Improving Referral Rates for an Early Childhood Home Visitation Program

Summary

Impact Statement:

Clark County Health Department increased the percent of eligible families that are referred to Kentucky’s home visitation program for new and expectant parents from 24% to 56%. Evidence indicates that increased participation in this program will positively impact preterm birth rates, low and very low birth rates, and incidence of child abuse and neglect.

Summary:

The Clark County Health Department’s quality improvement (QI) initiative goal was to improve the number of families benefiting from home visitation services provided by Kentucky’s Health Access Nurturing Development Services (HANDS) program. For a patient to be offered home visitation from HANDS, a referral screen is completed first, followed by a parent assessment. The referral screen is most often conducted at a family planning or Women, Infants, and Children (WIC) appointment and does not require much of the patient’s time. The parent assessment takes longer and usually requires a return visit to the health department or occurs at the patient’s home. HANDS services are offered free to patients once it is determined that they would benefit from the home visitation program. For a referral screen to be considered “assessed,” a parent assessment must be completed. The yearly audit revealed an opportunity for improvement in the rate of referral screens assessed. The project aim statement was to increase the percentage of referral screens assessed from 24% to 36%.

The QI team used the Plan, Do, Study, Act (PDSA) process to examine the referral screen assessment process. Process mapping, brainstorming, the 5-Whys, run charts, and cause-and-effect diagramming were among the QI tools used to manage the project. After identifying root causes and developing improvement theories, process changes were implemented for 3 months. To evaluate performance, the percentage of referral screens assessed was measured and referral screen audits were conducted to capture reasons why a referral screen was not being assessed. The team met and exceeded its aim statement goal of 36%, with an average referral screen assessment rate of 54% during the study period. The HANDS team adopted the changes into its standard process and will continue to track performance measures to sustain the gains made from this QI initiative.

Organization that conducted the QI initiative:

Clark County Health Department

Citation:

Willett, E. Public Health Quality Improvement Exchange. Improving Referral Rates for an Early Childhood Home Visitation Program. Wed, 03/08/2017 - 14:38. Available at http://www.phqix.org/content/improving-referral-rates-early-childhood-home-visitation-program. Accessed April 19, 2024.

Background and Aim

Aim statement:

By July 31, 2013, the Clark County HANDS program will increase the monthly referral screen assessment rate from 24% to 36%. This effort should improve the number of families receiving HANDS.

Need For The QI Initiative:

All HANDS programs receive audits from the state program office. The July–December 2011 audit revealed that almost half of the referral screens were not assessed during that 6-month period, meaning the patient did not receive a parent assessment. Because a parent assessment must be done before a patient can be offered home visitation service, this audit indicated that there could be a large number of families not benefiting from HANDS. At that point, the HANDS team decided to focus on improving referral screens and parent assessments for the first-ever HANDS QI project. Early QI work focused on improving the referral screen visit by working on dialogue, trust-building, and relationship-building techniques. Since late 2012, the QI initiative has shifted to focus on the parts of the process occurring from the referral screen to the completed parent assessment. Baseline data gathered in November 2012 showed that only 24% of referrals screens had been assessed that month. This data point formed the current aim statement for this project.

Area for Improvement:

The HANDS program is a voluntary home visitation program for new and expectant parents, based out of public health departments in the state of Kentucky. The HANDS program is based on the Healthy Families America Model (HFAM), with training outlines based on the HFAM. The main goals of HANDS are healthy pregnancies and births; healthy child growth and development; a healthy, safe home; and self-sufficient families. Since the program’s inception in 1999, Kentucky HANDS has completed more than 66,000 parent assessments, which has resulted in more than 1.6 million home visits and more than 60,000 families receiving services. There have been four statewide studies comparing HANDS participants with non-HANDS participants. The studies have found positive outcomes for participants in the HANDS program: 31% fewer premature births, 33% lower incidence of low birth weight, 55% lower incidence of very low birth weight, 70% less infant mortality, 50% less emergency room use, 29%–40% lower incidences of child abuse and neglect, 26% improved or increased education rates, and fewer developmental delays. The following indicators of maternal, infant, and child health gathered through Clark County’s community health assessment project suggest that this population would be well served by an increased number of families in the HANDS program: 1. Healthy People 2020 sets a target standard of 11.4% of live births being preterm, and according to the National Vital Statistics System, Clark County had 16.2% preterm births in 2008. 2. When looking at the incidence of low birth weight, Clark County had 8.9% in 2008 and increased to 10% in 2009 (Healthy People 2020 target: 7.8%). 3. According to the KIDS COUNT Mobile Data Center, there were 103 child victims of substantiated abuse or neglect in Clark County in 2010, which is higher than that for two peer counties in the same year, which were 94 and 40.

Root Cause:

The data that the QI team collected indicated that several internal and external factors were involved. Identifying a single root cause was difficult, and it was important to distinguish factors that were within the QI team's control and those out of the HANDS team's control. The factors deemed significant and in control of the HANDS team were as follows: 1. A HANDS team member was not conducting the referral screen during WIC appointments. 2. The lead person for conducting parent assessments had competing demands on work time because of supervisory and state trainer obligations. 3. The organization of the referral screen forms did not allow for quick identification of when babies are at risk of aging out of services. 4. Patients’ phone issues (e.g., disconnected, voicemail not set up) created a challenge for scheduling and completing parent assessments.

Planning and Execution Details

QI Implementation:

The first steps in this project included forming a new QI team consisting of one QI facilitator, one HANDS supervisor, two HANDS front-line staff members, and two clinic staff members. Guidance from the third edition of The Team Handbook (Oriel) was used to form a productive team with purpose, roles, expectations, and success metrics defined and captured in a team charter. The team established a routine meeting schedule for the duration of the PDSA cycle. From January to April 2013, the team worked through the Plan phase and met an average of two times per month for 1.5 hours each time. All meetings were conducted on site at the health department and were scheduled at the beginning of the work day to minimize disruption to clinic schedules. The team started with process mapping the steps involved in the referral screen and completing a parent assessment. The process map revealed variations in the referral screen process depending on appointment type. The most critical variation was the referral screen being conducted by a non-HANDS employee versus a HANDS employee. The initial contact with a patient is critical and is considered essential for building trust and establishing a relationship with patients and families. After process mapping, the team worked on identifying root causes to answer the question, “Why are referral screens not being assessed with a parent assessment?” Using cause-and-effect diagramming, the main categories of possible root causes were (1) family declines, (2) baby ages out (older than 12 weeks), (3) HANDS team factors, and (4) external factors (e.g., phone issues, family moved out of county). Through discussion and further analysis, the team determined the organization system of the referral screen forms, the role or assignment within the HANDS team, and patient phone issues to be the significant root causes for which they would identify improvement theories and strategies. Beginning in April 2013, the QI team implemented process changes to study improvements in the referral screen assessment rate. Those changes were as follows: 1. All efforts were made to ensure a HANDS employee conducted referral screens. All clinic and WIC staff now call overhead in the health department for a maternal and child health (MCH) specialist when a patient requires a referral screen. All HANDS staff know to respond to this call if they are in the building. 2. A different team member was designated as the lead parent assessment worker. This new lead does not have competing work demands and has the main responsibility of completing parent assessments. 3. Any patient who is unreachable has his or her chart flagged by the lead parent assessment worker. Flagging a chart indicates to all clinic and WIC staff to update the contact information at the patient’s next visit to the health department. In addition, this patient will once again talk with a HANDS team member during that visit and further attempts will be made to schedule the parent assessment visit. 4. Organizational design changes were made to allow the lead worker to more quickly identify when a baby has been born and when a baby is at risk of aging out of receiving services. Rather than organizing the referral forms only by month of referral, a section for “baby born” was added to each month. Once staff learned of a baby being born, the referral form was moved to this section, which allowed for quicker detection of referrals at risk of aging out of services. These changes were implemented for 3 months, after which data were gathered and analyzed to determine whether these changes led to improvements. The QI team found that the changes did lead to improvements in referral screen assessment rates and decided to adopt these changes into the standardized process. The performance measures will continue to be evaluated over time to ensure that the gains made through this QI initiative have been sustained.

Focus activities

Maternal and Child Health Services:

Early intervention services for children

MCH home visits

Prenatal care

Other Public Health Services:

Access to care

Administration:

Organizational effectiveness

QI Methods:

PDCA/PDSA Cycle (Plan, Do, Check/Study, Act)

Rapid Cycle Improvement

QI Tools:

Brainstorming

Cause and Effect Diagrams

Other QI tools:

Trend chart

Operational QI reporting plan template

Team charter

QI Tool Documentation:

Pilot study data—trend and radar charts

Cause-and-effect diagram

QI project—operational reporting plan

Team charter

Process map

Preliminary data—run and pie charts

Initiative Dates:

5/1/12 to 7/31/13

Initiative Duration:

Between 12-18 months

Methods of evaluation:

The QI initiative was evaluated by measuring the number of referrals brought to HANDS each month and the number of those referrals that received a parent assessment. This measure was compared with those from prior months to evaluate if reach to the target population increased. Another measure in this initiative was the type and incidence of reasons listed in the chart notes for a patient not receiving a parent assessment (e.g., phone disconnected, patient cancelled). This measure was evaluated by conducting an audit of the referral screens for each month. In addition, the audit results will give a yearly average of the referral records assessed, which will be helpful for determining long-term maintenance of improvements, independent of monthly fluctuations that may occur.

Supplemental Materials:

Storyboard

Supplemental Files:

Attachment	Size
HANDS QI Storyboard.pdf	730.78 KB

Results

Measurable QI Outcomes:

The team identified the following metrics: (1) the percentage of referral screens assessed each month, and (2) the incidence of reasons for referral screens not being assessed. The HANDS QI initiative demonstrated an increase in referral screens assessed during the 3-month pilot phase. From November 2012 to March 2013, the assessment rates were 24%, 0%, 11%, 16%, and 22%, respectively. After implementing the process changes, the assessment rates for April to June 2013 were 56%, 54%, and 52%, respectively (see trend chart). After the pilot period, “baby aged out” was not found in the referral screen audit as a reason for not receiving a parent assessment, and all patients received contact from HANDS either by phone call or text message.

Other QI Outcomes:

As a result of this QI initiative, several intangible outcomes were as follows: • improved ability and confidence with the use and application of QI tools by all team members; • increased interest in QI leadership among front-line staff; and • increased ability to demonstrate Public Health Accreditation Board (PHAB) requirements, especially concerning using performance management in programmatic areas. Additionally, the end-of-year report for July 1, 2012, to June 31, 2013, shows that the HANDS program reached 100% completion of its projected parent assessments. The number of visits for the jurisdiction is projected each year by the state HANDS program, and Clark County Health Department is evaluated on the completion rate. This 100% completion rate may be partly due to the QI initiative and process changes implemented during this fiscal year. The success of this project has led the HANDS team to start another QI project, leading to an increase in the number of active QI projects at this health department.

Lessons Learned, Observations and Insights:

Key successes of the QI initiative were as follows: • This initiative allowed the QI team the opportunity to use a new performance metric (incidence of reasons charted for not assessing a referral screen) for evaluating work on assessing referral screens. • The process was transparent to all HANDS team members regardless of being on the team, and the leadership appreciated this transparency; they felt comfortable being honest and open with their thoughts on the process and changes being implemented. • The identification of a team leader, separate from the QI coordinator, was helpful because the leader could take on duties such as meeting preparation, data collection assistance, team-building activities, and meeting wrap-ups. Health equity This initiative addressed health equity by understanding that financial hardship and poverty can make it difficult for people to maintain channels of communications necessary for being accessible to staff. The team understood that modes of communication can change with the patients, and they introduced a process change (flagging charts) to address this challenge that the target population faces.

Future Plans:

The changes made to the referral screen assessment process have been adopted and standardized as of August 1, 2013. The performance measures will continue to be tracked at least quarterly to sustain the gains made during this QI initiative. Future plans for this initiative include looking at the number of current HANDS families to determine if these process changes have led to an increase in families accepting home visitation services.

Improving Referral Rates for an Early Childhood Home Visitation Program

Summary

Background and Aim

Planning and Execution Details

Results

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Accreditation Details

Contact Information of the Submitter

Comments

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Improving Referral Rates for an Early Childhood Home Visitation Program

Summary

Background and Aim

Planning and Execution Details

Results

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Accreditation Details

Contact Information of the Submitter

Comments

QI Spotlight