Increasing Prenatal Referrals for Home Care Maternal and Child Health Nursing Services in Sullivan County

The initiative was championed by the SPHN, who manages the agency’s MCH nursing program. She had been tracking all MCH nursing referrals over several years and was frustrated by the lack of prenatal referrals to nursing. The SPHN thought that a consistent, well-organized team effort was needed to increase prenatal referrals, as her solitary efforts had been ineffective, and that writing a grant to support the project could legitimize it as a higher-priority activity within the agency. The director of public health had previously received a Community of Practice for Public Health Improvement (COPPHI) grant for a QI initiative that had been successful. The idea for the MCH QI initiative was discussed in management-level meetings, and the SPHN was encouraged to apply for COPPHI funding, which she did. The SPHN had some previous training in QI but was basically a beginner. Upon receiving funding, she recruited her team from two of the MCH nurses: the supervisor of the Healthy Families program and the assistant director of the Perinatal Network. She selected individuals with expertise in the subject and complementary skills; she thought these individuals would work well together. The team was scheduled to meet every week, first thing in the morning, for an hour. In December 2012, the SPHN attended a QI Open Forum conference in Charlotte, North Carolina, to be trained in QI techniques, and the grant also provided for her to receive 15 hours of coaching from a skilled QI instructor. The coaching began at the conference. The team meetings began in December and, at first, they comprised the SPHN educating the team about the problem, the project, grant requirements, the aim statement, the basics of QI, and the role of the coach. The SPHN assigned roles and rules and established how to share and disseminate information within the team. The SPHN was the team leader and set the agenda. The supervisor took notes, and the SPHN typed them and distributed them. At the next meeting, the SPHN presented existing data about prenatal referrals to nursing services; there had been only 1 referral in 2012 and 2 in 2011 from OB/GYNs. There were 30 prenatal referrals total in 2012 from other health care providers, most of which were from other programs within the agency, including WIC, the Healthy Families program, and the Community Health Worker program. The team began to work on a process map, depicting the process for a county resident who discovers her pregnancy and the agencies she would interact with while seeking prenatal care before getting referred to nursing services. The team explored obstacles that prevented pregnant women from getting referred to nursing. Team members also discussed how to spend the funding, and they agreed that some of the funds should be spent on education and equipment for nurses, such as new Dopplers, baby scales, temporal thermometers, and videos for MCH nurses to train or to refresh them on performing skilled nursing care of prenatal patients. The team developed a timeline for the grant period, using the PDSA model, and a charter. The meetings were positive and full of discussion and ideas. The SPHN provided coffee and refreshments and kept a running list of all the new ideas. The SPHN initially had been focused on getting prenatal referrals from the OB/GYNs and had made an appointment to meet with them. The team proceeded to work on this task as the first PDSA cycle. Improvement Theory 1: If OB/GYNs can be influenced through meetings and outreach to make prenatal referrals, our prenatal referrals will increase. This increase will be measured by the SPHN, who tracks all MCH referrals. The team developed materials to present to the OB/GYNs, including identification of medical and psychosocial risk factors in pregnancy, which could trigger a referral for home care nursing. The SPHN made the presentation to the OB/GYNS, who were interested and stated they would “make this happen,” but no referrals were immediately forthcoming. The SPHN then attempted e-mail contact with the OB/GYNs, which was ineffective. The SPHN received helpful coaching from Jim Butler via phone. He advised her (and the team) to slow down, trust the QI process, and refocus the aim statement toward increasing adult protection referrals to SCPHS from interagency sources, then apply those interventions to outside agency sources. He advised the team to focus first on changing processes over which it has most control and to follow the outline for the QI process. The team discussed that another possible source for referrals was WIC, which made hundreds of prenatal referrals each year to the Healthy Families program with basic contact information. The team involved the director of WIC in trying to obtain more detailed information about the clients’ risk factors, which could justify a nursing referral. The director could not gain permission from the state to release this information to the project. The team continued process mapping, then began work on a series of fishbone diagrams to identify root causes. One of the root causes identified was that the public (consumers) were unaware of the nursing service being available and that home care nursing was an effective intervention for a high-risk pregnancy. The team decided to develop a brochure describing MCH nursing services in English and Spanish and to distribute it as the second PDSA cycle. Improvement Theory 2: If providers, consumers, and staff can learn about the benefits of MCH nursing via a brochure, and if the team develops a brochure and distributes it widely, it will receive increased prenatal referrals. This increase will be measured by the SPHN, who tracks all MCH referrals. The time frame would be for a month after the brochure is distributed. The team developed and printed 2,000 brochures, purchased display stands, and distributed the brochures widely. The team began using a Gantt chart to track the progress of the cycles. Next, the team revisited the issue of the WIC referrals. The SPHN had been reporting on the project in management-level meetings and at Perinatal Consortium meetings. The director of public health suggested that the team should develop a pilot, with a script for reaching out to the WIC referrals by phone, to try to identify if the clients were at high risk, to educate them about the availability of services, and to offer nursing services if the clients were at high risk. The team was enthusiastic, and this new venture became the third PDSA cycle of the project. Once the team had developed a script, the SPHN distributed WIC referrals to the MCH nurses and instructed them how to use it. The nurse would make out the nursing referral if the patient accepted services, then the referrals were returned to the SPHN to track. Improvement Theory 3: If consumers can learn about the benefits of MCH nursing via a phone call from a friendly nurse and can identify factors that put them at high risk in their pregnancy, SCPHS will receive increased prenatal referrals. This increase will be measured by the SPHN, who tracks all MCH referrals. The time frame for this cycle began in late April and was extended for several months.

The team measured the impact of the project by tracking new referrals to MCH nursing, which are first recorded in the intake department of the Certified Home Health Agency and are listed and tracked separately by the SPHN of the MCH nursing program with the date of the referral, the source, when the patient is first seen, when the case is closed, and the assigned nurse. The SPHN kept a separate spreadsheet of the WIC referrals listed by the date they were received, whether a nursing referral was made, any risk factors identified, reason for refusal, and the nurse who had made the calls. She kept a simple count of the WIC referrals that resulted in a nursing referral. Some of the WIC referrals also came to be referred to MCH nursing by other interagency providers during the process while the patients were also being reached out to through the initiative; these referrals were also included in the count of WIC referrals that were referred for nursing. For the second PDSA cycle, the impact of the brochures, there were no self-referrals of clients who had seen the brochures and called for services. However, the team members did get calls from providers asking for replenishment of their brochures.