Collaborative Improvement & Innovation Networks (CoIINs) are large interdisciplinary teams setup by HRSA to come up with innovative solutions to complex problems. Along with three other states, California was assigned to take part in the Preconception CoIIN aimed at improving preconception screening and counseling in the medical setting more broadly. In 2018 the California state team identified two sites to innovate in this area: the Sutter Family Medicine Residency Program in Northern California, and Unicare Community Health Center in Southern California.

Sutter Health’s Project:
Through the human-centered design process (shown below), Sutter’s team in Sacramento and Davis constructed a plan involving multiple strategies to improve the rate of pregnancy intention screening in the outpatient setting. 

Strategies were tested, studied and continually adjusted from April to June 2019 before rolling out the project more broadly between the Sacramento and Davis care centers. Chart audits were conducted regularly and feedback was elicited from physicians to improve the project and to address concerns from physicians with low participation.

The final product included the following pieces:
1)    A screening tool developed for the project was placed in all new and established patient visit note templates for all providers. This both reminded the provider to screen their patient and also took the provider through the requisite screening questions depending on their answers to questions. Examples are shown below.

How screening tool appears in the note template

Example of one decision tree within the screening tool as answers are entered

2)    A Best Practice Advisory alert was programed into EHR to pop up whenever a patient was prescribed a medication known to be problematic in pregnancy. Example shown below.

3)    Providers with low screening rates on chart audits were approached regularly to address concerns and providers with high screening rates on chart audits were publicly praised each month.

The outcome:
In our full-spectrum family medicine practice, the percentage of patients that fell into the study population ranged from 18% to 26%. A pregnancy intention screening rate of 91% of all eligible patients was achieved during the study period with an increase in use in birth control methods in the cohort. This included a 30% increase in number of IUDs and 40% increase in hormonal implants placed in our clinic over the study period. Additionally, patients reported feeling appreciative of their physicians screening them and physicians did not feel that the addition was onerous or demanding of clinic time.

The bottom line:
This study shows that the above system aimed at improving pregnancy intention screening works to improve screening rates and increase birth control utilization in our clinic population. The above strategies are generalizable to other systems of care and lead to higher patient satisfaction without sacrificing physician satisfaction.

Additional Preconception CoIIN Screening Tools: