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 PREGNANCIES
Amount 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.
Nutrition/food safety
Exercise/mobility
PLAN
DO
CHEC
K
ACT
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
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
CHEC
K
ACT
Client A:
15 year old
30th week
School visits
Client B:
20 year old
17th week
Home visits
PLAN
DO
CHEC
K
ACT
• Clients A and B
• Contraceptive Technology Conference
• Conclusion: clients don’t know what they
don’t know
PLAN
DO
CHEC
K
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
CHEC
K
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 CHS
Quality Improvement Project
Increasing WIC fruit and
vegetable voucher redemption
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.
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
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%.
Getting Started
PLAN
Collection of Data
Focus Groups
Root Cause Analysis
Potential Solutions
PLAN
PLAN
Focus Groups
WIC staff
WIC participants
Local vendors
PLAN
Root Cause Analysis
5 Why’s
Fishbone Diagram
PLAN
Identify Potential Solutions
5 How’s
Prioritization of interventions by voting
Discussion with QI coach to prioritize and
chose best potential solutions
DO
Test the Theory
Taste Testing
May Kickoff
Every month in each county
Training
Collaboration with state and local WIC agencies
DO
STUDY
Assess Results
Will compare baseline data with future
report to determine if interventions
worked.
Comments from the Field
Taste Testing Comments from WIC
participants
ACT
Adopt, Adapt, or Abandon
based on the results
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
Next Steps
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
Contact Information
Allie Freidrichs
allie@mmspublichealth.org
507-766-3531
Jessica Remington
Jessica.remington@co.mcleod.mn.us
320-864-3185
Dual Enrollment of Pregnant
Women into WIC and Public
Insurance Programs
Mary A. Prignano RN, MS
DuPage County Health Department
Wheaton, Illinois
Dual Enrollment
Initiation of this QI Project
Pregnant 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
By Appointment
1. WIC Certification and
2. MPE Application
As Walk-In
1. MPE Application only
2. WIC
 Appointment if requested
 Second trip required
 Delay in entry to services
Dual Enrollment
Initial data collection demonstrated that some clients:
Received MPE without WIC.
Had delay in WIC enrollment
Had a greater chance of refusal.
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.
QI Project Team
WIC Service Area
WIC Program
Coordinator
WIC Case Manager
WIC Site Supervisor
Quality Improvement
Coordinator
Client Benefits Area
Customer Service
Supervisor
Client Benefitting
Specialist Supervisor
Office Supervisor
Client 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
MPE Applications for Addison Location
No WIC- Not in WIC at the time of the MPE Application
Total/ All
Centers
Addison
December'12
January'13
February'13
No WIC
Total Applications
% No WIC
No WIC
Total Applications
% No WIC
No WIC
Total Applications
% No WIC
19
35
54%
44%
37
55
67%
100
239
42%
14
19
74%
67
153
32
115
28%
Benefitting Process for Pregnant Women without WIC Appointment
Front Desk
Second Appointment
Check-in for CBS with
appointment or walk-in
Proof Pregnancy
Needed?
Check-in for CBS
yes
Client Benefit Specialist
no
yes
MPE and Kidcare Application
completed
If no appt., make
WIC
appointment?
yes
Pregnancy Testing
Completed
If no appt., make
WIC
appointment?
yes
Case Manager Follow-Up of MPE
applications without WIC
appointment
If no appt., make
WIC
appointment?
Refused/ No response
Case Manager
Follow-Up
WIC Clinic
no
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
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?
Fishbone Diagram
Casefinding Staff
WIC Staff
Pregnancy testing
Redundant Processes
Communication with CBS
Aware of Walk-in CBS Hours
Clients
Prepared with documents
Desire to receive both services
Knowledge about WIC
Clients difficult to reach once left office
Turnover/ Training
Sufficient Time
Return to clinic is an issue
Transportation Problems
Total Cost to Agency
Aware of differences in eligibility
Additional total time spent in enrolling
WIC Scheduling not available
Walk-in versus Scheduled appt.
Previous service received
Turnover/ training
Communication with WIC staff
Availability of Pregnancy testing
Administration
CBS Staff
Clients
Pregnant Client
does not enroll in
both
MPE& WIC
Fishbone Diagram Identified:
WIC Staff
CBS Staff
 Pregnancy Testing
 Knowledge of MPE
 Communication with CBS
 Pregnancy Testing
 Knowledge of WIC
Program
 Communication with WIC
MPE/ WIC QI Project
Review of Factors in Process Change
 Changeable?
 Strategies?
 Priority?
Selection for Pilot
MPE/ WIC QI Pilot
Who: Client Benefitting Specialists and WIC staff
Where: Addison office
When: May, 2013
What:
Use of instant messaging
Engage “Warm Handoff”
Complete WIC enrollment or scheduling
Process for WIC Enrollments for Pregnant Women (May, 2013)
NPHC Clinic Assistant
CBS Walkin
Phase
CBS Walkin: MPE and All Kids
Applications
Proof of
Pregnancy Yes/
No?
Pregnancy test presented
NO Pregnancy test
presented to CBS
Return to CBS for MPE
Are they currently
receiving WIC
Services?
NO
Does the client have WIC
proofs needed?
No proofs
Receiving WIC
Services: no action
required
Provide
direction to
client re:
proofs
needed
Offer WIC
appointment
Return to WIC Clinic
At later time
WIC Clinic
Proofs available
Pregnancy test
Completed
Offer WIC
appointment
No
Does client wish
to stay for WIC
Clinic?
Yes
WIC Certification
MPE/ WIC QI Pilot
Process Changes:
WIC staff relocated next to CBS
Instant Messaging
Clients escorted to WIC area
Clients seen regardless of residency
MPE/ WIC QI Pilot
Client Changes:
 Do clients have their documents for
enrollment?
 Do they wish to stay for WIC?
Pilot Results
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?
Challenges and Opportunities
 Opportunity of pregnancy testing
 Communication challenge: in person, email, instant
messaging
 Engaging client feedback
 Computer limitations