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Improving the Retention Rate of the Special Supplemental Nutrition Program for Women, Infants, and Children Clients in Yellowstone County, Montana
Summary
Impact Statement:
WIC enrollment is well below the eligible population in Yellowstone, MT, and a substantial number of those enrolled do not regularly pick up their food coupons, resulting in automatic disenrollment and loss of benefits. Utilizing PDCA, RiverStone Health addressed the root causes of the drop off in WIC participation.
Summary:
RiverStone Health, formerly known as Yellowstone City-County Health Department, sought to increase the retention rate of children in its Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). In 2010, an estimated 4,396 children were eligible for WIC benefits in Yellowstone County, and only 1,392 of them were served. In June 2012, 1,731 children were enrolled in WIC, and only 85% used WIC services. A multidisciplinary quality improvement (QI) team was established for the project; the team included a past WIC participant and the WIC program specialist for the Montana Department of Public Health and Human Services (DPHHS).
The initial aim statement was as follows: By August 1, 2013, RiverStone Health will increase the percentage of participants ages 1–5 who meet the WIC definition for active participation from 85% to 90%. The team identified the root cause of nonparticipation to be that clients were not required to schedule their next appointment before leaving the office, and the team tested a process change that required clients to schedule their next appointment before leaving the office. As a result of the QI initiative, the percentage of clients being scheduled increased from 56% to a high of 97%, and the number of clients who had benefits terminated per month decreased from 45 to 36. However, the percentage of participants who meet the WIC definition for active participation was 84.9%, which was not a significant change from the baseline of 85%.
Organization that conducted the QI initiative:
RiverStone Health
Citation:
Silveus, H. Public Health Quality Improvement Exchange. Improving the Retention Rate of the Special Supplemental Nutrition Program for Women, Infants, and Children Clients in Yellowstone County, Montana. Wed, 03/08/2017 - 14:45. Available at http://www.phqix.org/content/improving-retention-rate-special-supplemental-nutrition-program-women-infants-and-children. Accessed April 19, 2024.
Background and Aim
Aim statement:
The intended outcome of the QI initiative is summarized in the primary aim statement, supported by two process-oriented aim statements.
Main aim:
By August 1, 2013, RiverStone Health will increase the percentage of participants ages 1–5 who meet the WIC definition for active participation from 85% to 90%.
Specific aims:
By August 1, 2013, RiverStone Health WIC Clinic will increase the number of clients who schedule their next appointment before leaving the office from 58% to 80%.
By August 1, 2013, RiverStone Health WIC Clinic will decrease the monthly number of WIC clients who have had their benefits terminated from 45 to 35.
Need For The QI Initiative:
In WIC programs across the country, participation percentages seem to decline for children ages 1–5. The QI team wondered why a family with a child determined as eligible would not follow through with regular participation. Children make up the largest percentage of WIC participants, and nonparticipation affects overall participation rates, and ultimately funding levels, for WIC. Because these children are already enrolled in the program but are not coming in, eligible children are missing the proven benefits of WIC.
Program managers selected this target of improving retention in RiverStone's WIC department.
The team selected the improvement of ensuring that most follow-up appointments are scheduled. The data analysis showed that a large percentage of missed benefits (68%) correlated with no appointment scheduled. The change the team implemented was to ensure that most follow-up appointments are scheduled as part of each appointment.
Area for Improvement:
WIC provides nutrition education and assistance that has a positive impact on its participants' health status. RiverStone Health WIC staff observed that participants who are signed up for the program sometimes do not pick up their benefits. This lack of compliance is called nonparticipation.
Particularly, there is a drop-off in participation after an infant's WIC category has been changed to child—suggesting that the change in status that accompanied a change in benefit (from eligible for formula to not eligible for formula) represented a significant factor. The goal of this QI project was to identify root causes of this drop-off in participation and determine what changes could be implemented to increase the monthly retention rate of these children.
In 2010, an estimated 4,396 children were eligible for WIC benefits in Yellowstone County, and of these, only 1,392 were served. Based on these numbers, a substantial need clearly exists. In June 2012, 1,731 children were enrolled in WIC, and only 85% used WIC services, which means that 15% of potentially eligible children in the program are not returning to use services.
Root Cause:
The root cause that the QI team identified was that the process for scheduling follow-up appointments was not working. One of the requirements for eligibility is that clients be seen trimonthly at a minimum. At any appointment, clients were given the option to schedule their next appointment when they were in the office, or they could call back later to schedule their next appointment once they know what time and date fits their schedule. Administrative staff called clients to remind them of upcoming appointments, and if the client missed an appointment, staff contacted the client to reschedule. However, some clients never called back to schedule their next appointment. No reminder system was in place to alert administrative staff that the client needed to be seen; thus, the clients' eligibility expired because they did not return in the required time frame. Their name resurfaces only when it appears on a missed benefits report after their benefits are terminated.
Planning and Execution Details
QI Implementation:
The method used for the QI initiative was the Plan, Do, Study, Act (PDSA) cycle. This method served as a guide for the project’s timeline and for planning data collection, as well as analysis and implementation of the change. The group spent about half the time in the Plan phase, a quarter of the time in the Do phase, and the remainder divided between the Study and Act phases.
A variety of tools were used throughout the initiative. The team began with quantitative and qualitative data collection. For the qualitative data collection, the team facilitator conducted interviews with WIC participants. She interviewed both WIC participants who had a great benefit pickup history and who had never had their benefits terminated and clients who had their benefits terminated in the past. The results were compiled and presented to WIC staff at a meeting in which they provided their feedback on the interviews. This information was valuable to the staff because they were surprised by some of the themes and results from the interviews. The second part of the data collection piece was the quantitative data collection. RiverStone employees retrieved the retention rates, but for further demographic data and data on appointment types missed, etc., they partnered with the Montana DPHHS, which provided the raw data needed for further analysis of the WIC clients.
Flowcharts were used to examine the current process. This tool is much more visual than brainstorming and was used to help identify areas in which WIC employees were not performing duties uniformly. Many employees helped draft the flowcharts, including WIC staff who were not part of the QI team.
The brainstorming tool required creativity, given the multidisciplinary nature of the team. The QI team consisted of the director of Population Health Services, the director of WIC, the director of Family Health Services, a WIC educator, a past WIC participant, a home visiting nurse, the WIC program specialist for the Montana DPHHS, and the facilitator for the team—a prevention health specialist from Population Health Services. Many of these individuals were not accustomed to working together regularly; therefore, some were reserved and did not readily express their ideas and opinions. In addition, the time constraints of their schedules allowed the team to meet only once every other week for 1 hour. To make use of the time, the following technique was used to brainstorm the QI technique to implement: Each team member started with a blank sheet of paper, and for 4 minutes, they jotted down their ideas in silence. They then passed the paper to the person to their left, and that person had the option to add more ideas or build on ideas that already existed. This exercise lasted until the papers made it back to the original person. The exercise allowed for efficient time management and for focused and effective brainstorming.
Multivoting was also used. Once the team narrowed down several potential changes, each member was e-mailed a sheet with these options listed. The team members were given 250 points to divide among the options and were asked to rate them based on their importance. The best option could be given most or all of the points. The sheets were e-mailed, which allowed the members to vote in private and take their time deciding.
Meeting evaluations became a crucial part of the biweekly team meetings. At the end of the meeting, the facilitator would ask each member to verbally rate how they thought the meeting went. Did the team accomplish what it set out to do? Was time used effectively? How did the team members feel about the project's progress after the meeting? Did the team members have any concerns that were not addressed in the meeting? Participants could answer these questions and rate the meeting on a scale of 1–10, with 10 being the best. The team identified many concerns in this short time. Biweekly meetings also became a time to give congratulations and kudos to team members for their efforts.
Another way to engage not only the QI team members but also the WIC staff was to create a bulletin board display that gave monthly updates on the project and explained the aim statement of the project and data behind it.
The team reviewed all the data, and based on multivoting results, chose the following change: Schedule clients for their next appointment before they leave the office. This change was chosen after reviewing data provided by DPHHS. When studying the appointment types missed by those with terminated benefits, the team discovered that 68% of those with benefits terminated did not have an appointment scheduled. Further investigation into the current processes in WIC identified that an inconsistency in appointment scheduling may have contributed to these numbers. If clients are in fact scheduled for an appointment before leaving the office, their names go into the computer and administrative assistants are alerted to call and remind the client of his or her upcoming appointment. If the client misses the appointment, staff call to reschedule. However, if the client chooses not to schedule an appointment before leaving the office, no reminder system is in place to call and remind the clients that they need to call to schedule their next appointment before their benefits expire.
The simple change that was implemented was that all clients were scheduled for their next appointment before leaving the office, instead of being given the option to call back and reschedule. WIC administrative assistants and WIC nutrition educators implemented this change. In addition to the staff who were exposed, all clients who visited the clinic were exposed to the initiative. Staff were given prompts to remind them of this change when it first started, because it was habit to give the client an option to call back to reschedule. The initiative took place from mid-April through August 2013. This period was needed to track the data that were being collected to identify whether an improvement was being made.
QI Methods:
Other QI tools:
Meeting evaluations
QI Tool Documentation:
Initiative Dates:
12/15/12 to 8/1/13
Initiative Duration:
Between 6-12 months
Methods of evaluation:
The evaluation design used an ongoing, monthly data collection approach to evaluate the success of the initiative. The data used to craft the aim statements were provided by the state health department. The RiverStone team also used data available through their own database.
Other Information:
Quotes from QI team members in a post-project questionnaire were as follows:
"Positive aspects of the project were positive reinforcement to WIC staff for improvements, meetings to discuss solutions, and the frequent data that made the issue more real."
"When [QI is] done properly, people really can like QI."
"We had good support with [our QI team facilitators]. I could see data collection and interpretation not being everyone's forte, so it is worthwhile to find those that do and bring them into the discussion."
"In the future, have even more staff from the program involved to also see the process and have a voice."
Supplemental Materials:
The attached resources were produced for a roundtable discussion during the National QI Open Forum in June 2013.
Supplemental Files:
| Attachment | Size |
|---|---|
 Notes_ElectronicResource_2013.05.29.docx | 616.15 KB |
| Notes_RoundtableHandout_2013.05.28.docx | 59.53 KB |
Results
Measurable QI Outcomes:
The process measure for the initiative focuses on the following aim statement:
By August 1, 2013, RiverStone Health WIC Clinic will increase the percentage of clients who schedule their next appointment before leaving the office from 58% to 80%.
The outcome measures are guided by the following aim statements:
By August 1, 2013, RiverStone Health will increase the percentage of participants ages 1–5 who meet the WIC definition for active participation from 85% to 90%.
By August 1, 2013, RiverStone Health WIC clinic will decrease the total number of clients who have their benefits terminated from 45 to 35.
The project outcomes are as follows:
The clinic increased the percentage of clients who scheduled their next appointment before leaving the office from 58% to a high of 96.6% in June 2013 and ended with 84.2% by August 1, 2013.
The percentage of WIC participants ages 1–5 who actively participated was 84.9% by August 1, 2013, which did not represent a significant change from the baseline of 85%.
The total number of clients who had their benefits terminated decreased from 45 at the beginning of the project to 36 by August 1, 2013.
Other QI Outcomes:
In addition to the measurable QI outcomes, the health department incorporated small changes that fostered the continual growth of the QI culture. For example, in the break room, staff hung a bulletin board dedicated to displaying current QI projects. This visibility stimulates discussion and increases awareness of the work throughout the department. Staff who are engaged in this process can begin to feel empowered by seeing the positive changes their work is making.
The work from this QI project also led to a new collaboration across programs, both locally and statewide. First, the project was a collaboration between Family Health Services and Population Health Services. This type of initiative leads to a decreased "silo effect" within the agency and harnesses the expertise and knowledge of staff throughout the agency. The collaboration between the state and local health departments was empowering to the local health department because staff became aware of the resources that are available to monitor and develop programs at the local level. This collaboration will be shared at the statewide Montana Public Health Association conference in October 2013 so that other local health departments, particularly those working in WIC, are aware of the data and resources available at the state level.
In addition, WIC staff plan to continue a second round of QI using data that were gathered in the first initiative. This work will continue, even though no further funding sources have been secured at this time. This commitment to QI is a sign of the increased value of using process and outcome measures to guide changes and decisions within the organization.
Lessons Learned, Observations and Insights:
Throughout the QI initiative, many lessons were learned, and the team members learned to be flexible and adjust original goals and expectations to account for the findings. One example is that the original goal was to increase the retention rate of individuals ages 1–5 in the clinic. After reviewing data, staff decided to address overall retention instead of targeting only those children older than 1 year. This decision was made based on a set of data that showed a large percentage of those with benefits terminated did not have an appointment scheduled. The project became more focused on addressing this process measure than on addressing for whom the appointments were made.
Another difficulty that was addressed was how the improvement was measured. Originally, the team planned to measure the percentage of clients who had benefits terminated while not having their next appointment scheduled and track this percentage throughout the project. The baseline data were from January to March 2013. During this time, 79 clients had benefits terminated for reasons relating to missed appointments, and 62 of these clients (78.5%) had no appointment scheduled. However, once the project began, the monthly number of people decreased dramatically. In April 2013, 7 clients had benefits terminated for reasons related to missed appointments, and 4 of these clients (57%) had no appointment scheduled. Because of this unforeseen and significant decrease in the total number, the QI team decided to use other measures to track the progress of the report, because the small monthly numbers would not be statistically significant.
One success of the project was engagement from the various stakeholders. One reason that the initiative and the ideas created could move forward was because those with decision-making capabilities were involved from the beginning. These members included the directors. In addition, those who actually had experience using WIC and working in WIC were involved, which added transparency and realistic perspectives to the team. In addition, one team member was assigned a nonvoting role on the team. She focused on arranging all the meeting logistics, gathering, analyzing, and presenting data, and organizing all materials created and used throughout the project. This team member allowed other staff to focus on decision making and not get bogged down by planning and logistics.
Future Plans:
The plans to standardize the initiative include communicating to WIC staff that although the Study phase of the PDSA cycle is over, the intervention has proven effective and will remain in place. This plan will become part of the overall process of scheduling appointments. Data will still be collected from DPHHS and can used occasionally to perform audits on the department to determine whether staff are maintaining a high level of performance in this area. We hope that these audits will ensure that we hold the gains made during the grant period. In addition, the WIC program director will track monthly retention rates to determine whether any further gains are made in the months following the QI initiative.
Training and Preparation
QI Related Training Received:
This QI project was conducted as part of the National Network of Public Health Institutes (NNPHI) QI Award Program, a competitive initiative that provides a small financial award and 15 hours of distance-based and in-person coaching from a designated QI consultant. The program is part of the Community of Practice for Public Health Improvement (COPPHI), supported by the Robert Wood Johnson Foundation.
Other training that took place included the following:
• two team members met in person with the QI coach at a QI national forum in December 2012, and
• two team members attended a QI national forum in June 2013.
Information about the Community
Population Size:
Population Characteristics:
RiverStone Health, formerly known as Yellowstone City-County Health Department, serves Yellowstone County, Montana, and is located in the south central area of the state. Yellowstone County is home to 15% of Montanans (approximately 150,000). Yellowstone County is one of only four counties in Montana classified as urban based on the Economic Research Service Rural-Urban Commuting Areas (RUCA) definition. Of residents, 91.6% are white, 0.8% are black, 4.3% are American Indian and Alaska Native, 0.7% are Asian, and 0.1% are Native Hawaiian or other Pacific Islander. Of the population, 11.4% lives below the poverty line.
Information about the Health Department
Local/State Relationship:
Decentralized
Local Health Department Governance:
Local Governance - all LHDs in the state are units of local government
PHAB Accreditation Status:
Submitted statement of intent for accreditation
State-based accreditation?:
No
Annual QI Initiative Frequency:
QI activity level:
Organization Type:
QI Staff Information
Total number of Staff on QI Team:
7
Total number of FTEs on QI Team:
0.37
QI team members:
Role in the Initiative:
Assistant facilitator
Role in Organization:
Director of Population Health Services
FTE:
0.03
Role in the Initiative:
Voting member, organizational leadership support
Role in Organization:
Director of Family Health Services
FTE:
0.03
Role in the Initiative:
Voting member, program leadership support
Role in Organization:
Director of WIC
FTE:
0.04
Role in the Initiative:
Voting member
Role in Organization:
Past WIC Participant, Administrative Assistant
FTE:
0.03
Role in the Initiative:
Voting member
Role in Organization:
WIC Nutrition Educator
FTE:
0.08
Role in the Initiative:
Lead facilitator, data manager, document manager
Role in Organization:
Prevention Health Specialist in Population Health Services
FTE:
0.15
Role in the Initiative:
Voting member
Role in Organization:
Family Health Services Home Visiting Nurse
FTE:
0.03
Accreditation Details
PHAB Standards:
Domain 1: Conduct and disseminate assessments focused on population health status and public health issues facing the community›Standard 1.4 Provide and Use the Results of Health Data Analysis to Develop Recommendations Regarding Public Health Policy, Processes, Programs, or Interventions›Measure 1.4.1 A Use data to recommend and inform public health policy, processes, programs, and/or interventions
Domain 9: Evaluate and continuously improve health department processes, programs, and interventions›Standard 9.2 Develop and Implement Quality Improvement Processes Integrated Into Organizational Practice, Programs, Processes, and Interventions›Measure 9.2.2 A Implement quality improvement activities
Collaborations
Partner Organizations:
Montana DPHHS
Partner Organization Types:
Contact Information of the Submitter
First Name:
Hannah
Last Name:
Silveus
Organization:
RiverStone Health
Submission Status:
Completed
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Comments
Nice job on this QI
Nice job on this QI initiative. You've addressed the scheduling issue--now on to finding other causes that are affecting active participation! I hope your team shares future QI efforts with all of us. Keep up the good work.