Improving the Quality and Efficiency of the Prenatal Care Coordination Program

Summary

Impact Statement:

Wisconsin’s Prenatal Care Coordination (PNCC) program has been shown to decrease low-birth weight among single women, increase family support and involvement of the father, decrease preeclampsia, and decrease smoking among pregnant women. Clark County health department used QI to achieve 100% compliance with PNCC program guidelines, streamline the billing process and increase revenue from the program.

Summary:

PLAN: Identify an Opportunity and Plan for Improvement

1. Getting Started

Problem: Prenatal Care Coordination (PNCC) services have been provided in Clark County for many years. However, the health department recognized that the program has not been evaluated or updated since 2007. The policy and procedure were outdated and did not adhere to the requirements in the Wisconsin (WI) Medicaid PNCC Services Handbook, program forms were outdated, no flowsheet/checklist was in place to ensure consistency and chart compliance, and staff were not properly oriented to the program. Additionally, no clear billing guidelines were in place.

2. Assemble the Team

The health department committed the time of the lead public health nurse (PHN) as the project coordinator, as well as staff PHNs and the health officer to assist with the project.

• Brittany Mews, RN BSN-Lead PHN
• Cortney Olejniczak, RN BSN-PHN
• Sabrina Meddaugh, RN BSN-PHN
• Susan Backaus, RN BSN-PHN
• Robert Leischow, MPH-Health Officer

3. Examine the Current Approach

After a chart review process, the department found none (0%) of the PNCC charts were in compliance nor did they reflect the WI Medicaid PNCC Services Handbook. The department also tracked its PNCC Medicaid reimbursement from 2007 through 2011 and discovered it was being reimbursed only about 30% of the maximum allowable reimbursement per client.

Aim Statement: By November 30, 2012, after Clark County Health Department’s PNCC policy and procedure has been updated reflecting the WI Medicaid PNCC Services Handbook, program forms have been updated, a PNCC flowsheet/checklist developed, staff training conducted on the PNCC revisions, and 100% of the PNCC client charts will be in compliance after a chart review process.

Sub-Aim Statement: Billing guidelines will be established. These guidelines will result in an increase in Medicaid reimbursement for the PNCC program from an average of $270.00 per client in 2011 to an average of $540.00 or more per client in 2012, a 200% projected increase in revenue. (Total maximum Medicaid reimbursement is $887.46 per client.)

4. Identify Potential Solutions
• Update the PNCC policy and procedure.
• Update all program forms.
• Develop a chart audit flowsheet/checklist.
• Train staff on the new revisions.
• Establish billing guidelines.

5. Develop an Improvement Theory

Updating the PNCC policy and procedure and program forms, developing a chart audit flowsheet/checklist, training staff, and establishing billing guidelines will result in 100% of charts being in compliance and a 200% increase in Medicaid revenue.

DO: Test the Theory for Improvement

6. Test the Theory

The project coordinator reviewed the WI Medicaid PNCC Services Handbook protocols, updated the PNCC policy and procedure to reflect the Medicaid guidelines, updated all program forms, developed a chart audit flowsheet/checklist as well as a billing guideline cheat sheet, and trained staff on the new revisions.

A trial process began on August 15, 2012. Staff followed the newly developed policy and procedure and used the new forms, including the billing cheat sheet. Average Medicaid reimbursement was tracked per client.

STUDY: Use Data to Study Results of the Test

7. Study the Results

In October 2012, two PNCC chart audits were conducted. Both of these charts were 100% in compliance, using the newly developed chart audit flowsheet/checklist. The preliminary results of 100% chart compliance compared to the baseline data of 0% chart compliance indicate the test has been successful.

In October 2012, four clients' Medicaid reimbursement totals were analyzed. These four clients were a part of the new program revisions, and the nurses used the new billing guidelines established. The average reimbursement the department received between these four clients was $671.61 per client, a 250% increase (+$406.91) from the 2011 average reimbursement of $270.00. In addition to the Medicaid increase, it was discovered the Medicaid denials also decreased. These data signified that the billing guideline cheat sheet helped increase the revenue and streamlined the billing process.

ACT: Standardize the Improvement and Establish Future Plans

8. Standardize the Improvement

On November 1, 2012, the health department adopted and standardized the process. The health department's director formally approved the new PNCC policy and procedure and program forms, including the billing guideline cheat sheet.

9. Establish Future Plans

Additional PNCC chart audits will be performed each quarter to ensure compliance. The department plans to sustain the momentum of the project by reviewing and updating the program policy and procedure at least annually, updating program forms as needed, and tracking Medicaid reimbursement revenue.

Organization that conducted the QI initiative:

Clark County Health Department

Citation:

Mews, B. Public Health Quality Improvement Exchange. Improving the Quality and Efficiency of the Prenatal Care Coordination Program . Mon, 02/13/2017 - 12:20. Available at http://phqix.org/content/improving-quality-and-efficiency-prenatal-care-coordination-program. Accessed April 16, 2024.

Background and Aim

Aim statement:

By November 30, 2012, after the Clark County Health Department’s PNCC policy and procedure has been updated reflecting the WI Medicaid PNCC Services Handbook, program forms have been updated, a PNCC flowsheet/checklist developed, and staff training conducted on the PNCC revisions, 100% of the PNCC client charts will be in compliance after a chart review process. Sub-Aim Statement: Billing guidelines will be established. These guidelines will result in an increase in Medicaid reimbursement for the PNCC program from an average of $270.00 per client in 2011 to an average of $540.00 or more per client in 2012, a 200% projected increase in revenue. (Total maximum Medicaid reimbursement is $887.46 per client.)

Need For The QI Initiative:

As public health services are critically important to the health and wellness of mothers, mothers-to-be, and newborns, ensuring that PHNs consistently implement and adhere to best-practice PNCC guidelines/recommendations warranted attention. The department also discovered that its PNCC Medicaid reimbursement was significantly lower than the maximum allowable reimbursement per client and realized this was another area of improvement. The health department’s QI team collaboratively chose the project, committed the time of the lead PHN as the project coordinator, and added three additional PHNs and the health officer for assistance.

Area for Improvement:

The PNCC program is a Medicaid and BadgerCare Plus benefit that helps pregnant women get the support and services they need to have a healthy baby. The program was introduced in 1985 as a Medicaid benefit to impact low birth weight and prematurity. Services include outreach and assistance-finding services in the client’s community, initial assessment, providing personal one-on-one support, listening to client concerns, answering questions, and developing a personalized confidential plan of care from pregnancy to delivery to the postpartum/newborn care stage. Additionally, the program provides nutrition counseling, health education on a variety of topics, and ongoing care coordination and monitoring. The goal of the PNCC program is to improve birth outcomes among women who are deemed at high risk for poor birth outcomes based on the PNCC pregnancy questionnaire. Medicaid-eligible pregnant women with a high risk for adverse pregnancy outcomes during pregnancy through the first 60 days following delivery qualify for the program. Research has been conducted on the benefits of women enrolled in the PNCC program. Findings showed that single women are less likely to deliver low-birth-weight babies (Baldwin et al., 1998), and women are more likely to seek support from family and friends, have a labor support person, and involve the father of the baby (Olds et al., 1986). The research found women have increased weight gain (Olds) and increased vitamin use (Piper et al., 1996). Women who have been enrolled in the program have attended more medical prenatal visits (Hardy), have a reduction in preeclampsia (Hardt et al., 1987), and have made significant reductions in smoking behaviors (Olds et al., Middelton et al.; Reicketts et al. [2005]). In Clark County in 2010, 15.4 per 1,000 births were to teen mothers ages 15–19. A total of 17% of the total county births in 2010 were to single mothers, and 5% of the births in the county in 2010 were low-birth-weight infants. In 2010, 61% of births were to mothers who received first-trimester prenatal care. (Data obtained from the Maternal and Child Health - Wisconsin Statistics and Wisconsin Births and Infant Deaths, Wisconsin Department of Health Services, Division of Health, Center for Health Statistics.) The provision of PNCC services has been occurring in Clark County for many years. However, the health department recognized that the program has not been evaluated or updated since 2007. The policy and procedure were outdated and did not adhere to the requirements in the WI Medicaid PNCC Services Handbook, program forms were outdated, no flowsheet/checklist was in place to ensure consistency and chart compliance, and staff were not properly oriented to the program. Additionally, no clear billing guidelines were in place.

Root Cause:

People, resources/materials, time, and training/orientation

Planning and Execution Details

QI Implementation:

The quality improvement (QI) team started the initiative of improving the quality and efficiency of the PNCC program by describing the current PNCC process. The QI team involved all relevant program staff members who work in the PNCC program and asked for their input. From this process, the QI team developed a flowchart. Next, they collected data on the current process. As a result, they discovered none (0%) of the PNCC charts were in compliance nor did they reflect the WI Medicaid PNCC Services Handbook. The QI team realized the department had a significant staff turnover rate from 2010 to 2012. Last, they tracked their Medicaid reimbursement from 2007 through 2011. Their Medicaid reimbursement per client was the following: • 2007 = $160.87 • 2008 = $168.69 • 2009 = $135.41 • 2010 = $221.49 • 2011 = $270.70 The QI team's current reimbursement was only 30% of the maximum allowable reimbursement per client. Maximum reimbursement per client is $887.46. The QI team identified possible causes of the problem using a fishbone diagram. The four major cause categories included people, resources/materials, time, and lack of training/orientation. Next, the QI team identified potential solutions including updating the policy and procedure to reflect the WI Medicaid PNCC Services Handbook guidelines, updating all program forms, developing a chart audit flowsheet/checklist, training staff on the new revisions, and establishing billing guidelines. The QI team formulated an improvement theory. Updating the PNCC policy and procedure and program forms, developing a chart audit flowsheet/checklist, training staff, and establishing billing guidelines will result in 100% of charts being in compliance and a 200% increase in Medicaid revenue. The QI team developed a detailed action plan, identifying what needed to be done, who was responsible, and when each action should be completed by. This plan was developed with the PNCC staff members. The action plan was as follows: • Read and become familiar with the WI Medicaid and Badgercare PNCC Services Handbook guidelines/protocol. (All PHNs: Sue/Brittany/Sabrina/Cortney) - Billing codes/documentation procedure - Required program chart forms - *Complete by July 15, 2012. • Make PNCC billing cheat sheet. (Brittany) - *Complete by July 15, 2012. • Update health department’s PNCC policy and procedure to reflect WI Medicaid and Badgercare Services Handbook guidelines. (Brittany) - *Complete by July 15, 2012. • Update all program forms. - If form is not in an electronic version, type it. (Cortney/Brittany) -- Save all forms to share drive, PNCC, program forms. (Cortney/Brittany) - Get rid of unnecessary forms. (Cortney/Brittany) -- Remove from share drive. -- Remove from cubby shelf. - *Complete by July 15, 2012. • Develop PNCC chart audit flowsheet/checklist form. (Brittany) - Save in share drive, PNCC, program forms. - *Complete by July 15, 2012. • Train staff on the new PNCC program revisions. (Brittany) - *Complete by August 15, 2012. • Continue to track Medicaid revenue reimbursed per client (total at end of 2012–2013; monitor for potential increased revenue). (Bonnie: *ongoing) • Begin trial of new process using new forms (including billing), following updated policy and procedure, and using PNCC chart audit/flowsheet/checklist for every client. - *Begin trial on August 15, 2012. • Check/Study: By October 15, 2012, complete chart audits (tweak if necessary). • Act: By November 01, 2012, adopt, adapt, or abandon. To test the initiative, the project coordinator reviewed the WI Medicaid PNCC Services Handbook protocols, updated the PNCC policy and procedure to reflect the Medicaid guidelines, updated all program forms, developed a chart audit flowsheet/checklist as well as a billing guideline cheat sheet, and trained staff on the new revisions. A trial process began on August 15, 2012. The PHNs who carry out the PNCC program followed the newly developed policy and procedure and used the new forms, including the billing cheat sheet, on new clients. This process took place during home visits and office interactions. A total of four clients was exposed to the new initiative. Two PHNs were involved in this trial process. In addition, the PHNs and program assistant tracked the average Medicaid reimbursement per client for these four clients.

Focus activities

Maternal and Child Health Services:

MCH home visits

Prenatal care

QI Methods:

PDCA/PDSA Cycle (Plan, Do, Check/Study, Act)

QI Tools:

Check Sheet

Fishbone Diagram

Flow chart

Other QI tools:

Storyboard

Aim Statement Template

QI Tool Documentation:

fishbone diagram.doc

PNCC Storyboard.doc

Aim Statement Template info-pncc.docx

PNCC Flowchart.doc

PNCC Chart Flowsheet-Checklist.doc

PNCC Policy.docx

PNCC Billing Sheet.docx

master pncc packet-scanned.pdf

Initiative Dates:

4/1/12 to 11/30/12

Initiative Duration:

Between 6-12 months

Methods of evaluation:

The QI team measured the impact of the PNCC initiative by conducting chart audits and also by tracking Medicaid reimbursement totals for each client. Data sources used included the PNCC chart audit flowsheet/checklist, the new billing guideline cheat sheet, and billing data.

Other Information:

The QI team faced some barriers and challenges throughout the project. The first challenge is when the department first started the project, the QI team had minimal experience using QI tools. They overcame this by using the public health memory jogger pocket guide of tools for QI. This guide was concise and user-friendly. The team also used the National Network of Public Health Institutes (NNPHI) Web site's public health performance improvement toolkit, which was helpful. Last, if the team had questions, the QI coach Jack Moran was able to help and provide the right resources. A second challenge was finding time to dedicate to the program due to other PHN duties and responsibilities. The QI team overcame this obstacle by dedicating a designated time each week (even 15 minutes) to work specifically on the QI project. The team also divided tasks among staff members to decrease the workload burden on just one person. Other lessons they learned throughout the QI project were: be patient, don’t procrastinate, use your resources, and reach out to available QI experts. Last, the department learned that QI work is beneficial and needs to be a continual process.

Supplemental Materials:

Storyboard

Supplemental Files:

Attachment	Size
PNCC Storyboard.doc	290 KB

Results

Measurable QI Outcomes:

In October 2012, two PNCC chart audits were conducted. These two charts were clients included in the new program trial process. The flowsheet/checklist that was created as a result of this initiative includes all the PNCC program requirements. When PHNs use this checklist, they can ensure their client’s chart is in compliance. They first perform a self-audit to ensure no components are missing. Following their self-audit, the department had another PHN perform the chart audit. Both of these charts were 100% in compliance using the newly developed chart audit flowsheet/checklist. The preliminary results of 100% chart compliance compared with the baseline data of no (0%) chart compliance indicate the test has been successful. The health department’s program assistant tracks each client’s Medicaid reimbursement in a Microsoft Excel spreadsheet database. Each month, the PHN provides the program assistant with the client’s monthly billing form using the newly developed billing cheat sheet. The program assistant then bills for the activities and units incurred during the month's time. Once the client has delivered her child, and the PHN closes the case, the total amount reimbursed from Medicaid for that particular client is analyzed and tracked. In October 2012, four clients' Medicaid reimbursement totals were analyzed. These four clients were a part of the new program revisions, and the nurses used the new billing guidelines established. The average reimbursement the department received between these four clients was $671.61 per client, a 250% increase (up $406.91) from the 2011 average reimbursement of $270.00. In addition to the Medicaid increase, it was discovered the Medicaid denials also decreased. These data signified the billing guideline cheat sheet helped increase the revenue and streamlined the billing process.

Other QI Outcomes:

The QI initiative resulted in a determination that policies and procedures need to be updated annually. This project has driven the health department to review and update every policy and procedure with staff members each year.

Future Plans:

On November 1, 2012, the health department adopted and standardized the process. The new PNCC policy and procedure and program forms, including the billing guideline cheat sheet, were formally approved by the health department’s director. Additional PNCC chart audits will be performed each quarter to ensure compliance. The department plans to sustain the momentum of the project by reviewing and updating the program policy and procedure at least annually, updating program forms as needed, and tracking Medicaid reimbursement revenue.

Improving the Quality and Efficiency of the Prenatal Care Coordination Program

Summary

Background and Aim

Planning and Execution Details

Results

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Accreditation Details

Contact Information of the Submitter

QI Spotlight

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Improving the Quality and Efficiency of the Prenatal Care Coordination Program

Summary

Background and Aim

Planning and Execution Details

Results

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Accreditation Details

Contact Information of the Submitter

QI Spotlight