Perinatal Health Indicators...86.6Lawndale Christian Health Center 88.2Community Health Centers of...

AuthorsRajesh Parikh, M.D., MPH – Vice President of Clinical Services & Workforce Development, IPHCANaila Quraishi, MPH – Program Manager, IPHCA

Illinois Primary Health Care Association

Perinatal Health IndicatorsPerformance & Promising Practices

Based on Uniform Data Systems (UDS) Reports

3rd Edition

IPHCA Organizational Member Edition

Acknowledgement ............................................................................................................................................. iIntroduction ........................................................................................................................................................ ii

Performance & Promising Practices for Perinatal Health Indicators

Access to Prenatal Care ..................................................................................................................................... APerformance ....................................................................................................................................................... A-iReferences .......................................................................................................................................................... A-R

Low Birth Weight ............................................................................................................................................... BPerformance ....................................................................................................................................................... B-iReferences .......................................................................................................................................................... B-R

Promising Practices on Perinatal Health - 2013 .............................................................................................. C-iPromising Practices on Perinatal Health - 2014 .............................................................................................. C-iiReferences .......................................................................................................................................................... C-R

QI and System-Level Strategies ........................................................................................................................ C-1

AppendicesAppendix A – Health Center Stratification by Number of Patients Served .................................................... App AAppendix B – Prenatal Care Quality Tool ........................................................................................................ App BAppendix C – Referrals for High-Risk Prenatal Conditions ............................................................................ App CAppendix D – Postpartum Transition Strategies ............................................................................................. App DAppendix E – HITEQ Resources ....................................................................................................................... App EAppendix F – Guide to Patient and Family Engagement ................................................................................. App FAppendix G – The Joint Commission Health Literacy & Self-Management Tools........................................ App G

table of contents

i

As we continue to build on the Promising Practices and Performances document to foster peer to peer learning and develop a comprehensive resource of evidence-based recommendations, we are thankful for all the support and positive feedback we have received.

We are extremely thankful to Sachin Vispute for the initial draft of the document on performance section and to Samantha McCurties for the section on promising practices. In addition, we express our gratitude to Illinois Primary Health Care Association (IPHCA)’s Clinical Support Committee and IPHCA’s Chief Operating Officer, Kelly Carter* for their valuable feedback since the beginning. IPHCA’s Communications team provided tremendous support in editing and designing this resource.

Last, but not the least, without whom this report would be incomplete, a special thank you to all the health centers for their valuable time in discussing their successful strategies with us.

Finally, we want to express our profound admiration to all the health centers for their tremendous efforts in addressing health disparities.

Naila QuraishiRajesh Parikh

Authors:• Naila Quraishi, MPH – Intern• Rajesh Parikh, M.D., MPH – Vice President of Clinical Services & Workforce Development• Manasi Jayaprakash, M.D., MPH – Manager of Quality Improvement*

Health centers interviewed:• Promising Practices for 2013 data:

o PCC Community Wellness Centero Asian Human Services Family Health Centero Rural Health, Inc.o Shawnee Health Serviceo Community Health Improvement Centero Esperanza Health Centerso VNA Health Care

• Promising Practices for 2014 data:o Cass County Health Departmento Heartland Health Centerso Lawndale Christian Health Centero Heartland Community Health Clinic

* No longer with Association.

acknowledgement

ii

Illinois Primary Health Care Association (IPHCA) member performances are based on Uniform Data System (UDS) quality of chronic disease management indicators and its comparison with Healthy People 2020 (HP 2020) goals that were available. Community health centers (CHCs) reach populations that face the most burdens when accessing and maintaining health care. They have made admirable strides in bridging the gap between unaffordability and health care in this population group. However, with an influx of more patients through the Affordable Care Act and the existing burden of chronic diseases, health centers face multiple challenges. These include establishing continuity of care, need for culturally tailoring the services, transition to electronic health record (EHR) systems, shortage of a primary care workforce, resource constraints, and the challenge of navigating the Medicaid environment within the state. In the face of these challenges, there is a need for tracking performances against benchmarks and compilation of evidence-based guidelines and promising practices that are adaptable to primary care settings.

Methods IPHCA member health center performances for eight indicators on preventive health screening and services have been graphed using percentiles from 2010 to 2015 with data from Health Resources and Services Administration (HRSA). The HP 2020 targets are used as benchmarks to measure performance. In addition, evidence-based recommendations from experts such as Community Preventive Services Task Force and/or U.S. Preventive Services Task Force (The Task Force) and Promising Strategies Identified Through Literature Review are highlighted.

Purpose The essential purpose of this document is to provide a resource for health centers that consists of not only evidence-based recommendations, but also includes promising practices from some of the best performing health centers. Therefore, this document provides a platform to generate discussions on how to overcome challenges and how to best adapt successful practices to primary care settings. It is important to remember that health center characteristics, such as population group, location, revenue source, prevalence of diseases, and availability of resources are varied, which might contribute to significant challenges for some. In Appendix B, health centers are stratified by patient population size.

Current Limitations of Using UDS Data

introduction

Performance is not 100% reliable and generalizable as the reporting varies between health centers; some report a sample while others report universal data. However, it is the only publicly available data, which can be used to track performance and generate discussion.

IPHCA Member Characteristics In 2015-16, there were 44 member health centers from Illinois, two from Iowa and one from Missouri and therefore a total of 47 IPHCA member health centers for which UDS data was available. As of June 2017, the total number of patients served by Illinois grantees was 1,229,655; 78% of Illinois grantees are accredited as Patient Centered Medical Home (PCMH) and 93% of Illinois grantees have transitioned into Electronic Health Record (EHR) systems. Both the centers in Iowa are PCMH recognized and have EHR systems. The health center in Missouri also has an EHR system.

Using this Resource Strategies for improving preventive health screening and services are categorized into the following sections: Illinois Health Center Spotlights, The Task Force Recommendations and Strategies Identified Through Literature Search. Recommendations from the U.S. Preventive Services Task Force and Community Preventive Services Task Force are included under The Task Force recommendations. Both the task force recommendations are based on a scientific systematic review process that identifies recommendations from numerous existing studies with strong or sufficient evidence. The U.S. Preventive Services Task Force develops recommendations for clinical preventive services, while Community Preventive Services Task Force develops recommendations about community preventive services, programs and policies to improve health.

A

Access to Prenatal Care Rationale: If women enter care in their first trimester, then the probability of an adverse birth outcome will be reduced.

UDS Performance Measure: “Proportion of prenatal care patients who entered treatment during their first trimester.”

(Includes prenatal patients referred outside during their first trimester)

HP 2020 Objective: The objective for comparison is under Maternal, Infant, and Child Health (MICH) section.

MICH-10.1: Increase the proportion of pregnant women who receive prenatal care beginning in the first trimester to 77.9%.

National & State Comparison:Illinois’ average has been consistently higher than the national average. In 2015, although 75th and 25th percentile improved, a decline in the 25th percentile might have contributed to a slightly decreased average for Illinois. Close to 50% of health centers have met the Healthy People (HP) 2020 target.

Performance on Perinatal HealtH measures

Figure A: Comparison of UDS averages (Illinois & National) and IPHCA member health center percentiles based on UDS data for Access to Prenatal Care

A-i-1

6

Figure 1.2: 2010 Access to Prenatal Care data (%) of IPHCA member health centers and their percentiles

44.6 51.8 53.3

58.0 62.0 62.0 63.5 65.2 65.9 65.9 65.9

68.0 68.0 68.6 69.9 70.9 71.6 72.0 72.6 73.1 73.3 73.5 73.7 74.0

77.9 77.9 78.0 79.6 79.7 79.7

83.4 84.4 85.5 85.7 86.0 86.6

90.4 94.2

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0

Circle Family HealthCare NetworkTCA Health, Inc.

Mile Square Health CenterBeloved Community Family Wellness Center

Near North Health Service CorporationPCC Community Wellness Center

Community Health Care, Inc.Aunt Martha's Youth Service Center, Inc.Community Health Improvement Center

Family Christian Health Center25th PERCENTILE

Friend Family Health Center, Inc.Will County Community Health Center

Access Community Health NetworkHeartland Health Centers

Community Health & Emergency Services, Inc.Lake County Health Department

Heartland Community Health Clinic50th PERCENTILE

Greater Elgin Family Care CenterHeartland Health Outreach, Inc.

VNA Health CareCentral Counties Health Centers, Inc.

Southern Illinois Healthcare FoundationCrusader Community Health

HP 2020 TARGETChicago Family Health Center

Shawnee Health Service75th PERCENTILE

Lawndale Christian Health CenterChristopher Rural Health Planning Corporation

Community Health Centers of Southeastern…Alivio Medical Center

PrimeCare Community Health, Inc.Erie Family Health Center, Inc.

Christian Community Health CenterRural Health, Inc.

Asian Human Services Family Health Center

Figure A-i-1: 2010 Access to Prenatal Care data (%) of IPHCA member health centers and their percentiles

2010

Performance on access to Prenatal care

A-i-2

7

1Four health centers without prenatal patients


1 Cass County Health Department, Community Health Partnership of Illinois, Eagleview Community Health System, and Whiteside County Community Health Clinic.

52.2 53.8

58.9 59.4 61.6 62.9 63.1 64.3 64.5 65.2 67.3 68.0 68.4

71.0 72.0 74.0 74.8 75.4 75.8 76.2 77.2 77.3 77.9 78.7 79.2 81.4 81.7 81.7 83.0 83.5 84.1 86.1 86.6 88.2

91.2 91.5

98.0 100.0

0.0 20.0 40.0 60.0 80.0 100.0 120.0

Circle Family HealthCare NetworkAunt Martha's Youth Service Center, Inc.

Mile Square Health CenterTCA Health, Inc.

Community Health & Emergency Services, Inc.Community Health Improvement Center

Beloved Community Family Wellness CenterPCC Community Wellness Center

Central Counties Health Centers, Inc.25th PERCENTILE

Crusader Community HealthFriend Family Health Center, Inc.

Community Health Care, Inc.Family Christian Health Center

Will County Community Health CenterChristian Community Health Center

Lake County Health DepartmentSouthern Illinois Healthcare Foundation

50th PERCENTILEHeartland Community Health Clinic

Shawnee Health ServiceAsian Human Services Family Health Center

HP 2020 TARGETChicago Family Health Center

Alivio Medical CenterAccess Community Health Network

Greater Elgin Family Care CenterHeartland Health Centers

75th PERCENTILEPrimeCare Community Health, Inc.

VNA Health CareChristopher Rural Health Planning Corporation

Lawndale Christian Health CenterCommunity Health Centers of Southeastern…

Near North Health Service CorporationErie Family Health Center, Inc.

Rural Health, Inc.Heartland Health Outreach, Inc.


Four health centers without prenatal patients.2

2011


A-i-3

Six health centers without any prenatal patients.3 8

2Six health centers without any prenatal patients


2 Cass County Health Department, Community Health Partnership of Illinois, Eagle View Community Health System, Macoupin County Health Department, and Whiteside County Community Health Clinic.

44.9 56.9 58.8 58.9 60.1 61.1 61.7 63.3

67.9 67.9 67.9 69.3 70.4 70.9 71.7 71.9 73.5 74 74.3 74.3 74.8 75.2 75.5 76.8 77.9 78 79.2 80 80.9 80.9 80.9 82.7 84.6 85.2 85.5 85.7 86.9 87.1

94.3

0 10 20 30 40 50 60 70 80 90 100

Circle Family HealthCare NetworkBeloved Community Family Wellness Center

PCC Community Wellness CenterTCA Health, Inc.

Christian Community Health CenterNear North Health Service Corporation

Community Health Improvement CenterMile Square Health Center

25th PERCENTILESIU Center for Family Medicine

Community Health Care, Inc.Aunt Martha's Youth Service Center, Inc.

Heartland Health CentersChristopher Rural Health Planning Corporation

Access Community Health NetworkHeartland Community Health Clinic

Family Christian Health CenterFriend Family Health Center, Inc.

50th PERCENTILEWill County Community Health Center

Lake County Health DepartmentEsperanza Health Centers

Chicago Family Health CenterCentral Counties Health Centers, Inc.

HP 2020 TARGETVNA Health Care

Alivio Medical CenterSouthern Illinois Healthcare Foundation

75th PERCENTILECrusader Community Health

Shawnee Health ServiceAsian Human Services Family Health Center

Greater Elgin Family Care CenterCommunity Health Centers of Southeastern Iowa,…

Erie Family Health Center, Inc.Heartland Health Outreach, Inc.

Lawndale Christian Health CenterPrimeCare Community Health, Inc.

Rural Health, Inc.


2012


A-i-4

Eight health centers without any prenatal patients and4 One health center did not report data for 2013.5

10


5Eight health centers without any prenatal patients

5 Cass County Health Department, Community Health Partnership of Illinois, Henderson Co. Rural Health Center, Inc. (Eagleview Community Health System), Whiteside County Community Health Clinic, Chestnut Health Systems, Community Nurse Health Association, Knox County Health Department, and Community Health Care, Inc.

48.3 55.2 55.7 57.1

60.3 60.7 61.4 62.5 64.5 65.6 65.9 67.7 69.1 69.3 69.3 69.6 69.6 69.9

72.8 73.5 74.1 74.3 74.5 74.6 76.4 76.7 76.8 77.9 78.1 78.4 79.1 81 81.2 81.8

84 85.8 86.2 86.2 87.4

92.9

0 10 20 30 40 50 60 70 80 90 100

Circle Family HealthCare NetworkTCA Health, Inc.

Christian Community Health CenterHeartland Health Outreach, Inc.

Community Health & Emergency Services, Inc.Beloved Community Family Wellness Center

Near North Health Service CorporationMacoupin County Public Health Department

Community Health Improvement Center25th PERCENTILE

SIU Center for Family MedicineFamily Christian Health Center

Aunt Martha's Youth Service Center, Inc.Lake County Health Department

Heartland Community Health ClinicChristopher Rural Health Planning Corporation

Friend Family Health Center, Inc.Southern Illinois Healthcare Foundation

Will County Community Health Center50th PERCENTILE

Chicago Family Health CenterPCC Community Wellness Center

Heartland Health CentersVNA Health Care

Access Community Health NetworkMile Square Health Center

Crusader Community HealthHP 2020 TARGET

Asian Human Services Family Health CenterPrimeCare Community Health, Inc.

75th PERCENTILECommunity Health Centers of Southeastern…

Shawnee Health ServiceAlivio Medical Center

Esperanza Health CentersCentral Counties Health Centers, Inc.

Greater Elgin Family Care CenterLawndale Christian Health Center

Erie Family Health Center, Inc.Rural Health, Inc.


2013


A-i-5

2014


Figure A-i-5: 2014 Access to Prenatal Care data (%) of IPHCA member health centers and their percentiles.

Three health centers without prenatal patient data.6

A-i-6

2015


Figure A-6: 2015 Access to Prenatal Care data (%) of IPHCA member health centers and their percentiles

A-R

1. Three health centers without any prenatal data: Knox County Health Department, Hamdard Center for Health & Human Services, Preferred Family Healthcare, Inc

2. Cass County Health Department, Community Health Partnership of Illinois, Eagle View Community Health System, and Whiteside County Community Health Clinic.

3. Cass County Health Department, Community Health Partnership of Illinois, Eagle View Community Health System, Macoupin County Health Department, and Whiteside County Community Health Clinic.

4. Cass County Health Department, Community Health Partnership of Illinois, Eagle View Community Health System, Macoupin County Health Department, Whiteside County Community Health Clinic, Chestnut Health Systems, Community Nurse Health Association, and Knox County Health Department.

5. Community Health and Emergency Services, Inc.6. Three health centers without any prenatal data: Knox County Health Department, Hamdard Center for

Health & Human Services, and Preferred Family Healthcare, Inc.

access to Prenatal care – references

B

Low Birth Weight

Rationale: If there are fewer low birthweight (birth weight under 5.5 pounds or 2500 grams) children born, then there will be fewer children who suffer the multiple negative sequela of low birthweight, such as delayed or diminished intellectual and/or physical development.

UDS Performance Measure:“Proportion of patients born to health center patients whose birth weight was below normal (less than 2500 grams).”

(Includes prenatal patients referred outside of health center for delivery)

HP 2020 Objective: The objective for comparison is under Maternal, Infant, and Child Health (MICH) section. MICH-8 Reduce low birth weight (LBW) and very low birth weight (VLBW).

MICH08.1: To reduce the low birth weight percent to below 7.8%.

National & State Comparison:Illinois average has improved since 2010, and in 2015, it has surpassed the HP 2020 target and is nearing the National average. Majority of IPHCA member health centers have surpassed the HP 2020 target. Since 2010, 25th percentile has remained the same and improvement is called for among the health centers around the 25th percentile.

Note: The lower the percentage on this indicator, the better the performance.

Performance on low birtH weigHt

Figure B: Comparison of UDS averages (Illinois & National) and IPHCA member health center percentiles based on UDS data for Low Birth Weight

B-i-1

12

Figure 2.2: 2010 Low Birth Weight data (%) of IPHCA member health centers and their percentiles

7Health center names without any prenatal patient delivery

7 Cass County Health Department, Community Health Partnership of Illinois, Eagleview Community Health System, and Whiteside County Community Health Clinic.

24.0 21.4

13.6 11.2 11.0 10.9

10.5 10.3

9.8 9.8 9.8 9.8

9.4 9.1 8.9 8.8 8.7 8.6 8.6 8.5 8.3

8.0 7.9 7.8

7.1 6.8

6.0 5.9 5.9 5.9

5.3 5.3

4.2 4.0

2.2 2.1

1.7 0.0

0.0 5.0 10.0 15.0 20.0 25.0

Christian Community Health CenterTCA Health, Inc.

Rural Health, Inc.Aunt Martha's Youth Service Center, Inc.

Friend Family Health Center, Inc.Lawndale Christian Health Center

VNA Health CareCentral Counties Health Centers, Inc.

Access Community Health NetworkGreater Elgin Family Care Center

Shawnee Health Service25th PERCENTILE

Crusader Community HealthAlivio Medical Center

Heartland Community Health ClinicSouthern Illinois Healthcare Foundation, Inc.

Christopher Rural Health Planning CorporationCircle Family HealthCare Network

50th PERCENTILEPCC Community Wellness Center

Heartland Health CentersNear North Health Service Corporation

Family Christian Health CenterHP 2020 TARGET

Chicago Family Health CenterLake County Health Department

Will County Community Health CenterCommunity Health Improvement Center

Erie Family Health Center, Inc.75th PERCENTILE

Beloved Community Family Wellness CenterCommunity Health Care, Inc.

Community Health Centers of Southeastern…Mile Square Health Center

PrimeCare Community Health, Inc.Community Health & Emergency Services, Inc.

Asian Human Services Family Health CenterHeartland Health Outreach, Inc.

Figure B-i-1: 2010 Low Birth Weight data (%) of IPHCA member health centers and their percentiles

Health center names without any prenatal patient delivery.2

2010


B-i-2

13


8Health Center names without any prenatal patient delivery 9Unreported for 2011 8 Cass County Health Department, Community Health Partnership of Illinois, Eagleview Community Health System, Macoupin County Health Department, Whiteside County Community Health Clinic 9 Heartland Health Outreach

14.2 12.0

11.3 11.0 10.8

10.0 9.9

9.6 9.2 9.2 9.2 9.1

8.5 8.4 8.3 8.1 7.9 7.8

6.6 6.6 6.4 6.3 6.3 6.3 6.1

5.8 5.8

5.5 5.5 5.4

4.9 4.8 4.8 4.6 4.4

2.4 0.0

0.0 5.0 10.0 15.0 20.0 25.0

VNA Health CareFriend Family Health Center, Inc.

TCA Health, Inc.Alivio Medical Center

Aunt Martha's Youth Service Center, Inc.Access Community Health Network

PCC Community Wellness CenterLawndale Christian Health Center

25th PERCENTILEAsian Human Services Family Health Center

Shawnee Health ServiceCrusader Community Health

Central Counties Health Centers, Inc.Christian Community Health Center

Family Christian Health CenterSouthern Illinois Healthcare Foundation, Inc.

Rural Health, Inc.HP 2020 TARGET50th PERCENTILE

Chicago Family Health CenterWill County Community Health Center

Erie Family Health Center, Inc.Community Health & Emergency Services, Inc.

PrimeCare Community Health, Inc.Heartland Community Health Clinic

Heartland Health CentersChristopher Rural Health Planning Corporation

75th PERCENTILELake County Health Department

Near North Health Service CorporationCommunity Health Centers of Southeastern…

Greater Elgin Family Care CenterCommunity Health Care, Inc.

Circle Family HealthCare NetworkCommunity Health Improvement Center

Mile Square Health CenterBeloved Community Family Wellness Center


Health Center names without any prenatal patient delivery3 and unreported for 2011.4

2011


B-i-3

14


10Health center names without any prenatal patient delivery 10 Cass County Health Department, Community Health Partnership of Illinois, Henderson Co. Rural Health Center, Inc. (Eagleview Community Health System), Macoupin County Health Department, Whiteside County Community Health Clinic, Chestnut Health Systems, Community Nurse Health Association, and Knox County Health Department.

12.7 12.6

11.3 10.7

10.2 10 9.8 9.7 9.7 9.7 9.6 9.4

9.1 8.9 8.7 8.6 8.5 8.4 8.3 8.3 8.2

7.9 7.8

7.5 7.2

6.7 6.7

6.3 6.1 5.9 5.8 5.8 5.6 5.5 5.4

5.1 4.5

3.6 0 0

0 5 10 15 20 25

Central Counties Health Centers, Inc.Mile Square Health Center

Alivio Medical CenterAccess Community Health Network

Friend Family Health Center, Inc.Community Health Centers of Southeastern Iowa,…

VNA Health Care25th PERCENTILE

Crusader Community HealthSouthern Illinois Healthcare Foundation, Inc.

Family Christian Health CenterEsperanza Health Centers

Christopher Rural Health Planning CorporationCommunity Health Improvement Center

Shawnee Health ServicePCC Community Wellness CenterLawndale Christian Health Center

SIU Center for Family Medicine50th PERCENTILE

Chicago Family Health CenterHeartland Community Health Clinic

Asian Human Services Family Health CenterHP 2020 TARGET

Circle Family HealthCare NetworkCommunity Health & Emergency Services, Inc.

Christian Community Health CenterWill County Community Health Center

TCA Health, Inc.Aunt Martha's Youth Service Center, Inc.

Near North Health Service Corporation75th PERCENTILERural Health, Inc.

Lake County Health DepartmentGreater Elgin Family Care Center

Erie Family Health Center, Inc.Community Health Care, Inc.

Heartland Health CentersPrimeCare Community Health, Inc.

Beloved Community Family Wellness CenterHeartland Health Outreach, Inc.


Health center names without any prenatal patient delivery5

2012

Performances on low birtH weigHt

B-i-4

15


16.7 14.8

12.1 11.7 11.6

10.9 10.2 10.2 10.2

9.8 9.6

9.2 8.8

8.5 8.3 8.3 8.2 8.1 7.9 7.8 7.8 7.6 7.5 7.5 7.4 7.3

6.9 6.4 6.3

5.9 5.9 5.7 5.6

4.8 4.4

3.5 3.5

2.9 2.1

0

0 5 10 15 20 25

Heartland Health Outreach, Inc.TCA Health, Inc.

Christian Community Health CenterCentral Counties Health Centers, Inc.

PCC Community Wellness CenterCommunity Health & Emergency Services, Inc.

Lawndale Christian Health CenterSouthern Illinois Healthcare Foundation, Inc.

Mile Square Health Center25th PERCENTILE

Shawnee Health ServiceCommunity Health Improvement Center

VNA Health CareAccess Community Health Network

Crusader Community HealthMacoupin County Public Health Department

Chicago Family Health CenterAunt Martha's Youth Service Center, Inc.

Heartland Community Health ClinicHP 2020 TARGET50th PERCENTILE

Greater Elgin Family Care CenterFriend Family Health Center, Inc.

Will County Community Health CenterFamily Christian Health Center

Lake County Health DepartmentNear North Health Service Corporation

Asian Human Services Family Health CenterCommunity Health Centers of Southeastern Iowa,…

Erie Family Health Center, Inc.75th PERCENTILE

PrimeCare Community Health, Inc.Alivio Medical Center

SIU Center for Family MedicineChristopher Rural Health Planning Corporation

Heartland Health CentersEsperanza Health Centers

Rural Health, Inc.Beloved Community Family Wellness Center

Circle Family HealthCare Network


2013


Health center names without any prenatal patient delivery6

B-i-5

2014


Figure B-i-5: 2014 Low Birth Weight data (%) of IPHCA member health centers and their percentiles7

2015



B-i-6

B-R

low birtH weigHt – references

1. 41 health centers were included for the 2014 percentiles.2. Cass County Health Department, Community Health Partnership of Illinois, Eagle View Community Health

System, and Whiteside County Community Health Clinic.3. Cass County Health Department, Community Health Partnership of Illinois, Eagle View Community Health

System, Macoupin County Health Department, Whiteside County Community Health Clinic, and Heartland Health Outreach.

4. Cass County Health Department, Community Health Partnership of Illinois, Eagle View Community Health System, Macoupin County Health Department, Whiteside County Community Health Clinic, Chestnut Health Systems, Community Nurse Health Association, and Knox County Health Department.

5. Cass County Health Department, Community Health Partnership of Illinois, Eagle View Community Health System, Whiteside County Community Health Clinic, Chestnut Health Systems, Community Nurse Health Association, Knox County Health Department, and Community Health Care, Inc.

6. Health center names without any deliveries: Knox County Health Department, Hamdard Center for Health & Human Services, Preferred Family Healthcare, Inc., and Community Health Centers of Southeastern Iowa, Inc.

7. Two health centers with ‘0’ ‘Prenatal Patients who Delivered’ have been excluded from percentile calculation

C-i-1

Due to commonality of strategies for prenatal care and lowering the risk of low birth weight, strategies will be considered together under perinatal health.

Illinois Health Center Spotlight

1 Erie Family Health Center, Inc. – Chicago, ILErie has consistently performed above the HP 2020 target in maintaining high access to prenatal care

for pregnant women and low percentage of LBW since 2010 (Figure 1 on page 5-9 and Figure 2 on pages 10-14 ). In 2012, Erie had 86% of its pregnant women enter into prenatal care in first trimester and its LBW was 5.4%. Success behind this can be attributed to a successful program of pre-pregnancy testing, an active workforce of women’s health promoters, and an emphasis on continuous team-based provision of care. Based on Erie’s successful model of care for prenatal patients, they were highlighted by Health Resources Service Administration (HRSA) in their grantee spotlight.1 Strategies discussed during interview and identified through grantee spotlight are below:

• Free pre-pregnancy test – Women undergo a free walk-in pre-pregnancy test; and, if found positive, a women’s health promoter talks to them and immediately links them to a primary care physician of their choice ensuring the first access to prenatal care.

• Women’s health promoter – They are part of interdisciplinary women’s health care teams. They play a crucial role in facilitating early entry into prenatal care by being the first point of contact for pregnant women and women who suspect they might be pregnant. If pregnant, their roles can be identified as:○ Follow a standardized prenatal care intake

procedure.○ Recording patient’s health history.○ Assessing pregnancy risk status.○ Providing health education.○ Linking patients to case managers and social

services.• Centering Pregnancy – Group care is provided

in accordance with Centering Pregnancy. Also, women’s health promoters work as centering pregnancy facilitators and breast feeding counselors throughout a woman’s pregnancy.

• Continuous provision of care and care coordination – This is aided by the presence of a robust Electronic Medical Record (EMR) system. A standardized assessment tool aids the women’s health promoter in inputting all the necessary data. In addition, a spread sheet has been developed by

Erie’s Women’s Health Department and quality improvement staff, which is used by the women’s health promoter to track patients’ estimated date of delivery, including provider capacity and availability. It helps them assign new prenatal patients to providers on the date pregnancy is confirmed.

• Quality Improvement (QI) strategies – In addition to the above specific strategies for prenatal care, some QI strategies were also identified that are applicable to other indicators. They are:○ Goals are set collaboratively where various clinical

groups come together and share quality data and set goals for the following 18 months.

○ Peer review – Individual providers are benchmarked against other providers every quarter which helps in engaging providers in a competitive spirit.

2 Rural Health, Inc. – Anna, ILRural Health has maintained high performance in access to prenatal care since 2010 (Figure 1, on pages

5-9); in 2012, the percentage of prenatal patients having their first prenatal check-up was 94%. With respect to low birth weight (Figure 2, on pages 10-13), Rural Health has improved considerably; in 2010, LBW was 13.6%, which decreased to an impressive 5.8% in 2012 and crossed HP 2020 target of 7.8%. A comprehensive approach to prenatal care and a strong emphasis on health education at every visit has helped lower the percentage of low birth weight and maintain adequate prenatal care. Strategies practiced are:

• Comprehensive care – Being located in a rural area, most of the patients face challenges in reaching health centers. To overcome this and to avoid patients making multiple trips, a comprehensive approach is taken when prenatal patients visit the health center:○ During the first visit, patient meets with a nurse

and then the doctor. ○ While waiting, patient undergoes glucose tolerance

screening and watches health education videos.• Health education - at each visit that stresses on high

risk behaviors such as smoking, exposure to second hand smoke, alcohol consumption, drug use, and consequences due to these on perinatal health.

• Provider - The obstetrician is committed to seeing patients even if they are late, and maintaining a strong relationship with the area hospital, which is highly beneficial in a rural setting.

• QI strategies - Some QI strategies identified are also applicable to other indicators. ○ Monthly medical staff meetings and provider

education led by QI Nurse at each meeting are conducted.

Promising Practices on Perinatal HealtH – 2013

C-i-2

○ Flow sheet – Three years ago, an adult preventative flow sheet was created that includes majority of the questions for providers to follow related to UDS indicators. Several flow sheets are utilized for other services which help in auditing and patient care.

• Other Common Strategies - Some common strategies were also identified that are applicable to multiple indicators. In March 2012, NotifyMD helped create a patient outreach call system for certain diagnoses. ○ The system can include daily appointment

reminders or automated reply for no-show calls (e.g. missed appointment in case of prenatal care).

○ It could also include a routine call for reminder appointments. This has dropped the no-show rate from 16-18% to < 9% in the past two years.

The Community Guide

The Task Force recommendations are geared toward reducing fetal abnormalities through targeting alcohol consumption, smoking cessation, and weight loss. This recommendation is highly relevant especially with the investigation on alcohol and illicit drugs in newborns done by Stanley Manne Children’s Research Institute of Ann & Robert H. Lurie Children’s Hospital of Chicago. They investigated the rates in which Illinois newborns tested positive for alcohol, narcotics, hallucinogenic agents, and cocaine during the years 2008-12 using ICD-9 codes from hospital discharge data. The key findings of the data released by them in 2014 are:2

• The rates at which newborns test positive for alcohol is lower than for illicit drugs. It was identified that alcohol is metabolized much more quickly than illicit drugs, and thus it is assumed to be underestimated.

• The rates at which newborns test positive for cocaine has decreased significantly over time. However, cocaine is the highest detected substance (148.6 per 100,000 live hospital births in Illinois, 2008-12), followed by narcotics (108.3), hallucinogenic agents (48.8), and alcohol (17.7).

• A significant finding is the variation by race of the rates at which newborns test positive for narcotics and cocaine.○ Black newborns have the highest rate of substance

detection for all the tested substances.○ Hispanic newborns have the lowest rates of

substance detection when compared to blacks and whites.

○ The difference between black babies and both white and hispanic babies were greatest for alcohol and hallucinogens.

• Another important finding is the variation by region.

○ All regions had the same pattern as overall rates, except Peoria, where rates of testing positive for narcotics was three times higher than the rate of testing positive for cocaine (215.1 and 128.7 respectively).

• Chicago had the highest rate of testing positive for cocaine at 251.5 per 100,000 live hospital births.○ In the far South region of Chicago, detection of

narcotics and cocaine was nearly equal.○ The West, South, Southwest, and Far South

regions had dramatically higher rates of substance detection compared to the North, Northwest and Central regions.

The above data is of high value for Illinois health centers depending on the location of the health center and the patient population served. Moreover, national data reveals that 18% of pregnant women drink alcohol during early pregnancy and 9% of all pregnant women reported to have consumed alcohol.3 The Task Force recommendations address some of the problems as revealed by above data and are:

• Preventing Excessive Alcohol Consumption – Based on strong evidence of effectiveness, The Task Force recommends electronic screening and brief intervention (e-SBI) in reducing self-reported excessive alcohol consumption and alcohol-related problems. E-SBI uses electronic devices such as computers, telephones, or mobile devices to facilitate the delivery of key elements of traditional screening and brief intervention (SBI). SBI involves screening individuals for excessive drinking and delivering a brief intervention that provides personalized feedback about the risks and consequences of excessive drinking.4

• Tobacco Use Among Pregnant Women – 15.9% of pregnant women reported to have smoked cigarettes in the past month, based on 2011 and 2012 data.5 The Task Force therefore recommends quitline interventions, especially proactive quitlines where follow-up counseling calls are offered to increase tobacco cessation among clients interested in quitting.6 Mobile phone-based interventions for smoking cessation are also recommended where these interventions use interactive features to deliver evidence-based information, strategies, and behavioral support directly to tobacco users interested in quitting.7

• Weight Loss – Technology-supported multicomponent coaching or counseling interventions intended to reduce or maintain weight are recommended in improving weight-related behaviors or weight-related outcomes. Technology-supported components may include computers, video conferencing, personal digital assistants, pagers, pedometers with computer interaction, or computerized telephone system interventions.8


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Other Strategies From Literature Search

1 Recommendations to address alcohol and illicit drug use among prenatal patients:In the investigative report by Child Health Data Lab

of Ann & Robert H. Lurie Children’s Hospital of Chicago, some recommendations have been made on how best to address alcohol and illicit substance use among prenatal patients. Considering the underserved population that the health centers serve and some of the underserved locations, these recommendations are highly valuable.9

• Incorporating a screening tool for misuse or abuse of alcohol, legal medication, illegal drugs and smoking into every prenatal intake and history form. ○ It is identified that quick and brief questionnaires

can be effective in prenatal care for assessing alcohol and drug use.

○ Questions when asked in a health context can lessen the stigma associated with the topic, which also expresses concern for the health of the mother and baby.

○ Treatment for substance abuse during pregnancy is significantly more effective than at other times in a woman’s life.

○ Even if mothers do not disclose the use, many pregnant women reduce their use of drugs or alcohol following supportive advice from a health care professional.

• Finding an approach that is comfortable to the provider and being nonjudgmental and supportive while screening can identify more at-risk prenatal patients.

• Identifying places to refer a patient for further assessment and treatment.

2 Nurse-Family Partnership Program:Nurse-Family Partnership (NFP) is a non-profit organization. The program is derived from an

evidence-based model that partners public health nurses with first-time mothers to empower them to make the right choices in lifestyle to improve pregnancy outcomes; help parents to provide responsible and competent care to improve child health and development; and help parents achieve economic self-sufficiency. The key elements of the model are to enroll first-time, low-income mothers early in their pregnancies; trained public health nurses deliver home-visits over two-and-a-half years; and establish support for the program within an implementing organization.10

In Illinois, NFP was launched in 2000 as an Illinois charity.11 The partnership serves clients in DuPage, Jefferson, Kane, Lake and Marion Counties and in South Chicago. The 2013 Illinois state report identifies client demographics and positive outcomes. Key client demographics were: 87% Medicaid recipients, Median age of 18 years, 68% white, 27% African American, and 49%

Hispanic/Latina. Some of the positive outcomes for clients served by Illinois’ Nurse-Family Partnership are:12

• 92% of babies were born full term and 92% were born at a healthy weight – at or above 5.5 lbs.

• 62% reduction in domestic violence during pregnancy.

• 83% of mothers initiated breast feeding. • 94% of children receive all recommended

immunizations by 24 months.

For those health centers located in the above mentioned counties, local agencies can be contacted; for those health centers who would like to inquire about bringing NFP into their communities, the NFP business development manager can be contacted. To contact, visit www.nursefamilypartnership.org/locations/Illinois.

3Summary from a peer learning conversation on early prenatal care entry:The peer learning call was presented by National

Academy for State Health Policy (NASHP) in collaboration with HRSA in April 2014. The goal was to share promising practices from health centers performing well on creating early access to prenatal care. Health centers featured were Harbor Health Services in Massachusetts, Seattle Indian Health Board in Washington, and other participating health centers.

Designing protocols to facilitate early entry into prenatal care and address the need of pregnant mother.

• Harbor Health Services’ policy ensured that a patient expecting to be pregnant not only met with a provider, but was also started on prenatal vitamins, connected with social and community services, received healthy pregnancy counseling, and received a next appointment. They also created ‘Perinatal Collaborative’ with representatives from the health center’s Women’s Health Department, on-site Women, Infants, and Children (WIC), pediatrics, social services, and behavioral health. The collaborative goal is to meet every month for developing programs and initiatives to improve perinatal care outcomes.

• Seattle Indian Health Board created walk-in, same day appointments for women who might be pregnant. They created ‘Prenatal Thursdays’ and made available providers to see prenatal patients for pregnancy testing and early prenatal visits, including a pharmacist, nutritionist, and breastfeeding educator.


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• To address provider and space shortages, one health center started a group prenatal welcome visit prior to the initial exam that included an hour-long health education presentation by a nurse or health educator. Educational materials are distributed on issues such as prenatal appointment schedules, labs, prenatal screening tests, health center’s call system to reach providers, dietary changes, community resources, and relevant state programs.

Utilizing EHR in establishing continuity of care, care coordination, and for monitoring and tracking performance. Although all health centers found the transition to EHR challenging, the benefits over time clearly outweighed the difficulties of transition.13

Additional resources from Illinois State Medical Society on screening pregnant women for alcohol, tobacco and drug use can be found at: www.isms.org/Resources/For_Physicians/Pregnancy/Screening_Pregnant_Women_for_Alcohol,_Tobacco_and_Drug_Use/.

Application To Health Centers

Not all of these strategies can be implemented in all health center settings, nevertheless social determinants of health plays a critical role in perinatal health and must be tackled when possible. Health centers should seek to address social determinants through health education and collaboration with community organizations. Key strategies are:

• A comprehensive approach addressing clinical assessment and health education during the same visit will help those patients who have barriers to frequently access care.

• Culturally and linguistically appropriate women’s health promoter might play a key role in ensuring regular follow-up of prenatal patients.

• Health education tailored to patients background (level of education, socioeconomic status, availability of resources) will help in lowering the chances of low birth weight.

• Connecting early with pregnant women, assessing risk factors, providing tailored education, and connecting with community and social services will help in retention and ensure provision of quality prenatal care.

• Extra effort needs to be taken in health centers to address the racial disparities and geographic differences in illicit substance and alcohol use among prenatal patients.

Erie Family Health Center – Chicago, ILErie serves more than 50,000 patients from 12 sites. Erie is PCMH-accredited and has EHR. According to 2013 UDS data, 94% of its patients belong to racial/ethnic minority group – 78% Hispanic/Latino, 46% African American, 9% Asian. 53% of the patients are best served in a language other than English. 98% of patients are below 200% of Federal Poverty Line. 33% are uninsured. In 2013, Erie saw 3,479 prenatal patients of whom 1,730 were delivered by Erie providers. www.eriefamilyhealth.org.

Rural Health Care, Inc. – Anna, ILRural Health serves close to 12,000 patients from 7 sites. 9.8% of its patients belong to racial/ethnic minority group – 3.3% Hispanic/Latino, 5% African American. Majority of the patients (93.5%) were white. 76.2% of patients were below 200% of Federal Poverty Line. 16.6% were uninsured and 35.9% had Medicaid. In 2013, Rural Health saw 210 prenatal patients of whom 105 delivered. www.ruralhealthinc.org.


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Illinois Health Center Spotlight

1 Heartland Health CentersHeartland Health Centers (HHC) is located in Chicago, Illinois. Over the past few years, Heartland Health

Centers has significantly improved and maintained a high percentage of women receiving prenatal care in the first trimester. Access to prenatal care at HHC increased from 69.9% in 2010 to 84.6% in 2014. In addition, HHC has maintained a low percentage of low birth weight (LBW) performing above the 75th percentile since 2012. The LBW decreased from 4.5% in 2012 to 3.5% in 2013 to 2.8% in 2014. These achievements in improvement can be attributed to the following strategies:

• Patient Tracking and Follow-up: Once patients are identified, they are enrolled in prenatal care immediately. Aggressive follow-up of missed appointment helps ensure good prenatal care. Some of the follow-up methods are:o Obstetrics RN Care Coordinator conducts

education and outreach to patients.o Additional staff were added to schedule

appointments where follow-up is beyond mailing reminders.

• Behavioral Health Integration: To reduce LBW, an integrated care approach identifies prenatal patients with anxiety and depression. o Health center staff work diligently around smoking

cessation among prenatal patients. o Referrals to specialists are tracked to ensure

continuity of care.

2 Christopher Greater Area Rural Health Planning CorporationChristopher Greater Area Rural Health Planning

Corporation is located in Christopher, Illinois. Christopher Rural has significantly improved access to prenatal care performance from 2013 to 2014: access to prenatal rate care increased from 69.6% to 87.2%. In addition, LBW has also significantly reduced from 8.7% in 2013 to 4.7% in 2014 putting it well above the HP 2020 target. Focused strategies include:

• Utilizing a mid-level provider, who is available five days a week to see prenatal patients, has greatly improved access to prenatal care.

• Availability of free pregnancy tests daily at sites and immediate enrollment and referral to provider for patients with a positive pregnancy test.

• Access to a dietitian for prenatal patients. • Continuous tracking by nurses to ensure

appointment scheduling for adequate routine prenatal care:o Prenatal patients are educated on the importance

of keeping appointments.o Nurses also ensure missed appointments are

rescheduled right away.

Task Force Recommendations

The United States Preventive Services Task Force (Task Force) released its recommendation in January 2016 on screening for depression in the general adult population, including pregnant and postpartum women: Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. The recommendation expands on its earlier recommendation of 2009 and broadens the scope by including pregnant and postpartum women. The Task Force also concludes with certainty that there is a moderate net benefit to screening for depression in pregnant and postpartum women who receive care in clinical practices that have cognitive behavioral therapy or other evidence-based counseling available after screening.14

Other Strategies

1 Local Initiatives:a. Preconception, Postpartum and Inter-conceptional

Care Health Communication Toolkit

This toolkit has been developed with funding from Children’s Health Insurance Program Reauthorization Act (CHIPRA) grant. The toolkit has been designed for providers as a resource to help inform their patients. It can be customized to include health center logos and contact information.15

On the next page, there is a table that outlines the content and description of the toolkit.16

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Promising Practices on Perinatal HealtH – 2014Illinois Department of Healthcare and Family Services

CHIPRA Quality Demonstration GrantPerinatal Education Toolkit – Content and Uses

Tools Description Format Suggested Use

For Patients

Health Education and Social Marketing Materials

Directed at women of childbearing age, all of these materials include an image and a clear message on preconception, prenatal, postpartum, and interconception health topics.

Electronic and print-ready. All materials can be reproduced on business cards, flyers, billboards, and posters. The organization’s logo can be easily added to each item.

- Display/distribute posters, brochures, and flyers in waiting rooms, exam rooms, and private consulting areas.- Print educational handouts to reinforce education provided.- Display on billboards, bus ads, or giveaways to raise awareness throughout the community.

Prenatal and Postpartum Checklist Brochures

These brochures are intended to educate women about the importance of prenatal and postpartum care, what to expect at visits, and includes questions women can ask their providers.

Electronic with the ability to add the organization’s logo and print.

- Use to reinforce one-on-one education and patient engagement in care. - Display/distribute in waiting areas.

text4baby Brochure and Poster

These materials are intended to educate women about how to sign up for the free text4baby mobile health information service.

Electronic and print-ready. - Use to supplement one-on-one education and educational materials provided.- Display/distribute in waiting areas, exam rooms, and private consulting areas.- Distribute brochures during prenatal visits.

For Providers

Prenatal Care Quality Tool (Appendix C)

This is a compilation of minimum prenatal care services based on ACOG and IAFP guidelines. The information is organized by visit/trimester and includes clinical services, labs, education, and referrals.

Paper checklist or integration in an electronic health record.

- Use the tool in either format to assure recommended prenatal care services are provided to women at the appropriate times.

High-Risk Referral Crosswalk (Appendix D)

This tool crosswalks ACOG guidance for high-risk referrals with the Illinois Perinatal Code.

Paper or electronic. - Use as a reference guide for assuring that high-risk women are appropriately referred for consultation or higher level care.

Health Education Resources Matrix

This is a comprehensive electronic guide of resources on preconception, prenatal, postpartum and interconception health topics for use by medical and social service providers for educating women of childbearing age on perinatal and well-woman topics. Educational topics align with those on the Prenatal Care Quality Tool.

Electronic access to fact sheets, health information, and websites that provide easy click and print capability. Available here: http://healthychoiceshealthyfutures.org/education-matrix.

- Use for one-on-one patient education.- Use to supplement and reinforce one-on- one education.- Recommend and provide websites for patient self-education.

Postpartum Visit and Perinatal Care Transitions

The HFS Provider Notice dated September 29, 2015 shares best practices for perinatal care transitions.

Paper or electronic. - Use the best practices checklist to assess performance and identify gaps.Paper or electronic. - Use the best practices checklist to assess performance and identify gaps.- Incorporate applicable best practices into the workflow and adopt as policy.- Use the Quick Reference tool to assist in identifying the patient’s PCP

Postpartum Transition Strategies (Appendix E)

Proposed strategies for consideration by providers who have contact with women at various points during the perinatal period, including prenatal providers (obstetricians, family physicians, APNs), hospital labor and delivery units, and pediatricians. The strategies are intended to increase the number of women who receive postpartum services.

Electronic. - Implement one or more of the strategies by incorporating into the work flow and adopting as policy.- Use the proposed strategies as a springboard to explore other ways to increase the number of women who receive postpartum services.

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Promising Practices on Perinatal HealtH – 2014b. Illinois Perinatal Quality Collaborative

The Illinois Perinatal Quality Collaborative (ILPQC) was formed in late 2012, with support from Illinois CHIPRA Quality Demonstration grant and March of Dimes, by the coming together of Perinatal Quality Collaborative of Illinois (PQCI), a neonatology-focused collaborative and obstetric quality improvement leadership to form a statewide quality collaborative that would work closely with the Illinois Regionalized Perinatal System (RPS) on both obstetric and neonatal quality improvement initiatives. It is an ongoing collaborative that is seeking perinatal health-related providers for their participation in their Obstetrics, Neonatal and Data Advisory Workgroups. More information can be found at http://ilpqc.org/node/40.

2 National Initiatives: Perinatal Quality CollaborativesState perinatal quality collaboratives (PQCs) are

networks of perinatal care providers and public health professionals working to improve pregnancy outcome for women and newborns by advancing evidence-based clinical practices and processes through continuous quality improvement (CQI). PQC members identify care processes that need to be improved and use the best available methods to make changes and improve outcomes. State PQCs include key leaders in private, public, and academic health care settings with expertise in evidence-based obstetric and neonatal care and quality improvement. Some available resources are:

a. Ohio PQC Quality Improvement Resources https://opqc.net/projects/improvement%20resources

b. Improving Health Care Response to Preeclampsia: A California Quality Improvement Toolkit17 – This is an extensive toolkit covering a series of articles on best practices for hypertensive disorders that range in topic from diagnostic challenges to appropriate implementation of accepted medical therapy and recognition of institutional limitations in providing care for these complex maternal patients.

CMQCC PREECLAMPSIA TOOLKIT PREECLAMPSIA CARE GUIDELINES

CDPH-MCAH Approved: 12/20/13

31

PREECLAMPSIA EARLY RECOGNITION TOOL (PERT)

Adapted from the Modified Obstetric Early Warning System (MEOWS) in “Saving Mothers Lives: Reviewing maternal deaths to make motherhood safer (2003-2005). The Seventh Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom 2007

11.8.13.v1

YELLOW = WORRISOME Increase assessment frequency

#Triggers TO DO

1 •Notify provider ≥2 •Notify charge RN

•In-person evaluation •Order labs/tests •Anesthesia consult •Consider magnesium sulfate •Supplemental oxygen

**Physician should be made aware of worsening or new-onset proteinuria

Preeclampsia Early Recognition Tool (PERT)

ASSESSNORMAL(GREEN)

WORRISOME (YELLOW)

SEVERE(RED)

Awareness Alert/oriented• Agitated/confused • Drowsy • Difficulty speaking

• Unresponsive

Headache None • Mild headache • Nausea, vomiting • Unrelieved headache

Vision None • Blurred or impaired • Temporary blindness

Systolic BP(mm HG) 100-139 140-159 ≥160

Diastolic BP (mm HG) 50-89 90-105 ≥105

HR 61-110 111-129 ≥130

Respiration 11-24 25-30 <10 or >30 SOB Absent Present Present

O2 Sat (%) ≥95 91-94 ≤90

Pain: Abdomen or Chest None

• Nausea, vomiting •Chest pain•Abdominal pain

• Nausea, vomiting •Chest pain• Abdominal pain

Fetal Signs • Category I • Reactive NST

• Category II • IUGR • Non-reactive NST

• Category III

Urine Output (ml/hr) ≥50 30-49 ≤30 (in 2 hrs)

Proteinuria(Level of proteinuria is not an accurate predictor of pregnancy outcome)

Trace • > +1** • 300mg/24 hours

Platelets >100 50-100 <50AST/ALT <70 >70 >70

Creatinine <0.8 0.9-1.1 >1.2MagnesiumSulfate Toxicity

• DTR +1 • Respiration 16-20 • Depression of patellar reflexes • Respiration <12

= WORR

GREEN = NORMAL Proceed with protocol

RED = SEVERE Trigger: 1 of any type listed below TO DO

1 of any type • Immediate evaluation • Transfer to higher acuity level • 1:1 staff ratio

Awareness Headache Visual

• Consider Neurology consult • CT Scan • R/O SAH/intracranial hemorrhage

BP

• Labetalol/hydralazine in 30 min • In-person evaluation • Magnesium sulfate loading or

maintenance infusion Chest Pain • Consider CT angiogram Respiration SOBO2 SAT

• O2 at 10 L per rebreather mask • R/O pulmonary edema • Chest x-ray

•Respiration <12

One of the tools, Preeclampsia Early Recognition Tool:

Quality Improvement Strategies

1 Heartland Health Centers – Chicago, IL• HHC has implemented a health information

exchange with a hospital that allows real-time data exchange on labs, discharges and notes from ER.

• E-prescribing and medication reconciliation are carried out.

• HHC participated in a 12 month Institute for Healthcare Improvement (IHI) learning collaborative, which included weekly meetings to satisfy deliverables. IHI also provided the structure to collect data and provided access to external resources and tools. Best practices were also shared as part of this learning collabrotive.

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• HHC has created two different kinds of roles: o Integrated Care Specialist – works with Medical

Home Network (MHN) Connect. They work on patients discharged from hospital and emergency rooms (ER) and look at preventive care measures to facilitate follow-up for diabetes, colon cancer, Hepatitis C and cervical cancer screening. In addition, care specialists receive a list of patients and preventive care measures from Illinois Health Connect and other insurers.

o Referral Specialist – works with provider-identified referrals. They aid in navigating managed care for their patients and identifying specialists.

2 Christopher Greater Area Rural Health Planning Corporation – Christopher, IL• Continuous tracking by nurses to ensure

appointments are scheduled for adequate routine prenatal care. Nurses also ensure missed appointments are rescheduled right away.

• Patient Care Coordinators track the Illinois Health Connect roster to bring in patients due for preventive screenings.


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1. Health Resources and Services Administration. Facilitating Early Prenatal Care Entry. Retrieved on 5/13/2014. http://bphc.hrsa.gov/spotlight/eriefamilyhc/.

2. Child Health Data Lab. Injuries to Illinois and Chicago Youth: Alcohol and Illicit Drugs in Newborns. Stanley Manne Children’s Research Institute. State and Community Reports on Injury Prevalence and Targeted Solutions (SCRIPTS). Issue 11, July 2014.

3. Substance Abuse and Mental Health Services Administration. The National Survey on Drug Use and Health Report: 18 percent of pregnant women drink alcohol during early pregnancy. Sep 9 2013. Accessed from: www.samhsa.gov/data/spotlight/spot123-pregnancy-alcohol-2013.pdf.

4. Guide to Community Preventive Services. Preventing excessive alcohol consumption: electronic screening and brief intervention (e-SBI). Accessed from: www.thecommunityguide.org/alcohol/eSBI.html.

5. Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings. Accessed from: www.samhsa.gov/data/nsduh/2012summnatfinddettables/nationalfindings/nsduhresults2012.htm#ch4.3.

6. Guide to Community Preventive Services. Reducing tobacco use and secondhand smoke exposure: quitline interventions. Accessed from: www.thecommunityguide.org/tobacco/quitlines.html.

7. Guide to Community Preventive Services. Reducing tobacco use and secondhand smoke exposure: mobile phone-based cessation interventions. Accessible from: www.thecommunityguide.org/tobacco/mobilephone.html

8. Guide to Community Preventive Services. Obesity prevention and control: technology-supported multicomponent coaching or counseling interventions to reduce weight and maintain weight loss. Accessible from: www.thecommunityguide.org/obesity/TechnologicalCoaching.html.

9. Child Health Data Lab. Injuries to Illinois and Chicago Youth: Alcohol and Illicit Drugs in Newborns. Stanley Manne Children’s Research Institute. State and Community Reports on Injury Prevalence and Targeted Solutions (SCRIPTS). Issue 11, July 2014.

10. Nurse-Family Partnership, helping first-time parents succeed. Accessed from: www.nursefamilypartnership.org/about/what-we-do.

11. Nurse-Family Partnership, helping first-time parents succeed. Nurse-Family Partnership of Illinois Accessed from: www.nursefamilypartnership.org/locations/Illinois.

12. Nurse-Family Partnership, helping first-time parents succeed. State profile 2013: Nurse-Family Partnership in Illinois. Accessed from: www.nursefamilypartnership.org/assets/PDF/Communities/State-profiles/IL_State_Profile.

13. National Academy for State Health Policy. Creating change in early prenatal care entry: a peer learning conversation April 9, 2014. Accessible from: http://bphc.hrsa.gov/technicalassistance/trainings/creatingchangeearlyprenatalcare.pdf.

14. Final Recommendation Statement: Depression in Adults: Screening. U.S. Preventive Services Task Force. January 2016. www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/depression-in-adults-screening1

15. Healthy Choices Healthy Futures – Perinatal Health Toolkit. September 2015. Accessed from: http://healthychoiceshealthyfutures.org/

16. Reprinted with permission from IL CHIPRA Quality Demonstration Grant.17. Maurice L. Druzin, MD; Laurence E. Shields, MD; Nancy L. Peterson, RNC, PNNP, MSN; Valerie Cape, BSBA.

Preeclampsia Toolkit: Improving Health Care Response to Preeclampsia (California Maternal Quality Care Collaborative Toolkit to Transform Maternity Care) Developed under contract #11-10006 with the California Department of Public Health; Maternal, Child and Adolescent Health Division; Published by the California Maternal Quality Care Collaborative, November 2013. Accessible from: http://ilpqc.org/docs/htc/CDPH_Approved_Preeclampsia_Toolkit__Errata_v3.5.13.14_with_slideset.pdf

Promising Practices – references

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Qi & system-level strategies

Resources for System-Level Strategies

1Enhancing Quality Improvement Approach a.HITEQ Collaboration Health Information Technology, Evaluation and

Quality Center (HITEQ) is a HRSA-funded National Cooperative Agreement that collaborates with HRSA partners including Health Center Controlled Networks, Primary Care Associations, and other National Cooperative Agreements to support health centers in full optimization of their EHR/Health IT systems.

IPHCA collaborated with HITEQ to provide 11 health centers with Health IT/Quality Improvement (QI) through strategies and tools discussed in learning sessions. These learning sessions were based on the QI approach outlined in the “Guide to Improving Care Processes and Outcomes in Health Centers.” The approach provides a framework as well as tools to enhance current QI approaches or use as the basis of a new QI approach. HITEQ leader Jillian Maccini conducted four monthly online learning sessions with health centers from February through May 2017 that involved the following:

• Move toward optimal care delivery through care transformation supported by Health IT-enabled QI.

• Reinforce organizational foundations for QI with tools for engaging stakeholders and validating data.

• Select QI targets using health IT-informed data, current outcomes, and prioritization tools.

• Use comprehensive CDS/QI worksheet to document and analyze

This learning collaborative culminated in a final in-person session that took place in Springfield, IL on June 6, 2017. At this session, health centers were able to present and showcase their targeted QI project and the progress they had made thus far. Throughout the collaborative, HITEQ resources and tools were provided to participants and can be found in Appendix B.

2Care Coordination a. Toolkit for Coordinating Care “Reducing Care Fragmentation: A Toolkit

for Coordinating Care” was developed by Group Health’s MacColl Institute for Healthcare Innovation and support by The Commonwealth Fund. This toolkit was designed to improve care coordination by enhancing patient referrals and transitions at clinics, practices, and health systems. The toolkit includes a Care Coordination Model as well as six key changes to support the model with resources to help facilitate change:

1. Decide as a primary care clinic to improve care coordination

2. Develop a tracking system3. Organize a practice team to support patients and

families4. Identify, develop, and maintain relationships

with key specialist groups, hospitals, and community agencies

5. Develop agreements with these key groups6. Develop and implement information transfer

system The complete toolkit can be accessed from http://www.improvingchroniccare.org/downloads/reducing_care_fragmentation.pdf.

b. Team-Based Care The Primary Care Team Guide was developed by a national program of the Robert Wood Johnson Foundation called “The Primary Care Team: Learning from Effective Ambulatory Practices” – also known as “LEAP.” The Guide provides a number of resources to engage the health care team in patient-centered care and build the care team to be more effective. The guide provides tools to improve teamwork, expand roles of health care professionals, and improve efficiency in primary care practices.

The first section of the Primary Care Team Guide is composed of “Build the Team” learning modules which provide the roles and responsibilities of each primary care team in order to make up an effective team. The “Do the Work” learning modules describe the necessary functions needed for high-performing primary care practices. The learning modules under “Do the Work” highlight taking on the following functions to improve the primary care practice:

• Improving Care Through Teamwork• Enhancing Access• Self-Management Support• Population Management• Planned Care• Care Management• Medication Management• Referral Management• Behavioral Health Integration• Communication Management • Clinic-Community Connections

All learning modules include assessments, action steps to implement, and useful resources and tools in order to achieve team-based care.

• “Build the Team” learning modules can be accessed from: http://www.improvingprimarycare.org/team

• “Do the Work” learning modules can be accessed from: http://www.improvingprimarycare.org/work

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3 Patient and Family Engagement a. 6 Step Toolkit Patient-Centered Primary Care Collaborative Support

worked in collaboration with Planetree International and Alignment Network, with support from the Institute for Patient and Family-Centered Care (IPFCC) to develop a toolkit called “6 Steps to Creating a Culture of Person and Family Engagement.” This toolkit provides practices with strategies to improving person and family engagement through creating a culture in the practice that emphasizes patient and family perspectives in order to improve quality of care. The six steps detailed in the toolkit include:

1. Engage Leaders2. Empower and Energize Staff3. Equip, Enable and Support Patients to Engage4. Enlist Patients and Families as Partners5. Encourage Family Participation in Care6. Emphasize Patient and Family Engagement in All

You Do

Further details on these six steps can be found in Appendix G along with a 30 Day Kick-Start Plan to take action on these steps.

b. Improving Patient Safety Guide The Agency for Healthcare Research and Quality (AHRQ) is developing “The Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families” to help health professionals in primary care work together with patients and families in order to promote stronger engagement and improve care. The final guide will be released in early 2018, however four strategies with supporting materials have already been provided by AHRQ:

• Teach-Back: Health care providers can use this technique to ensure they have explained medical information clearly to patient and family and also understand what is communicated to them.

• ‘Be Prepared to Be Engaged’: This toolkit is to help patients and their families prepare for the medical appointment and become fully engaged by being ready for the appointment, speaking up, asking questions, and taking notes.

• Medication Management: These tools will help health care professionals engage with patients and caregivers to create a complete and accurate medication list using the ‘brown bag method.’ This will also help to identify risks of an adverse drug event or other factors that limit adherence.

• Warm Handoff: This strategy allows a transfer of care between two members of the health care team in front of the patient and family. This allows the patient and their family to hear what is said and engages them in communication – which gives them the opportunity to clarify information or ask questions.

Supporting material for each strategy can be accessed at:

https://www.ahrq.gov/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/interventions/index.html

c. Improving Self-Management Goals On April 6, 2017 The Joint Commission hosted a teleconference around ‘Health Literacy and Self-Management Goals Made Simple.’ This recording is archived and can be streamed from https://www.jointcommission.org/hrsa_grantee_technical_assistance_teleconference_list/. In addition, The Joint Commission has shared the following tools (Appendix D) to aid in improving health literacy and self-management goals.

• Health Literacy Assessment Tool – This resource provides multiple sample screening tools for health literacy.

• Handout on Self-Management Goals – This tool, available in English and Spanish, helps patients set their own self-management goals to improve health behaviors.

• Bookmark for Goals – This bookmark helps patients set goals and easily mark off

4 Improving Preventive Screeningsb. Proactive Office Encounter Intervention The University of Kentucky collaborated with a

federally qualified health center (FQHC) known as White House Clinics (WHC) that serves over 30,500 patients in a rural, medically underserved, and economically stressed population in Appalachian Kentucky. In order to ensure patients are up-to-date with preventive screenings, the collaboration launched the Proactive Office Encounter (POE) intervention. This system-level approach aims to provide a preventive health assessment in addition to the actual office visit purpose. POE provides medically tailored and evidence-based protocol for each patient with the following process:

• Pre-encounter > Reviewing patient’s EMR for cancer screening completion; creating summary of patients recent screening history and socio-demographics; allowing provider to address health needs; and ordering referrals to the visit.

• Appointment > More time with provider for shared-decision making and encouraging patient for recommended cancer screenings.

• Post-encounter > Track patients’ screening completion

The POE procedures were also integrated into the EMR system to include care guidelines templates and reports to identify gaps in preventive care. The POE model was launched at 4 out of 8 WHC clinics in January 2015. As of December 2015, UDS measures indicate an increase in breast and CRC, HIV, and HCV screenings. In addition, influenza, pneumonia, and shingles vaccination rates have increased. Between 2014 and 2015, WHC had a 36% increase in CRC screenings; five times the number of HIV screenings (831 vs. 4,371) and eight times the number of HCV screenings (378 vs. 3,334).

Qi & system-level strategies

C-3

HealtH center information – 2014

Heartland Health Centers – Chicago, ILHeartland Health Centers (HHC) has 15 locations and served 26,096 patients according to UDS 2014 data. Heartland is PCMH certified through The Joint Commission and has EHR. In 2015, it was awarded the Health Center Quality Leader award from HRSA and it is also a part of the Million Hearts Initiative. Age distribution of the patient population includes: 26.7% children, 69.8% adults, and 3.5% older adults (age 65 and over). A majority (70.1%) of the patients belong to a racial and/or ethnic minority: 36.2% Hispanic/Latino, 25.5% African American, and 7.7% Asian. 94.6% of patients lived at or below 200% of the poverty level in 2014. 36.3% of patients were uninsured and 18.8% of children were uninsured. 40.5% of patients were on Medicaid/CHIP. 75.7% of the female patient population was in the 15-64 year age group. The number of prenatal patients in 2014 was 481 and the number of patients who delivered was 249.www.heartlandhealthcenters.org

Christopher Greater Area Rural Health Planning Corporation – Christopher, ILChristopher Greater Area Rural Health Planning Corporation (CRHPC) served 45,387 patients from its 17 locations in 2014. CRHPC is PCMH recognized and has EHR. Age distribution of its patients includes: 32.5% children, 52.6% adults, and 14.8% older adults. The majority (92.9%) of the patient population was white and 7.1% belong to a racial and/or ethnic minority. In 2014, 85.9% of patients lived at or below 200% of the poverty level. 14.0% of the patient population was uninsured in 2014. 38.0% of patients were on Medicaid/CHIP, 16.6% had Medicare, and 31.4% had different third party insurance. The number of prenatal patients in 2014 was 265 and the number of patients who delivered was 193.www.crhpc.org

APP-A-1

aPPendix a – HealtH center stratification by number of Patients served - 2014

Health Centers Serving <5,000 Patients

Health Center Name Number of Sites Total Patient Population

Hamdard Center for Health & Human Services 2 783

Preferred Family Health Care, Inc. (MO) 2 1,505

Chestnut Health Systems 1 1,659

Beloved Community Family Wellness Center 3 3,152

Community Nurse Health Center 4 3,908

Knox County Health Department 1 3,938

Cass County Health Department 2 4,097

Macoupin County Public Health Department 2 4,539

Health Centers Serving 5,000 to < 10,000 Patients


Eagle View Community Health System 2 5,623

TCA Health Inc. – NFP 2 6,965

Heartland Health Outreach, Inc. 55 7,661

Asian Human Services Family Health Center, Inc. 3 9,303

Community Health Partnership of Illinois 5 9,717



Rural Health, Inc. 5 10,972

Whiteside County Community Health Clinic 1 12,478

Christian Community Health Center 6 12,569

SIU Center for Family Medicine 1 13,040

Will County Community Health Center 2 14,103

Central Counties Health Centers, Inc. 3 15,443

Community Health Centers of Southeastern Iowa, Inc. (IA) 4 16,163

Heartland Community Health Clinic 5 17,207

Esperanza Health Centers 4 17,241

APP-A-2



PrimeCare Community Health, Inc. 5 20,374

Family Christian Health Center 2 21,234

Crossing Healthcare 9 21,633

Alivio Medical Center 7 23,302

Heartland Health Centers 15 26,096

Friend Family Health Center, Inc. 5 27,197

Chicago Family Health Center, Inc. 5 30,235

Shawnee Health Service 11 30,351

Mile Square Health Center 13 30,585

Near North Health Service Corporation 9 34,076

Community Health Care, Inc. (IA) 12 35,305

Greater Elgin Family Care Center 28 37,590

Lake County Health Department/CHC 7 39,155

Health Centers Serving ≥ 40,000 Patients


Christopher Rural Area Health Planning Corporation 17 45,387

Lawndale Christian Health Center 7 45,570

PCC Community Wellness Center 13 47,418

Crusader Community Health 14 47,787

Aunt Martha’s Youth Service Center, Inc. 31 56,802

VNA Health Care 13 59,901

Erie Family Health Center, Inc. 13 61,860

Southern Illinois Healthcare Foundation, Inc. 35 106,054

Access Community Health Network 35 176,389

aPPendix a – HealtH center stratification by number of Patients served - 2014

APP-A-3

aPPendix a – HealtH center stratification by number of Patients served – 2015

Health Centers Serving <5,000 Patients


Hamdard Center For Health & Human Services 2 1,654

Chestnut Health Systems 2 2,010

Preferred Family Healthcare Inc. (MO) 3 3,246

Beloved Community Family Wellness Center 2 3,727

Community Nurse Health Center 2 4,187

Cass County Health Department 2 4,297

Knox County Health Department 1 4,721

Macoupin County Public Health Department 2 4,885



Eagle View Community Health System 2 5,018

TCA Health Inc. – NFP 3 7,049

Heartland Health Outreach, Inc. 3 8,972

Asian Human Services Family Health Center, Inc.

4 10,119

Community Health Partnership of Illinois 8 10,981



Whiteside County Health Department 2 12,545

Rural Health, Inc. 5 12,652

Will County Community Health Center 2 12,887

Central Counties Health Centers, Inc. 3 13,649

Christian Community Health Center 4 13,398

Community Health Centers of Southeastern Iowa, Inc. (IA)

4 17,459

Heartland Community Health Clinic 5 17,656

Esperanza Health Centers 3 18,517

SIU Center for Family Medicine 1 20,116

APP-A-4



Family Christian Health Center 2 20,824

PrimeCare Community Health, Inc. 8 21,091

Alivio Medical Center 6 23,021

Crossing Healthcare 7 25,982

Heartland Health Centers 16 29,609

Shawnee Health Service 12 30,175

Chicago Family Health Center, Inc. 5 30,318

Friend Family Health Center, Inc. 7 30,706

Community Health Care, Inc. (IA) 9 33,095

Near North Health Service Corporation 9 34,736

Mile Square Health Center 12 37,717

Greater Elgin Family Care Center 26 40,666

Lake County Health Department 10 40,322

Health Centers Serving ≥ 40,000 Patients


Christopher Rural Health Planning Corporation 11 43,203

PCC Community Wellness Center 12 47,184

Crusader Community Health 6 48,234

Lawndale Christian Health Center 15 49,141

Aunt Martha’s Youth Service Center, Inc. 17 49,746

VNA Health Care 10 61,717

Erie Family Health Center, Inc. 13 68,417

Southern Illinois Healthcare Foundation, Inc. 26 101,624

Access Community Health Network 36 180,981

aPPendix a – HealtH center stratification by number of Patients served – 2015

APP-B-1

aPPendix b – Prenatal care Quality tool

Pren

atal

Car

e Q

ualit

y To

ol C

heck

list

This

doc

umen

t was

dev

elop

ed u

nder

gra

nt C

FDA

93.

767

from

the

U.S

. Dep

t. of

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uman

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ente

rs fo

r Med

icar

e &

Med

icai

d S

ervi

ces.

H

owev

er, t

hese

con

tent

do

not n

eces

saril

y re

pres

ent

the

polic

y of

the

U.S

. Dep

t. of

Hea

lth a

nd H

uman

Ser

vice

s, a

nd s

houl

d no

t ass

ume

endo

rsem

ent b

y th

e Fe

dera

l gov

ernm

ent.

Dat

e: _

____

____

____

____

__

____

Trim

este

r

X La

bs

U

rine

anal

ysis

/cul

ture

Pap

Tes

t as

clin

ical

ly

indi

cate

d

GC

/Chl

amyd

ia

C

BC

Ant

ibod

y sc

reen

Blo

od T

ype

R

h Ty

pe

R

ubel

la

R

PR

Hep

atiti

s B

H

IV

H

emog

lobi

n el

ectro

phor

esis

if

indi

cate

d (1

)

Ear

ly s

cree

ning

for

Dia

bete

s if

risk

fact

ors

(3)

U

ltras

ound

if L

MP

is

unkn

own

or u

ncer

tain

or

if n

ot c

onsi

sten

t with

ex

am

O

ffer a

neup

loid

y sc

reen

ing

(ser

um)

and/

or N

IPS

(non

-in

vasi

ve p

rena

tal

scre

enin

g; m

ater

nal

seru

m c

ell-f

ree

feta

l D

NA

) and

/or

diag

nost

ic te

stin

g (a

mni

o/C

VS)

X C

linic

al E

lem

ents

His

tory

(inc

ludi

ng

med

icat

ions

/ sup

plem

ents

, fa

mily

or p

erso

nal h

isto

ry

of g

enet

ic d

isor

ders

) P

hysi

cal E

xam

inat

ion

(incl

udin

g br

east

and

pel

vic

exam

)

Cou

nsel

and

offe

r gen

etic

an

d an

eupl

oidy

sc

reen

ing/

diag

nost

ic

optio

ns a

ppro

pria

te to

the

patie

nt

H

t/Wt,

BP,

BM

I

Scr

een

for i

llici

t su

bsta

nces

, alc

ohol

and

to

bacc

o

Scr

een

for i

mm

uniz

atio

ns

Offe

r inf

luen

za v

acci

ne

durin

g flu

sea

son

(Sep

t-M

ay)

S

cree

n fo

r pre

term

labo

r ris

k fa

ctor

s: in

par

ticul

ar

prio

r pre

term

del

iver

y,

mul

tiple

ges

tatio

n, u

terin

e an

omal

ies,

sho

rt ce

rvix

Dom

estic

vio

lenc

e sc

reen

Scr

een

for p

erin

atal

men

tal

heal

th d

isor

ders

(e.g

. de

pres

sion

) (4)

X Ed

ucat

ion

P

rovi

der c

onta

ct/e

mer

genc

y nu

mbe

rs/h

ospi

tal i

nfor

mat

ion

Ant

icip

ated

cou

rse

of p

erin

atal

car

e

War

ning

sig

ns o

f mis

carr

iage

Nut

ritio

n in

pre

gnan

cy

A

ppro

pria

te w

eigh

t gai

n in

pr

egna

ncy

P

hysi

cal a

ctiv

ity in

pre

gnan

cy

Li

fest

yle

educ

atio

n: w

ork,

sex

ual

activ

ity a

nd tr

avel

Pre

nata

l vita

min

s/fo

lic a

cid

supp

lem

enta

tion

M

edic

atio

n av

oida

nce

- pr

escr

iptio

n an

d ov

er th

e co

unte

r/ su

pple

men

ts a

nd v

itam

ins

P

reca

utio

ns -

caffe

ine/

to

xopl

asm

osis

/Lis

teria

/fish

/ V

aric

ella

/hot

tub/

en

viro

nmen

tal/o

ccup

atio

nal

S

ubst

ance

Use

/ Alc

ohol

/Tob

acco

C

essa

tion-

5 A

's (2

)

Sea

tbel

ts/ S

mok

e de

tect

ors/

Gun

sa

fety

in h

ome

R

evie

w s

tress

fact

ors

D

iscu

ss s

igns

of p

reec

lam

psia

if >

20

wks

ges

tatio

n

Pro

vide

info

rmat

ion

on c

hild

birth

an

d br

east

feed

ing

clas

ses

V

BA

C c

ouns

elin

g if

appr

opria

te

B

reas

t fee

ding

ben

efits

Sel

ectio

n of

a h

ealth

care

pro

vide

r or

med

ical

hom

e fo

r the

new

born

Cou

nsel

ing

for H

IV te

stin

g

X R

efer

rals

Ref

erra

l to

WIC

Ref

erra

l to

Fam

ily C

ase

Man

agem

ent

Pro

vide

info

rmat

ion

on c

hild

birth

cl

asse

s

Pro

vide

info

rmat

ion

on

brea

stfe

edin

g cl

asse

s

X H

igh-

Ris

k R

efer

rals

Hig

h-R

isk

cond

ition

iden

tifie

d?

Rea

son:

___

____

____

____

____

__

R

efer

ral t

o m

enta

l hea

lth

prof

essi

onal

or s

ocia

l wor

ker i

f in

dica

ted

R

efer

ral t

o O

B o

r MFM

if in

dica

ted

1.

Med

iterr

anea

n, S

outh

east

Asi

an, o

r Af

rican

Am

eric

an d

esce

nt

2.

5 A’

s –

Ask,

Adv

ice,

Ass

ess,

Ass

ist,

Arra

nge

follo

w-u

p 3.

O

besi

ty (B

MI>

30),

stro

ng fa

mily

his

tory

of

dia

bete

s, p

rior G

DM

or d

eliv

ered

in

fant

>9l

bs, g

lyco

suria

, or k

now

n im

paire

d gl

ucos

e m

etab

olis

m

4.

HFS

app

rove

d as

sess

men

ts: E

dinb

urg

Post

nata

l Dep

ress

ion

Scal

e, B

eck

Dep

ress

ion

Inve

ntor

y, P

rimar

y C

are

Eval

uatio

n of

Men

tal D

isor

ders

Pat

ient

H

ealth

Que

stio

nnai

re (P

HQ

9), P

ost-

partu

m D

epre

ssio

n Sc

reen

ing

Scal

e,

Cen

ter f

or E

pide

mio

logi

c St

udie

s D

epre

ssio

n Sc

ale.

1st P

rena

tal V

isit,

Reg

ardl

ess

of G

esta

tiona

l Age

Plac

e pa

tient

stic

ker h

ere.

APP-B-2


Pren

atal

Car

e Q

ualit

y To

ol C

heck

list

This

doc

umen

t was

dev

elop

ed u

nder

gra

nt C

FDA

93.

767

from

the

U.S

. Dep

t. of

Hea

lth a

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uman

Ser

vice

s, C

ente

rs fo

r Med

icar

e &

Med

icai

d S

ervi

ces.

H

owev

er, t

hese

con

tent

do

not n

eces

saril

y re

pres

ent

the

polic

y of

the

U.S

. Dep

t. of

Hea

lth a

nd H

uman

Ser

vice

s, a

nd s

houl

d no

t ass

ume

endo

rsem

ent b

y th

e Fe

dera

l gov

ernm

ent.

Dat

e: _

____

____

____

____

__

X C

linic

al E

lem

ents

Vis

it fre

quen

cy s

houl

d be

eve

ry

4 w

ks

W

t, B

P at

eve

ry v

isit

In

fluen

za v

acci

ne o

ffere

d du

ring

flu s

easo

n if

not p

revi

ousl

y gi

ven

(Sep

t-May

)

X La

bs

U

rine

dip

for

prot

ein/

gluc

ose

X R

efer

rals

Ref

erra

l to

WIC

Ref

erra

l to

Fam

ily C

ase

Man

agem

ent

X H

igh-

Ris

k R

efer

rals

Hig

h-R

isk

cond

ition

iden

tifie

d?

Rea

son:

____

____

____

____

___

R

efer

ral t

o m

enta

l hea

lth

prof

essi

onal

or s

ocia

l wor

ker i

f in

dica

ted

R

efer

ral t

o O

B o

r MFM

if

indi

cate

d

X Ed

ucat

ion

R

evie

w o

f abn

orm

al la

b re

sults

17-a

lpha

Hyd

roxy

prog

este

rone

ca

proa

te fo

r pat

ient

s w

ith

hist

ory

of p

rete

rm b

irth

due

to

pret

erm

labo

r or P

PR

OM

to

begi

n at

16

wee

ks

1st T

rimes

ter,

1-12

Wee

ks (i

n ad

ditio

n to

firs

t pre

nata

l vis

it)

Plac

e pa

tient

stic

ker h

ere.

APP-B-3


Pren

atal

Car

e Q

ualit

y To

ol C

heck

list

This

doc

umen

t was

dev

elop

ed u

nder

gra

nt C

FDA

93.

767

from

the

U.S

. Dep

t. of

Hea

lth a

nd H

uman

Ser

vice

s, C

ente

rs fo

r Med

icar

e &

Med

icai

d S

ervi

ces.

H

owev

er, t

hese

con

tent

do

not n

eces

saril

y re

pres

ent

the

polic

y of

the

U.S

. Dep

t. of

Hea

lth a

nd H

uman

Ser

vice

s, a

nd s

houl

d no

t ass

ume

endo

rsem

ent b

y th

e Fe

dera

l gov

ernm

ent.

Dat

e: _

____

____

____

____

___

X Ed

ucat

ion

S

igns

and

sym

ptom

s of

pr

eter

m la

bor

A

war

enes

s of

feta

l m

ovem

ent/

teac

h ki

ck c

ount

s

Rev

iew

lab

resu

lts if

ne

cess

ary

B

reas

tfeed

ing

rein

forc

emen

t at

eve

ry v

isit

R

evie

w s

igns

of

pree

clam

psia

Offe

r chi

ldbi

rth a

nd

brea

stfe

edin

g cl

asse

s

P

ostp

artu

m b

irth

cont

rol p

lan

(sig

n co

nsen

t for

tuba

l lig

atio

n af

ter 2

0 w

eeks

if

indi

cate

d)

X La

bs

U

rine

dip

for

prot

ein/

gluc

ose

D

iabe

tic s

cree

n be

twee

n 24

-28

wee

ks w

ith 1

hou

r G

TT (5

0 gm

glu

cose

lo

ad)

C

BC

bet

wee

n 24

-28

wee

ks

O

ffer u

ltras

ound

for

stru

ctur

e an

d da

ting

at

18-2

0 w

eeks

X C

linic

al E

lem

ents

Vis

it fre

quen

cy s

houl

d be

ev

ery

4 w

ks u

nles

s m

ore

frequ

ent v

isits

are

clin

ical

ly

indi

cate

d

Wt,

BP,

Fun

dal h

eigh

t at

ever

y vi

sit

Fe

tal h

eart

tone

s at

eve

ry v

isit

17

-alp

ha

Hyd

roxy

prog

este

rone

ca

proa

te to

beg

in a

t 16

wee

ks, i

f clin

ical

ly in

dica

ted

X R

efer

rals

Ref

erra

l to

WIC

Ref

erra

l to

Fam

ily C

ase

Man

agem

ent

X H

igh-

Ris

k R

efer

rals

Hig

h-R

isk

cond

ition

iden

tifie

d?

Rea

son:

____

____

____

____

____

_

Ref

erra

l to

men

tal h

ealth

pr

ofes

sion

al o

r soc

ial w

orke

r if

indi

cate

d

Ref

erra

l to

OB

or M

FM if

indi

cate

d

2nd T

rimes

ter,

12-2

8 W

eeks

Plac

e pa

tient

stic

ker h

ere.

APP-B-4


Pren

atal

Car

e Q

ualit

y To

ol C

heck

list

This

doc

umen

t was

dev

elop

ed u

nder

gra

nt C

FDA

93.

767

from

the

U.S

. Dep

t. of

Hea

lth a

nd H

uman

Ser

vice

s, C

ente

rs fo

r Med

icar

e &

Med

icai

d S

ervi

ces.

H

owev

er, t

hese

con

tent

do

not n

eces

saril

y re

pres

ent

the

polic

y of

the

U.S

. Dep

t. of

Hea

lth a

nd H

uman

Ser

vice

s, a

nd s

houl

d no

t ass

ume

endo

rsem

ent b

y th

e Fe

dera

l gov

ernm

ent.

Dat

e: _

____

____

____

____

X La

bs

U

rine

dip

for

prot

ein/

gluc

ose

H

emog

lobi

n or

he

mat

ocrit

Rep

eat G

C/C

hlam

ydia

if

high

risk

(5) , b

efor

e 36

w

eeks

Rep

eat H

ep B

if h

igh

risk,

bef

ore

36 w

eeks

Rep

eat H

IV if

hig

h ris

k,

befo

re 3

6 w

eeks

Rep

eat R

PR

if h

igh

risk,

bef

ore

36 w

eeks

If R

hoga

m is

indi

cate

d,

antib

ody

scre

en a

t the

tim

e of

adm

inis

tratio

n

Gro

up B

Stre

p cu

lture

at

35-

36 w

eeks

X Ed

ucat

ion

S

igns

and

sym

ptom

s of

pre

term

la

bor a

nd p

reec

lam

psia

Aw

aren

ess

of fe

tal m

ovem

ent/k

ick

coun

t edu

catio

n an

d ex

pect

atio

n

Rev

iew

labo

r and

del

iver

y ex

pect

atio

n (in

clud

ing

anes

thes

ia)

and

the

patie

nt’s

pla

n fo

r tra

nspo

rtatio

n to

the

hosp

ital

B

reas

tfeed

ing

rein

forc

emen

t

Fina

lize

post

partu

m b

irth

cont

rol

plan

s

Rev

iew

circ

umci

sion

pla

n

Dis

cuss

pla

n fo

r new

born

's

heal

thca

re p

rovi

der/m

edic

al h

ome

R

evie

w n

eed

for c

ar s

eat

R

evie

w n

umbe

rs to

cal

l for

em

erge

ncie

s/la

bor

Im

porta

nce

of a

void

ing

elec

tive

deliv

erie

s pr

ior t

o 39

wee

ks

Fa

mily

med

ical

leav

e

Saf

e nu

rser

y se

t up

to p

reve

nt

SID

S –

Bac

k to

Sle

ep C

ampa

ign

R

evie

w s

igns

and

sym

ptom

s of

pe

rinat

al m

enta

l hea

lth d

isor

ders

(e

.g. d

epre

ssio

n)

O

ffer c

hild

birth

and

bre

astfe

edin

g cl

asse

s

X C

linic

al E

lem

ents

Vis

it fre

quen

cy s

houl

d be

eve

ry

2 w

eeks

unt

il 35

-36

wee

ks th

en e

very

w

eek

until

del

iver

y un

less

mor

e fre

quen

t vi

sits

are

clin

ical

ly

indi

cate

d.

W

t, B

P, F

unda

l hei

ght

at e

very

vis

it

Feta

l hea

rt to

nes

at

ever

y vi

sit

P

erin

atal

men

tal h

ealth

sc

reen

ing

(4)

B

egin

NST

/AFI

whe

n/if

clin

ical

ly in

dica

ted

G

ive

Rho

gam

at 2

8 w

eeks

if in

dica

ted

H

erpe

s pr

ophy

laxi

s st

artin

g at

36

wee

ks if

in

dica

ted

O

ffer T

dap

vacc

ine

afte

r 27

wee

ks

X R

efer

rals

Tran

sfer

of m

edic

al re

cord

s to

an

ticip

ated

del

iver

y ho

spita

l

Ref

erra

l to

WIC

Ref

erra

l to

Fam

ily C

ase

Man

agem

ent

X H

igh-

Ris

k R

efer

rals

Hig

h-R

isk

cond

ition

iden

tifie

d?

Rea

son:

____

____

____

____

____

_

Ref

erra

l to

men

tal h

ealth

pr

ofes

sion

al o

r soc

ial w

orke

r if

indi

cate

d

Ref

erra

l to

OB

or M

FM if

indi

cate

d

3rd T

rimes

ter,

28-3

9 W

eeks

Plac

e pa

tient

stic

ker h

ere.

APP-B-5


Pren

atal

Car

e Q

ualit

y To

ol C

heck

list

This

doc

umen

t was

dev

elop

ed u

nder

gra

nt C

FDA

93.

767

from

the

U.S

. Dep

t. of

Hea

lth a

nd H

uman

Ser

vice

s, C

ente

rs fo

r Med

icar

e &

Med

icai

d S

ervi

ces.

H

owev

er, t

hese

con

tent

do

not n

eces

saril

y re

pres

ent

the

polic

y of

the

U.S

. Dep

t. of

Hea

lth a

nd H

uman

Ser

vice

s, a

nd s

houl

d no

t ass

ume

endo

rsem

ent b

y th

e Fe

dera

l gov

ernm

ent.

Dat

e: _

____

____

____

____

_

X La

bs

U

rine

dip

for

prot

ein/

gluc

ose

G

roup

B S

trep

cultu

re,

if no

t don

e at

35-

36

wee

ks

X R

efer

rals

Ref

erra

l to

WIC

Ref

erra

l to

Fam

ily C

ase

Man

agem

ent

X H

igh-

Ris

k R

efer

rals

Hig

h-R

isk

Con

ditio

n Id

entif

ied?

R

easo

n: _

____

____

____

____

__

R

efer

ral t

o m

enta

l hea

lth

prof

essi

onal

or s

ocia

l wor

ker i

f in

dica

ted

R

efer

ral t

o O

B/M

FM if

indi

cate

d

X Ed

ucat

ion

A

war

enes

s of

feta

l mov

emen

t

Sig

ns a

nd s

ympt

oms

of p

rete

rm

labo

r and

pre

ecla

mps

ia

La

bor a

nd D

eliv

ery

expe

ctat

ion

and

plan

(inc

ludi

ng a

nest

hesi

a) a

nd th

e pa

tient

’s p

lan

for t

rans

porta

tion

to

the

hosp

ital

Fa

mily

med

ical

leav

e

Rei

nfor

ce B

reas

tfeed

ing

impo

rtanc

e

R

evie

w b

irth

cont

rol p

lans

Rev

iew

nee

d fo

r car

sea

t-ref

er to

D

HS

if in

nee

d of

a c

ar s

eat

Im

porta

nce

of a

void

ance

of e

lect

ive

deliv

erie

s pr

ior t

o 39

wee

ks

R

evie

w n

umbe

rs to

cal

l for

em

erge

ncie

s/la

bor

Im

porta

nce

of p

ostp

artu

m v

isit

and

ongo

ing

heal

thca

re a

fter d

eliv

ery

S

afe

nurs

ery

set u

p to

pre

vent

SID

S –

Bac

k to

Sle

ep C

ampa

ign

D

iscu

ss im

porta

nce

of p

ostp

artu

m

visi

t and

try

to s

ched

ule

post

partu

m

visi

t if f

easi

ble

D

iscu

ss im

porta

nce

of o

ngoi

ng

heal

thca

re a

fter d

eliv

ery

and

iden

tify

med

ical

car

e ho

me/

PC

P

X C

linic

al E

lem

ents

Vis

it fre

quen

cy s

houl

d be

w

eekl

y

Wt,

BP,

Fun

dal h

eigh

t at

ever

y vi

sit

Fe

tal h

eart

tone

s at

eve

ry

visi

t

Cer

vica

l exa

m if

indi

cate

d

Con

firm

feta

l pos

ition

Con

side

r offe

ring

vers

ion

if no

n-ce

phal

ic p

rese

ntat

ion

N

ST,

BP

P if

clin

ical

ly

indi

cate

d

3rd T

rimes

ter,

38 W

eeks

to D

eliv

ery

Plac

e pa

tient

stic

ker h

ere.

APP-B-6


Pren

atal

Car

e Q

ualit

y To

ol C

heck

list

This

doc

umen

t was

dev

elop

ed u

nder

gra

nt C

FDA

93.

767

from

the

U.S

. Dep

t. of

Hea

lth a

nd H

uman

Ser

vice

s, C

ente

rs fo

r Med

icar

e &

Med

icai

d S

ervi

ces.

H

owev

er, t

hese

con

tent

do

not n

eces

saril

y re

pres

ent

the

polic

y of

the

U.S

. Dep

t. of

Hea

lth a

nd H

uman

Ser

vice

s, a

nd s

houl

d no

t ass

ume

endo

rsem

ent b

y th

e Fe

dera

l gov

ernm

ent.

Dat

e: _

____

____

____

____

__

___

Wee

ks P

ost D

eliv

ery

X La

bs

P

ap T

est i

f due

(c

olpo

scop

y if

need

ed)

2

hour

GTT

scr

eeni

ng

or a

ppro

pria

te s

cree

ning

fo

r all

gest

atio

nal

diab

etic

s

X C

linic

al E

lem

ents

Phy

sica

l inc

ludi

ng b

reas

t, ab

dom

inal

and

pel

vic

ex

amin

atio

n

Per

inat

al m

enta

l hea

lth

scre

en

S

cree

n fo

r inc

ontin

ence

(fe

cal,

urin

ary

and

gas)

Scr

een

for b

reas

tfeed

ing

diffi

culti

es

B

irth

cont

rol m

etho

d re

ceiv

ed

Hig

hly

effe

ctiv

e m

etho

d:

IUD

, im

plan

t M

oder

atel

y ef

fect

ive

met

hod:

inj

ectio

n, p

ills,

patc

h, v

agin

al ri

ng

X R

efer

rals

Ref

erra

l to

men

tal h

ealth

pr

ofes

sion

al o

r soc

ial w

orke

r if

indi

cate

d

Ref

er to

lact

atio

n co

nsul

tant

or

hotli

ne if

indi

cate

d

Ref

erra

l to

PC

P /m

edic

al h

ome

for

ongo

ing

care

Ref

erra

l to

WIC

Ref

erra

l to

and

Fam

ily C

ase

Man

agem

ent

X Ed

ucat

ion

R

ecom

men

d ex

clus

ive

brea

stfe

edin

g fo

r at l

east

6

mon

ths

dura

tion,

add

ress

co

ncer

ns

P

ostp

artu

m s

exua

l act

ivity

and

bi

rth c

ontro

l met

hods

Ben

efits

of i

nter

preg

nanc

y sp

acin

g

Res

ume

phys

ical

act

ivity

R

etur

n to

wor

k/sc

hool

Rev

iew

sig

ns a

nd s

ympt

oms

of

post

partu

m m

ood

diso

rder

s

Saf

e nu

rser

y se

t up

to p

reve

nt

SID

S –

Bac

k to

Sle

ep

Cam

paig

n

Post

partu

m

Plac

e pa

tient

stic

ker h

ere.

APP-C-1

aPPendix c – referrals for HigH-risk Prenatal conditions

Referrals for High-Risk Prenatal Conditions

January 2014

Page 1 of 4

This document was developed under grant CFDA 93.767 from the U.S. Dept. of Health and Human Services, Centers for Medicare & Medicaid Services. However, these content do not necessarily represent the policy of the U.S. Dept. of Health and Human Services, and should not assume endorsement by the Federal government.

Reproductive History

Perinatal Code

ACOG Referral / Consultation

1st Trimester loss No Referral

Successive 1st trimester losses

MFM and Reproductive Endocrinologist if available

2nd Trimester loss MFM -perinatal death mid trimester loss

OB OB or MFM if available

3rd Trimester loss MFM perinatal death mid trimester loss

OB or MFM if available

History of LBW or VLBW OB OB or MFM

History of preterm delivery <34 wks

MFM - 34 weeks OB (or prior PROM) OB or MFM

History of Preeclampsia/eclampsia

OB or MFM

Family history of genetic disorder

MFM MFM or Genetic Specialist

Developmental or Intellectual Disability

MFM

Birth with congenital anomalies

MFM MFM MFM/ultrasound

Uterine abnormalities OB OB or MFM

Abnormal Pap OB for possible Colposcopy referral when indicated

Prior birth with complication resulting in handicap

MFM OB or MFM

Prior fetal/neonatal death

OB OB or MFM

Prior cervical insufficiency

MFM

Prior myomectomy or C-section

OB OB

Prior gynecological malignancy

OB or MFM

APP-C-2



January 2014

Page 2 of 4


Active Medical Conditions

Perinatal Code


Pregestational Diabetes MFM- IDDM class B or >

Class A-C (OB) Class D or> (MFM)

MFM

Controlled Hypertension

MFM -Essential HTN on medications

MFM- with renal/cardiac dis. OB-w/o cardiac dis.

OB or MFM

Uncontrolled Hypertension

MFM

MFM- with renal/cardiac dis. OB-w/o cardiac dis.

MFM

Cardiovascular disease MFM MFM MFM and Cardiology

Sickle Cell disorders MFM MFM MFM

HIV OB or MFM (based on CD4 counts

MFM and ID

Active Hepatitis B or C MFM and GI

Autoimmune disorders (including SLE)

MFM and Rheumatologist

Seizure disorders OB MFM and Neurologist

Renal disease MFM

Creat>3-MFM Chronic-OB Proteinuria-OB

MFM and Nephrologist

Cystic Fibrosis MFM

Thyroid disease OB and Endocrinologist or MFM

ITP MFM

Thromboembolic disease

OB- Hx of PE/DVT MFM

Anemia (HCT<28%, unresponsive to iron therapy)

Hemophilia MFM and Hematologist

Malignancy MFM

Physical disability OB or MFM

Pulmonary Disease MFM -Severe OB-Moderate

OB and Pulmonologist or MFM

Asthma on steroids OB- on meds MFM- if multiple hospitalizations

MFM

Perinatal code- Chronic medical problems with known increase in perinatal morbidity and mortality ACOG- Any systemic disease that adversely affects pregnancy should have an MFM consultation

APP-C-3



January 2014

Page 3 of 4


Obstetrical Complications

Perinatal Code


Di/Di twin gestation MFM -multiple gestation OB- multigestation OB

Mono/Di or Mono/Mono twin gestation

MFM-multiple gestation MFM

Triplets or greater MFM -multiple gestation MFM

Positive Quad screen MFM - abnormal genetic evaluation

OB OB or MFM

Cervical insufficiency OB MFM

Short cervix MFM

IUGR MFM OB OB or MFM

Polyhydramnios OB- hydramnios by ultrasound

OB or MFM

Oligohydraminos OB OB or MFM

Viral exposure (TORCH) during pregnancy

OB or MFM

Gestational Hypertension/ Preeclampsia/eclampsia

MFM OB - diastolic >90, w/o proteinuria

OB or MFM

Abnormal fetal presentation at 3rd trimester

OB

Induction of labor prior to term

OB or MFM

Abnormal antenatal testing

OB

Abnormal labor OB

IUFD OB OB or MFM consult

Premature/Preterm labor

MFM < or = 36 weeks OB< 37 weeks OB

PPROM, PROM OB OB

Anticipated elective C-section

OB

Severe postpartum hemorrhage

OB

Repair of 3rd or 4th degree laceration

OB

3rd trimester bleeding MFM OB> 14 weeks OB

Post date > or = 42 wks MFM OB OB

Abnormal fetal ultrasound

OB or MFM MFM

Isoimmunization MFM MFM MFM

APP-C-4



January 2014

Page 4 of 4


Psych/Social Perinatal Code

ACOG AAFP Referral / Consultation

Bipolar Psych OB and Psych if available

Depression Psych OB and Psych if available

Schizophrenia Psych OB and Psych if available

Anxiety disorder Psych OB and Psych if available

History of Post-partum depression/psychosis

Psych OB and Psych if available

Active substance disorder

Other OB - drug and alcohol use

MFM -drug addiction

Actively suicidal Admission to inpatient Admission to inpatient

Domestic/Partner violence

Social service Social Service

Housing Social service Social Service

APP-D-1

aPPendix d – PostPartum transition strategies

Strategies for Improving the Postpartum Visit Rate for HFS-Enrolled Women

Health Care Provider

Strategy

Timing

Intervention

Prenatal Provider

Education During last scheduled prenatal visit

EHR alert to provide postpartum education Discuss the importance of the postpartum visit

and encourage the woman to schedule and complete the appointment

Provide a patient postpartum checklist to the woman (in combination with verbal education above)

Schedule Appointment

During the last scheduled prenatal visit

EHR alert to schedule postpartum appointment Schedule postpartum appointment

After delivery Upon notification of delivery by hospital, outreach to patient to schedule postpartum appointment

Hospital Notification Prior to discharge Develop a system to provide immediate notification of delivery to prenatal care provider

Education Prior to discharge EHR alert and/or checklist to provide postpartum education

Discuss the importance of the postpartum visit and encourage the woman to schedule and complete the appointment


Schedule Appointment

Prior to discharge Develop a system to ensure that the woman has a postpartum visit scheduled

Following education (above), encourage the woman to make the postpartum appointment

Confirm that appointment was made; offer assistance

Pediatrician Education During the first well baby visit

EHR alert to provide postpartum education Ask the woman if she has a postpartum

appointment scheduled Discuss the importance of the postpartum visit

and encourage the woman to schedule and complete the appointment


aPPendix e – HiteQ resources

APP-E-1

The HITEQ Center is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U30CS29366 titled Training and Technical Assistance National Cooperative Agreements (NCAs) for grant amount $500,000. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

HEALTH IT ENABLED QUALITY IMPROVEMENT: A GUIDE TO IMPROVING CARE PROCESSES AND OUTCOMES

Available on HITEQCenter.org

1

CHECK/ REINFORCE FOUNDATIONS

Cultivate shared commitment and shared understanding

Ensure leadership support and buy-in from the whole team

Ensure access to and validate data that will underpin the QI efforts.

Ensure stable and reliable health IT systems (including people, processes, and technology related to systems)

o Recommended tools, all available on HITEQcenter.org, under Health IT Enabled QI :

Health IT enabled Quality Improvement Project Charter: The first step in a QI project (link) Accessing your Data: Questions to Consider with your EHR vendor (link) Analytics Capability Assessment, from Center for Care Innovations (link) Health Center Data Validation Tool (link for Adult BMI, others coming to HITEQCenter.org)

UNDERSTAND HEALTH IT ENABLED QUALITY IMPROVEMENT

Everyone participating in the QI work should have a shared understanding of key definitions, frameworks (e.g., CDS 5 Rights, below), strategies (e.g., the QI process outlined under the Implement and Evaluate Changes heading.), tools (e.g., Essential CDS/QI Worksheet), and key QI project success factors.

1 Osheroff, Jerome A. "Improving Care Processes and Outcomes in Health Centers. HRSA Health Information Technology, Evaluation and Quality Center. 9 Sept. 2016. Web. 21 Nov. 2016


APP-E-2


The CDS 5 Rights framework, a recommended CMS best practice QI approach to support decisions and actions that drive performance targeted for improvement, says that improving care processes for optimal outcomes requires getting the right information to the right people in the right formats through the right channels at the right times.2

Be sure to consider people, processes, and technology, in that order!, when considering processes and engaging in quality improvement. Improvement to care processes and other quality drivers must be done WITH people, not to them.


Guide to Improving Care Processes and Outcomes in Health Centers (link)

SELECTING QUALITY IMPROVEMENT TARGET, INITIATE QI PROJECT

What quality improvement target should be selected? Consider the following: o Business imperatives, such as value-based payment initiatives or awards (such as HRSA Quality

Leader or Technology awards). o Seek QI synergies with pertinent initiatives such as PCMH recognition and HRSA Health Center

Quality Improvement Grant Awards. o Those measures or outcomes that have experienced unexpected change in performance

o Operational initiatives such as: Behavioral health integration Oral health integration Collecting and operationalizing sexual orientation/ gender identity data Collecting and operationalizing social determinants of health data

Document the selected target, including specific quality measure when possible as well as time period, specific population, and so on. Also document current performance.


Prioritization Matrix, to select from multiple target options (link) Document selected target in first section (target and current performance) of Essential

CDS/ QI Worksheet (link)

DOCUMENT AND ANALYZE FLOWS, IDENTIFY IMPROVEMENTS

Consider the following questions about workflow and information flow, as it relates to your selected target:

o What are we currently doing? What are we trying to improve and what is the baseline? [using analytics]

o What should we be doing to produce better processes and results? [using best practices]

2 TMIT Consulting, 2016.


APP-E-3


o What changes might we make to produce better processes and results? [adoption]

Consider individual patient activities, such as what is done to support the given target when the patient is in the clinic, as well as population management activities, such as tools or activities used to identify and address care gaps across the patient panel, and foundational activities, such as the health IT systems, policies, and protocols that support all activities in the health center.


Collaboratively, with your team representing all stakeholders, document What are we currently doing [related to our selected target]? in the Current Workflow/ Information Flow lines of the Essential CDS/ QI Worksheet (link)

Complete the Individual Patient Activities section, in Orange, as well as Population Management activities, in Blue, and Foundational Activities, in Green of the worksheet, as each section relates to your selected target.

Document What should we be doing? in the Potential Enhancement lines of the Essential CDS/ QI Worksheet (link)

When considering improvements/ potential enhancements using this worksheet, consider the following:

o Cells or sections where the current flow is not known o Instances where stakeholders are not aligned on processes (i.e. different

providers or care teams do different things or have different workflows) o Instances where no policy/ protocol is in place o Instances where the 5 Rights are not well orchestrated; i.e. the right

information is not available at the right time through the right channels o Instances where policies and workflows are in place, but outcomes are still

suboptimal– are there population factors?

IMPLEMENT AND EVALUATE CHANGES

Using a QI methodology such as PDSA cycles, engage frontline staff and all key stakeholders in care processes and results to design, implement and evaluate one selected enhancement.

o Be sure to do this work with all the stakeholders and not to them (i.e., seek and act on team member and patient input and feedback throughout the process).

Monitor implementation activities with structured tools that help you document and manage who’s doing what when, as well as the results.

Evaluate the impact of the change based on results and feedback from those involved, determine final action related to the tested enhancement: adopt, adapt, or abandon. Recommended tools:

o For assistance in selecting one potential enhancement to test first, use the prioritization matrix again.

o PDSA Worksheet, such as this one from Oregon Primary Care Association, or this one from the Institute for Healthcare Improvement

o Data collection tools and plan for monitoring, such as these from Oregon Primary Care Association o Monitoring Worksheets from Chapter 8: Putting Interventions into Action and Chapter 9: Measuring

Results and Continuously Refining the Program in “Improving Outcomes with Clinical Decision Support: An Implementer’s Guide. Second Edition” provided with permission from HIMSS


APP-E-4


IMPLEMENT AND EVALUATE CHANGES

Apply this learning and these results to strengthen ongoing ‘maintenance’ efforts on the current target and other target-focused QI initiatives.

o Transition target-related QI efforts from ‘project-focused’ to ‘this is how we do business.’ Build in ability to detect the need for, and implement, tweaks to target-related processes when required because of changes to people/processes/technology.

i.e., Feedback loops! o Be sure to incorporate the insights and results from each QI project into subsequent QI initiatives.

Although a particular target-focused QI project may be time-limited, the QI and clinical teams should remain alert for ways to continually improve care across all targets.

For example, learning from a QI project might indicate opportunities to more broadly modify clinical and quality work and roles, as well as health IT configurations or integrations.

Recommended tools/ references: o Harnessing the Power of Feedback Loops, Wired.com. o Zikmund-Fisher BJ, et al. Graphics help patients distinguish between urgent and non-urgent

deviations in laboratory test results. Journal of the American Medical Informatics Association 2017;24(3):520-528.

o Developing Effective Data Dashboards, a primer on a process and tips in developing a data dashboard from HITQ.

o Data Monitoring: Population Health Data Strategies (Webinar) o Worth a Thousand Words: How to Display Health Data from California Healthcare Foundation

APP-F-1

aPPendix f – guide to Patient and family engagement

Steps to Creating a Culture of Person and Family Engagement

Engage LeadersLeadership sets the tone for any organizational culture. Through words and actions, it falls to leaders to cultivate a supportive and trusting workplace culture, facilitate a continuous learning environment, and ensure that person and family engagement is integrated into organizational structure and strategy.

Enlist Patients and Families as PartnersCreate systems and processes to harness insights from patients and families about their experiences, gaps in care, and opportunities for continuous improvement. Examples include focus groups, participation on practice improvement teams, and patient and family advisory councils.

Empower and Energize StaffJoy in practices is created in part by feeling a sense of purpose that transcends specific tasks. To create this shared purpose, reserve time for staff to share stories of the positive impact they have made on patients’ lives. Introduce systems that invite all staff to participate in improving care and making the practice a better place to work.

Encourage Family Participation in CareFamily can be a vital source of continuity and coordination across episodes and settings of care. Invite patients to identify a family Care Partner. Then, elicit Care Partners’ observations and questions during visits. Equip Care Partners with tools for monitoring their loved one’s health and managing their care.

Equip, Enable and Support Patients to Engage

Patients’ goals, preferences and cultural norms cannot be integrated into care without their engagement in treatment planning and self-management. Adopt strategies such as teach back, medication management, and shared decision-making to support patients to become active members of the care team.

Emphasize PFE in All You DoPerson and family engagement isn't one more thing to do. It is the tie that binds all that you do together. With patients and family members as advisors, consider ways to modify the physical environment to promote engagement. Seek out community partners that will enable you to better engage patients and their family caregivers where they live, work, learn, worship and play.

The culture of a practice encompasses its attitudes, behaviors, practices and norms. The six steps below are designed to guide genuine transformation in culture to promote person and family engagement.

© 2017 Planetree - may be reproduced for non-commercial purposes

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Not sure where to start? This 30-day kick-start plan maps out concrete actions you can take in each of the six culture change steps within the next month. These early activities establish the vision of culture change, emphasize this as an inclusive effort built on partnership, and generate enthusiasm for the changes to come.

Engage Leaders• Complete this leadership self-assessment to identify opportunities to lead change.

• During your next staff meeting, walk the entire team through these 6 steps of culture change. Invite them to weigh in on how the steps can be applied in your office.

Enlist Patients and Families as PartnersTrain a team member to conduct brief patient and family interviews during wait times. Ask patients and family members what has kept them loyal to the office. Invite them to complete this sentence: “I wish this office would…” Use these ideas to guide improvements.

Empower and Energize Staff• Kick off your next staff meeting with a patient story.

• Invite all staff to complete a personal commitment card where they identify a specific way they will contribute to the office’s culture of person and family engagement.

Encourage Family Participation in Care• Develop a process for identifying and documenting family care partners in a patients’ record.

• Audit your exam rooms to ensure that there is ample space and seating to accommodate the presence of family. Ask patients for feedback as well!

Equip, Enable and Support Patients to EngageInvite patients to partner with you to identify practical tools for making their visits even more constructive. Share a selection of tools for them to review, trial and provide feedback on. Examples include: the I Wish I Had Asked That tool, Ask Me 3 and this Patient Note Sheet.

30 Day Kick-Start Plan

Emphasize PFE in All You DoConsider how the set-up of the office and exam rooms is welcoming and conducive to building relationships. Every space should facilitate personal connection, engagement and eye contact. Examine the front office overall; in exam rooms assess placement of the computer screen and keyboard, availability and height of chairs, positive diversions for patients, etc.

© 2017 Planetree - may be reproduced for non-commercial purposes

aPPendix f – guide to Patient and family engagement

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aPPendix g – tHe Joint commission HealtH literacy and self-management tools

Health Literacy

AHRQ defines Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.

Differences in health literacy level were consistently associated with increased hospitalizations, greater emergency care use, lower use of mammography, lower receipt of influenza vaccine, poorer ability to demonstrate taking medications appropriately, poorer ability to interpret labels and health messages, and, among seniors, poorer overall health status and higher mortality.

Sample Screening Tools for Health Literacy:

Rapid Estimate of Adult Literacy in Medicine—Short Form (REALM-SF)

The Rapid Estimate of Adult Literacy in Medicine—Short Form (REALM-SF) is a 7-item word recognition test to provide clinicians with a valid quick assessment of patient health literacy.

The REALM-SF has been validated and field tested in diverse research setting, and has excellent agreement with the 66-item REALM instrument in terms of grade-level assignments.

SAHLSA (Short Assessment of Health Literacy for Spanish-speaking Adults)

The SAHLSA consists of a word-recognition section, designed after the REALM, in addition to a comprehension test that employs multiple choice questions. It was designed to assess the health literacy for adults who speak Spanish.

SILS (Single Item Literacy Screener)

The SILS is a single item instrument designed to identify patients who need help with reading health-related information. The instrument asks one question “How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?” with possible responses ranging from “1” (never) to “5” (always).

In this primary care population, one in six had limited reading ability. With the known negative impact of limited reading ability on health outcomes, enhancing communication for this population is critical. The SILS performs moderately well at ruling out limited reading ability in adults and allows providers to target additional assessment to those most in need. Application of the SILS in clinical settings has the potential to improve outcomes and processes of care for chronically ill individuals with limited reading ability.

S-TOFHLA

The S-TOFHLA, a 7-minute test, with 36 reading comprehension items in 2 passages. The passages on the S-TOFHLA use a modified Cloze procedure where every fifth to seventh word is omitted and subjects select the correct word from among a set of four options. The passages contain information about an upper gastrointestinal tract x-ray procedure, and the “Rights and Responsibilities” section from a Medicaid application, Each selection is scored a “1” for correct or a “0” for incorrect and scores are summed over items to create a total score. The 36-point scale of the S-TOFHLA is divided into three categories of functional literacy: inadequate (0-16), adequate (17-22) and functional (23-36)

In early developmental studies, the reading comprehension passages in the S-TOFHLA had a reliability coefficient of 0.97 and correlation with the Rapid Estimate of Adult Literacy in Medicine (REALM) of 0.81.

NVS (Newest Vital Sign)

The NVS consists of a nutrition label with 6 accompanying questions to assess literacy. It takes approximately 3 minutes to administer, and is meant to allow healthcare providers to make a quick assessment of patients’ literacy, which can then allow them to adapt communication to achieve better outcomes. It assesses literacy and numeracy, and is available in both English and Spanish versions.

Since the Newest Vital Sign was published in the Annals of Family Medicine (December 2005), it has appeared in more than 25 peer-reviewed studies. The NVS has been used to assess health literacy in populations ranging from parents of young children to older adults, among racial/ethnic minorities, and applied to a wide variety of health conditions.

(Measuring Adult Literacy in Health Care: Performance of the newest Vital Sign, Am. J Health Behav 2007)

“In comparison to the REALM and the S-TOFHLA, the NVS – which was developed as a screening tool – has high sensitivity for detecting limited literacy. Its specificity varies depending on whether the REALM or S-TOFHLA is used as the comparison standard. The performance of the NVS in both of these studies suggests it may be useful as a clinical screening tool when high sensitivity is acceptable, but less in research settings that require precision in measurement. It should be noted that health literacy experts do not currently recommend literacy screening in the clinical setting unless healthcare professionals and the healthcare system are willing to implement communication strategies appropriate for patients with limited literacy.”

“In this set of studies, we found the NVS to be more strongly correlated with the S-TOFHLA than the REALM. The NVS was also not found to be associated with health knowledge or outcomes, whereas the S-TOFHLA was linked to these variables. This gives the S-TOFHLA a stronger predictive validity than the NVS, which should be considered when deciding which instrument to use for research purposes.”

Used with Permission from The Joint Commission

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