Problem Addressed

• A common problem for perinatal women: Mood disorders, including depression, anxiety, obsessive compulsive disorder, and/or posttraumatic stress syndrome, affect approximately 10 to 15 percent of women during the perinatal period.^1,2,3
• Significant health risks, particularly for those with severe depression: A small minority of women with perinatal depression requires inpatient care; at the University of North Carolina (UNC), this figure averages roughly 5 percent. Those with severe perinatal depression face a significant risk of suicide (as high as 5 percent) and infanticide (4 percent).⁴ Severe depression can also impair maternal-infant interactions and affect the child’s cognitive, emotional, social, and behavioral development.⁵
• Lack of tailored inpatient programs: Few inpatient facilities have programs and/or services specifically designed to meet the unique needs of women with severe perinatal depression. As a result, these women end up being admitted to units that also serve patients with other mental illnesses, such as schizophrenia, alcoholism, drug addiction, or dementia. Often these units place strict restrictions on the ability of the mother to see or interact with her child, thus impeding the ability to bond. (See the Context section for more details.)

Description of the Innovative Activity

• Initial referral and admission: Patients must meet the eligibility criteria for inpatient psychiatric care to be admitted to the unit. Most have thoughts of hurting themselves or their babies, with many being unable to function effectively or care for their children. Referrals typically come from physicians at UNC’s outpatient perinatal psychiatry program, emergency department physicians in the area, and community-based physicians throughout the region. In most cases, patients can be admitted directly to the unit; in rare cases in which no bed is available, patients either remain in their home for a day or two (if it is safe for them to do so) or get admitted to a general psychiatric unit until a bed opens up. (See bullet below about flexible capacity for more details.) In some cases, women may be too severely ill to take advantage of unit programming, such as those with severe bipolar disorder or other forms of postpartum psychosis. In these cases, the patient may first be admitted to the psychotic disorders unit until they are well enough to benefit from services on the perinatal unit.
• Flexible capacity: The perinatal psychiatry unit has at least three beds at all times—a double room and a private room. In addition, two sets of swinging doors can be opened to allow for two more private rooms on the unit when needed, for a maximum capacity of five beds. These two rooms function as “swing” capacity, meaning that they can serve as part of either the perinatal psychiatry unit or the adjacent geropsychiatry unit.
• Individualized treatment plan: Each newly admitted patient gets a full history and physical, including a formal evaluation of their social support structure, coping skills, attachment and family issues, and other factors. Based on this evaluation, physicians develop a customized treatment plan that includes needed treatments, medications, consultations, and services.
• Tailored design, staffing, and policies: The freestanding unit has physical features and has put in place staffing patterns and policies that cater specifically to women with severe perinatal depression, as outlined below:
  • Physical design and features: The unit design caters to postpartum women, as outlined below:
    • Living/family room area: The unit features a good-sized “living/family room” area with couches, a place to eat, a television, and room for activities. It also has a nurse’s station and a room for patients requiring a private medical examination or consultation.
    • Breastfeeding equipment and support: Each bed has a glider and hospital-grade breast pump. The unit also offers the services of lactation consultants and provides freezer/refrigerator storage to make pumping as easy as possible.
  • Experienced staff: Patients are served by registered nurses (RNs) who work exclusively on the unit, along with psychiatrists, resident physicians, occupational and physical therapists, psychologists, registered dietitians, chaplains, social workers, midwives, and a case manager who also serve patients on the larger, adjacent geropsychiatric unit. Other consultants can be brought in at the discretion of the patient’s psychiatrist. All staff are interested in and receive training on how to treat women with perinatal depression, and many have experience in doing so.
  • Policies to promote recovery and bonding: The unit has developed policies to promote recovery and mother-child bonding and attachment, as outlined below:
    • Extended visiting hours: Unlike most inpatient psychiatric units (which generally do not allow children to visit), the unit features extended visiting hours for spouses/partners, children, and other family members. Infants and other children can generally be in the mother’s room until 9 pm, and unit staff encourage mothers to interact frequently with their baby throughout the day (including breastfeeding the child). As a safety precaution, the unit requires the spouse/partner or another adult to be with the mother and child while visiting.
    • Protected sleep time: Infants are not allowed to stay overnight in their mother’s room, thus giving the mother “protected” sleep time, an important part of recovery from postpartum depression.
• Wide array of services, customized based on plan: In addition to standard medical treatment (e.g., psychotherapy, counseling, drug treatment, and obstetric/gynecological consultations), the unit provides a comprehensive array of group and individualized treatment and support services designed to meet the needs of women experiencing severe perinatal depression. The frequency of offerings varies by service, with some programs held each day and others once or a few times a week. Patients participate in most activities, with staff members who lead them using the individualized treatment plan to customize services to individual patient needs. Key services are outlined below:
  • Recreational and biofeedback therapy: The unit offers group classes and individual sessions that teach patients how to manage their emotions and bring their bodies to a less stressed state. Patients use a device (developed by a private company called HeartMath) that allows them to visualize their breathing and heart rhythms and see how they change under different circumstances, such as during deep breathing or other relaxation techniques. The classes also feature various forms of exercise, including therapeutic yoga tailored to postpartum women.
  • Nutrition therapy: A registered and lactation-certified dietician provides individual and group education related to nutrition, including customized consultations.
  • Occupational therapy: Occupational therapists and their assistants teach and facilitate coping strategies, including strategies to help new mothers map out their day to ensure time for both self-care (e.g., a shower, exercise, sleep) and taking care of their child’s needs. To that end, therapists work to promote healthy habits, rituals, and routines; provide information on community-based resources that support new mothers; teach and reinforce effective ways to manage time and stress; promote communication skills; and assist in goal setting, role development, and building self-awareness and self-esteem.
  • Mother-infant attachment therapy: Known as the Building Relationships Group, this weekly group class addresses common problems faced by mothers with perinatal depression, including distorted thinking, understanding the child’s signals, and responding to them. Mothers are encouraged to bring their children.
  • Family and partner therapy: This class focuses on supporting spouses, partners, family members, and other significant individuals in the mother’s life. The goal is to help them understand what is or is not helpful for a new mother or mother-to-be who struggles with her mental health. The mother also attends the session, which includes sharing of information by other couples and families in similar situations, along with an opportunity for mother and partner to discuss how the partner can best support the mother in the hospital and after returning home.
  • Spiritual support: The unit offers group and individual support from hospital chaplains with expertise in the issues and challenges facing women in the perinatal period, including stress, grief, healing, and meaning in life.
• Proactive discharge planning to ease transition to community: Beginning right after admission, the social worker collaborates with patients and their families to arrange for outpatient treatment after discharge, either at UNC or in the patient’s community. The social worker helps to ensure that discharged patients have access to community-based support services, making a special effort to connect Medicaid beneficiaries (some of whom lose coverage 3 months after giving birth) with such resources, including subsidized childcare services.

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Innovator Disclosures

Results

• Less severe depression and reduced anxiety: An analysis of the first 55 patients treated in the unit found a statistically significant decline in the severity of depression and in anxiety levels between admission and discharge, as measured by commonly used screening and assessment tools. (More details will be available in a forthcoming journal article.)
• Better able to cope with work and social life: The same set of patients experienced a statistically significant improvement in their ability to perform effectively at work and have meaningful social interactions, as measured by a common assessment tool. (More details will be available in a forthcoming journal article.)
• High satisfaction: More than 90 percent of patients rated unit services in the top 2 categories on a 5-point Likert scale (“always” or “mostly” satisfied).

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Securing approval for pilot test: Leaders of the outpatient program and the chair of the psychiatry department began discussing ways to better serve women with perinatal depression who require inpatient care. Aware of the success of dedicated units in Europe and elsewhere, the leaders proposed (and the department chair approved) a pilot test of a similar approach at UNC.
• Designing services for target population: Several physicians and nurses with backgrounds in perinatal psychiatry conducted research to learn more about how the program might work, including talking to the leaders of mother-baby units in other countries and reading literature on the topic. Using the information gathered, the group developed a set of services tailored to the needs of UNC patients and the parameters of the U.S. health care system. For example, recognizing that anxiety was a huge issue for many patients, they decided to include biofeedback therapy to help patients learn practical skills for managing stress. They also decided to allow babies to visit their mothers for an extended period of time each day (but not stay overnight), since third-party payers in the United States would not be willing to cover the costs of nursery services while the mother slept.
• Configuring beds for pilot test: In 2008, the hospital designated two beds in a shared room on the geropsychiatry unit to serve patients with perinatal depression. Hospital staff made minor modifications to the room, including painting and purchasing gliders and hospital-grade breast pumps for each bed.
• Training staff: Leaders of the outpatient program held several training sessions with staff who volunteered to serve patients during the pilot test, including recreational therapists, social workers, and others. Tremendous enthusiasm existed among staff about the pilot test, as many had a strong interest in improving care for these patients.
• Careful evaluation during pilot test: Between 2008 and 2010, the hospital tracked patient volumes and outcomes. The evaluation suggested that sufficient patient demand existed to keep 3 beds occupied on a regular basis, with periods in which additional beds would be needed. The test also suggested that the program could be financially viable on a standalone basis, and that it would generate high levels of patient satisfaction and lead to improvements in clinical outcomes.
• Renovating space to create dedicated unit: The success of the pilot test convinced hospital leaders to approve a dedicated unit. In 2010, the hospital applied for and received approval from the North Carolina Department of Health and Human Services to convert five existing beds in the geropsychiatric unit (including those used in the pilot test) to create the new perinatal unit. Because the hospital was not adding beds, the proposal did not have to go through the state’s certificate-of-need approval process. In addition to reconfiguring the beds, the renovation involved converting existing office and storage space into the day room, nurse’s station, and examination room. The unit opened in August 2011.
• Ongoing training and program review: Each month, program leaders meet with all staff caring for patients on the unit. During these sessions, they teach staff about appropriate care of severe perinatal depression and also elicit feedback and suggestions about how to improve the program. Program leaders routinely use this information to modify services so as to improve the patient experience.
• Ongoing activities to promote awareness: Since the UNC outpatient program opened in 2004, program leaders have spoken on a regular basis at local, regional, and national meetings about appropriate care for women with perinatal depression. Since the start of the pilot program in 2008, these presentations have included information about the inpatient unit, with the goal of raising awareness among referring physicians.

Resources Used and Skills Needed

• Staffing: The unit has 1 RN on duty at all times when the census is 3 patients or below, which equates to 4.2 full-time equivalent (FTE) RNs. When the census is above 3, a nurse assistant joins the RN, meaning that the unit has 8.2 FTEs, divided evenly between RNs and assistants. All other staff serve patients on the unit as part of their regular job responsibilities on the larger, adjacent geropsychiatric unit. Most nurses have experience in treating patients with perinatal depression; for example, one of the newly hired RNs is licensed and certified in prenatal and postpartum care and previously taught yoga on the unit as a volunteer during the pilot test.
• Costs: The upfront costs for renovation totaled approximately $80,000. On an ongoing basis, unit operating costs are similar to those of other units.

Funding Sources

Tools and Other Resources

Getting Started with This Innovation

• Start small and prove concept before expanding: It took 4 years for UNC to move from a pilot test to opening the dedicated unit. This period proved critical to demonstrating that adequate demand existed and that the unit could improve patient outcomes, both necessary prerequisites to securing the approval of hospital administrators.
• Leverage existing staff and infrastructure: Hospitals with an existing outpatient perinatal psychiatry program, enthusiastic staff, and/or other relevant infrastructure will be in a better position to create this type of program than those without such resources.
• Involve key staff in planning: Many staff on the geropsychiatry unit at UNC were very enthusiastic about the proposed unit and offered valuable insights and support during the planning stages.

Sustaining This Innovation

• Regularly elicit feedback from staff and physicians: UNC’s monthly meetings with all team members give program leaders a chance to hear about the effectiveness of various unit services, identify what is and is not working, and make timely adjustments as needed. Program leaders also routinely reach out to physicians who round on the unit to identify and address any problem areas.
• Provide periodic education and training: Program leaders regularly bring in outside speakers and hold other educational programs for unit staff, typically as part of the monthly meetings. These sessions help to keep staff excited and engaged.
• Recognize and celebrate success: Program leaders regularly recognize staff for outstanding work and encourage them to submit to and present at national conferences and other venues. UNC generally makes funding available to support these activities.
• Maintain contact with referring physicians: As noted, program leaders regularly speak at local, regional, and national meetings, reviewing appropriate outpatient and inpatient care for those with perinatal depression. These activities keep physicians aware of the program, making it more likely they will refer patients who can benefit from it.

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