Midwives were asked about the ToC and referral of women and families following discharge from hospital or maternity services. Referral in the form of discharge summaries to CFH nursing services was most common (77.4%) with almost half of the services also referring to general practice (48.2%).
Midwives reported the most common mechanism for transfer of information from maternity to CFH services was ‘direct fax from maternity service to the CFH centre’ (45.2%), and ‘electronic referrals’ (35.7%). This differed across the country. Almost three-quarters (72.4%) of midwives from Western Australia, reported ‘electronic referrals’ as the most common mechanism for ToC, whereas in Queensland, one third (36%) of midwives reported ‘women just presenting or ringing the CFH nurse’.
CFH nurses reported information from maternity services predominantly transferred via an electronic data system (51%), including mandatory birth notification. Email and fax were also common (29.7%) - either directly to the CFH centre or central intake point. The most notable variance was in Queensland where CFH nurses and midwives both reported a high percentage of ‘women just presenting or ringing the CFH nurse’ (40%).
Midwives were asked how ToC took place for women and babies with additional needs or risk factors. In most jurisdictions, midwives reported using a ‘standard’ written discharge summary process most often. This implied that information about the woman and her infant was detailed on a discharge summary and sent to the CFH nursing service or GP without any contact between the two services. Approximately one quarter of all respondents (25.6%) indicated that someone from the maternity service telephoned the CFH nurse or other services for families requiring additional support. Variations were found in the states of Victoria and Tasmania where midwives 51.6% and 58.8% of midwives respectively reported ToC occurring via telephone contact. This suggests that in these two states a higher proportion of midwives prioritised a person-to-person transfer of information for women and families with risk factors.
When asked about the timing of information transfer, 88.5% of midwives reported routinely sending discharge summaries. However, only three quarters (74.5%) of midwives who worked in private hospitals reported routine discharge summaries being provided for all women compared with almost all (92.9%) of the midwives working in the public sector. A small proportion of midwives (3.4%) reported providing discharge summaries only for women with risk factors identified (8.5% in the private and 2.2% in the public sector). In contrast, midwives in the private sector were less likely to send discharge summaries for women who were judged not to have risk factors compared with the public sector (14.9% vs 3.6%).
The professional responsible for completing the discharge summary was most often the midwife caring for the woman at discharge from hospital. Over two-thirds of the midwives (70%) reported that discharge summaries were completed within two days of discharge (i.e. including those completed on or before the day of discharge). CFH nurses reported that their service received birth notifications or discharge summaries within five days of discharge (82.7%), and an additional 7.2% indicated this occurred by 10 days. A further 10% of CFH nurses reported that their service received summaries greater than 10 days after discharge from maternity services.
Midwives were asked whether their maternity service offered a postnatal home visiting service and to identify the type and length of service provided. The majority of respondents (88.7%) indicated that their service did provide home visiting (Table
2). In maternity services offering home visiting, 47.4% visited at least three times in the first week (Table
2). Additional client information collected by the midwife during the home visiting period recorded in the client record was not routinely included in the discharge summary.
Table 2
Type of maternity home visiting services and frequency of contacts
Hospital-based midwife visits as part of postnatal service | 350 | 81.4 |
Caseload or group practice provides midwifery home visits | 242 | 56.3 |
Community midwife visits at home | 183 | 42.6 |
Other | 47 | 10.9 |
N of respondents*
|
430
| |
Type of contact | Australia |
N | % |
Face to face contact | | |
3+ visits in first 7 days | 176 | 47.4 |
6+ visits in first 7 days | 26 | 7 |
Mean visits in first 7 days | | |
2.9 | |
Standard deviation | 1.63 | |
Phone contact | | |
3+ calls in first 7 days | 107 | 28.8 |
6+ calls in first 7 days | 30 | 8 |
Mean calls in first 7 days | 2.3 | |
Standard deviation | 1.76 | |
N of respondents*
|
371
| |
Text comments from CFH nurses in relation to the ToC indicated problems with the transfer of information collected by maternity home visiting services to CFH nursing services
‘Lack of communication between domiciliary midwifery care and CFH centres. CFH nurses often unable to take phone call due to workload. When call returned – domiciliary midwife not available. Perhaps a better electronic systems of handover.’ (CFH nurse, 786 VIC)
‘The information is not current at times and does not include [domicillary] information--differing levels of communication to add this info some times.’ (CFH nurse, 271 NSW)
Almost one in five CFH nurses (17.8%) reported that their service made first contact with some women in the antenatal period. However, most CFH nurses (83%) reported that their service first contacted women within two weeks of the baby’s birth. An additional 12% reported that their service first contacted women and families within four weeks (Table
3).
Table 3
Usual time of CFH nurse first contact with new clients and frequency of receiving necessary information from maternity services in Australia
< 2 weeks | 431 | 82.9 |
2-4 weeks | 64 | 12.3 |
4-8 weeks | 7 | 1.4 |
Other | 17 | 3.3 |
Unsure | 1 | 0.2 |
N of responses = 100%*
| |
520
|
Frequency | Australia |
| N | % |
All the time | 115 | 17 |
Frequently | 338 | 49.7 |
Sometimes | 180 | 26.6 |
Rarely | 36 | 5.3 |
Not at all | 10 | 1.5 |
N of respondents = 100%*
| |
679
|
The quality of information included in the discharge summary is critical as it is used by the CFH service to inform the level of support required and the prioritisation of women with higher levels of need [
38]. Early engagement of women and the provision of support and access to support through mothers groups, professional services and other resources in the community is especially important for women with or at risk of mental health issues [
39].
CFH nurses were asked to indicate how often they perceived that their service received ‘all the necessary information’ about a woman and her newborn from the maternity service to provide ongoing support. Two-thirds (66.7%) perceived that they received all the necessary information from the maternity service ‘all of the time’ or ‘frequently’ (Table
3). Information was reported as received ‘sometimes’ by 26.6% and ‘rarely’ or ‘not at all’ by 6.8% of CFH nurse respondents (Table
3). Similar ratings were provided by the midwives who were asked to indicate whether they believed the information provided in the discharge summary was sufficient for the CFH professional to plan ongoing care. Midwives used a five-point scale, ranging from 1 (insufficient information) through to 5 (more than sufficient information). Midwives rated the information provided in the discharge summary as ‘sufficient’ (45.7%) and ‘more than sufficient’ (26.6%) (Table
4). No variation across states was noted in either the CFH nurse or midwifery scores regarding adequacy of information transferred.
Table 4
Midwives rating of the adequacy of information in discharge summaries, by Australian State and Territory
1. Insufficient | 18 | 12 | 4 | 4.5 | 9 | 12 | 7 | 20 | 3 | 5.8 | 1 | 6.3 | 0 | 0 | 3 | 16 | 45 | 9.7 |
2 | 34 | 22 | 11 | 12 | 9 | 21 | 6 | 17 | 8 | 15 | 5 | 31 | 2 | 10 | 2 | 11 | 84 | 18 |
3. Sufficient | 65 | 41 | 41 | 46 | 9 | 48 | 14 | 40 | 23 | 46 | 10 | 63 | 9 | 45 | 11 | 58 | 213 | 46 |
4 | 33 | 21 | 24 | 27 | 10 | 13 | 6 | 17 | 14 | 29 | 0 | 0 | 6 | 30 | 3 | 16 | 98 | 21 |
5. More than sufficient* | 6 | 3.8 | 9 | 10 | 4 | 5.3 | 2 | 5.7 | 4 | 7.9 | 0 | 0 | 3 | 15 | 0 | 0 | 26 | 5.6 |
Mean rating | 2.8 | | 3.2 | | 2.8 | | 2.6 | | 3.1 | | 2.6 | | 4 | | 2.7 | | 2.9 | |
Standard deviation | 1.1 | | 1 | | 1.1 | | 1.3 | | 0.9 | | 0.7 | | 1 | | 0.9 | | 1 | |
N of respondents
|
156
| |
89
| |
75
| |
35
| |
52
| |
16
| |
20
| |
19
| |
466
| |
This was not supported by many of the open text responses where midwives indicated that the information persuaded was inadequate. Respondents described this as being due to: staffing issues (shortages or inexperienced staff filling out the forms) and the design of the discharge summary. One midwife wrote:
[The] information is not always accurate due to limited postnatal care and time in hospital. It would be so much better to actually be able to handover verbally/face to face information re high risk families to the nurse that will be providing the care: currently too much red tape and admin blocks that are all too time consuming. We have lost what the focus for the referral actually is all about: to provide appropriate follow-up for the families that most need the care, not to meet KPI's [key performance indicators] re universal health home visiting…’ (Midwife 119, NSW)
Specific problems included limited options in official documentation on where to provide individualised information especially on social and emotional problems. In public hospital services, psychosocial assessment was reported to be undertaken routinely by 86.9% of midwives, however only 38.9% reported this information being included in discharge summaries. This discrepancy was even more notable in the private sector with 52.3% reporting routine psychosocial assessment being undertaken while only 15.9% including psychosocial details in discharge summaries (Table
5).
Table 5
Results of routine psychosocial assessment included in discharge summary
| N | % | N | % | N | % |
Yes | 291 | 86.9 | 23 | 52.3 | 314 | 82.8 |
No | 39 | 11.6 | 21 | 47.7 | 60 | 15.8 |
Unsure | 5 | 1.5 | 0 | 0 | 5 | 1.3 |
N of respondents = 100%*
| 335 | 100 | 44 | 100 | 379 | 100 |
Psychosocial assessment in discharge summary? | | | | | | |
Yes | 130 | 38.9 | 7 | 15.9 | 137 | 36.2 |
Sometimes | 101 | 30.2 | 20 | 45.5 | 121 | 32 |
No | 81 | 24.3 | 9 | 20.5 | 90 | 23.8 |
Unsure | 22 | 6.6 | 8 | 18.2 | 30 | 7.9 |
N of respondents = 100%*
| 334 | 100 | 44 | 100 | 378 | 100 |
Effectiveness of transition of care
The overall effectiveness of the ToC process from maternity care to CFH services was assessed using a 5 point scale, ranging from 1 (not effective) through to 5 (extremely effective). Only 36.6% of midwives rated the process for ToC for the majority of women and/or babies as effective (4) or extremely effective (5), despite previously reporting information provided in the discharge summary as ‘sufficient’ or ‘more than sufficient’ (72.3%) (Table
4). The transition process for women and/or babies identified with at risk factors for poor physical or mental health outcomes was only slightly better with 40.4% 4 or above (Table
6).
Table 6
Effectiveness of transition from maternity to CFHN services for majority of women and for families at risk, percentages
1. Not effective | 7.0 | 7.2 |
2. | 17.7 | 14.4 |
3. Somewhat effective | 38.7 | 37.6 |
4. | 28.6 | 30.4 |
5. Extremely effective | 8.0 | 10.4 |
Mean rating | 3.1 | 3.2 |
Standard deviation | 1.04 | 1.07 |
N of respondents
|
486
|
473
|
Midwives were asked to explain their rating of effectiveness by responding to an open-ended question. There were 372 textual responses of which, 113 (30%) provided negative feedback regarding the effectiveness of the ToC process. Negative comments included; insufficient or missing individualised data, doubling up of service provision, lack of feedback to midwives from CFH service, staffing issues, and system issues of time lag, difficulty in contacting CFH nurse¸ being actively prevented from contacting CFH nurses directly if concerned about a family.
There were also comments which indicated tensions regarding the ToC. For example, one midwife indicated that women are often coerced into agreeing to transition to the CFH service and then suggests that neither general practice nor the CFH nursing service is able to cater for family’s needs. This midwife wrote:
‘It is an expectation that women WILL want the [CFH nurse] service, women are approached [about ToC at] 7.30-8 am, often on day 3 when they are vulnerable, a CFHN/stranger walks into the room, with all this information, women know little about the service and generally agree to anything to get the CFH nurse out of their room, not all women can afford to see GP for follow up care/6 week check/concerns about their baby, OR there is a 6-8 week wait for an appointment. CFH nurse appointments only and wait [the waiting time] is similar. "Transition" is dreadful.’ (Midwive 69, VIC)
In contrast, some midwives were concerned that women would not connect with CFH service if left to arrange their own transition, for example:
‘most mothers are expected to find their child health clinics themselves’ (Midwife 372, QLD)
‘most low risk women left to self refer but most risk factors may not be evident until after discharge from maternity service’ (Midwife 608, QLD)
Some midwives indicated that their role in postnatal care is misunderstood by CFH nurses and others emphasised the misunderstanding of midwife’s role and differences in philosophies of care.
‘[ToC] happens by default - there is no communication and no acknowledgement, appreciation or understanding of our role as important.’ (Midwife 608, Qld)
‘Very different information and style of care [between maternity and CFH]. The maternity service provides a strength based support and there are many CFH nurses with very old fashioned ideas imposing them on women.’ (Midwife 40, SA)
CFH nurses were also asked to comment on the effectiveness of ToC. Of the 525 responses, 245 provided negative feedback regarding the ToC process. CFH nurses perceived problems were due to: discharge from SCN and NICUs, early postnatal discharge, transitions from private hospitals and a lack of understanding of the CFH nurses’ role. For example:
‘Very rare to receive recent information from hospital i.e. history etc. Even after making contact and leaving details with SCN (Special Care Nursery) babies are often discharged without notifying CFH nurse.’ (CFH nurse 609, Vic)
‘With early discharge those women in public hospitals are entitled to one or two Domiciliary Home visits to care for breastfeeding issues etc. However, often only have one visit then a quick phone call "is everything alright?" CFH nurse doesn’t get to see mothers until day 7 - 14 so many disasters can and do occur…’ (CFH nurse 994, Vic)
Problems between the private sector and CFH service included lack of follow-up support for women, non referral to either the CFH nursing service or to a GP, inadequate information transfer (delayed or poor quality). The CFH nurses identified:
‘Electronic birth notification as per legislation. Verbal or written(fax/email) information is patchy and almost never from Private hospitals. We are told this is because hospital midwives are too busy to regularly give a handover to maternal + child Health Nurses.’ (CFH nurse, 546 VIC)
‘... often information is not received from the private hospital until requested by the child health nurse following presentation of the mum to clinic or phone call from mum…’ (CFH nurse706, NT)
‘major [public] hospitals provide home visiting but private patients miss out and it is expected CFH nurse has to pick up the slack especially if premature and early discharge. Certain private hospitals do not necessarily always have good breastfeeding follow-up.’ (CFH nurse 888, Vic)
CFH nurses also perceived that maternity staff underestimated the value of the CFH nursing service and therefore do not actively promote the service to women. This in turn may contribute to a poor ToC for families. For example:
‘I do not believe that maternity staff (clerical and nursing/midwifery) understand the nature of the ongoing service that (CFH nurses) provides and hence undervalue the importance of timely handover of information that would aid service delivery.’ (CFH nurse NSW, 539)
Improving transition of care
Text responses regarding the effectiveness of the TOC process included a small number of suggested strategies to improve the TOC from midwives (4%) 16/372 and from CFH nurse (6%) 23/525. A specific liaison role to support ToC was the most common suggestion by both groups. Other suggestions included: joint visits to families by CFH nurses and midwives to facilitate handover, all women provided with information antenatally or during hospitalisation on the value of CFH nursing service, an opt out system of consent to ensure all women are contacted by CFH nursing service, improve information content, improve communication pathways for vulnerable families, allocation of CFH nurses to visit hospitals to inform women and staff of the CFH service.
When asked to identify from a list of strategies the one they believed would best improve the ToC, the majority (57%) of midwives recommended implementing an electronic data system for easier sharing of information. A quarter (24.5%) selected the use of the same or similar assessment tools. This was supported by open text responses:
‘I would prefer an ‘opt out’ system of consent to contact, as currently a lot of work on part of hospital midwife, central administration, local CFH nursing service administration and local CFH nurse just to get a client on our list. Also we miss quite a few who have signed consent but we never get the paperwork.’ (CFH nurse 881, SA)
‘Regular visiting to the maternity unit by CFH nurse, weekly case conferencing with midwives, CFH, Indigenous Health Worker, Indigenous Liaison worker, social worker, Child Protection officer and monthly attendance from the Aboriginal medical service. Faxed referrals are received from the private hospital.’ (CFH nurse 1014, SA)
The majority of midwives (53%) suggested regular meetings between maternity and CFH services to discuss transition and problems experienced by ‘at risk’ families. Approximately one-third (32.4%) suggested verbal handover as a strategy.