Improving Equitable Postpartum Care in an Urban Private Clinic with Predominantly Black Patients.

INTRODUCTION: Maternal health disparities based on race, ethnicity, and socioeconomic factors exist in the United States, with Black women experiencing significantly worse outcomes. With much of perinatal morbidity and mortality attributed to the postpartum period, attention to equitable postpartum care is necessary for addressing this disparity. PROCESS: A rapid-cycle quality improvement initiative was implemented in an urban clinic serving predominantly Black, Medicaid-insured clients. Although baseline data indicated 95% of clients experienced comorbidities, only 65% attended a comprehensive postpartum visit (PPV). The project's goal was to improve equitable postpartum care by increasing PPV attendance and quality of postpartum care to 90% in 8 weeks. The clinical team was engaged throughout to promote organizational change within the clinic. A provider checklist was implemented to improve PPV care metrics, and shared decision-making was initiated surrounding contraception and mood disorders. A care log tracked clinical practice guideline adherence with regular feedback informing the change process. OUTCOMES: Postpartum care improved across a variety of factors studied over 8 weeks. The provider checklist prompted a 78% documentation rate of PPV care metrics, and care log tracking reflected an ending PPV attendance rate of 93%. Client satisfaction with postpartum care education was measured using a Likert scale of 1 to 5 (1 = dissatisfied and 5 = satisfied) with a noted improvement from a baseline score of 4.3 to an overall mean of 4.8. DISCUSSION: This quality initiative addressed a key factor in health equity for a predominantly Black, Medicaid-insured population in an urban clinic by raising PPV attendance rates above national standards of 90% and improving client satisfaction and the quality of care received during these visits. The project was low cost and created sustainable systems for maintaining evidence-based equitable care. Limitations included the coronavirus disease 19 pandemic, clinic staff turnover, and staff and client biases. Continued innovative research targeted at improving health equity is needed.

Screening and Follow-Up Care for Perinatal Mood and Anxiety Disorders at a Rural Obstetric Clinic.

OBJECTIVE: To improve screening for perinatal mood and anxiety disorders (PMAD) and follow-up care while balancing team workload. DESIGN: Four rapid plan-do-study-act cycles were implemented over 8 weeks. SETTING/LOCAL PROBLEM: At baseline, only 2% of patients with PMAD were identified at a rural obstetric clinic, and none (n = 0 of 50) received screening with a validated tool. Of the 12 patients who had a current or prior history of PMAD, 92% (n = 11) were not screened for self-harm, and 67% (n = 8) received no referral. The clinic had no standardized care for PMAD. PARTICIPANTS: Patients (n = 253) screened at initial pregnancy intake, early in the third trimester, and at the 6-week postpartum visit. INTERVENTION/MEASUREMENTS: Following the screening, brief intervention, and referral to treatment model, patients were screened using the Edinburgh Postnatal Depression Scale, and brief intervention and referral to treatment were used with a point-of-care checklist. Data were collected three times weekly for run chart analysis, and team surveys measured workload. RESULTS: At the end of 8 weeks, effective screening for PMAD and follow-up care were achieved for 98% of patients and included screening, education, shared decision-making for management, referral, and clinic and phone follow-up to support mental health care uptake. CONCLUSIONS: Standardizing screening and follow-up care can increase identification of PMAD and increase uptake of mental health care. For sustainability, a decision aid can streamline patient-provider communication and reduce visit length.

Implementing Effective Care Through Utilization of Diabetes-Focused "Right Care" Visits in a Suburban Primary Care Setting.

Background: Diabetes is the seventh leading cause of death in the United States and the leading cause of lower limb amputations, adult-onset blindness, and renal failure. It is estimated that 34.2 million Americans have a diabetes diagnosis, and the prevalence of this condition has continually increased over the last two decades. This study includes patients at a large, suburban primary care practice in southwest Ohio who were considered to have uncontrolled diabetes based on their last Hemoglobin A1c of greater than 9%. Compliance with recommended annual screenings among this population was 15%. Objectives: The aim of this project was to improve glycemic control and increase the number of patients who received the recommended annual screenings through the implementation of nurse practitioner-driven, diabetes-focused "Right Care" visits.C Methods: This quality improvement pilot study consisted of interventions implemented over the four plan-do-study-act cycles. Each cycle included a test of change that was identified based on data from previous cycles to ensure continuous improvement throughout project implementation. Four interventions were evaluated including the utilization of a diabetes registry, implementation of a "Right Care" checklist during "Right Care" visits, use of a patient engagement tool with a focus on individualizing diabetes medication regimens, and implementation of a team-engagement plan. Results: Average Hemoglobin A1c reduction was 2.4% post-"Right Care" visit. Compliance with the annual screening bundle increased to 44% over 8 weeks. Utilization of the patient/provider relationship increased visit compliance by 18%, and the team engagement plan decreased work-related stress by 12%. Conclusions: The implementation of "Right Care" visits led to improved glycemic control and increased compliance with the recommended annual screenings among patients with an A1c greater than 9%. The patient engagement tool identified key factors related to diabetes medication adherence and team engagement decreased work-related stress and improved annual fundoscopic exam screening compliance. Implications for Nursing: Nurse practitioner-led "Right Care" visits utilize the knowledge and skills of advanced practice registered nurses to improve glycemic control in patients with uncontrolled diabetes.

Using American College of Gastroenterology Guidelines to provide effective health maintenance for patients with inflammatory bowel disease.

BACKGROUND: Patients with inflammatory bowel disease (IBD) are at increased risk for infections, malignancies, and osteoporosis, related to both the disease state and medical therapy. Identification and treatment of depression and anxiety is crucial for disease management. Guidelines developed by the American College of Gastroenterology include recommendations for preventive health maintenance in patients with IBD to guide quality care. LOCAL PROBLEM: Chart audits in a private gastroenterology practice revealed that only 20% of patients with IBD were receiving recommended health maintenance. The aim was to increase effective preventive care of patients with inflammatory bowel disease by 50% by the end of 8 weeks. METHODS: The quality improvement project consisted of four rapid Plan-Do-Study-Act cycles. INTERVENTIONS: The interventions implemented for this quality improvement project included a patient questionnaire, an order sheet/order set, a case management log, and team engagement. RESULTS: Providers identified deficiencies and ordered needed health maintenance for 100% of patients with IBD. While effective preventive care orders increased, order completion rates were unchanged during the project. CONCLUSIONS: Patient questionnaires, order sheets, a case management log, and teamwork were successfully used by providers in a private gastroenterology practice to increase orders placed for preventive care in patients with IBD. The project tools could easily be modified and implemented in other specialty practices who care for patients with specialized health maintenance needs.

Improving equitable access to inclusive sexual healthcare in a small urban college health setting.

BACKGROUND: Sexual and gender minorities (SGM) experience many disparities in sexual health. College health centers must address early inequities for this population. LOCAL PROBLEM: Significant access disparity was noted for SGM students at a small urban college health center. The aim of this quality initiative was to increase equitable access by 20% over 90 days. METHODS: A rapid-cycle quality improvement project was initiated using a Plan-Do-Study-Act model. INTERVENTIONS: Templated nurse-led visits, a discussion starter tool, and an inclusive care checklist were introduced, with assurance of equity for each metric, and a focus on team collaboration. RESULTS: Access to sexual health services increased by 22.6% over 8 weeks with SGM utilization increasing 2.7-fold. Guideline-concordant care improved by 94% for all students. Student comfort scores (Likert range 1-5) also improved, from a baseline of 3.53 to a project mean of 4.62. CONCLUSIONS: This project addressed equity in a college health setting through improved student engagement, targeted workflow innovation, and enhanced team collaboration. Application of key findings to other health topics will continue to mitigate disparities in college health centers. Tools may also be applied to adolescent and adult primary care settings to improve patient comfort and SGM-inclusive sexual health service delivery.