Academy of Pediatrics American College of Obstetricians and Gynecologists, Guidelines For Perinatal Care, 3rd Ed., 91-115. Copyright 1992. 38) American Academy of Pediatrics American College of Obstetricians and Gynecologists Guidelines For Perinatal Care, 3rd Ed., 255. Copyright 1992. 15