Phase One: Plan

Steps

• Step 1: Establish Implementation Champions

  To begin, your practice will need to select two champions: an obstetric care clinician champion and a practice champion. The way this is done depends upon your practice. Typically, these are people who are motivated to integrate mental health care into the practice and who can authorize a quality improvement initiative or engage others who may be a good fit to serve in these roles.

  Obstetric care clinician champion: A licensed independent practitioner (eg, physician, nurse practitioner, or certified nurse–midwife) who is an advocate and figurehead and can engage and support obstetric care clinicians and staff in the QI process. The obstetric care clinician champion commitment is typically one to two hours per week for three to six months.

  Practice champion: A person typically working in an administrative role (eg, practice manager or administrative leader) who is dedicated to this QI effort and can spend the needed time to make sure the initiative moves forward. For the implementation to be successful, your practice will need to support and commit to the practice champion having the dedicated time and authority needed for the QI project. Time needed is estimated to be three to four hours per week for three to six months.

  Once designated, your obstetric care clinician champion and practice champion will begin to establish a time line and corresponding expectations using the Aims for Obstetrics Practices Integrating Perinatal Mental Health Care and implementation planning meetings and agendas documents.

• Step 2: Establish the Practice QI Team

  Your obstetric care clinician and practice champions will invite practice staff and obstetric care clinicians to become part of a practice QI team. Your practice QI team will tailor the procedures outlined in this guide to your practice and facilitate implementation of practice changes. See the practice QI team roles and responsibilities below for details. The practice QI team will be comprised of members representing the various roles in your practice, including obstetric care clinicians, nursing, mental health care professionals, administrative staff, and your practice manager. It is very important to include members who represent all areas that will be affected by the changes. Excluding administrative support staff who may be instrumental to screening tool distribution, for instance, may make smooth implementation of changes more challenging.

  Once your practice QI team has been formed, schedule a first QI team meeting. During this meeting, the implementation champions will need to …

  • Explain the vision for integrating perinatal mental health care into your practice. See Aims for Obstetrics Practices Integrating Perinatal Mental Health Care to learn what you need to integrate the full mental health care pathway into your workflow.
  • Explain the implementation process and expectations for each team member using the practice QI team roles and responsibilities document (DOC). Use the practice QI team responsibilities form (DOC) to document the roles of the individual team members in your practice once they are determined.
  • Schedule team meetings and study activities. The implementation meeting schedule (DOC) provides a template for scheduling meetings. The practice QI team meeting 1 agenda (ZIP) will guide you through the activities. To facilitate scheduling, Lifeline for Moms has created an Excel document titled Tool to Schedule Implementation Meetings and Create Practice Goals (XLSX) to help you schedule meetings and measure your progress towards goals.
• Step 3: Complete a Baseline Assessment

  The baseline assessment will help your practice QI team compare your current care and workflow to the Aims for Obstetrics Practices Integrating Perinatal Mental Health Care. This comparison will help you set goals for your practice and will also serve as a benchmark for measuring progress as you implement changes. The baseline assessment is comprised of two items that can be completed concurrently: the chart spot check form (DOC), which will help you review patient medical records (example also available (PDF)) and the practice self-assessment instrument. Please see the instructions for completing assessments (PDF) for directions on completing these documents. You will also find instructions for entering data into the tool to schedule implementation meetings and create practice goals (XLSX).

  Please also note that this is a good time to begin training for obstetric care clinicians and clinical staff. Find information about how to begin this process in Step 7.

• Step 4: Draft Specific, Measurable Perinatal Mental Health Care Goals

  To integrate a full mental health care pathway in your practice, make sure you have addressed all of the aims for obstetric practices integrating perinatal mental health care. While these aims may take time to accomplish, approaching them by setting discrete goals can provide a metered approach that may give your group a better understanding of your progress and a feeling of accomplishment as you go.

   

  Write at least one specific and measurable goal for each mental health care pathway aim. Goals should be specific, measurable, attainable, relevant, and time bound. Measurable goals facilitate progress monitoring, which can be done through electronic health record review, surveys, or interviews with staff and patients. For each goal, identify ways to measure progress toward goal attainment. Find a few goal examples in the implementation goal examples document (DOC) and a comprehensive list of goals in the aims, sub-aims, and goals document (DOC). You can select and customize any of these goal examples for your setting using the implementation goal template (DOC). A complete list of goals is also available in the “Goal Ideas” tab of the tool to schedule implementation meetings and create practice goals (XLSX), as described in the instructions for completing assessments (PDF). In the second practice QI team meeting, you will draft goals (ZIP). Prepare a starting goal draft before the meeting to advance goal setting during the meeting.

  It is critical that you develop a plan for communicating with the rest of the team so that you have an opportunity to elicit feedback before your implementation project begins, address any issues, and increase the likelihood of future success.

• Step 5: Develop a Workflow to Address Perinatal Mental Health Conditions

  Your baseline assessment provided you with insight into the parts of your current workflow that are strong and where there are opportunities to strengthen processes. The next step is to look at your current practice workflow to evaluate whether it includes every step of the full mental health care pathway.

   

  Elements of the Mental Health Care Pathway

  Consider these specific elements in your workflow. You can find resources, including screening tools and assessment and treatment algorithms, to support these steps in the Lifeline for Moms Perinatal Mental Health Tool Kit™.

   

   

  In the third practice QI team meeting you will work with your team to develop a workflow (ZIP). Use the Workflow for Perinatal Mental Health Care (DOC) as an editable guide for creating a perinatal mental health workflow customized for your practice. This example workflow will prompt you to think through all of the pathway components and give you examples of verbiage to use when speaking with patients that you can customize for your practice. Lifeline for Moms has also created a practice training on mental health care workflow template (PPT) to integrate your baseline assessment results, goals, and workflow. You can also share this template with staff during training.

  Prepare a draft workflow before the meeting to facilitate a workflow development discussion. Your workflow document will provide a visual representation for your practice QI team as you refine your workflow and may be helpful in describing your practice QI team recommendations to your obstetric care clinicians and staff.

  Considerations for Specific Parts of the Pathway

  Below are questions to consider as you determine how best to integrate perinatal mental health care into your workflow. Please note that this document (PDF) includes additional information and case examples.

  Education about Mental Health and Dissemination of Patient Materials

  An environment with ample displays of and access to mental health-related information can help to reduce stigma, empower perinatal individuals and their families to seek help, and let perinatal individuals know that they are not alone if they’re experiencing mental health conditions. Place posters, pamphlets, and other materials throughout your office and provide educational materials to all new prenatal patients and again to patients at their postpartum visit. The first administration of perinatal mental health screening tools should be accompanied by the provision of educational materials for the patient and family that outline relevant symptoms and resources. For an example of helpful materials, see the Action Plan for Mood Changes during Pregnancy and after Giving Birth and the Self-Care Plan (PDF).

  Having conversations about mental health early can decrease stigma, normalize screening and detection, and encourage perinatal individuals to discuss any mental health concerns. In addition, perinatal individuals, their families, and members of their support system should be encouraged to contact the practice if they are concerned about mental health. Let everyone know that you are there to help and you want them to reach out to you or your colleagues at the practice.

  Considerations:

  • Who will educate the patient about screening and mental health in general?
  • When will this be done? At the first prenatal visit or after a positive screen?
  • What materials will be given out before the screen? What materials will be given out to patients who have a positive screen? What materials will be given out to patients who have a negative screen?
  • Who will give out the materials?
  • In what format will the materials be given out? For example, will they be distributed as printouts, online, through a patient portal, or over email?

  Mental Health Care Pathway: Detect and Assess

  In some practices, screening tools are sent to perinatal individuals electronically in advance of appointments. It is important to think through what the gap in time may be between a person completing the screening tools and someone seeing the responses. Practices should establish processes by which a score cut-off or positive response to a self-harm question triggers an alert or notification so that it can be addressed in a timely manner.
  
  Visit ACOG’s screening page for information on screening timepoints and administering and scoring screening tools and for specific information on bipolar disorder. You’ll also find a full composite screening test for use at baseline that contains several commonly used validated screening instruments for depression, bipolar disorder, generalized anxiety disorder, and posttraumatic stress disorder to provide a comprehensive assessment of a perinatal individual’s mental health.
  
  It's important to note that perinatal individuals who have a history of depression or other mental health conditions, who have previously taken psychiatric medications, or who have screened positive for mood or anxiety symptoms in a pregnancy or postpartum episode often need more frequent monitoring. Readministering screening tools monthly and as needed can facilitate monitoring of symptoms, treatment effectiveness, and follow‐up care with the goal of full symptom remission.

  Considerations:

  • How and when will the screening be completed? For example, will the screening be paper based or electronic? Will screening be completed in advance of an appointment or in person?
  • What are next steps after a screening is completed? If screening is completed in advance of an appointment, is the form printed and returned or completed electronically? If screening is to be completed in person, will it take place at the time of check-in, at time of appointment registration, or upon rooming?
  • If a screen is positive, how is the health care professional to be notified so that an assessment is completed?

  It is imperative that screening instruments be scored before a patient leaves their appointment so that clinicians can discuss and address positive and negative screening results and provide an assessment as needed. The responsible obstetric care clinician should be made aware of positive screening scores if they themself did not administer the screening tools or do the scoring so that they can perform an assessment or designate an appropriate person to do so.

  It is also important to think through how your practice will respond to an emergency mental health situation. Ask yourself: Is there a practice safety protocol, and if one is in place, does it need to be revised? What responses to specific questions alert your practice of the need for further assessment? Who performs the assessment following these responses? If a patient needs an emergency psychiatric evaluation, what are the next steps, when and where are those steps taken, and by whom is the evaluation administered?

  When screening for suicidal ideation, begin with the patient’s response to question 10 on the Edinburgh Postnatal Depression Survey (EPDS) or question 9 on the Patient Health Questionnaire-9 (PHQ-9). If the patient answers with anything other than “never,” consider following up by having the obstetric care clinician administer the patient safety screening test to stratify the patient’s risk level.

  The Lifeline for Moms Perinatal Mental Health Tool Kit™ contains algorithms to help you assess the results of the screening tests.

  Considerations:

  • How will the screening tool be scored? For example, will it be scored electronically or both electronically and manually?
  • Who will review the results and when? If the screenings are printed, will the medical assistant or registered nurse review? Will the reviewer then communicate results to the obstetric care clinician?
  • When will the screening results be reviewed if they’re administered electronically? For example, will the results be reviewed when the screening test is completed or at the time of the visit? Will there be a gap in time between when a patient completes the screening test and when someone will see the results?
  • What systems or alerts are in place if a score is particularly high or if the patient answers positively to self-harm questions?
  • Who will discuss the screening test results with the patient?
  • What will they say to the patient? For more information, see Talking to Your Patient about Mental Health and Screening.

  After you have developed a process for detection and assessment, you will need to ensure that your screening test records are properly stored and easily accessible. After a patient completes the screening test, the test should be scored, entered into the patient’s chart, and included in an electronic medical record.

  Considerations:

  • How will results be saved?
  • Where are results available?
  • If using paper screening tools, are the results scanned into the electronic medical record or documented in progress notes?
  • Can the results be found in integrated electronic forms, a flow sheet, or a problem list?

  Mental Health Care Pathway: Treat

  As you consider treatment options, keep in mind that the Lifeline for Moms Perinatal Mental Health Tool Kit™ offers treatment algorithms to assist in managing mental health conditions. As a reminder, it is important to have a system in place to support treatment options.

  Therapy

  Considerations:

  • Who will discuss treatment with the patient?
  • What is the procedure for facilitating a patient’s entry into therapy? For example, will you make a referral, provide the patient with a list of mental health practitioners, or direct the patient to a website for reference?
  • Who will make the referral or provide resources to patient?
  • When will the referral be made?
  • Who will follow up with the patient to check on the status of the referral?
  • What materials will be provided to the patient?

  Medication Treatment

  When discussing treatment options, provide a balanced perspective of treated versus untreated illness and associated risks and benefits. Let perinatal individuals know that their health, including their mental health, is a priority, and that you will be checking in regarding mental health regularly throughout obstetric care.

  Considerations:

  • When are obstetric care clinicians expected to prescribe?
  • Who will prescribe medication? What is the plan for medication if the obstetric care clinician does not prescribe? Would the clinician provide a referral for psychiatric care?
  • Who will make the referral?
  • What is the plan for referral?
  • What resources will be given to the patient?
  • What is the plan if there is a long wait for an appointment with a psychiatric care professional?
  • Would the clinician provide bridge treatment to support the patient in the time between referral and appointment?

  If assistance with treatment is needed, clinicians can call their state perinatal psychiatry access program with questions about the diagnosis and management of perinatal mood and anxiety disorders. If there’s no program in the state, Postpartum Support International’s Perinatal Psychiatric Consult Line is available to all clinicians throughout the U.S. Call (877) 499-4773 or visit the website to schedule a one-on-one consultation by phone with a perinatal psychiatry expert.

  Mental Health Care Pathway: Follow-Up

  Follow-up includes monitoring the effectiveness of a patient’s treatment plan during prenatal and postpartum care and, for patients who continue to have mental health conditions when postpartum care is completed, facilitating continuing mental health care for the patient.

  Considerations:

  • How will you know if the patient is responding to mental health treatment? Will you have a process for repeat screening at a time other than the standard time periods?
  • When will you rescreen? How often will you rescreen?
  • What screening tool will be used?
  • Who will do the repeat screening?
  • What happens when a screen is positive for the first time at the postpartum visit? What steps will you take to connect the patient to mental health care?
  • What happens when a screen remains positive at the postpartum visit because the patient has not responded to the treatment? How will you ensure that the patient has ongoing mental health care?

   
• Step 6: Identify Tasks, Roles, and Responsibilities to Achieve Goals

  In this step, you will determine how to accomplish your goals. The goals and tasks example (DOC) illustrates two ways of breaking down goals into tasks. You’ll note that one staff person is assigned to each task and that each task is very specific. To determine how to achieve your goals, copy and paste your practice goals into the goals and tasks blank template (DOC) and then add the associated tasks as you identify them. Below are some questions to help you think through what tasks need to be completed to achieve your goals:

  • What needs to happen to accomplish the goals you have set?
  • What supplies, equipment, materials, and space are needed?
  • Who will be involved with or affected by the task being accomplished?
  • Who is responsible for carrying out each task?
  • Who will be responsible for ensuring that tasks are completed?
  • Can tasks related to multiple goals be consolidated?
  • Is there an order in which the tasks for a given goal need to be completed?
  • Can the goal be completed within the designated period?

  As your practice QI team works through defining tasks, you may decide to modify goals. For example …

  • Change the target date for accomplishing the goal
  • Change the benchmark for success
  • Change a task to a goal if you find the goal to be unattainable after defining related tasks

  Be sure to obtain input from those involved with and affected by the implementation of each goal, as they will have invaluable information about what makes the most sense for the implementation process and what training may be required for success. Getting input is particularly important when the successful attainment of the goal rests upon people in multiple roles, such as nurses, administrative support staff, and obstetric care clinicians.

  Developing a Resource and Referral Directory

  When creating your list of goals, be sure to address Aim 5, Develop and Use a Repository of Mental Health Resources and Treatment Referral Sources Tailored to the Needs of Your Patient Population. When screening is implemented in your practice workflow, it is important to have identified mental health treatment and consultation resources. Your directory should include information about and from the following resources:

  • Local and regional listings for patient support and treatment
  • Your state perinatal psychiatry access program, as applicable; visit the website to find out if your state has a program
  • Postpartum Support International (PDF)
  • Federal Communications Commission’s 211 service, operated by local organizations
  • Patient warmlines and hotlines
  • Consultation lines for physicians and other obstetric care clinicians

  Complete this step during the fourth practice QI team meeting (ZIP).