KEY ACTIVITY #3:

Use Care Gap Reports or Registries to Identify All Patients Eligible and Due for Care

This key activity involves the following elements of person-centered population-based care: implement condition-specific registries; address social needs.

Overview

This foundational activity provides detailed guidance on how to reliably and efficiently develop and use a regularly updated list of all pregnant patients eligible for recommended care through a care gap report or registry. Like registries used to identify patients who require preventive services for chronic diseases, a perinatal care registry can be used to track all perinatal care patients and assist in ensuring their individual prenatal and postnatal care needs are addressed in a timely manner. The registry should be integrated with the practice’s EHR or population health tool. It should include a list of all perinatal care patients by week of gestation, their corresponding perinatal-specific and general preventive care gaps (either due or overdue), and pregnancy risk level. The care team utilizes the perinatal care registry to monitor the completion of necessary services throughout the episode of pregnancy.

Care gaps are gaps between the recommended care that a patient should receive according to clinical guidelines and protocols and the care a patient has actually received. Most EHRs already have a module that identifies what services are due for each patient. Care gap reports or registries are recommended as a way to monitor the perinatal care population to ensure that pregnant patients receive timely, comprehensive perinatal care.

FIGURE 4: EXAMPLE CARE GAP REPORT FOR AN INDIVIDUAL PATIENT

FIGURE 5: EXAMPLE OF A CARE GAP REPORT FOR A PANEL OF PATIENTS

FIGURE 6: EXAMPLE OF A PRENATAL CARE GAP REPORT AT THE POPULATION LEVEL

Rather than put the responsibility of searching through charts or remembering which patients need further preventive care or follow-up on the individual care team member, this key activity demonstrates how the practice can efficiently leverage EHRs for all its patients.

Action steps and roles

1. Plan the care gap report.

Suggested team member(s) responsible: Site director and panel manager or data analyst. If it is not clear how the report can be produced, this step may involve one or more people from the practice will work on the EHR and, possibly, the EHR vendor.

As a team, decide what screenings or treatment guidelines are appropriate for your population of focus and prioritize the most important care gaps to run reports on. Start with the core and supplemental measures and any process measures your practice is tracking, and consider if there are any other gaps, clinical guidelines, or measures your practice feels important to prioritize.

Identify the inclusion criteria for each report, such as age, any exclusion criteria, and factors that make someone high risk.

Important resources:

• U.S. Preventive Services Task Force (USPSTF) recommended preventive services for the maternity population.
• ACOG’s Optimizing Postpartum Care.
• Postpartum parental depression screening registries, prenatal labs and education checkpoints, such as outlined in the Comprehensive Perinatal Services Program (CPSP).

2. Build the report.

Suggested team member(s) responsible: Data analyst.

Determine whether the EHR has an existing report or one that can be modified to fit the inclusion criteria. You should talk to staff who are familiar with the electronic record. In some cases, it may be necessary to consult with the EHR vendor to confirm this information and how to run the report.
Leveraging technology for automation: Each EHR is different, but they generally offer guidance or support on developing care gap reports. In the absence of automatic reports, it may be necessary to engage other staff with the capacity to use other reporting software to develop reports from EHR data.

The care gap format should include:

• Criteria for inclusion in the report.
• The overall compliance rate for the care gap being measured.
• All patients eligible for the screening and their addresses and phone numbers.
• The last date the test was performed, if known or if applicable, the previous results, and the type of test used.
• Preferred method of communication (e.g., phone, email, text).

Reports should be able to display and/or disaggregate the data based on:

• Race, ethnicity and language (REAL) as well as sexual orientation and gender identity (SOGI).
• Any known social or behavioral needs.
• Communication preferences or other preferences that would inform the screening modalities offered, such as documented refusal of prior screenings.
• Data on any other characteristic, including insurance data, that could pose a barrier to completing screening.

3. Standardize the data format.

Suggested team member(s) responsible: Panel manager or data analyst.

Standardizing the data format and where it is entered is critical to ensuring accuracy in the resultant report. Once you know that a report can be produced, understand the specific data elements that are needed to produce the reports.
Document how each data element must be entered into the EHR in order to populate the fields needed for reporting. In some cases, data on completion of screening must be entered by hand (e.g., when the test is performed by a lab that does not communicate with the legacy EHR). Doing this will require a decision on the part of the practice as a whole and may require staff training and reinforcement on an ongoing basis. Where issues or apparent confusion are identified, regular discussion at team huddles or staff meetings will help in maintaining a standard approach.

Tip: Assign responsibility for the initial review of the reports to confirm data integrity.
 

4. Develop workflows to support improved patient screening and preventive care completion rates.

Suggested team member(s) responsible: Panel manager and care team.

Identify staff members responsible for the ongoing running and review of care gap reports. Formalize workflow to integrate care gap data into daily clinical practice. Determine who has access to these reports (medical assistants, providers, care coordinators, etc.).

At the patient level, ensure that the care gap report can be used for or linked with reminders or alerts for clinicians, as well as for sending reminders to patients who need to come into the practice for recommended pregnancy-related care or testing.

Depending on communication preferences that have been expressed by patients, the patient care gap report may be exported to an automated reminder system that can trigger reminders by phone, text, email, or postal mail.

In addition, as part of the practice’s pre-planning process, patient care gaps should be reviewed and flagged as part of the daily huddle. See Key Activity 6: Develop or Refine and Implement a Pre-Visit Planning Process for more details.
 

5. Develop a process for review of gaps at the population level.

Suggested team member(s) responsible: Panel manager.

Set a report frequency to review care gap reports at regular care team meetings or huddles in order to develop a plan for improvement at the population level. This may include an outreach campaign to build community awareness of the importance of prenatal and postpartum care and the availability of easily accessed, affordable prenatal and postpartum services.

One limitation of care gap reports for the perinatal population is that they typically only identify patients who have presented to receive care and received confirmation of pregnancy. Patients who have received a positive pregnancy test result within emergency departments, urgent care, or freestanding family planning clinics will not show up within an organization’s care gap report for timely prenatal care. Due to the sensitivity of pregnancy-related services, when considering population-level concerns, patient confidentiality is paramount.
 

6. Monitor the care gap report for accuracy and completeness.

Suggested team member(s) responsible: Panel manager or data analyst.

It is critical to have bidirectional feedback with the practice’s care team about any real or potential errors in the care gap report, such as:

• Errors in how the data is entered compared to what is required under the new standardized data format.
• Patients who are eligible for and due for screening who are missing from the report.
• Patients who have recently been screened who are still listed as due for a screening.

Errors should be investigated through a chart review. If errors in the report specifications are discovered, the care gap report or process for producing the report should be modified. If the issue is incorrect documentation, staff training and reinforcement of documentation standards will be required.

Additional consideration for sustainability: Ensure there is an internal process for updating the criteria included in the EHR for care gap reports as clinical guidelines change.

KEY ACTIVITY #4:

Use a Systematic Approach to Decrease Inequities within the Population of Focus

This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; implement condition-specific registries; proactive patient outreach and engagement; pre-visit planning and care gap reduction; care coordination; behavioral health integration; address social needs.

Overview

This activity provides guidance for a systematic, evidence-based approach for identifying and then reducing inequities for pregnant people. It focuses on the first primary driver in PHMI’s Equity Approach: Reduce inequities for populations of focus.

FIGURE 8: PHMI EQUITY DRIVER DIAGRAM

Action steps and roles

1. Build the data infrastructure needed to accurately collect REAL, SOGI, social needs and other demographic data.

Suggested team member(s) responsible: Data analyst.

• Race, ethnicity and language (REAL).
• Sexual orientation and gender identity (SOGI).

The PHMI Data Quality and Reporting Guide provides guidance and several resources for collecting this information. According to this guide, the initial step in addressing disparities is to collect high-quality data that fosters a holistic view of patient characteristics and needs. This entails incorporating REAL data, demographic data (age, SOGI, geography) and social needs data. By collecting and monitoring this information, healthcare practices can gain valuable insights into disparities in access, continuity and health outcomes. Steps two to four below provide more information on this process.

Collecting REAL information allows for practices to identify and measure disparities in care while also ensuring that practices are able to interact successfully with patients. This is done by understanding patients’ unique culture and language preferences.^[12] KHA Quality has a toolbox that assists with REAL data collection.

The Uniform Data System (UDS) Health Center Data Reporting Requirements (2023 Manual) provides detailed guidance on REAL and SOGI. While UDS does not currently require that practices report on the preferred language of each patient, practices should make an effort to identify and record each patient’s preferred language due to UDS reporting still requiring for languages other than English to be reported.

Accurate data collection requires appropriate fields and options in the EHR and other employed technologies, as well as appropriate human workflows in collecting the data. Staff responsible for data collection should be continuously trained and assessed for best practices in data collection, including promotion of patient self-report.

In addition, practices should work to ensure that patients understand the importance and use of this information to help them feel comfortable and support its collection. High rates of “undetermined” or “declined” responses in these fields may be indicative of the need to attend to these staff training needs.

Collecting this data is important, especially to obtain a complete picture of health for patients who identify as transgender or gender-expansive. Perinatal services are typically highly gendered and by understanding the needs of patients more fully, Providers can make more informed decisions for the best treatment of their patients. World Professional Association for Transgender Health (WPATH) has provided further guidance regarding standards of care related to gender diversity.
 

2. Use the practice’s electronic health record (EHR) and/or population health management tool to understand inequitable health outcomes at your practice by stratifying your data.

Suggested team member(s) responsible: Data analyst.

This includes reviewing your care gap report or care registry and being able to stratify all of the following:

• Core measures for the population of focus.
• Supplemental measures for the population of focus.
• Process measures for the population of focus.

Stratify this data by:

• Race, ethnicity and language (REAL).
• Sexual orientation and gender identity (SOGI).
• Other factors that can help identify subpopulations in need of focused intervention to reduce an equity gap (e.g., immigrants, people experiencing homelessness, etc.).

FIGURE 9: EXAMPLE OF DATA STRATIFIED BY RACE AND ETHNICITY

This is not a one-time event, but rather a continuous process (see step 13 below) and should be done in tandem with step three below.

Each practice should define the frequency of review and use of their registry to stratify data. In early use, the stratified data will support the identification of areas of inequity and allow interventions to be prioritized.

See also Key Activity 3: Use Care Gap Reports or Registries to Identify All Patients Eligible and Due for Care
 

3. Screen patients for social needs.

Suggested team member(s) responsible: Care team.

The Key Activity 7: Use Social Needs Screening to Inform Patient Treatment Plans provides guidance on screening patients for health-related social needs and how the information can begin to be used to inform patient treatment plans, including referral to community-based services.

This is not a one-time event, but rather a continuous process and should be done in tandem with step two above.
 

4. Analyze the stratified data from steps two and three to identify patterns in inequitable outcomes within the population of focus.

Suggested team member(s) responsible: Data analyst, QI leads, care team.

This includes:

• Using data tools to visualize and understand disparities across different populations or subpopulations.
  • Data over time (using run charts).
• Exploring trends, patterns and significant differences to understand which demographic groups will require a focused effort to close equity gaps.

This is not a one-time event, but rather a continuous process (see step 13 below) and should be done in tandem with step two (above) and step four (below).

Periodic review of the stratified data allows for the recognition of gap closures and the emergence of new disparities.
 

5. Use a root cause analysis to identify improvement approaches for subpopulations with lagging health outcomes.

Suggested team member(s) responsible: Multidisciplinary team.
Select root cause analysis approaches that work best for the equity gap you are closing:

• Engage and gather information from patients affected by the health outcome in your root cause analysis (see step six).
• Brainstorming.
• Systems thinking (understanding how interconnected social, economic, cultural and healthcare access factors may be impacting the health outcome).
• Tools that rank root causes by their impact and the feasibility of addressing them (e.g., prioritization matrix and/or an impact effort matrix)
• Visual mapping of root causes and effects (e.g., fishbone diagram).
• Perform focused investigations into selected root causes and gather qualitative data through interviews, surveys or focus groups with the subpopulation of focus.

Present the findings to a broader group of stakeholders to validate the identified root causes and gain additional insights. Incorporate their feedback and refine the analysis, as needed.
 

6. Partner with patients to build successful strategies addressing inequitable outcomes.

Suggested team member(s) responsible: Care team and people with lived experience (patients who are members of the population(s) of focus).

Using one or more human-centered design methods, such as focus groups, Journey Mapping, etc. (see links to these methods below), engage patients to better understand perspectives that may influence the health outcome of interest. This may include collecting information on:

• Values, needs and preferences.
• Experiences with outpatient prenatal care, intrapartum care at partnering hospital(s), and both inpatient and outpatient postpartum care.
• Cultural beliefs, including traditional healing practices.
• Level of trust in healthcare generally and in the topic of focus specifically (e.g., access to prenatal care visits, experience of perinatal depression screening, etc.).
• Barriers to accessing care.
• Barriers to remaining engaged in care.
• Trusted sources of information or communication mechanisms.
• Their ideas for improving health outcomes.

The patients you partner with for this and other steps in this key activity may be part of a formal or informal patient group and/or identified and engaged specifically for this equity work. Fairly compensating patients for participating in improvement activities is a best practice.

Selected resources on human-centered design and co-design:

• Center for Care Innovations (CCI) Human Centered Design Curriculum via CCI Academy.
• IDEO’s Field Guide to Human-Centered Design.
• IDEO’s Design Kit: Methods.

7. Identify key activities in this guide that address or partially address the root causes of the identified equity gaps.

Suggested team member(s) responsible: Care team and people with lived experiences.

Based upon the insights your practice has developed for a population of focus and your root cause analysis, determine which of the key activities could address or partially address the equity gap.

Most of the key activities either explicitly address an equity challenge or can be adapted to better address an equity challenge. Examples of key activities that can be adapted to reduce identified equity gaps include but are not limited to:

• Key Activity 12: Proactively Reach Out to Patients Due for Care.
• Key Activity 7: Use Social Needs Screening to Inform Patient Treatment Plans (such as providing a referral for one of the CalAIM Community Supports).
• Key Activity 13: Coordinate Care.
• Key Activity 18: Strengthen Community Partnerships.

8. Develop new strategies and ideas to address the identified equity gaps.

Suggested team member(s) responsible: Care team and people with lived experience.

If one or more of your root causes cannot be addressed fully through key activities, use one or more human-centered design methods (see resources below), to develop ideas to improve health outcomes and reduce inequities among pregnant people.

Developing these ideas is best done with representatives of the population of focus, as they have expertise and experience that may be missing from the practice’s care team. Compensating these patients and community members for time spent on improvement activities is a best practice. During this brainstorm, you are developing ideas without immediate judgment of the ideas in an effort to generate dozens of potentially viable ideas.
 

9. Determine which strategies to test first.

Suggested team member(s) responsible: Care team and people with lived experience.

Steps seven and eight above help your practice identify existing key activities and generate new ideas.

There are many ways to prioritize ideas. The Institute for Healthcare Improvement (IHI) often recommends a prioritization matrix and/or an impact effort matrix.

If you have organized your key activities and new ideas into themes or categories, you may choose to work on one category or select one to two ideas per category to work on.

The number of key activities and/or new ideas that you prioritize for testing first should be based on the team’s bandwidth to engage in testing. Thus, it is critical to determine the bandwidth for the team(s) who will be doing the testing so thou can determine how many ideas to test first.
 

10. Use quality improvement (QI) methods to begin testing your prioritized key activities and new ideas.

Suggested team member(s) responsible: Care team and people with lived experience.

Nearly all of the key activities and all of your new ideas will require some degree of adaptation for use within your practice and to be culturally relevant and appropriate to your population(s) of focus.

Whenever testing a key activity or new idea, we recommend that the practice:

• Use plan, do, study, act (PDSA) cycles to test your ideas and bring them to scale. See more information on PDSAs below in the tips and resources section.
• Generally, start with small-scale tests (e.g., test with one patient, for one afternoon, in a mailing to 10 patients, etc.). Use Figure 10 below in the tips and resources section to help you decide what size test is most appropriate. Increase the size of the test as your degree of confidence in the intervention grows.

Develop or refine your learning and measurement system for the ideas you are testing. A simple, yet robust learning and measurement system will help you understand areas for improvement, unintended secondary effects, and how implementation is going.

By working out the inevitable challenges in the idea you are testing in a small-scale PDSA cycle, the ultimate improvement activity will work better for patients and be less frustrating to the care team. Testing and refining also can eliminate the inefficient workarounds that occur when a new process is imposed onto an existing system or workflow without sufficient testing.

Select resources for quality improvement (QI):

•  Institute for Healthcare Improvement (IHI) QI Essentials Tool Kit.
  • Cause and effect diagrams.
  • Driver diagrams.
  • Failure modes and effects analysis.
  • Flowcharts.
  • Histograms.
  • Pareto charts.
  • PDSA worksheets.
  • Project planning forms.
  • Run charts.
  • Scatter diagrams.
• IHI’s Videos on the Model for Improvement (Part one and Part two).
• Rapid Experiments to Improve Healthcare Delivery.
• CCI’s ABC's of QI via CCI Academy.

11. Educate staff and providers on importance of addressing inequities.

Suggested team member(s) responsible: QI team; care team; patients; diversity, equity and inclusion (DEI) workgroup.

In addition to sharing information from research and data on social inequities, educate staff and clinicians on the existence of social inequities within your organization. Highlight activities that specifically focus on these disparities. Incorporate lessons learned from patients and partner organizations.

Prior to full scale implementation, education can help to ensure buy in from staff and clinicians.
 

12. Implement – bring to full scale and sustain – those practices that have proven effective.

Suggested team member(s) responsible: Care team

Once an idea has been well tested and shown to be effective on a small scale, it is time for your practice to hardwire the idea, approach or practice into your daily work. Consider using the MOCHA Implementation Planning Worksheet to think through:

• Measurement.
• Ownership.
• Communication, including training.
• Hardwiring the practice.
• Assessment of workload.

Sometimes, implementation may require that you update your protocol and/or policies and procedures for the populations of focus.
 

13. Once you have tested, refined and scaled up the initially prioritized ideas, begin testing other ideas.

Suggested team member(s) responsible: Care team and people with lived experience.

Consider revisiting the ideas that were developed previously but not were not initially prioritized for implementation. You might also move through the testing steps above to develop and prioritize new ideas or adapt ideas to better serve additional subpopulations of focus.
 

14. Establish formal and informal feedback loops with patients and the care team.

Suggested team member(s) responsible: Care team and people with lived experience.

Establishing formal and informal feedback loops regarding new processes will ensure that your practice’s ideas are meeting the needs of patients and are reducing identified equity gaps. These feedback loops also ensure the changes are feasible and sustainable for your practice.

For patients, feedback loops could be created using many of the human-centered design tools used to design your improvement activity (e.g., surveys, interviews, focus groups).
Consider establishing a standing funded patient advisory board that is available to design, implement and evaluate all of your practice’s improvement activities.

For the care team, feedback loops might include:

• Existing and new staff satisfaction and feedback mechanisms.
• Regularly scheduled meetings and calls to get staff feedback on processes, methods and tools. Leverage existing meetings to mitigate staff burnout.

15. Continually analyze your data to determine if your efforts are closing equity gaps.

Suggested team member(s) responsible: Care team.

This includes regular (at least monthly) review of the stratified measures for all of the following:

• Core measures for the population of focus.
• Supplemental measures for the population of focus.
• Process measures for the population of focus.
• Social needs data.
• Any additional measures collected as part of your testing and refinement effort.

Share the data with patients to both show your work to decrease known equity gaps and to solicit ideas for closing them.

KEY ACTIVITY #5:

Develop and Implement Standing Orders

This key activity involves the following elements of person-centered population-based care: operationalize clinical guidelines; pre-visit planning and care gap reduction.

Overview

A standing order is a preapproved provider order to perform a specific intervention for any patient who meets the criteria for the order. It is employed by a licensed (LVN, RN) or nonlicensed (MA, health educator) professional when the step in the workflow specifically requires the order of a qualified provider. Standing orders describe the action to be taken and identify who on the care team is authorized to complete the order. Standing orders are designed to enable care team members other than the primary care provider (PCP) to initiate specific clinical actions to provide timely screening and care, provided that specific criteria are met.

An important characteristic of a standing order is that all the patients who meet the criteria for the order receive the same treatment, thereby embedding equality into the clinical approach. Common standing orders include preventive measures, such as immunizations, cancer screenings and other screenings to be conducted ahead of the clinician’s time with the patient. Common standing orders in perinatal include preventive screening guidelines as well as specific testing at certain stages of pregnancy, such as initial pregnancy labs, gestational diabetes screening and group beta strep testing.

To limit the potential for errors and ensure patient safety, standing orders should be carefully designed, regularly reviewed and revised as necessary. They should be based on evidence-based recommendations and best practices, and they should have broad support from the medical director, practice manager, physicians and other staff. In addition, they should outline the criteria for initiating, modifying or discontinuing a particular course of action or treatment for a patient.^[13]

Action steps and roles

The steps below outline the actions required to create standing orders. They are adapted from the University of California, San Francisco (UCSF) Center for Excellence in Primary Care (CEPC).^[14]

1. Review and understand the latest clinical guidelines for the required standing order and your practice’s already established protocols.

Suggested team member(s) responsible: Quality improvement lead; panel manager, data analyst, medical director or equivalent.

See the California Nursing Standardized Procedures, Protocols, Order Sets, Clinical Pathways, and Standing Orders Policy for information on California nursing standardized procedures.

Interventions specific to the perinatal care population are initiated upon the patient presenting with a positive pregnancy test and indicating they intend to continue the pregnancy. It is recommended that practices ensure access to initial and ongoing perinatal care services through the following best practices:

• As soon as a pregnancy is identified and the patient indicates a plan to continue the pregnancy, practice staff connect the patient with perinatal service staff to initiate prenatal care services.
• Upon notification, perinatal services staff outreach to schedule new prenatal patients for an initial intake visit and a provider visit.
• A workflow is utilized to identify high-risk pregnancies and determine the need for referral to outside specialty obstetrics services.
  • If referred, workflow should exist to reengage the patient and new baby after delivery.
• Practice participates in the California Prenatal Screening Program.
• Standing orders are in place for routine prenatal and postpartum testing, including depression screening.
• To maximize completion of postpartum depression screening, the standing order should be executed at the first postpartum visit or integrated within the first well child check with the pediatrician to complete the postpartum depression screen at any visit where the new parent presents. See The Council on Patient Safety in Women’s Health.

2. Translate the appropriate clinical guidelines into a standing order.

Suggested team member(s) responsible: Medical director and panel manager or data analyst.

The standing order will follow the relevant clinical guidelines and be updated whenever clinical guidelines are updated. It will generally allow the following:

• Registered nurses (RNs) and/or medical assistants (MAs) with proper training may initiate the agreed upon standing order process when patients meet the agreed upon criteria for initiating screening, and do not have any clinical history that may require a clinician to address the concern.
• This may include initiating an order, initiating a referral, or notifying the PCP of the need for screening and/or testing.
  In addition to the written standing order, the practice should develop a process map or update other documentation outlining how and when the standing order is to be implemented in the practice’s current workflows.

3. Obtain approval for standing orders from clinical leadership.

Suggested team member(s) responsible: Panel manager and/or data analyst and medical director or equivalent.

For the standing order to be valid and in effect, it must be approved by clinical leadership at the practice, signed by a designated valid signatory (e.g., medical director or other physician), and dated, and it must include the effective date for the standing order. Practices should consider including an expiration date and flagging this date in their system to help ensure that the standing order is reviewed and updated regularly. As the clinical guidelines change or other components are updated, the standing order should be signed and dated again by the appropriate party with an effective date for the revision.
 

4. Train practice staff on how to use standing orders and include this training in clinical onboarding of new staff.

Suggested team member(s) responsible: Medical director or equivalent.

It is critical that practice staff, both those directly named in the standing order and other members of the care team, receive training on the use of this standing order. Such training should include a thorough review of the written standing order and ensure that practice staff understand all of its aspects, including the associated workflow and any additional materials related to the workflow, such as patient education or instructional materials that include nuances that the care team will need to understand.

Training should be provided on each standing order at least annually, retraining should be provided before the effective date on any revisions, and the training should be part of the orientation for all new members of the practice care team.

Based on feedback from the staff, the standing order can be refined to make the instructions clearer (e.g., during training several staff members were confused by a specific instruction, indicating that the instruction needed to be revised).
 

5. Institute mechanisms to ensure the proper use of the standing order and its effectiveness.

Suggested team member(s) responsible: Clinical director or equivalent or their designee.

It is likely that one or more aspects of the standing order will not work as planned. For example, the practice’s workflow may not fully support the standing order, the wording may be confusing to one or more staff members, or the standing order’s protocol may not be regularly followed exactly (e.g., staff are using workarounds). The practice should routinely check for these and other common challenges and revise and update the standing order as needed to ensure that it works for the practice and meets all applicable regulations and guidelines.
 

FIGURE 11: COMMON PREGNANCY-RELATED STANDING ORDERS

KEY ACTIVITY #6:

Develop or Refine and Implement a Pre-Visit Planning Process

This key activity involves the following elements of person-centered population-based care: operationalize clinical guidelines; pre-visit planning and care gap reduction; care coordination; address social needs.

Overview

This activity provides guidance for how the care team can effectively and efficiently implement a pre-visit planning process (PVP).

Pre-visit planning is typically driven by the medical assistant with help from other care team members and includes steps taken:

• At the end of the current visit to ensure the patient understands any actions they need to take and to schedule for any follow-up.
• Prior to a scheduled appointment, to “scrub” the chart and identify any pre-visit tasks per the pre-visit checklist.
• The day of an appointment, during the daily huddle and before the patient sees the obstetric provider.

Action steps and roles

1. Assess the current state of the pre-visit planning (PVP) process across your practice.

Suggested team member(s) responsible: Implementation team or QI team.

Understand how the process currently works for prenatal and postpartum care in light of your practice’s performance on core and supplemental measures. Compile existing paperwork and process documentation into one place and talk to medical assistants and other members of the care team to understand their questions and challenges around the pre-visit planning process.

Consider making current-state process maps that communicate the major steps in the PVP process and acknowledge pain points or challenges in the process. Pain points are places where the process isn’t working well for patients, staff or specific subpopulations or demographic groups for which your data analysis has revealed equity gaps. In addition, pay attention to places where staff are creating workarounds to the process. The presence of workarounds indicate that the process might need further clarification or refinement to support the care team to reliably implement it.

Your team may find it helpful to compile process maps for both the high-level pre-visit planning as detailed in Figure 13 in addition to more detailed documentation for specific clinical workflows.

FIGURE 13: PRE--VISIT PLANNING (PVP) WORKFLOW EXAMPLE

2. Identify where to update the PVP process to more consistently and reliably address care gaps.

Suggested team member(s) responsible: Implementation team or QI team. May include the data manager to assist with identifying patients through EHRs.

Examine where you can further incorporate or streamline your practice’s clinical protocols and standing orders into PVP, including via the PVP checklist, daily huddles and other key clinical workflows. Examples and considerations for updating the PVP process are included below.

Patient provider continuity is associated with better patient and provider satisfaction. Determine if the PVP process can be leveraged to improve provider continuity for perinatal patients.

Clinical guidelines and care gaps: Consider which preventive and maintenance services could be addressed more reliably using PVP, including those in your EHR’s care gap module. The Pre-Visit Planning: Leveraging the Team to Identify and Address Gaps in Care resource provides a more complete list of preventive services for adults and children.

PVP checklist: A generic PVP checklist to be completed by the MA or licensed vocational nurse (LVN) at least one to three days before the appointment is provided in Figure 14. Most EHRs will have a health maintenance module that identifies what preventive care is due, but a printed or digital checklist provides a starting point for ensuring key steps aren’t missed. For prenatal or postpartum care, the PVP checklist should include checklist items directly relevant to obstetric services. One approach is to create trimester-specific checklists to guide the MA or LVN in identifying key information.

FIGURE 14: PRENATAL AND POSTPARTUM PVP PLANNING CHECKLIST

Daily huddles: Design or redesign the team’s daily huddle so the care team can review prioritized action items for the list of patients scheduled to come and any further follow-up for patients seen in the previous days. For more information, see the Care Team and Workforce Guide Resource 4: Daily Huddles Overview and Process.

The Center for Excellence in Primary Care resource on healthy huddles includes tools, a video and examples around how pre-visit planning flows into the daily huddle process, including a healthy huddle warm-up, which can help MAs prepare for huddles.

Patients requiring special considerations: Ensure that the PVP includes a process to flag for the care team:

• Patients requiring special attention, such as those with:
  • Chronic conditions impacting their pregnancy.
  • Conditions that require increased coordination with specialty care or other services (e.g., patients with gestational diabetes).
  • Complex psychosocial needs.
  • Recent hospitalizations.
• Patients who need extended time or additional services during their visit (e.g., translation services, mobility assistance, screenings).

Detailed clinical workflows: Clinical workflows should be updated to describe at which step in PVP or the patient visit a care team member will address a specific gap in care with the patient. This may include the following details:

• Who will initiate the discussion with the patient based on the needs (e.g. preferred language) and preferences of the patient.
• How and when the care team member will plan to have the discussion before, during or after the visit.
• How they will be prepared to address common barriers or concerns the patient may have.
• Educational materials available for use that are relevant to the patient.

Planning for care after the visit: Effective PVP includes scheduling pre-visit labs and other diagnostics at the end of the current visit and coordinating care and referrals for services not available at the practice. See Key Activity 13: Coordinate Care for more information. Confirm the patient understands the purpose of any follow-up care.

The American Medical Association (AMA) has an online guide for implementing pre-visit planning, which includes forms, templates and other resources.

3. Test planned changes to the PVP workflows and support care teams in implementing the workflow.

Suggested team member(s) responsible: Implementation team or QI team.

Test and refine important changes to the PVP process with one or two care teams before considering rolling out the change more broadly at the practice.

Implementing the change includes updating documentation and creating a staff training schedule or training refresher for staff to sustain workflow changes. For example, train MAs every six months on the PVP. If they have difficulty, have them retake training with a different highly effective MA and monitor closely until competency in the task is reached.

For further streamlining of the process, practices can customize EHR templates to align with PVP workflows. Be sure to account for potential costs associated with creating new templates, staff training and IT.

4. Establish a process to review and update PVP workflow.

Suggested team member(s) responsible: Care team with quality improvement manager.

Identify staff responsible for reviewing and updating the PVP process at least annually to incorporate the latest clinical guidelines and check for any workarounds that have developed.

KEY ACTIVITY #7:

Use Social Needs Screening to Inform Patient Treatment Plans

This key activity involves the following elements of person-centered population-based care: behavioral health integration; address social needs.

Overview

This activity provides guidance on screening patients for health-related social needs and how the information can begin to be used to inform patient treatment plans, including referral to community-based services. Social needs are defined as individual material resources and psychosocial circumstances required for long-term physical and mental health and well-being, such as housing, food, water, clean air, sanitation and social support.

Action steps and roles

1. Pick a validated standardized screening instrument and establish how to document results.

Suggested team member(s) responsible: Clinical leadership.

Pick a standardized screening tool that fits your organizational environment and the context of your patient population. Kaiser Permanente, in partnership with the Social Interventions Research and Evaluation Network (SIREN), conducted a systematic review of social needs screening tools and provides a comparison and search tool for different tools for adults and children. Currently available standardized tools you might consider include:

• Protocol for Responding to and Assessing Patients’ Assets, Risks and Experiences (PRAPARE) developed by the National Association of Community Health Centers (NACHC).
• The Centers for Medicare and Medicaid Services (CMS) Accountable Health Communities (ACH) screening tool.
• REACH by Health Leads.
• The Academy of Family Practice (AFP) tool.

For the perinatal population, it is especially important to assess the safety of the pregnant person from intimate partner violence and determine if any intervention or support is needed. Consider a validated tool that has comparable questions found in the California Comprehensive Perinatal Services Program (CPSP) intake assessment.

Work with your clinical informatics team to determine how staff will document screening results in your EHR. Some EHR systems have screening tools already embedded and many are moving quickly to incorporate screening; some EHRs may be able to auto-populate Z-codes based on screening results. Your managed care plans may offer additional guidance or support and can be a resource to connect your practice to other organizations who have experience with screening instruments and technology tools. By using the same screening tools and/or information technology platforms, the consistency and quality of care delivery can be enhanced.

For the patient’s problem list, Department of Health Care Services (DHCS) provides a list of 25 Priority Social Determinants of Health (SDOH) Codes to focus on. This shorter list of codes is intended to capture areas where the health system may have the greatest impact on identifying and addressing social needs. Train providers to add these codes to the pregnant patient’s problem list as appropriate.
 

2. Understand resources and community referrals for positive screens.

Suggested team member(s) responsible: Referral manager, community health workers.

Through CalAIM, the California Department of Healthcare Services (DHCS) has taken steps to ensure that Medi-Cal members have access to social support that can impact health outcomes. Connect with your managed care plan (s) (MCPs) and regional area consortia (RAC) to understand what services and resources they have in place to support patient access to community-based social services. Many MCPs are developing relationships with social services agencies to meet the needs of their members. For Medi-Cal members with the highest level of social needs, MCPs offer Enhanced Care Management (see section on care management) and some or all of 14 Community Supports: these Community Supports provide resources to address social needs such as housing navigation, post-hospitalization recuperative care, and medically tailored meals. Some MCPs use the new CalAssist tool for Medi-Cal members to self-identify whether they are eligible for any of the 14 CalAIM Community Supports and generate a referral to the applicable community support provider.

Beyond these relatively new benefits that may meet the social needs of your pregnant and postpartum patients, your practice may also refer to existing community-based organizations and public agencies to support patient needs like nutrition assistance, employment readiness, childcare support, postpartum paid family leave, rent and utility assistance, and resources for transportation. Existing free social support programs for your pregnant and postpartum patients include California Home Visiting Programs and home visitors (public health nurses or peers) who are well-versed in meeting patient social needs. Such existing programs, often administered by your local public health department in partnership with community-based organizations, should be leveraged where possible to support new social needs screening and response processes in your practice.

Many patients will screen positive for social needs and will benefit from connection to alternative resources that are not part of Community Supports. Contact your MCP to see if they have established relationships with providers who connect individuals to social services. Health plans may contract with an online provider or with a social services network lead entity that can connect you with existing community-based organizations and public agencies in the area. These contracted services will often include a process for making closed loop referrals, where the referring provider is notified if the patient has successfully accessed the referral. Closed loop referrals are a best practice in care coordination that lead to higher levels of patient and provider satisfaction.^[23]

Key services to catalog include nutrition assistance, employment readiness, childcare support, postpartum paid family leave, rent and utility assistance, and resources for transportation. Other places to look to build sources for local community referrals include:

• Your current social work staff and/or community health workers, who may have many go-to resources already identified.
• Free online aggregators for local community services in California, such as findhelp.org.
• 2-1-1 a free telephone number providing access to local community services for housing, utility, food and employment assistance.
• Resource networks maintained by a local hospital or larger health system in your area.

For going deeper in this area, practices can consider prioritizing quality improvement activities that establish new or previously underutilized community resources to address specific social needs as part of Key Activity 4: Use a Systematic Approach to Decrease Inequities within the Population of Focus. Case studies provided in the resources linked below provide examples of these improvement initiatives.
 

3. Establish a workflow for screening and referrals.

Consider screening before the patient meets with the PCP and have a workflow in place for follow-up of positive screen (e.g. meet with care coordinator or care management staff who will facilitate referral). Take steps to flag the positive screen so the PCP is aware and can address any positive screen during the visits.

Train staff in the new workflows and Implementing Population Health Management in Trauma-Informed Ways. Staff often initially resist screening if there is a sense they feel they don’t have the tools to help address positive screens.

• Following screening, ask patients for their prioritized need and whether they would like assistance before making a referral.
• Providing a written script for staff and accompanying sage can build confidence in dealing with the challenging circumstances many patients experience.

4. Provide person-centered care that acknowledges social needs.

Suggested team members responsible: PCPs and the expanded care team.

Information about a patient’s social needs can be used to provide tailored person-centered care and treatment plans that patients are more likely to follow. For example, if a patient screens positive for food insecurity, that could influence details around dietary advice given for pregnancy. If a patient screens positive for transportation insecurity, discuss what options might be available to ensure proper access to appointments. Use trauma-informed ways of engaging patients in their own care, including developing shared goals, providing self-management support, and using communication techniques such as motivational interviewing. See more here: Implementing Population Health Management in Trauma-Informed Ways

The desires and goals of the patient will inform how and when to move ahead in addressing social needs. It is important to support patients through motivational interviewing and trauma-informed practices to create a person-centered care plan. By having processes in place to support ongoing person-centered care planning, such as a warm handoff to a care coordinator or a documented plan to follow up on issues discussed at the next visit, will help to build trust and support connection to community referrals when the patient is ready.

KEY ACTIVITY #8:

Provide Prepregnancy Healthcare

This key activity involves the following elements of person-centered population-based care: proactive patient outreach and engagement; pre-visit planning and care gap reduction.

Overview

This activity provides guidance on delivering effective prepregnancy healthcare. The CDC and U.S. Office of Population Affairs describe preconception as any time that a person of reproductive potential is not pregnant but at risk of becoming pregnant, or when a man is at risk for impregnating his female partner.^[24] While many organizations and agencies still utilize the term “preconception,” there is increasing adoption of “prepregnancy care” as alternative language.^[25] Prepregnancy health services aim to identify and modify biomedical, behavioral and social risks to an individual’s health or future pregnancy outcomes through prevention and management. Individuals of reproductive age should receive services tailored to their unique needs before getting pregnant (prepregnancy health services) or between births (interconception health services).^[26] Based on the unique needs identified, healthcare providers should suggest a treatment plan or follow-up care as needed.^[27]

Action steps and roles

1. Assess current preconception health services to identify gaps between current and recommended practices.

Suggested team member(s) responsible: Population health staff, care managers, data analysts, all care team members.

Review current preconception health evidence-based guidelines and recommendations. Determine if the recommended eight areas of risk screening for preconception health services are in place. Based on assessment findings, develop and implement a quality improvement plan over time. Your practice might want to start with a focus on one specific process change to support prepregnancy health that might be most impactful in your patient population.
 

2. Ensure prepregnancy health assessments incorporate social health.

Suggested team member(s) responsible: All care team members.

Incorporate life course theory into preconception health assessments. Life course theory describes how contextual and environmental factors inform individuals’ health across their lifetimes and shape health and disease patterns across populations and communities. Before counseling a client about healthy behaviors, providers should routinely assess the client’s context and environment.

Balanced information on risks and benefits should be presented:

• Preconception Health Toolkit.
• National Preconception Health and Healthcare Initiative: Women’s Health Practice Bulletin 2020
• Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs
• Client-Centered Reproductive Goals and Counseling Flow Chart (parenthood and pregnancy attitude, timing, and how).

See Key Activity 7: Use Social Needs Screening to Inform Patient Treatment Plans.
 

3. Routinely assess all patients’ reproductive goals.

Suggested team member(s) responsible: All care team members and patients.

A standardized and systematic approach is recommended to assess patients’ reproductive goals.5 A standardized approach can decrease bias and inequity in screening and service provision.

PATH (Parenting/Pregnancy Attitudes, Timing, How Important) questions are one client-centered approach to assess parenthood and pregnancy attitude, timing, and pregnancy prevention.

PA: Do you think you might like to have (more) children at some point?
T: When do you think that might be?
H: How important is it to you to prevent pregnancy (until then)?

PATH can be used with clients of any gender, sexual orientation or age. PATH is designed to facilitate listening and efficient client-centered conversations about preconception care, contraception and fertility, as appropriate.

To adapt for EHR, a screening question can be, “Do you think you might like to have (more) children any time soon?”

Another option is One Key Question®. One Key Question® (“Would you like to become pregnant in the next year?”) can be used by healthcare providers, community health workers and home visiting nurses to guide a conversation with patients on a routine basis about pregnancy desires and goals and offer personalized counseling and care based on their response.^[32] The One Key Question® is person-centered as it guides a conversation, supporting those who want to get pregnant, those who do not and those who are uncertain.7 One Key Question® (“Would you like to become pregnant in the next year?”) has four possible answers (there is no right or wrong answer): “Yes,” “no,” “unsure,” or “OK either way.”5 The benefits are its simplicity and ability to easily incorporate into routine intake questions and EHR workflows. The question of, “How important is preventing a pregnancy to you?” should also be explored.5

The importance of standardizing: All patients benefit from prepregnancy health services. Following a standardized and systematic approach to assessing patients’ reproductive goals can decrease bias and inequity in screening and service provision.5 Establishing effective referrals systems and making referrals based on identified needs ensures promotion of whole-person care.
 

4. Assess risk factors for adverse health and adverse pregnancy outcomes before conception.

Suggested team member(s) responsible: All care team members.

The goal of preconception (or prepregnancy) care is to optimize health outcomes by providing education and addressing modifiable risk factors.2 Any visit with a client who has reproductive potential is an opportunity for prepregnancy counseling. After a discussion of the client’s reproductive desires, a prepregnancy counseling conversation can be introduced, if relevant, with: “Since you said ______, would you like to talk about ways to be prepared
for a healthy pregnancy?” For example, the Preconception Counseling Checklist.
 

5. Make appropriate referrals based on the prepregnancy counseling conversation and assessment.^[33]

Suggested team member(s) responsible: All care team members.

Referral and communication pathways between healthcare providers, community-based organizations, and state and public health agencies can enhance access to, and utilization of, services and supports for patients.

Making referrals encompasses a spectrum of potential information-giving and supportive behaviors ranging from providing information on specific services to follow-up on service utilization and outcomes and assessment of the quality of referrals. “Cold” and “warm” are often used to describe referral behaviors at two points along this spectrum. A cold referral means providing information to the client about another agency or service, and it is then the client’s responsibility to contact the agency or service. A warm referral involves contacting another agency or service provider on the client’s behalf. This entails calling and making an appointment for the client, viding support to overcome barriers to care, and following up to determine if the appointment has been kept.
 

6. Strengthen the quality and responsiveness of prepregnancy health services.

Suggested team member(s) responsible: All care team members.

Unique factors affect each client’s health. Health centers should provide prepregnancy health education, counseling, care and referrals that align with evidence-based guidelines and take into account the goals, risks, social needs, and contextual and environmental factors gathered during a client’s prepregnancy health assessment.
 

7. Collaborate with community partners to improve preconception health.

Suggested team member(s) responsible: All care team members, community health workers, outreach workers and navigators, community partners, and patients.

Although improving the quality of prepregnancy health services in the clinical setting is important, it is insufficient for reducing maternal morbidity and mortality at scale. Local and national agencies and local birth-centering programs must work together to address social needs, which drive health inequities within communities of color and increase their burden of poor health outcomes. Engaging in diverse collaborative community partnerships can help family planning agencies identify additional opportunities for improving maternal health outcomes.

For going deeper in this area, please see Key Activity 18: Strengthen Community Partnerships.

KEY ACTIVITY #9:

Conduct Postpartum Planning and Care

This key activity involves the following elements of person-centered population-based care: operationalize clinical guidelines; implement condition-specific registries; proactive patient outreach and engagement; pre-visit planning and care gap reduction; care coordination; behavioral health integration; address social needs.

Overview

This activity provides guidance on conducting effective postpartum planning and care. Postpartum care is a critical part of the reproductive healthcare continuum.^[34] The postpartum period is a vulnerable time for patients from both physical and mental health perspectives: most pregnancy-related deaths in California occur during the postpartum period^[35], and pregnancy-associated mood disorders are the most common comorbid conditions in the perinatal period^[36]. Optimal postpartum care should be an ongoing process with, at minimum, two visits completed by three and 12 weeks after birth. The timing and frequency of postpartum visits should be tailored to a patient’s individual health concerns and needs^[37] (e.g., adding a visit in the first seven days for a blood pressure check, modifying the schedule to allow for contraception method initiation, or increasing the frequency of follow-up visits for a mood concern).

Care during the postpartum period should include other preventive health screenings and services a patient might be due for, such as depression screening, substance use screenings, cancer screenings and immunizations. Additional elements of optimal postpartum care include screening for social needs and linkage to specialty care and services; certifying paid family leave; management of pregnancy-specific health conditions; anticipatory guidance addressing the transition to parenthood and well-person care; comprehensive contraceptive services; and interconception counseling. Postpartum visits present a good opportunity to discuss interconception care^[38]; the provider and patient can reflect on any birth complications and discuss modifiable risk factors that might improve subsequent birth outcomes (e.g., monitoring for recurrence of preterm birth and aspirin to prevent recurrent preeclampsia). Although the postpartum period begins after birth, the postpartum transition may be experienced for six months or more; therefore, planning for this important period, or “fourth trimester,” should begin during pregnancy.^[39]

Action steps and roles

These action steps were adapted from Postpartum Discharge Transition Change Package. Institute for Healthcare Improvement. 2022

Readiness

1. Develop and maintain a set of referral resources and communication pathways.

Suggested team member(s) responsible: Clinic manager and referral coordinator.

Referral and communication pathways between obstetric providers, hospitals, community-based organizations, and state and public health agencies can enhance access to and utilization of services and supports for pregnant and postpartum families.

Making referrals encompasses a spectrum of potential information-giving and supportive behaviors ranging from providing information on specific services to follow-up on service utilization and outcomes and assessment of the quality of referrals.^[41] “Cold” and “warm” are often used to describe referral behaviors at two points along this spectrum.^[42] A cold referral means providing information to the client about another agency or service, and it is then the client’s responsibility to contact the agency or service.^[43] A warm referral involves contacting another agency or service provider on the client’s behalf. This entails calling and making an appointment for the client, providing support to overcome barriers to care, and following up to determine if the appointment has been kept.^[44]

Agency policies should indicate the type of referral that is usually most appropriate for each service. Referral type may also depend on the client’s individual circumstances, so providers should use their best judgment.

Establish technology-based partnerships to allow staff at Community Health Centers (CHCs) to access hospital discharge summaries and other relevant inpatient records.

2. Ensure resource lists are available in languages representative of the populations in the health center service area.

Suggested team member(s) responsible: Translation staff.

Review resource lists to ensure availability in preferred languages spoken in the community and, when possible, refer patients to resources and services that are available in their preferred language.

3. Collaborate on the development of a patient-facing discharge summary form.

Suggested team member(s) responsible: Outpatient clinicians, prenatal assistants, hospital staff.

Wherever possible, postpartum appointments should be made prior to discharge from the birth facility for your patients. Discharge summaries can serve as a mechanism for patient and family member engagement and postpartum education. Convene an interdisciplinary team of inpatient and outpatient providers to develop a standard patient-facing discharge summary form that highlights risk factors, complications or diagnoses, necessary follow-up, and health system contact information. Engage people with lived experience in development of patient-facing discharge summary documents to ensure they are clear, understandable and meet patient needs.

4. Educate clinicians and staff on optimizing postpartum care.

Suggested team member(s) responsible: Medical director or designates, clinic manager.

Providing multidisciplinary staff education on optimizing postpartum care, including why and how to screen for life-threatening postpartum complications and how to engage family members and caregivers in discharge education and planning will ensure that any encounter birthing people and family members have with health center staff is an opportunity for prevention or early intervention.

The schedule of postpartum visits encourages the postpartum person to see their provider at three weeks, six weeks and 12 weeks after birth. It is important to remember that postpartum recovery can take approximately six months or longer. By engaging in whole-person care, health centers will engage the postpartum pen and their support network to ensure optimal health outcomes and any identified concerns can be mitigated.

5. Support professional development opportunities on trauma-informed practice and protocols.

Suggested team member(s) responsible: Medical director or designates.

Developing trauma-informed protocols and trainings to address healthcare team member biases enhances quality of care. See resource: Trauma-Informed Population Health Management)

6. Educate clinicians and staff on how to use a standardized discharge summary form.

Suggested team member(s) responsible: Informatics team, EHR IT.

Clinicians and staff ability to effectively review patient data ensures that recommendations made for postpartum care follow-up and community services and resources have been carried out. Health centers will review the mechanisms that are in place to share delivery and discharge information with obstetrician (OB) or midwife and primary care provider (PCP), with consideration for situations where the delivery hospital is not part of the same system as the OB, midwife or PCP.

Ensure clinicians and staff recognize that patients and family may be the primary source of information at the time of visit, if outside records are not available.

Recognition and prevention

7. Discuss reproductive desires during prenatal visits and revisit at postpartum visit.

Suggested team member(s) responsible: Providers and clinic staff.

Prenatal visits should include discussion about the birthing person’s reproductive desires, including the desire for and timing of any future pregnancies, and include in postpartum care plans. Offer appropriate resources, including access to a full range of contraceptive options in accordance with safe therapeutic regimens.^[45] A birthing person’s future pregnancy intentions provide a context for shared decision-making regarding contraceptive options.

At the postpartum visit, re-assess previously stated contraception preferences and provide relevant services.

8. Provide anticipatory guidance during pregnancy with the development of a postpartum care plan that addresses the transition to parenthood and well-person care.

Suggested team member(s) responsible: Providers and clinic staff.

Providing anticipatory guidance during prenatal visits optimizes postpartum care and can help to inform the development of a postpartum care plan.4 Co-design postpartum care plans that emphasize patient and family needs and wishes by engaging in open, transparent and empathic communication. Encourage the participation, as appropriate, of the support network in the development of a postpartum care plan.

The American College of Obstetricians and Gynecologists (ACOG) suggests components of the postpartum care plan include care team member names (inclusive of family and friends) and contact information; time, date and location of postpartum visits; infant feeding plan; reproductive life plan; pregnancy complications and follow-up; and anticipatory guidance regarding signs and symptoms of perinatal depression or anxiety. See ACOG Committee Opinion Number 736: Optimizing Postpartum Care. May 2018 for a complete list of suggested components for postpartum plans.

9. Establish a system for scheduling the postpartum care visit and needed immediate specialty care visit or contact (virtual or in-person visit) prior to discharge or within 24 hours of discharge.

Suggested team member(s) responsible: Clinic manager and prenatal assistants.

All postpartum people should have contact with a perinatal care provider within the first three weeks postpartum. This initial assessment should be followed up with ongoing care as needed, concluding with a comprehensive postpartum visit no later than 12 weeks after birth. The timing of these visits should be individualized and person-centered. Attempt to schedule the patient with their preferred perinatal care provider who they saw during their pregnancy.

10. For primary care or other non-OB/GYN settings, assess and document if a patient presenting is pregnant or has been pregnant within the past year.

Suggested team ”ember(s) responsible: Providers and clinic staff.

Include the question, "Have you been pregnant in the last year?" in standard intake scripts in EHR, and ensure gender inclusivity in assessment. If they answer yes, assess for need for prenatal or postpartum services. Screen for postpartum risk factors and provide linkage to community services and resources.

Response

11. Conduct a comprehensive postpartum visit for at least 30 minutes.

Suggested team member(s) responsible: Providers and clinic staff.

The comprehensive postpartum visit should include a full assessment of physical, social and psychological well-being.4 This is also an opportunity to engage the postpartum patient in discussions around elements of postpartum self-care. Consider scheduling needs to allocate sufficient time in the provider’s schedule.

12. Engage the birthing person’s support team.

Suggested team member(s) responsible: Providers, social workers, clinic staff.

Encourage the presence of a designated support person (e.g., doula, CHW, partner, friend, family member) during all instances of care as desired and particularly when teaching or education occurs. Connect the patient with local birth centers and peer support groups for additional community building and postpartum support, like lactation support or new parenting groups.

Reporting and systems learning

13. Develop and systematically utilize a standard comprehensive postpartum visit template.

Suggested team member(s) responsible: EHR IT, clinic manager, providers, clinic staff.

Engage a multidisciplinary team to create and test a standard postpartum visit template. Include patients in the development of the template to ensure the visit components meet their needs.

14. Identify and monitor postpartum quality measures.

Suggested team member(s) responsible: QI and implementation team.

Review all process and outcome data disaggregated by race, ethnicity and language to assess for inequities. Engage clinicians and staff in the review and discussion of the data. Engage leaders in messaging about destigmatizing discussion and identification of inequities to ensure diverse populations have access to respectful, whole-person, quality care. Include patient-facing surveys or other feedback options.

15. Monitor data related to completed postpartum comprehensive visits.

Suggested team member(s) responsible: QI and implementation team.

Disaggregate postpartum comprehensive visits by race and ethnicity, at a minimum, to evaluate disparities in rate of follow-up visit completion and identify strategies for improvement. Consider sharing data on postpartum visit attendance with hospital systems where patients deliver and identify strategies to improve referral and scheduling processes.

Respectful, equitable and supportive care

16. Include each pregnant or postpartum person and their identified support network as respected members of and contributors to the multidisciplinary care team.

Suggested team member(s) responsible: Providers and clinic staff.

By facilitating open conversations with the pregnant or postpartum person helps to ensure that concerns are adequately addressed, and there is opportunity to investigate possible causes when patients express that something is "off." Having a member or members of the birthing person’s support network present during these conversations may help to unearth concerns as well as ensure the appropriate support is in place when the patient returns home. During these conversations providers should consider ways in which implicit bias and structural racism may influence response to patient concerns and response to pain.

17. Promote life-long learning among clinicians and staff.

Suggested team member(s) responsible: Leadership team, including medical director and clinic manager

Educate clinicians and staff on providing respectful care by engaging in the lifelong learning of cultural humility, understanding that individuals cannot learn all aspects of any culture, including their own.

Review local resources and benefits available to pregnant and postpartum clients to increase staff and provider knowledge of such services. See more in Key Activity 17: Continue to Develop Referral Relationships and Pathways and Key Activity 18: Strengthening Community Partnerships.

FIGURE 15: POSTPARTUM VISIT TOPIC CHECKLIST

Evidence base for this activity

Alliance for Innovation on Maternal Health (AIM) Patient Safety Bundles: Postpartum Discharge Transition.

KEY ACTIVITY #10:

Support Patient Self-Care

This key activity involves the following elements of person-centered population-based care: proactive patient outreach and engagement; care coordination; behavioral health integration.

Overview

The term “self-care” refers to patients’ engagement in the activities and decisions that improve their health and well-being. Supporting self-care involves activities that enhance the capacity of individuals to engage in their care. Research demonstrates that pregnancy can be a particularly impactful time for patients to make positive changes with respect to self-care^[46].

Action steps and roles

1. Improve information resources for patients.

Suggested team member(s) responsible: If a patient and family advisory council is in place, ask them to develop and/or refine patient information materials along with clinic staff.

• Update patient information materials, translating to language prevalent in the community, and reviewed by patients and families where possible.
• Support patient use of a patient portal that links to reputable health information. Consider including links to respected websites and social media accounts.
• Be aware of each patient’s health literacy, their ability to use health information effectively. Ensure materials are written at appropriate literacy level.
• Discuss a patient’s interest in information about health topics during clinic visits and preferred ways to receive information. Rather than assuming a patient needs and wants certain information, use tips from the field on motivational interviewing to ask open-ended questions.

Tip: Self-care coaching can begin with new patients. Consider holding on-boarding group visits for new pregnant patients that orient the patients to the clinic, its workflows and resources, and opportunities for self-care support.

2. Identify opportunities to enhance patient knowledge and confidence.

Suggested team member(s) responsible: Clinic staff including social workers, educators, nurses and providers.

Enhance knowledge and emotional support through a support network of family, friends and doulas so that the patient feels empowered to fully utilize health resources, services and supports.

Birth plans can be a particularly impactful way to engage clients in their own prenatal and birth experiences. ACOG and the California Maternal Quality Care Collaborative have resources to share with clients regarding birth plans.

3. Implement shared care plans with patients.

Suggested team member(s) responsible: Care team, patients and family members, if appropriate.

Shared care plans (see AHRQ Shared Care Plans) involve decisions of how the patient/provider discussion will be fit into the clinic visit workflow; training in facilitating collaborative conversations with patients; what format a shared care plan will take (a pa vs. electronic copy to be shared at the end of any interaction); and how the shared care plan will be documented.

4. Address health-related social needs that impact self-care.

Suggested team member(s) responsible: Care team.

• Implement universal Social Needs Screening and use the results to identify health-related social needs of patients. See Activity 7: Use Social Needs Screening to Inform Patient Treatment Plans for more information.
• Update a directory of community-based resources (see Activity 18: Strengthen Community Partnerships for examples) and routinely refer patients to appropriate resources through the care coordination process already in place.
• Follow up with patients who have been referred to community-based resources to learn if the referral was helpful.
• Begin self-care coaching in the exam room. Consider opportunities to leverage the extended members of the care team who often are representative of the populations you are serving. The self-management coaching can occur before being seen by a clinician (while waiting for the provider) and after seeing the provider. The key is to ensure the self-management coaching is well coordinated by the integrated care team.
• Self-care coaching for people with behavioral health conditions: National Institute of Mental Health (NIMH): Caring for Your Mental Health.

5. Implement self-management support.

Suggested team member(s) responsible: Care team.

• Self-Management Support (SMS) is a technique that enables patients to play an active role in their healthcare. SMS uses the ask-tell-ask approach, patient-directed goal setting, and follow-up to support individuals in making decisions that benefit their health and well-being. Training for staff and providers will be necessary to implement SMS.
• Assessment of self-activation capacity of patients can help health centers identify system-level interventions that can build self-care capacity at a population level. For example, offering classes for specific populations or group visits.
• See technology considerations for guidance on using apps to support self-care for pregnant patients.

Evidence base for this activity

Dineen-Griffin S, Garcia-Cardenas V, Williams K, Benrimoj SI. Helping patients help themselves: A systematic review of self-management support strategies in primary healthcare practice. PLoS One. 2019 Aug 1;14(8):e0220116. doi: 10.1371/journal.pone.0220116. PMID: 31369582; PMCID: PMC6675068.

Hibbard JH, Greene J. What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs. Health Aff (Millwood). 2013 Feb;32(2):207-14. doi: 10.1377/hlthaff.2012.1061. PMID: 23381511.

Roy D, Meador M, Sasu N, Whelihan K, Lewis JH. Are Community Health Center Patients Interested in Self-Measured Blood Pressure Monitoring (SMBP) – And Can They Do It? Integrated Blood Pressure Control [Internet]. 2021 Feb [cited 2021 Aug 8];Volume 14:19–29. Available from: https://dx.doi.org/10.2147%2FIBPC.S285007.

Action of Patients for Successful Self-Management, J Ambulatory Care Manage Vol. 32, No. 1, Simmons, L., et al, 2009.

KEY ACTIVITY #11:

Behavioral Health Screening, Including Postpartum Depression

This key activity involves the following elements of person-centered population-based care: operationalize clinical guidelines; pre-visit planning and care gap reduction; behavioral health integration.

Overview

This key activity provides guidance on behavioral health screening during pregnancy and postpartum. All perinatal patients should be screened for mental health conditions. Prenatal and postpartum depression screening are both HEDIS supplemental measures. ACOG’s Committee Opinions #757, “Screening for Perinatal Depression 1,” recommends screening patients at least once during the perinatal period for depression and anxiety, and, if screening in pregnancy, it should be done again postpartum. Opinion #736, “Optimizing Postpartum Care 2,” recommends a full assessment of physical, social and psychological well-being within a comprehensive postpartum visit that occurs no later than 12 weeks after birth.^[48]

The Substance Abuse and Mental Health Services Administration (SAMHSA) defines depression as a disorder of the brain. It is a serious mood disorder that is more than just a feeling of being "down in the dumps" or "blue" for a few days. Postpartum depression (PPD) affects gestational parents after having a baby. It causes intense, long-lasting feelings of anxiety, sadness and fatigue, making it difficult for parents to care for themselves and/or their babies, as well as handle daily responsibilities. PPD can start anywhere from weeks to months after childbirth. The American Academy of Pediatrics (AAP) recommends that pediatricians screen people who have given birth for PPD at the infant's one-, two-, four- and six-month well child visits.

Action steps and roles

Here is a sequence of steps that practices can use to implement screening for behavioral health conditions in the perinatal period.

1. Understand current recommendations for perinatal behavioral health screening.

Suggested team member(s) responsible: QI lead and frontline staff.

Current guidelines for screening are available from ACOG: Implementing Perinatal Mental Health Screening.

ACOG’s Clinical Practice Guideline 4: “Screening and Diagnosis of Mental Health Conditions During Pregnancy and Postpartum” recommends:

• Everyone receiving well-person, prepregnancy, prenatal and postpartum care be screened for depression and anxiety using standardized, validated instruments.
• Screening for perinatal depression and anxiety at the initial prenatal visit, later in pregnancy, and at postpartum visits.
• Implementing mental health screening with systems in place to ensure timely access to assessment and diagnosis, effective treatment, and appropriate monitoring and follow-up, based on severity.
• Completing screening for bipolar disorder before initiating pharmacotherapy for anxiety or depression, if not previously done.
• When someone affirmatively answers a self-harm or suicide question, clinicians immediately assess for likelihood, acuity and severity of risk of suicide attempt and then arrange for risk-tailored management.
• Clinicians provide immediate medical attention for postpartum psychosis.

2. Create a care gap report.

Suggested team member(s) responsible: QI lead and frontline staff.

Establish a baseline by assessing the percentage of patients or visits at which behavioral health screening occurred (e.g., postpartum depression screening was documented at 33% of visits at which postpartum depression screening is recommended to occur).

See Key Activity 3: Use Care Gap Reports or Registries to Identify All Patients Eligible and Due for Care for additional guidance on care gap reports.
 

3. Flag all eligible patients for behavioral health screening and administer screening.

This should be programmed as an alert in the EHR so staff are aware at the time of visit.

There are many validated tools available. To screen for depression, consider:

• During pregnancy: Patient Health Questionnaire-2 (PHQ-2) and Patient Health Questionnaire-9 (PHQ-9) (PHQ-2 In Spanish; PHQ-9 in Spanish).
• During postpartum: Edinburgh Postnatal Depression Screen (EPDS). (In Spanish).

To screen for anxiety, consider:

• General Anxiety Disorder 7 (GAD-7) screen, seven questions.

To screen for posttraumatic stress disorder (PTSD), consider:

• Primary Care PTSD Screen for DSM-5 (PC-PTSD-5).

To screen for bipolar disorder, consider:

• Mood Disorder Questionnaire (MDQ), 14 questions.The MDQ needs to be done only once in the perinatal period as it queries lifetime experience as compared to the other screening tools, which ask how a person has felt in the last seven days to one month.

Combined tool:

•  Combined EPDS, MDQ, GAD-7, PC-PTSD-5 screening tool.

4. Create a protocol to screen for behavioral health conditions.

Ensure standardized clinical workflows are in place for routine prenatal and postpartum screening. In many CHCs, medical assistants or other clinical support staff administer the mental health screenings in advance of the clinician visit. Clinicians then review the results and, if appropriate, offer relevant treatments or referrals.

To maximize completion of behavioral health and postpartum depression screening, the workflow should be executed at any visit where the new parent presents (e.g., at the first postpartum visit, integrated within the first well child visit with the pediatrician).

See the Perinatal Mental Health Conditions guide from Alliance for Innovation on Maternal Health.
 

5. Develop workflows for integrating postpartum mental healthcare, including provision of pharmacotherapy when indicated.

Identify mental health screening tools to be integrated universally in every clinical setting where patients may present.

• Establish an evidence-based, person-centered response protocol based on what is feasible for each area of practice and local mental health resources. Ideally, responses are tailored to condition severity and are strength based, culturally relevant and responsive to patient’s values and needs.
• Ensure staff can activate an immediate suicide risk assessment and response protocol as needed for patients with identified suicidal ideation, significant risk of harm to self and/or others, or psychosis.
• Include each pregnant and postpartum person and their identified support network as respected members of and contributors to the multidisciplinary care team.
• Provide information to prescribing providers and patients on evidence-based, safe pharmacological depression treatment options for pregnant and postpartum patients. ACOG has clinical practice guidelines outlining such medications.

6. Educate clinicians, frontline staff, administrative staff, patients and patients’ designated support networks on optimal care across the preconception and perinatal mental health pathway, including prevention, detection, assessment, treatment, monitoring, and follow-up best practices.

• Facilitate trauma-informed training and education to address healthcare team member biases and stigma related to mental health conditions, including anti-racism considerations.
• Incorporate mental health into multidisciplinary rounding to establish a non-judgmental culture of safety.
• Provide staff and provider training on common modalities to treat depression in pregnancy and postpartum.
• Engage in open, transparent, empathic and trauma-informed communication with pregnant and postpartum people and their identified support network to facilitate understanding of diagnoses, options and treatment plans.

7. Develop and maintain a set of referral resources and communication pathways between obstetric providers, community-based organizations, and state and public health agencies to address patient needs, including health-related social needs.

• Establish care pathways that facilitate coordination and follow-up among multiple providers throughout the perinatal period for pregnant and postpartum people referred to mental health treatment.
• Identify local resources for mental health conditions necessitating immediate treatment (e.g., postpartum psychosis, suicidality).
• Ensure clear protocol for communication between pediatric providers and OB/GYN and primary care providers when a parent has a positive screen at a well child visit.
• Incorporate resources that recognize the range of providers and services that can provide mental health support from community groups to licensed providers. Personalize referrals depending on the needs of the client.
  • Therapists, psychiatrists, doulas, midwives, social workers and new parenting groups.

8. Screen and provide linkage to resources for structural and health-related social needs that may impact clinical recommendations for treatment plans.

• Transportation, childcare and housing, among other factors, may impact a patient’s ability to adhere to a mental health treatment plan.

Source: Perinatal Mental Health Conditions Change Package.