Improving Access to Prenatal Care

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Quality
Improvement
Story Board
Improving Access
to Prenatal Care in
the First Trimester
Project coordinated by Kansas Health Institute, Kansas Association of Local Health Departments,
Kansas Department of Heath and Environment, and KUMC Area Health Education Centers
Act Plan
Study Do
MLC-3 in Kansas QI Team Members:
1. Background
The Lower 8 of
Southeast Kansas
collaborated to
address barriers to
early prenatal care.
We had noticed that
young women were
not receiving prenatal
care during the first
trimester of their
pregnancy.
Statistical information
was downloaded from
KDHE/KIC (Kansas
Information for
Communities) to determine if this was true
of all age groups or if there was a specific
age which needed to be addressed. The
15–24 year age group was more likely to
receive inadequate prenatal care. Between
2003–2007, 35 percent of women in this age
group did not receive prenatal care in the
first trimester. There were 77 births which
received no prenatal care.
After reviewing data and collecting anecdotal information, it was decided that a lack of
insurance was the most likely contributing
factor. The application process for Medicaid/
CHIP seemed to be the bottleneck.
2. Aim Statement
By Dec. 31, 2009, we will promote an
increase of 2 percent in the enrollment of
eligible pregnant women in the Medicaid/
CHIP program during the first trimester
of pregnancy over the previous quarter’s
Women, Infants and Children (WIC) data.
Assistance in completing the application and
faxing the application to the Kansas Health
Policy Authority will be offered to all eligible
women.
3. Examine the Current Approach
Current practices and processes revealed:
● Lack of a uniform approach within a
public health region.
● Need for educational information.
● Need for comprehensive Maternal and
Child Health (MCH) services.
● Need for Medicaid/CHIP application
assistance.
4. Identify Potential Solutions
Provide assistance to pregnant women with
the Medicaid/CHIP application process.
5. Develop an Improvement Theory
● Develop a pregnancy testing checklist.
● Standardize pregnancy/history form.
● Make a sample Medicaid/CHIP application.
● Provide training to all staff for the
application process.
6. Test the Theory
The region:
● Reviewed best practices and
recommendations for increasing the
timeliness of prenatal care.
● Collected WIC data for March–May, 2009
for a measurement baseline.
● There were 69.2% of Medicaid/CHIP
women who received first trimester
care in this time period.
● Combined the questionnaire and checklist
into a one-page document.
● Standardized existing pregnancy/history
form.
● Made a sample of the Medicaid/CHIP
application.
● Developed a checklist for the health
departments’ staff to use.
● Provided training to all staff regarding the
utilization of forms and the application
process.
● Tested the standardized questionnaire/
checklist in the Lower 8 health
departments beginning July 1, 2009.
7. Study the Results
Evaluation of implemented
intervention took place in
October–November 2009
by:
● Review the survey
information collected
from WIC clinics of
newly pregnant enrollees
for the months of
July–September. There
were 76.6 percent of
Medicaid/CHIP women
who received first
trimester care in this
time period, an increase
of 10.7 percent.
● Conduct staff meeting to get feedback
from all eight health departments on new
process.
● Share feedback with Lower 8 MLC-3 team
members.
8. Standardize the Improvement
● Continue use of the questionnaire/
checklist to assist in uniformity and
continuity.
● Continue to provide assistance with
Medicaid/CHIP application process.
9. Establish Future Plans
● Continue to gather WIC data on a semiannual basis.
● Analyze data to determine if theory
continues to achieve the desired outcome.
Do
Study
Act
Lower 8 of Southeast Kansas
Counties: Chautauqua, Cherokee,
Crawford, Elk, Labette, Montgomery,
Neosho, and Wilson
Serving a population of: 154,883
● Ruth Bardwell
● Debbi Baugher
● Jeanie Beason
● Kandy Dowell
● Todd Durham
● Betha Elliott
● Janis Goedeke
● Teresa Starr
Plan

10
20
30
40
50
60
70
80
First Trimester Prenatal Care Access Among
Medicaid/CHIP Beneficiaries
March 2009 –
May 2009
July 2009 –
Sept. 2009
10.7%
increase
69.2%
76.6%
Intervention
Prenatal Care Accessed in
First Trimester (%)
Lack of a
Support System Resources Financial Physicians
Education Cultural Barriers
Lack of
knowledge of
importance of
prenatal care
Complex
SRS
application
process
Language
Habits
Parental
Non-involvement
of boyfriend
Job-related
issues
(absences
Schools from work)
Geography
(distance
from provider)
Traditions
Lack of
insurance
Embarassed
to seek
financial
assistance for
prenatal care
Lack of
hospital
Unable
to get
appointment
Physicians do not
initiate care until
second trimester
No provider
for prenatal
care in
county
Religious beliefs
Attitudes about
prenatal care
Fishbone Diagram: Root causes for the lack of timely prenatal care
in the Lower 8 of Southeast Kansas Subregion
Barriers
to
Timely
Prenatal
Care
Quality
Improvement
Story Board
Improving Access
to Prenatal Care in
the First Trimester
Project coordinated by Kansas Health Institute, Kansas Association of Local Health Departments,
Kansas Department of Heath and Environment, and KUMC Area Health Education Centers
Act Plan
Study Do
MLC-3 in Kansas QI Team Members:
1. Background
The Northeast Corner Subregion, which
consists of the Shawnee County Health
Agency and the Jefferson County Health
Department, serves a significant number of
women of childbearing age. For the purpose
of this project, services provided to women
through certain programs will engage
consumers by linking them to the health
care delivery system through guidelines and
provider networking.
2. Aim Statement
By Oct. 1, 2009, in
four clinic programs
at two local health
departments,
pregnant women not
enrolled in prenatal
care will consistently
be given a current
listing of community
obstetricians, 90
percent of those
with limited
resources will
receive staff
assistance in making
a prenatal intake
appointment, and 95 percent of those
intakes will be scheduled within 10 working
days from the date of request.
3. Examine the Current Approach
Current practices and processes:
● Verbal counseling on prenatal care to all
pregnant women.
● Not all clinics provide listings of area
obstetricians to all pregnant women, or
consistently refer pregnant women to
prenatal services.
● Limited number of prenatal intake
appointments are available each week.
4. Identify Potential Solutions
● Keep both health departments current
on clinic schedules.
● Offer to make intake appointments while
clients are still on-site.
● Collect primary data from women of
childbearing age through a survey in order
to identify common barriers.
5. Develop an Improvement Theory
● Open the clinic intake appointment
book to accommodate two to five more
intakes per week.
● Eliminate “cold handoff “ referral of
providing written provider contact
information only and move to “warm
handoff” of making the first prenatal
intake appointment.
● Administer a survey tool to identify
barriers to prenatal care.
● Reformat intake registration form and
change the process of how the form is
filled out.
6. Test the Theory
The team implemented a number of quality improvement interventions during
the course of the project. First, the team
focused on accommodating as many new intake appointments as the clinics’ schedule allowed. By opening their scheduling registers
and demanding flexibility, two to five more
intake visits per week
were scheduled.
Second, the new
system made sure
that prenatal intake
appointments were
scheduled on-site.
Third, the focus was
on administration of a
survey tool to identify
reasons why women
did not receive timely
prenatal care.
7. Study the Results
Creation of additional appointment
slots per week resulted in a substantial
increase in the number of follow-up
appointments scheduled within two
weeks of the initial request. Before the
scheduling intervention, only 83 percent of
appointments were within that timeframe.
After the intervention, that rate went up to
97 percent — a 17 percent increase. The
intervention also contributed to an increase
in the number of women who entered
prenatal care in the
first trimester by 35
percent — from 51
percent to 69 percent.
The surveys
administered as
part of the third
intervention showed
that two-thirds of the
pregnant women at
both clinics did not
plan their pregnancies,
making it harder
for them to access
prenatal care in a
timely fashion after
conception.
8. Standardize the Improvement
● Continue to expand the number of
prenatal intake appointments.
● Standardize the process to schedule
prenatal intake appointments within ten
working days.
● Adopt reformatted
intake registration
form in both English
and Spanish.
9. Establish Future
Plans
Form a group to
focus on barriers
to prenatal care
identified by survey
respondents.
Northeast
Corner
Subregion
Counties: Shawnee and Jefferson
Serving a population of: 193,130
● Eileen Filbert
● Anne Freeze
● Teresa Fisher
● Kay Powell
● Judy Willett
● Debbie McNary
● Allison Alejos
● Barbara Heston
● Martha Conlin
Plan
Do
People Information/Feedback Machines
Scheduling
Appointments
more than two
weeks out
Lack knowledge of
prenatal care
Lack knowledge of
prenatal care
Good resources not available?
What
resources
are most
useful?
Not a patient priority
Community OB’s
not invested in
1st trimester
Lack family support
Not easily
retrievable
Decreased potential or timely
for miscarriage in
2nd trimester
Not listening to
information
What are patients’
resources for
information
Lack knowledge
No support
system at all
Limited pre
natal data
available
Don’t seek care until
having a problem
Talk themselves
out of early care
Have had previous healthy babies
Patients lack knowledge
of prenatal care
In 2008, 49%
of women did
not access
early prenatal
care at the
SCHA-CHC
M&I clinic.
85% were age
20 years or
older.
Fishbone Diagram: Root causes for the lack of timely prenatal care in the
Northeast Corner Subregion
Study
Act

10
20
30
40
50
60
70
80
Jan. 1, 2008 –
Dec. 31, 2008
May 22, 2009 –
Aug. 14, 2009
51%
69%
35%
increase
Intervention
Prenatal Care Accessed in
First Trimester (%)
First Trimester Prenatal Care Access Among
Medicaid/CHIP Beneficiaries
Methods/ Materials/Equipment
Procedures
Motivation/Incentives
Family influence:
No money/coverage No transportation
to pay for care
SRS application process is complex
No phone to
make appointments
No appropriate
educational
materials

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