Applying qi to maternal child health: initial stories from the nnphi qi award program

1. Belinda Johnson-Cornett, Osceola County Health Department Brittany Boyer, Clark County Health Department Applying qi to maternal child health: initial stories from the nnphi qi award program

2. Early Access Prenatal CareEliminating Barriers by Improving Processes Belinda Johnson-Cornett, MS, RN-BC, MBA Administrator Osceola County Health Department

3. We will talk about… • Osceola County Health Department • Why we choose this project…Health Status Indicators • AIM Statement • QI Project…thus far • Key Lessons Learned

4. Osceola CountyQuick Facts • Located in east Central Florida • Walt Disney World • across both Osceola and neighboring Orange County • Population of 270,000 residents • daily average of 99,000 overnight visitors • can swell seasonally to 138,000 • Volume of world-wide tourists = huge potential impact on public health • Increased demand for epidemiological, environmental, and public health preparedness services

5. Osceola County Health Department Our Mission: • “protect & improve the health of all residents in Osceola County” From Our 2008-2013 Strategic Plan: • monitor & improve the community’s health status • improve access to health care services • integrate a culture of organizational performance excellence The Joint Commission Accreditation in Ambulatory Care

6. Background – Health Disparity Osceola has a majority population (57%) considered more likely to suffer from health disparities: • Hispanic / Latino – 46% • Black / African American – 11%

7. Background – Health Status Indicators Late entry into prenatal care (after 1st trimester) • Hispanic / Latino – 20% • Black / African American – 26% • Both worse than national benchmark -16% • Both equal to or worse than national severe benchmark – 20%

8. Background – Health Status Indicators Low birth weight • Hispanic / Latino – 8% • Black / African American – 13% • Both worse than national benchmark - 6% • Black / African American worse than national severe benchmark – 10%

9. Background – Health Status Indicators Infant Mortality (per 1,000 population) • Hispanic / Latino – 10 • Black / African American – 17 • Both worse than national benchmark - 7 • Both worse than national severe benchmark – 9

10. Fetal & Infant Mortality/Morbidity Review • FIMMR committee set up as part of 2008-2013 Strategic Plan objectives • Researched Osceola’s poor birth outcome indicators • Results: • 13% of mothers had no prenatal care • Highest fetal/infant deaths in 2 zip codes • In these 2 zip codes - 66% health disparate population 55% Hispanic / Latino 11% Black / African American

11. Our QI Project…based on our prenatal health indicators GOAL = Improve access to prenatal care Our Improvement Theory Prediction: “IF…we reduce barriers to accessing care… THEN…we will have a positive impact on • Women obtaining earlier prenatal care • Reducing poor birth outcomes

12. Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Langley, Nolan, et.al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance.

13. 9-Step Process Management Methodology / PDCA

14. 9-Step Process Management Methodology / PDCA 14

15. Develop Process MapQI Tool – Input/Output Diagram Inputs Activities (In-Process) Outputs Pregnant woman needs prenatal care • Pregnancy test • Eligibility appointment • Eligibility determined • Provider appointment Pregnant woman gets prenatal care Outcome Better chance for healthy pregnancy and healthy baby!

16. Process Flow Chart Pregnancy test Eligibility Prenatal Workup Nurse Provider Visit • Testing • Healthy Start • Screening • Provider Selection • Schedule Eligibility • appointment • Financial Screening • PEPW • County Pay • application • Schedule Nurse • Work-up Visit • Lab Testing • Prenatal History • Education • Schedule Provider • visit • 1st prenatal • care

17. Process Issues / Problems • Too many appointments - inconvenient to clients • Prolonged access to care • Delay caused clients to seek care elsewhere • Inefficient use of staff time and scheduling • Loss of revenue due to non-billable nurse workup visits if client chooses not to return for provider visit

18. Root Cause QI Tools used: • Brainstorming • Fishbone Diagram Determined Root Cause… Artificially imposed barriers to make system work for the agency…not necessarily for the patient! • I.e. too many separate, specialized visits

19. Revised Process Flow Pregnancy test Eligibility Provider Visit Prenatal Workup Nurse • Testing • Healthy Start • Screening • Provider Selection • Schedule Eligibility • appointment • Financial Screening • PEPW • County Pay • application • Schedule 1st provider • Visit • Prenatal History • Education • Lab testing • Complete physical • exam • Schedule routine • follow-up visits • Lab Testing • Prenatal History • Education • Schedule Provider • visit

20. AIM Statement By November 2012, • improve access to prenatal care services • by increasing percentage of pregnant women receiving their initial prenatal medical exam within 2 weeks of a positive pregnancy test • from baseline of 4% to 75%

21. Reflects Baseline (4%) & Target (75%) Data used to help identify process problems & needed interventions P-D-Check-A Step 7: Monitor Performance % 1st prenatal exam within 2 weeks of pregnancy test Good Target 75% Dropped Nurse Work-up visit Revised elig. schedules Started Early Access Clinic Added 1 elig. staff 2011-2012

22. Next Steps • Continue to monitor performance data • Identify tweaks to improve our process • Revisit our in-process indicators to ensure we are measuring the right things • Consider revision of AIM Statement

23. Key Lessons Learned …or 30 seconds of advice • Use a systematic process management methodology to ensure the team stays on track • We are using our 9-Step Process Management Methodology with PDCA as our QI project roadmap • Resist the temptation to conclude too quickly that you have found the Root Cause of the problem. • Really dig for those root causes…they often are well-hidden! • You may have to dig again!

24. …30 seconds MORE of advice • Your ability to actually measure whatever measures you decide on, will result, in part, in how effective your effort to improve will be. • We are re-evaluating our in-process measures • I.e., number of days pregnancy test to eligibility and eligibility to 1st provider visit – • doesn’t account for patient-imposed variables (such as no-show or choosing appointment further out) • May decide to do random checks for “next appointment availability” instead – a more accurate measure of how the system is working

25. Contact for further information: Belinda Johnson-Cornett, MS, RN-BC, MBA Administrator – Osceola County Health Department Belinda_Johnson-Cornett@doh.state.fl.us

26. Applying QI to Maternal and Child Health: Initial Stories from the NNPHI QI Award Program-Prenatal Care Coordination (PNCC) Presented By: Brittany Boyer, RN BSN Clark County Health Department

27. Outline • Background of Clark County, Wisconsin • Prenatal Care Coordination (PNCC) Program Overview • Reason For Choosing PNCC for A QI Project • Aim Statement • Completed Work Thus Far • QI Tools Utilized • Challenges • Key Lesson(s) Learned • Anticipated Goals/Results • Questions/Comments

28. Clark County, Wisconsin • Very rural county- located in the heart of Wisconsin • Characterized by rustic roads, grazing cattle, an abundance of wildlife, agricultural land, forests, lakes, parks, atv/dirtbike/snowmobile/horseback riding trails, numerous recreational activities, historic sites, residential communities, and outstanding businesses and industry

29. Clark County, Wisconsin • Total county population = 34,412 people • Estimated that 1/3 of our total county population is comprised of Amish or Mennonites-poses unique public health nursing considerations, challenges, and opportunities • 2011: 243/585 births were Amish/Mennonite = 42%

30. Prenatal Care Coordination (PNCC) Program Overview • What is PNCC? • A Medicaid and BadgerCare Plus benefit that helps pregnant women get the support and services they need to have a healthy baby • Introduced in 1985 as a Medicaid benefit to impact low birth weight and prematurity • Services include: • Outreach and assistance finding services in the client’s community • Initial assessment • Providing personal one on one support-listening to client concerns, answering questions, developing a personalized confidential plan of care from pregnancy, to delivery, to the postpartum/newborn care stage • Providing nutrition counseling and health education on a variety of topics • Ongoing care coordination and monitoring

31. Prenatal Care Coordination (PNCC) Program Overview • What is the goal of the PNCC program? • Improve birth outcomes among women who are deemed at high risk for poor birth outcomes bases on the Prenatal Care Coordination Pregnancy Questionnaire • Who is eligible for services? • Medicaid-eligible pregnant women with a high risk for adverse pregnancy outcomes during pregnancy through the first 60 days following delivery

32. Prenatal Care Coordination (PNCC) Program Overview • Who are the coordinators? • 4 Public Health Nurses who provide services in Clark County • Where do we receive referrals from? • Women, Infants, Children (WIC) program, local hospitals, high schools • Clark County PNCC enrollment • 2010: 33 clients • 2011: 25 clients

33. Prenatal Care Coordination (PNCC) Program Overview • Benefits of PNCC Program-Women Enrolled in Program • Single women less likely to deliver low birth weight babies (LBW) (Baldwin et al., 1998) • More likely to seek support from family, friends, have a labor support person, and involve father of baby (Olds et al., 1986) • Teen mothers have reduced rates of LBW births (Hardy et al., 1987; Korenbrot et al, 1989; Olds et al., 1989; Baldwin et al., 1998) • Increased weight gain (Olds), increased vitamin use (Piper et al, 1996) • More medical prenatal visits (Hardy) • Receiving psychosocial assessment & intervention reduced risk of LBW baby (Wilkinson et al., 1998) • Reduction in preeclampsia (Hardy et al., 1987) • Significant reductions noted in smoking behaviors (Olds et al., Middelton & al.; Reicketts et al. (2005)

34. Reason For Choosing PNCC for A QI Project • The provision of PNCC (Prenatal Care Coordination) services has been occurring in Clark County for many years • Program has not been evaluated or updated for quite some time • Realized several improvement opportunities exist • Had several other QI projects in mind, however the PNCC program was our priority focus • Important program that makes a significant impact • Wanted to ensure our program was being conducted in the most evidence based manner • Saved our brainstorm list of other potential QI projects and will initiate those in the future

35. Reason For Choosing PNCC for A QI Project • Became aware of program inconsistencies among staff • Lack of staff adhering to the State of WI Medicaid Prenatal Care Coordination Services Handbook • Current policy and procedure is outdated and not reflective of up-to-date evidence-based practices • Outdated program forms • No clear billing guidelines in place • Recognition of staff turnover/lack of staff orientation to PNCC program • Lack of communication/resource sharing • No PNCC flow sheet/checklist in place to ensure consistency and chart compliance

36. Aim Statement • By November 30, 2012, after the Clark County Health Department’s prenatal care coordination (pncc) policy and procedure has been updated reflecting the WI Medicaid Prenatal Care Coordination Services Handbook, program forms have been updated/revised, pncc flow sheet checklist developed, and staff training conducted on the pncc revisions, 100 % of the pncc client charts will be in compliance after a chart review process. • Sub Aim Statement • This improvement will improve billing practices since all required forms and information will be update and in compliance. This will result in an increase in Medicaid reimbursement for the pncc program from a current level in 2012 (being determined) by 5 % in 2013.

37. Completed Work Thus Far • Described the current process • Developed a flowchart on the PNCC process • Involved all staff members and their input • Collected data on the current process • Found 0 % of PNCC chart audits are in compliance • Realized the department had a significant staff turnover rate • Developed a run chart • From 2008-2009 the health officer, program assistant, and 3 PHN’s left • Since 2009, 3 New PHN’s, a program assistant, and a new health officer started • 2010, 1 PHN left • 2011, 1 PHN left, 1 new PHN started • 2012, 1 new PHN started • Documented length of current charting process • Time staff are spending on the process

38. Completed Work Thus Far • Identified possible causes • Developed a fishbone diagram • 4 major cause categories included: people, resources/materials, time, training/orientation • Identified potential improvements • Update policy and procedure to reflect WI Medicaid PNCC handbook guidelines • Update all program forms • Develop chart audit flow sheet/checklist form • Train staff on the new PNCC program revisions • Developed improvement theory • By November 30, 2012, after the Clark County Health Department’s prenatal care coordination (pncc) policy and procedure has been updated reflecting the WI Medicaid and BadgerCare Prenatal Care Coordination Services Handbook, program forms have been updated/revised, pncc flow sheet checklist developed, and staff training conducted on the pncc revisions, 100 % of the pncc client charts will be in compliance after a chart review process. • Developed a detailed action plan • Identified what needs to be done, who is responsible, and when it should be completed • Developed with staff members • Action plan is in process

39. Challenges • Time • Lack of time to dedicate to program due to other public health nursing duties/responsibilities • Learned to dedicate a designated time each week (even 30 minutes) to work specifically on the QI project • Divided tasks among staff members to decrease work load burden • Lack of experience using QI tools • Utilized the public health memory jogger pocket guide of tools for QI (concise-user friendly) • Used the NNPHI website-public health performance improvement toolkit

40. Key Lesson(s) Learned • Have patience • Don’t procrastinate • Dedicate a designated time each week to work specifically on QI projects to stay on task • Can’t do everything yourself • Involve all respective staff members/ask for help with duties • Don’t hesitate to ask for assistance for questions/feedback • Use QI tools/resources available • Wealth of resources-take advantage of them • Can’t expect change to occur over night • Little steps do make a difference and add up over time • There is always a program/process that can be improved • Realized QI work needs to be a continuous process

41. Anticipated Goals/Results • Measurable objective in the aim statement will be met • By November 2012, 100 % of the PNCC client charts will be in compliance after a chart review process • Therefore hoping to adopt-standardize the improvement • Celebrate our success and hard work • Continue the momentum • Start next potential QI project

42. Questions/Comments

43. References • Department of Health Services-Division of Care Access and Accountability-P1046 • State of Wisconsin Medicaid Prenatal Care Coordination Services Handbook