OPQC Progesterone Project Action Period Call

March26, 2015

12:15-1:15 PM ET

Welcome!

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Progesterone Teams • AGMC's Women's Health Clinic

• Aultman Physician Center-OB/GYN Clinic

• Brown County Women's Health

• Center for Women’s Health, University of Cincinnati Medical Center

• Doctors Hospital Women's Health Center

• Faculty Medical Center—OB Resident Clinic GSH (TriHealth)

• Fairview Perinatal Department (Cleveland Clinic)

• Five Rivers Health Centers, Center for Women's Health (Miami Valley Hospital)

• MacDonald Women's Hospital Clinic (Family Practice and OB Faculty Clinic)

• Maternal Fetal Medicine at Hillcrest Hospital Atrium (Cleveland Clinic)

• Mercy OB/GYN Associates Family Care Center/ MFM Clinic

• MetroHealth Women's Clinic

• Mount Carmel St. Ann’s OB/GYN Clinic

• Mt. Carmel West Outpatient Clinic

• OSU McCampbell Clinic

• OSU Martha Morehouse MFM

• Outpatient Care Center at Grant Medical Center

• ProMedica Center for Health Services – Women’s Services (ProMedica Toledo Hospital)

• Riverside OB Community Care Clinic/ MFM Consultative Practice

• St. Elizabeth Boardman’s Health Center

• Tri-State Maternal Fetal Medicine Associates, Inc.

• Wellness on Wheels, OhioHealth

• Women's Health Center at Summa Akron City Hospital

12:15 PM Welcome and objectives Martha Rome

12:20 • Monthly Aggregate Data • Work with Medicaid and

Medicaid Managed Care

Dr. Jay Iams

12:30 PDSA 1 Team 1

12:40 PDSA Team 2

1:00 Progesterone Late Start questions

Martha Rome

1:10 PM Wrap Up and Next Steps • Are you able to collect

births per month for your patients?

Martha Rome

Agenda

Objectives for Today’s Call

• Analyze data collected and graphs to date

• Study PDSAs – small, testable, evaluate learning

• Review MPR questions for “late start” of Progesterone

• Explore opportunities to create PDSAs with the Parent Advisory Group for OPQC

WHERE ARE WE?

DRIVERS

Revision Date: 09-19-14

Draft PROGESTERONE PROJECT KEY DRIVER DIAGRAM

SMART AIM

BY July 1, 2016,

DECREASE THE

RATE OF

PREMATURE

BIRTHS in Ohio

less than 37 weeks

by 10%, and less

than 32 weeks by

10%

GLOBAL AIM

REDUCE INFANT

MORTALITY IN OHIO

BY REDUCING

PREMATURE BIRTHS

Consistent and

early recognition of

prior preterm birth

Expedite

progesterone

supplementation

Use patient-

centered medication

management

Adopt a cervical

length ultrasound

screening protocol

INTERVENTIONS

• Educate on benefits of progesterone and

use evidence-based counseling methods

(e.g. Motivational Interviewing) if there

are concerns

• Involve key support individuals

• Connect women to insurance, home

care, social services, etc. to ensure

progesterone available &administered

• Create a written protocol for identified

candidates

• Start progesterone as soon as possible

(according to ACOG and SMFM

guidelines) after identification of

eligible woman

• Follow up with women to check on

continued use of progesterone as

prescribed

• Screen women for OB history of

preterm birth

• Align and communicate with EDs, WIC,

etc. to screen and refer when history of

preterm birth

• Facilitate rapid new OB appointments

• Postpartum counseling on

progesterone for those eligible in next

pregnancy

• Use sonographers trained in cervical

length measurement

• Develop a practice protocol to

selectively or universally screen

cervical length (consider population

risk)

Key message: Women at risk of preterm birth are a high-risk population that needs to be identified and actively managed.

MEDICAID AND MEDICAID

MANAGED CARE

The Changing Role of

Medicaid Managed Care in Ohio

• Old role: they paid providers for the care

given to women and children (fee for service)

• New role: partnership with providers to

ensure reliable high quality evidence-

based care (value based payment)

– Broader expectations for Managed Care

– State government requiring a change in role

and scope of services provided by Managed

Care

OPQC & Managed Medicaid

Providers & the Dept. of Medicaid

• Embarking on a journey to work together

to meet OPQC’s goal of reducing preterm

birth in Ohio

• Two guiding principles related to the

Progesterone Project

– Improving the two way communication with

the patient’s Medicaid provider and practice

– Reducing barriers to get progesterone

OPQC & Managed Medicaid

Providers & the Dept. of Medicaid

• We will email you to ask 1) dominant

Managed Medicaid Provider(s) for your

patient population and 2) practice tax ID #

• In the near future, we will ask you to test

ways to improve communication with

Medicaid providers, using QI principles

(PDSA cycles)

Action Period Call

March 26th, 2015

Team 1

Measure, Key Driver and

Intervention

• Progesterone candidates will receive

their 17-P within 72 hours of an Alere

referral

• Expedite progesterone

supplementation in women who are

candidates

PDSA Cycle

Plan ◦ Alere referral forms are now also a Plan of Care. This process should expedite

medication administration.

◦ Before the new form, Alere would fax a plan of care for additional signatures before initiating care. This also happened even if a script was included with a physician signature. It would prolong start of medication up to 2 weeks or more.

◦ Hetty Walker spoke with Alere administration to come up with the all in one form.

Do ◦ We used the new form two times in January.

◦ The first patient accessed care at 17 weeks. A referral was made at her first visit.

◦ The second patient accessed care at 10.4 weeks. Referral made at 13.3 weeks.

Do

Study Act

Plan

PDSA Cycle

• Study

◦ With the first patient, we received a plan of care requesting a signature the next day (wrong patient information was on this form). Alere was called to correct information over the phone. We explained that they already had the physician signature included with original form.

◦ That patient did not receive her first injection for another 2 weeks. (17-P was started in

19th week).

◦ The 2nd patient came back at 15 weeks, she still had not heard from Alere. The nurse contacted Alere at this visit and had the patient speak with them to get a start date. This patient started meds at 16 weeks after the clinic nurse had to go back and forth with Alere about not refaxing plan of care orders that were sent at 13.3 weeks.

◦ We did not expect Alere to refax a plan of care back to us (multiple times) after we sent the “all

in one form”.

• Act – We found that if we called Alere with the patient in the office, that med administration

happened sooner. We plan to do this with our next referral.

– Alere was contacted by Hetty Walker after a our office notified her of this barrier.

– Alere contacted our office and wants notified of our next referral to make sure it goes smoother.

– We will monitor with our next referral.

Do

Study Act

Plan

Next PDSA cycle

• Our next referral, we will use our all in one

form.

• We will call Alere with patient in office to

get a start date.

• We will notify our Alere contact of the new

referral.

• We will monitor our progress.

Action Period Call 3/26/2016

Team 2

Paper Initiated

July 2014 • Initial OB patient visit: staff would

document progesterone questions on

paper form

• Identified Primary RN at each office to

receive qualifying documents

• Nursing at each office, assists patients

that have progesterone ordered to obtain

medication

Paper Form

Patient Lists Initiated

September 2014

• From Paper Form Shared Patient List

• Training provided to Primary RN for usage

of Patient List

• Primary RN adds identified

patient to “Shared Patient

List” in EPIC

EMR-EPIC

January 2015 • Added screening questions into EMR,

(EPIC) in the First OB Questionnaire

• Added provider follow up in Routine Visit

Checklist

• Training provided to support staff via GoTo

meetings and conference calls

• Provider training by Quick Reference

Guides (QRG)

EMR-EPIC

January 2015

-Added additional

questions to current

OB Risk Screening

-Asked on Initial

Prenatal Visit to all

patients

If answer is NO, screening

is complete

New EPIC Screening Process Replaced Paper Forms

OB Risk Screening

• If Yes “Have you had a prior singleton preterm”: You will be

prompted with additional questions

• If the patient answered NO to “Was your preterm delivery”

spontaneous?” Screening is complete

OB Risk Screening

• If YES to both questions you will be prompted to answer “Provider

notified?”

Rooming Staff

to continue to

notify RN to add

to “Patient

Lists” and

ensure

medication is

ordered for

patient

Routine Prenatal Visits:

Prenatal Checklist

If the patient answers yes to BOTH Preterm screening questions – it will flow to

the Prenatal Checklist for provider follow up at 15-22 through 33-36 weeks.

-Provider to

verify if patient

taking

Progesterone

Routine Prenatal Visits:

Prenatal Checklist Barriers:

If patient reports No: Please indicate reason they are

not taking Progesterone

Next PDSA cycle 1. Update wording and weeks, on the initial question:

-Question 1: Have you had a history of spontaneous preterm singleton live birth,

between 20 and 36 6/7 weeks? If yes:

-Question 2: Did you present in active spontaneous labor or have ruptured

membranes or advanced cervical dilation or effacement?

2. Updating Barriers from free text to drop down choices:

– Cost

– Inconvenience (related to frequency of dosing)

– Uncomfortable/refusing injections (won’t accept shots)

– Concern for fetal side effects/harm

– Previous allergic reaction or maternal side effect

– Other

Next PDSA Cycle

3. Reporting Workbench : EPIC reports in progress that will populate patients

that were screened- positive screen.

-Potential to eliminate the need for the Patient Lists

4. Best Practice Alert (BPA): to fire on identified patients.

Smartset containing:

– Medication orders

– Possible consult to MFM/ cervical length screening

5. Clinical Resources: Investigate pharmacy

compounding agencies for referrals

-add to EPIC under Clinical Resources

Questions

LATE START INVESTIGATION

Progesterone Late Start Cause Investigation

• When is the right time to find out about a previous preterm birth?

– At first contact prenatally – on phone, with nurse or appointment staff??

– At first visit – depends on when patients are advised to make appointments or when they find out they are pregnant

• How long does it take to prescribe Progesterone?

Consider:

– Patient education and counseling

– Insurance authorization

– Home care outreach

Possible reasons for late starts • Payment / funding

• Insurance authorization • Change in status or plan • Self pay – difficulty

getting funds • Undocumented • Delay in accessing

donated funds or medication

• Social Circumstances • Late entry to care • Translation or

counseling • Lost to follow up • Transportation • Other?

• Home Care • Difficulty reaching

patient • Other?

OPQC Progesterone Late Start Cause

Investigation

Identify up to 5 women who in a previous

pregnancy had a spontaneous preterm birth (< 37

weeks) after preterm labor and who in the current

pregnancy started Progesterone supplementation

later than 20 weeks.

Finding the Five!

• If you collect the number of patients who come late for prenatal care, we will ask you to tell us that number.

• PLEASE do not use those patients for the Progesterone Late Start Investigation.

• This information is meant to help us learn if there is an opportunity to improve our systems to ensure that women start progesterone on time.

Questions on MPR

Five forms for five different patients that started Progesterone later than 20 weeks

• Risk factors: – Prior spontaneous preterm birth? Date recognized: __________

– Short cervix? Date recognized: __________

– Both?

• Progesterone prescription: – 17-P prescribed:______w___________d_____

– Vaginal product prescribed:________w________d

– Was the product you prescribed the one you wanted to prescribe? Yes No

– If not, what did you choose to prescribe?_________________________

– Insurance name, if insured: _____________________________

– Home Care Agency, if used: _____________________________

Questions on MPR (cont.)

Reasons for late start (check as many as

applicable and briefly describe circumstances): – Transportation problems [describe]

– Financial [describe]

– Insurance [describe]

– Arrived late for care [describe]

– Late referral [describe]

– Need for translation services [describe]

– No available appointment [describe]

– Patient delayed treatment [describe]

– Home Care Company issue ⦋describe⦌

– Pharmacy ⦋describe⦌

– Provider ⦋describe⦌

Next Steps

• Complete the Monthly Site Profile by April. 5th https://portal.opqc.net/Progesterone/SitePages/Home

.aspx

• Complete Candidate Forms for all patients at

28 weeks / complete GA after birth! https://portal.opqc.net/Progesterone/SitePages/Home

.aspx

• The Monthly Progress Report link will be sent

to your Key Contact by Friday – please

complete by April. 5th

Poll

Our team can capture data on “the number

of women who delivered from our clinic or

practice this month”… 1. Yes, we report this number every month

2. No, we have not yet found a way to report this number

3. We are able to report this number, but it is at a date

later than the Monthly Site Profile is due (after the 5th of

the next month)

4. We have other difficulties with the Monthly Site Profile

such as determining the # of new OB patients or # of

premature births.

Please enter comments in the

Question box below to give us

more information on the Monthly

Site Profile

THANK YOU!

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