Article Figures & Data
Figures
- Figure 1.
Design of the maternal health QI intervention study.
FQHC = Federally Qualified Health Center; QI = quality improvement.
Tables
Study Aim Measure Data Source Quantitative aim: identify if and the extent to which the QI intervention improved primary care use for high-risk prenatal patients Structure measure: criteria for defining high-risk patients have been defined and implemented Internal FQHC tracking Structure measure: a registry to identify high-risk patients is in place and implemented Internal FQHC tracking Structure measure: a process to coordinate care for high-risk patients is in place and implemented Internal FQHC tracking Process measure: cumulative number of clinic sites implementing Internal FQHC tracking Process measure: number of staff trained Internal FQHC tracking Outcome measure: change in proportion of high-risk patients with a documented primary care visit within 6 months postdelivery, compared between baseline (calendar year 2020) and postimplementation (calendar year 2021) EHR extraction and manual record reviews Outcome measure: change in proportion of high-risk patients with a documented postpartum visit, compared between baseline (calendar year 2020) and postimplementation (calendar year 2021) EHR extraction and manual record reviews Qualitative aim: assess the experience of FQHCs participating in the QILC to gain an understanding of the challenges and successes of participating and of implementing the QI activities FQHC staff experience of participating in QILC Semistructured key informant interviews of 11 health care professionals EHR = electronic health record; FQHC = Federally Qualified Health Center; QI = quality improvement; QILC = Quality Improvement Learning Collaborative.
Quantitative Aim FQHC Perinatal Care Providersa,b,c Perinatal Support Staff/Nursesb,c Prenatal Patientsb,d Prenatal Patients Who Deliveredb,d Clinic Sitesb,d FQHC A 1-5 6-10 1-500 1-500 10-20 FQHC B 1-5 6-10 1,001-2,999 500-1,000 10-20 FQHC C 1-5 1-5 3,000-5,000 1,000-2,999 10-20 FQHC D 6-10 6-10 501-1,000 1-500 10-20 FQHC E 1-5 1-5 501-1,000 1-500 1-5 FQHC F 6-10 10-20 3,000-5,000 1,001-2,999 1-5 Total 33 46 11,430 6,001 61 Qualitative Aim Key Informante Leadership Role Case Management Role Clinician Rolef Other Role A1 X A2 X B1 X B2 X X C1 X D1 X D2 X X D3 X X E1 X X F1 X F2 X X ↵a Physicians, nurse practitioners, physician assistants, and midwives.
↵b Ranges used to help ensure anonymity of participating sites.
↵c Data reported to the research team, 2021.
↵d Publicly available data from the Health Services and Resources Administration Uniform Data System, 2021.29
↵e For key informant identifiers, letter refers to clinic, number refers to participant in order of interviewing.
↵f An employee with a clinical position (eg, physician, nurse); titles defined this way to also ensure anonymity.
- Table 3.
Structure and Process Measures for the Maternal Health QI Intervention, Before, During, and After Implementation
Measure Before Implementation Midpoint of Implementation After Implementation Sustained Implementation Structure measures FQHCs with high-risk criteria defined and implemented, No. (%)a 3 (50) 5 (83) 6 (100) 5 (83) FQHCs with a registry to identify high-risk patients in place and implemented, No (%)a 3 (50) 5 (83) 6 (100) 5 (83) FQHCs with a process to coordinate care for high-risk patients in place and implemented, No. (%)a 0 (0) 5 (83) 6 (100) 5 (83) Process measures Perinatal staff trained, No. (%)b 0 (0) 50 (63) 54 (68) NA Clinic sites implementing initiative, No. (%)c 0 (0) 16 (26) 19 (31) 18 (30) FQHC = Federally Qualified Health Center; NA = not applicable.
↵a Total number of participating FQHCs was 6.
↵b Total number of perinatal staff was 79 (33 perinatal care providers + 46 perinatal support staff and nurses, as shown in Table 2).
↵c Total number of clinic sites was 61, as shown in Table 2.
Notes: Before implementation (baseline): calendar year 2020. Midpoint of implementation: June 2021. After implementation (postimplementation): calendar year 2021. Sustained implementation: after December 2021.
- Table 4.
Outcome Measures for the Maternal Health QI Intervention, Before, During, and After Implementation
Measure Before Implementation Midpoint of Implementation After Implementation P Valuea Postpartum visitsb Total high-risk prenatal patientsc 61 64 96 No. (%) with a postpartum visit 51 (83) 45 (70) 87 (91) .04 Primary care visitsd Total high-risk prenatal patientsc 102 87 134 No. (%) with a primary care visit 26 (25) 38 (44) 97 (72) <.001 QI = quality improvement.
↵a Comparing values before implementation (baseline) and after implementation (postimplementation).
↵b Within 6 weeks of delivery.
↵c Difference in denominators is due to a preexisting clinic policy for 1 site that refers high-risk patients for prenatal and postpartum care.
↵d Within 6 months of delivery.
Note: Before implementation (baseline): calendar year 2020. Midpoint of implementation: June 2021. After implementation (postimplementation): calendar year 2021. Sustained implementation: after December 2021.
- Table 5.
Themes and Selected Quotes From Key Informant Interviews of Participants in the Maternal Health QI Intervention
Theme Quote Facilitator: buy-in “Because it’s been a project that’s been blessed by the medical director and by the administration team that we’ve been able to get the resources that we needed and the right people at the table to be able to make this happen … So, having this team-based approach and having the primary stakeholders in terms of the administration and the medical director approving this, I feel like that was hugely instrumental in making this project as successful as it is.” – Key informant A2 Facilitator: flexibility “It was like, ‘However you wanna’ do it, as long as you can get us these key things, it’s however you wanna’ create it.’ And so that gave us opportunity to really look at our program processes and to fine tune some of those areas that were weak. So, it actually helped us, because we know we needed to do it, but we actually have the focus on it. We had a reason why that we needed to focus.” – Key informant F2 Facilitator: collaboration “But also, when they show us different metrics from other health centers, it helps us to see like, ‘Okay. Are we just doing really, really badly? Or is this something that we’re all struggling with, so therefore, it’s good to be altogether, struggling together, so we can come up with a better solution?’ I like that.” – Key informant A1 Barrier: staffing “Well, my challenge is that I’m the only person doing the study, personally … it’s not sustainable for me alone to be running this program. As they add more and more duties to my job, I spend less and less time on the high-risk list. I can’t look at it every day. I used to be able to eyeball it every day, but now I can look at it every other day, and now I can really only look at it a couple times a week.” – Key informant D2 Barrier: infrastructure “Barriers are it’s not easy to put everyone on an Excel spreadsheet. And the way I did it was scanning the schedules every day and looking for anyone who was scheduled for a new OB appointment. But sometimes patients were misscheduled under new patient, so I might miss them … And also, that’s time-consuming and then cutting and pasting them, and putting every detail on this spreadsheet … But I do feel like there’s got to be an easier way to pick up these patients. And I know the [central organization] did implement a little bit of a new system for capturing them, but we haven’t started that yet.” – Key informant D1 FQHC = Federally Qualified Health Center; OB = obstetrics; QI = quality improvement.
Note: For the key informant identifier, the letter refers to clinic, and the number refers to participant in order of interviewing.
SUPPLEMENTAL MATERIALS IN PDF FILE BELOW
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