Improving MCH through QI: Post-partum Contraception Plans

1. Improving MCH through QI:Post-partum Contraception Plans Lori Cannon, RN Red Cliff Community Health Center Red Cliff Band of Lake Superior Chippewa

2. 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

3. Intervals Between Pregnancies

4. 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.

5. Nutrition/food safety • Exercise/mobility • Post-partum contraception • Signs of pre-term labor • Doulas • Labor & delivery • Breastfeeding • Bottle feeding • Post-partum moods/depression • Car seats/infant safety • Swaddling/safe sleep PLAN DO • What do you know about different birth control methods? • -pill • -patch • -Mirena/IUD • -Implanon/Nexplanon • -NuvaRing • -Diaphragm • -Depo • Where do you get most of your information on birth control/family planning? • What factors affect your decision-making about having children? • What would be helpful to you in terms of making decisions about family planning? CHECK ACT

6. PLAN Client A: 15 year old 30th week School visits Client B: 20 year old 17th week Home visits DO CHECK ACT

7. PLAN DO CHECK • Clients A and B • Contraceptive Technology Conference • Conclusion: clients don’t know what they don’t know ACT

8. Updated and enhanced information • New technology • Risks • Multi-media • Hands-on • Video PLAN DO CHECK ACT

9. 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

11. PLAN • Client A • Client B • Client C DO CHECK ACT

12. 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.

13. Meeker-McLeod-Sibley CHSQuality Improvement Project Increasing WIC fruit and vegetable voucher redemption

14. Background • 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.

15. 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 participantsis 1,900 for all three counties

16. 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

17. PLAN 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%.

18. Getting Started

19. PLAN Collection of Data Focus Groups Root Cause Analysis Potential Solutions

20. PLAN

21. PLAN Focus Groups WIC staff WIC participants Local vendors

22. PLAN Root Cause Analysis 5 Why’s Fishbone Diagram

24. PLAN Identify Potential Solutions 5 How’s Prioritization of interventions by voting Discussion with QI coach to prioritize and chose best potential solutions

25. DO Test the Theory Taste Testing May Kickoff Every month in each county Training Collaboration with state and local WIC agencies

26. DO

27. STUDY Assess Results Will compare baseline data with future report to determine if interventions worked.

28. Comments from the Field Taste Testing Comments from WIC participants

29. ACT Adopt, Adapt, or Abandon based on the results

30. Lessons Learned • 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

31. Next Steps Will continue with testing interventions in PDSA cycle

32. Next Steps Continue to create a Quality Improvement Culture

33. Next Steps “Excellent firms don’t believe in excellence- only in constant improvement and constant change.” Tom Peters

34. Contact Information Allie Freidrichs allie@mmspublichealth.org 507-766-3531 Jessica Remington Jessica.remington@co.mcleod.mn.us 320-864-3185

35. Dual Enrollment of Pregnant Women into WIC and Public Insurance Programs Mary A. Prignano RN, MS DuPage County Health Department Wheaton, Illinois

36. Dual Enrollment Initiation of this QI Project Pregnant women are seen as priority populations for the WIC Supplemental Nutrition Program.

37. 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).

38. 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.

39. Dual Enrollment As Walk-In 1. MPE Application only 2. WIC Appointment if requested Second trip required Delay in entry to services By Appointment 1. WIC Certification and 2. MPE Application

40. Dual Enrollment Initial data collection demonstrated that some clients: • Received MPE without WIC. • Had delay in WIC enrollment • Had a greater chance of refusal.

41. Dual Enrollment AIM STATEMENT By 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.

42. QI Project Team Client Benefits Area Customer Service Supervisor Client Benefitting Specialist Supervisor Office Supervisor Client Benefit Specialist WIC Service Area • WIC Program Coordinator • WIC Case Manager • WIC Site Supervisor • Quality Improvement Coordinator

43. QI Project Data MPE application data entered into spreadsheet. To inform the QI team of: • progress toward dual enrollment • locations and # of enrollments

44. QI Project Data

46. QI Project Data Sources 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

47. Client Benefit Specialist Interviews 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?

48. Fishbone Diagram

49. Fishbone Diagram Identified: WIC Staff • Pregnancy Testing • Knowledge of MPE • Communication with CBS CBS Staff • Pregnancy Testing • Knowledge of WIC Program • Communication with WIC

50. MPE/ WIC QI Project Review of Factors in Process Change • Changeable? • Strategies? • Priority? Selection for Pilot