Tatiana Lin, M.A. Kansas Health Institute

1. Promoting Changes to Improve Birth Outcomes: Kansas MLC-3 Experience MLC-3 Open Forum • September 2009 Tatiana Lin, M.A. Kansas Health Institute

2. In Kansas, We Believe That… “Everyone, no matter where they live, should reasonably expect the local health department to meet certain standards” Acknowledgment: Edie Snethen and Gianfranco Pezzino

3. Snapshot of Kansas • Decentralized - local governments have direct authority over the local health department, with or without a local board of health. • Home rule state - “Home rule” statutes authorize local governments to directly address specific local public health issues through local laws. • 105 counties and 100 local health departments (LHDs)

4. Snapshot of Kansas, continued.. 15 Regions, 103/105 counties

5. Frontier Rural Densely Settled Semi-urban Public Health Structure Urban 100 local health departments 10 serve populations > 50,000 64 serve populations < 10,000 Snapshot of Kansas, continued.. Acknowledgment: Edie Snethen, 2007 APHA Presentation

6. Kansas Local Health Departments:Population Served 52% 63% of Pop. Served by 10 LHDS 37% of Pop. Served by 90 LHDs 36 31 28 26% 11% 7% 5 5 4% 26% 7% 4%

7. Looking for Solutions • Regional Cooperation • “Regional Cooperation” is a consortium of local health departments working together under a formal agreement to provide a specific range of services that could not be provided by each individual local health department. • “Regional Cooperation” is not consolidation. Members of the region remain county health departments but work together as a region to provide certain service functions that are not available within each member local health department.

8. Regional Cooperation: Rules of Engagement • At Least 3 Contiguous Counties • You Pick Partners • Inter-local Agreement • Approved by County Commissions • Governance • Each County has One Member on Board

10. Target Areas – Why? • Infant Mortality – Kansas • 18th highest in the nation • Rates are higher than U.S. for all race and ethnic groups • Ranks 47th among states for black infant mortality rate • Needs to increase state funding to local public health prenatal programs (legislative initiative) • Community Health Profile – Kansas • 21 local health departments completed a capacity assessment using the NACCHO operational definition. Monitoring and assessing community health was identified as a universal gap in almost all local health departments.

12. Mini-Collaborative Projects Team Selection • Outreach Activities: • MLC-3 Information Session – Kansas Public Health Association Conference (KPHA) • Packets: Handbook, Request for Proposal (RFP),Calendar of Activities and Events • Team Selection: • Interest and commitment to apply QI principles and methods • Potential for contribution to the statewide team efforts • Quality of the design of the specific activities proposed for the region • Strength of collaboration and commitment of regional partners • Meaningful evaluation plans for the regional activities • Development of a logical budget • Demonstrated ability to engage all the local health departments in the region

13. Northeast Corner Subregion

14. Northeast Corner Subregion • Team Description: • 2 LHDs, 9 members: Shawnee County Health Agency (SCHA) and the Jefferson County Health Department (JFCHD) • Identified Focus/Need: • Provide pregnant women who are not enrolled in prenatal care a current listing of community obstetricians • Provide 90% of pregnant women with limited resources staff assistance in making a prenatal intake appointment • Schedule 95% of prenatal intake appointments within 10 working days • Current Approach • Provide verbal counseling on prenatal care • Not all clinics provide a listing of area obstetricians • Not all clinics consistently refer pregnant women to prenatal services

15. Teams: Northeast Corner Subregion, continued…. • Data and Tools • QI Tools (selected): Flow Charts, Fishbone Diagram, 5 Why’s, Affinity Diagram, Pareto Chart, SWOT Analysis • Data: Kansas Information for Communities (KIC) • Identified Barriers (selected) • Outdated information in regard to clinic hours and choices available for delivery sites • Providing a listing of obstetricians does not guarantee the client will make a prenatal appointment • No standard process for providing obstetrician information to clients • Staff is challenged to complete referral paperwork for other services • Limited number of prenatal intake appointment available each week • Printed educational material does not include some information on prenatal care

16. PDSA #1: Increase the Number of Intake Appointments Activities • Open/flex the clinic intake appointment book to accommodate 2 – 5 more intakes per week as the schedule allows. • Administer a survey tool. • Make intake appointment while the client is still on site – “Warm handoff.” • Reformat Intake Registration form and change the process of how the form is filled out. . Results • Increased the percentage of intake appointments from 83% to 97%. (increase of 17% of women entered prenatal care in 1st trimester) • Staff were better able to meet the demand for intakes by the second week of testing using the expanded number of appointment slots. • Documenting appointment status on the schedule book was an easy way to capture information and provided an easy visual for analyzing results.

17. State Team- KDHE

18. State Team - KDHE

19. State Team Role in MLC-3 • Project Team • Support Quality Improvement and Accreditation • Provide Support to Regional Teams • Link to datasets maintained by KDHE

20. State Team, continued… • Team description • Team members were selected from a range of bureaus and offices in KDHE to ensure a broad perspective of the issue of access to early prenatal care. • Identified focus/need • Improve coordination among Kansas Department of Health and Environment (KDHE) programs that impact early entry into prenatal care.

21. State Team, continued…. • Data and Tools (selected) • Brainstorming, Cause and Effect Diagram,Forced Choice or Prioritization Matrix • Interventions/Activities • Identify KS Department of Health and Environment (KDHE) programs that impact early entry into prenatal care for women of childbearing age. • Conduct a systematic review of activities and program interventions. • Make recommendations for changes to address gaps and increase coordination.

22. State Team - Recommendations • All KDHE programs involving or serving women of childbearing age should: • Provide assistance to clients in applying for Medicaid • Indicate pregnancy status on the upper portion of all Medicaid/HealthWave applications • Fax applications to the clearinghouse for expedited processing • Follow-up with the client within three weeks after the fax is sent, to assure that Medicaid has responded to the client and an appointment has been made • Use safety net data to assess improvements in access to early prenatal care: • Select indicators (example: trimester of entry into prenatal care; adequacy of prenatal care; the number of prenatal clients seen by each clinic) • Compare this data to other information sources within KDHE, identify gaps and duplication of efforts • Propose interventions or remedies, implement and revise

23. Recommendations, continued.. • Significant change has occurred in reporting of prenatal care visits on birth certificates. • Review quality of data provided by birth clerks • Identify discrepant data reporting processes • Provided training in correct procedures • Develop a resource directory of low-cost sources of prenatal care. • This resource directory should include: • A list of providers • Providers places of service • The scope of the services provided • Criteria used in determining client eligibility for service • Update this resource directory quarterly • Provide public easy access to resource directory

24. Lower 8 of SE Kansas

25. Lower 8 of SE Kansas • Team description • Eight Administrators of LHDs • Identified Focus/Need • To provide assistance to pregnant women during Medicaid/HealthWave application process   • Rational • Women ages 15 – 24 years received inadequate prenatal care • Between 2003 – 2007, 35% of women in this age group did not receive prenatal care in the 1st trimester • 77 births received no prenatal care

26. Lower 8 of SE Kansas, continued… • Current Approach • Lack of uniform approach within PH Region • Provide educational information • Provide limited Maternal and Infant Service: laboratory testing such as blood sugar, blood pressure, weight gain • One department – provides application assistance • Data/Tools • Fishbone Diagram, Kansas Information for Communities (KIC) • Interventions/Activities • Develop a pregnancy testing check list • Standardize current pregnancy/history form • Make a sample of the Medicaid/HealthWave application • Provide training to all staff regarding the utilization of forms and the application process

27. Lower 8 of SE Kansas, continued…. • Results (current) • Started testing pregnancy testing protocols • Provided training to all staff regarding the utilization of forms and the application process • Enhanced data analysis skills

28. Accomplishments and Challenges • Accomplishments • Enhanced cross-regional collaboration • Enhanced data analysis skills • Learned new process mapping tools • Accomplished QI projects across programs and county boundaries • Learned Vyew software • Captures and documents meeting work realtime • Eliminates duplication of effort in recording actions and discussions after meetings • ReadyTalk is useful in connecting a large number of people by phone for a minimal cost • Identified areas for future improvement

29. Challenges • Competing priorities • Development of an aim statement • QI concepts • Vyew • Limitations and availability of data • Diversity of departments in terms of programs and staff • Distance

30. Kansas Health Institute Information for policy makers. Health for Kansans.