In July and August 2012, the quality improvement (QI) team learned of the National Network of Public Health Institutes (NNPHI) grant and submitted an application to help support this project. In November, the QI team was notified of the grant award and started some tangible discussions with WHF about how to construct a sustainable process.
First, the QI team revised the vaccine policy to allow for vaccination of pregnant women who are at more than 20 weeks of gestation with a written prescription from their obstetrician or primary care physician confirming the fetus's gestational age was more than 20 weeks.
Second, the QI team identified the VPAP as a sustainable source of the vaccine. CCHD staff reviewed requirements and registered as a provider with the vaccine company. The VPAP requires the patient to complete an application and submit official financial data (pay stubs, W-2 forms, etc.) showing income eligibility. The QI team met with WHF staff and discussed how to obtain this information easily. The QI team learned that WHF was already collecting financial data as part of its enrollment process. WHF agreed to have women complete the application and forward it, a copy of the financial information, and a signed release of information to the Adult Health Clinic. Many of the women are unemployed or only have income documented through handwritten letters of support.
The QI team worked with the vaccine company and determined that the company could accept a letter of explanation from WHF to support this documentation. A form letter was developed and used when formal financial documents were unavailable. The QI team's initial plan was to have women complete the documents during their enrollment visit with WHF. WHF would then send the application and financial documentation to the Adult Health Clinic for processing. When the women reached 20 weeks of gestation, they would be directed to make an appointment with the Adult Health Clinic for the Tdap vaccine.
The QI team held a meeting with Adult Health Clinic staff, the WHF clinic coordinator, WHF support staff who would be asking women to complete the applications, and CCHD medical records staff. A process map of the initial process plan was created. Brainstorming was used to identify the following list of potential barriers that might inhibit the process: financial sustainability and workload for both WHF and CCHD, transportation, client declination, and clients' inability to attend appointments.
In December, the QI team initiated the first phase of the process and began collecting VPAP applications from WHF clients. The first check in January showed that 52% of applications were returned to WHF because of incomplete data
Rapid cycle intervention: The QI team met with the clinic coordinator, who retrained staff and returned incomplete applications to staff who processed the applications and held clients accountable for completing them at the next appointment. Only five of the initially returned applications were not completed and returned, and the current rate of return for incomplete documentation is down to only 3%–5%.
An unforeseen roadblock that could impact sustainability was identified. Initial understanding based on the application wording was that VPAP would cover clients with Medicaid because Medicaid will not cover vaccines for adults. Merck clarified that Medicaid clients could not receive VPAP, and the QI team estimated that between 25% and 35% of the clients were not eligible under this program.
CCHD identified funding from the local Board of County Commissioners that could be used to support clients who are ineligible for VPAP.
In March, the QI team realized that women were not making appointments to receive the Tdap vaccine. This was an initial concern, so the QI team met with WHF again and noted an opportunity to provide many of these women with the vaccine while they were waiting for their obstetric appointments in the joint waiting room. The QI team brainstormed potential changes to the current process map and completely revised the appointment phase to better serve the customer.
The new process began with WHF staff flagging charts of women who have a prescription for Tdap and who are at 28–32 weeks of gestation. When the women arrive for their appointments, they are given the prescription and told to check in with the registration desk in the waiting room. CCHD staff administer the Tdap vaccine while the women are waiting for their obstetric appointments. If the clinic staff cannot accommodate the walk-in clients, the medical records staff schedule the next available appointment.
WHF had no way to identify who had completed an application and was approved; many of the women had registered before the implementation date and did not have an application. The QI team thought that trying to pick and choose would decrease buy-in from WHF, so it identified funding to cover all women and asked the WHF to send all clients at 28–32 weeks of gestation regardless of whether they had completed VPAP forms.
Approximately 15 staff members from WHF and 7 from CCHD participated in the development and implementation of this initiative. A total of 479 women either completed applications or were referred for the vaccine (those who registered with WHF before program inception).