improving mch through qi: post-partum contraception plans lori cannon, rn red cliff community health...
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IMPROVING MCH THROUGH QI:POST-PARTUM CONTRACEPTION PLANS
Lori Cannon, RN
Red Cliff Community Health Center
Red Cliff Band of Lake Superior Chippewa
RED CLIFF COMMUNITY HEALTH CENTER
Full service clinic for 1,200 Tribal members and residents of surrounding counties
Baminiijaanisag – “support with having a child” Prenatal Care Coordination – from conception through two
years post-partum
INTERVALS BETWEEN PREGNANCIESAmount of time after giving birth until next pregnancy
Percent of Women
>17 months 52.6%
Within 17 months 26.3%
Within 11 months 15.8%
Within 6 months 10.5%
AIM STATEMENT
By July 31, 2013, 30% of women served through the Red Cliff Community Health Center’s PNCC program will have a plan for post-partum contraception in place with their provider prior to the birth of their child.
PLAN
DO
CHECK
ACT
Nutrition/food safetyExercise/mobilityPost-partum contraceptionSigns of pre-term laborDoulasLabor & deliveryBreastfeedingBottle feedingPost-partum moods/depressionCar seats/infant safetySwaddling/safe sleep
1.What do you know about different birth control methods?
-pill-patch-Mirena/IUD-Implanon/Nexplanon-NuvaRing-Diaphragm-Depo
2.Where do you get most of your information on birth control/family planning?3.What factors affect your decision-making about having children? 4.What would be helpful to you in terms of making decisions about family planning?
PLAN
DO
CHECK
ACT
Client A: 15 year old30th weekSchool visits
Client B:20 year old17th weekHome visits
PLAN
DO
CHECK
ACT
• Clients A and B• Contraceptive Technology
Conference• Conclusion: clients don’t know
what they don’t know
PLAN
DO
CHECK
ACT
• Updated and enhanced information• New technology• Risks
• Multi-media• Hands-on• Video
CONTRACEPTIVES Copper IUD (Paragard) Hormonal IUD (Mirena) Implant (Nexplanon/Implanon)
Depo Provera
Oral contraceptives (combined and progestin-only) Patch (Ortho-Evra) Ring (NuvaRing)
Diaphragm Condoms
PLAN
DO
CHECK
ACT
• Client A• Client B• Client C
AIM STATEMENT
By July 31, 2013, 30% of women served through the Red Cliff Community Health Center’s PNCC program will have a plan for post-partum contraception in place with their provider prior to the birth of their child.
Meeker-McLeod-Sibley CHSQuality Improvement Project
Increasing WIC fruit and vegetable voucher redemption
Meeker-McLeod-Sibley was formed in 1980 and is governed by a community health board through a joint powers agreement.
Staff work in teams across the three counties according to assigned program areas and have identified team leaders.
WIC program is a consolidated program across the three counties.
Background
Meeker-McLeod-Sibley Community Health Services (MMS CHS) has a total population of 75,177
MMS CHS is categorized as a rural farming community with industrial businesses.
Largest city within 3 counties is Hutchinson with a population of 14,093
Average Hispanic rate for three counties is 5.1%
Average number of monthly WIC participants is 1,900 for all three counties
Background
Identification of the Problem
Staff were finding unused, outdated fruits and vegetable (f/v) vouchers in WIC folders
State report showed MMS had an average of 75.94% of fully redeemed f/v vouchers
Background
AIM STATEMENT
By July 31st, 2013, the MMS CHS WIC QI team will increase
redemption of fruit and vegetable voucher dollars from 76% to 85%.
PLAN
Getting Started
Collection of DataFocus Groups
Root Cause AnalysisPotential Solutions
PLAN
PLAN
Focus GroupsWIC staff
WIC participantsLocal vendors
PLAN
Root Cause Analysis
5 Why’sFishbone Diagram
PLAN
Identify Potential Solutions
5 How’sPrioritization of interventions by votingDiscussion with QI coach to prioritize and chose best potential solutions
PLAN
Test the TheoryTaste Testing
May KickoffEvery month in each county
TrainingCollaboration with state and local WIC agencies
DO
DO
Assess ResultsWill compare baseline data with future report to determine if interventions worked.
STUDY
Taste Testing Comments from WIC participants
Comments from the Field
Adopt, Adapt, or Abandon based on the
results
ACT
• Start with a simple concrete project and apply a simple tool to get the hang of it and to get staff buy in. Then proceed forward with a larger project.
• Don’t jump to solutions• Get buy in from staff• People realizing they were doing QI all along, but now have
a name for it• Gather enough data• Plan for adequate time for testing interventions in the PDSA
cycle• Realize the importance of root cause analysis • Crucial to have leadership support• Have staff on the same page
Lessons Learned
Will continue with testing interventions in PDSA cycle
Next Steps
Continue to create a Quality Improvement Culture
Next Steps
“Excellent firms don’t believe in excellence- only in constant
improvement and constant change.”
Tom Peters
Next Steps
Dual Enrollment of Pregnant Women into WIC and Public Insurance
Programs
Mary A. Prignano RN, MSDuPage County Health
DepartmentWheaton, Illinois
Initiation of this QI ProjectPregnant women are seen as priority populations for the WIC Supplemental Nutrition Program.
Dual Enrollment
Initiation of QI Project
Pregnant women were attending the walk-in hours for benefitting, where they could have their applications completed for public insurance, termed Medically Presumed Eligible (MPE).
Dual Enrollment
Initiation of the Project The Benefitting (MPE) services and the
WIC services were in two different departments of the Health Department
When pregnant women completed MPE first, they needed to return for WIC.
Dual Enrollment
Dual Enrollment
By Appointment
1. WIC Certification and2. MPE Application
As Walk-In
1. MPE Application only
2. WIC Appointment if
requested Second trip required Delay in entry to
services
Initial data collection demonstrated that some clients:
Received MPE without WIC.Had delay in WIC enrollmentHad a greater chance of refusal.
Dual Enrollment
AIM STATEMENTBy July 31, 2013, the DuPage County Health Department will implement a benefitting process that results in a 10% increase in the number of pregnant women who are dually enrolled in MPE/ Medicaid public insurance program and the WIC Nutrition Program.
Dual Enrollment
QI Project Team
WIC Service Area
WIC Program Coordinator
WIC Case ManagerWIC Site SupervisorQuality Improvement
Coordinator
Client Benefits Area
Customer Service Supervisor
Client Benefitting Specialist Supervisor
Office SupervisorClient Benefit
Specialist
QI Project Data
MPE application data entered into spreadsheet.
To inform the QI team of: progress toward dual enrollment locations and # of enrollments
QI Project Data
AddisonTotal/ All Centers
December'12 No WIC 19 67Total Applications 35 153% No WIC 54% 44%
January'13 No WIC 37 100Total Applications 55 239% No WIC 67% 42%
February'13 No WIC 14 32Total Applications 19 115% No WIC 74% 28%
MPE Applications for Addison LocationNo WIC- Not in WIC at the time of the MPE Application
Benefitting Process for Pregnant Women without WIC AppointmentFr
on
t D
esk
Clie
nt
Be
ne
fit
Spe
cial
ist
WIC
Clin
icC
ase
Man
age
r Fo
llow
-Up
Second Appointment
Check-in for CBS with appointment or walk-in
MPE and Kidcare Application completed
Proof Pregnancy Needed?
Pregnancy Testing Completed
If no appt., make WIC
appointment?
yes
no
If no appt., make WIC
appointment?
Case Manager Follow-Up of MPE applications without WIC
appointment
Check-in for CBS
yes
If no appt., make WIC
appointment?
yes
yes
no
Refused/ No response
Client Benefit Specialist Interviews
Structured interviews were conducted with the Client Benefits Specialists (CBS)
All 5 health department office locations.
Completed by the QI Coordinator
QI Project Data Sources
1. Do prenatal clients have tendency to walk-in or to schedule a CBS appointment?
2. Why do some clients decline to make WIC appointment?
3. Is pregnancy testing available/offered onsite before or after MPE visit?
4. If client is leaving CBS visit to go make appointment, where are they instructed to go?
5. Why do you think it is important for these clients to access WIC services?
Client Benefit Specialist Interviews
Fishbone Diagram Redundant Processes Clients difficult to reach once left office Total Cost to Agency Additional total time spent in enrolling
Pregnant Client does not enroll in
both MPE& WIC
Casefinding Staff
WIC Staff Clients
Administration CBS Staff Clients
Pregnancy testing
Communication with CBS
Aware of Walk-in CBS Hours
Turnover/ Training
Prepared with documents
Desire to receive both services
Knowledge about WIC
Sufficient Time
Return to clinic is an issue
Previous service received
Walk-in versus Scheduled appt.
Transportation Problems
Availability of Pregnancy testing
Communication with WIC staff
Turnover/ training
WIC Scheduling not available
Aware of differences in eligibility
Fishbone Diagram Identified:
WIC Staff
Pregnancy Testing Knowledge of MPE Communication
with CBS
CBS Staff
Pregnancy Testing Knowledge of WIC
Program Communication
with WIC
Review of Factors in Process Change Changeable? Strategies? Priority?
Selection for Pilot
MPE/ WIC QI Project
Who: Client Benefitting Specialists and WIC staffWhere: Addison officeWhen: May, 2013What:
Use of instant messaging Engage “Warm Handoff”Complete WIC enrollment or
scheduling
MPE/ WIC QI Pilot
Process for WIC Enrollments for Pregnant Women (May, 2013)N
PH
C C
lin
ic A
ssis
tan
tC
BS
Wa
lkin
W
IC C
lin
ic
Phase
CBS Walkin: MPE and All Kids Applications
Does the client have WIC proofs needed?
Provide direction to
client re: proofs needed
WIC Certification
Proof of Pregnancy Yes/
No?
Pregnancy test Completed
Offer WIC appointment
Are they currently receiving WIC
Services? NO Pregnancy test presented to CBS NO
Proofs available
No proofs
Return to CBS for MPE
Does client wish to stay for WIC
Clinic?
Receiving WIC Services: no action
required Return to WIC Clinic At later time
YesOffer WIC
appointment No
Pregnancy test presented
Process Changes:WIC staff relocated next to CBSInstant Messaging Clients escorted to WIC areaClients seen regardless of
residency
MPE/ WIC QI Pilot
Client Changes: Do clients have their documents for enrollment?
Do they wish to stay for WIC?
MPE/ WIC QI Pilot
Addison Pilot ran for 4 weeks.Two pregnant clients were seen each week
7 of the 8 clients agreed to completion of the WIC assessments (87.5%)- 1 refusal
3 of the 7 clients received their food instruments that same day (43%)
4 of the 7 clients returned to complete their pickup as scheduled (57%)
Pilot Results
Instant Messaging- Staff needed to be introduced to each other by the supervisory staff, including correct spelling of their names.
Warm “hand off”- Clients expressed appreciation for walking them over
to the next station of the interview
Pilot Results
Engage the QI Team in deciding next steps:
Pilot expansion from MPE walk-in to appointment?
Pilot expansion to infants and children?
Pilot expansion to other office locations?
Pilot Results
Opportunity of pregnancy testing Communication challenge: in person,
email, instant messaging Engaging client feedback Computer limitations
Challenges and Opportunities