Introduction/Background: Depression is a serious mental health issue and is the number one complication of childbirth. Postpartum depression (PPD) is a treatable medical illness that affects 15-20% of women. The rate increases with low socioeconomic status. 50% of individuals with PPD are never detected because symptoms overlap with usual discomforts: fatigue, difficulty sleeping. PPD occurs from a few weeks up to 1 year and is most common in the first 3 months; it can occur with any pregnancy i.e. first, second. Only 15% of all women with perinatal mood/anxiety disorders including PPD get professional treatment. It is important that women in the postpartum period be assessed for actual and potential risk factors and educated about signs and symptoms, available resources and treatment options.
The UPMC Health Plan, a part of the UPMC Health System, is a managed care organization located in Pittsburgh, PA. The UPMC Health Plan shares a common set of values with the rest of the system to create a consistent UPMC experience across the continuum for the patients, health plan members, employees, and the communities it serves. A telephonic maternity care management program is available for pregnant members with commercial health insurance, as well as members enrolled in government programs such as Medical Assistance. The program is staffed by registered nurses with extensive obstetrical nursing experience functioning in the role of maternity care managers. The role of the maternity care manager is to contact members by telephone and complete a prenatal health review assessment, offer prenatal and postpartum education and appropriate resources. The goal is to promote pregnancy wellness and encourage positive outcomes for both mother and baby.
Purpose: The purpose of this project was to ensure members enrolled in the maternity program are screened consistently for postpartum depression and to increase care managers comfort level with screening by providing education and ongoing support. A standardized care pathway for PPD was also developed to ensure consistency when members are at risk or identified with postpartum depression.
Methods: With the support of Sigma Theta Tau International (STTI) Maternal Child Health Nursing Leadership Academy (MCHNLA), sponsored by Johnson and Johnson, this fellow; Kimberly Hite, the leadership mentor; and Katheryn Arterberry, the STTI MCHNLA faculty advisor, participated in a leadership program to gain the leadership skills necessary to facilitate a quality improvement project focused on improving maternal-child outcomes. The Fellow had a team that consisted of four maternity care managers, three pediatric care managers, a pediatrician, a social worker and a maternity liaison. To help develop the project, a Logic Model framework was used. A review of current evidence based practice was done by the team focusing on risk factors, diagnosis, treatments and resources. The staff was educated via a PowerPoint presentation and provided with a resource packet. A standardized postpartum depression care pathway was developed as well and the maternity staff care managers were educated on the use of the pathway.
To evaluate the project, a pre/post education survey, using a Likert scale was given to all maternity care managers to assess their comfort level with identifying risk factors and assessing members for postpartum depression and referring for treatment. An audit tool was developed to assist with data collection focusing on recorded calls and clinical documentation observing for a change in behavior when using the Patient Health Questionnaire (PHQ-9) tool and asking questions verbatim. Call and chart audits are planned for three month intervals to evaluate change in care manager behavior. Ongoing reinforcement and education will be provided to current and new staff to improve consistency of assessments.
Results: The pre and post education surveys showed improvement in overall comfort assessing for postpartum depression. Call and chart audits are still being collected and will be evaluated. Feedback is provided to individuals as well as a group on an ongoing basis. Staff has been provided with a postpartum depression resource folder. A postpartum depression workflow has been designed, staff educated on its use and workflow implemented.
Conclusions: The project found that staff were not consistently asking postpartum assessment questions verbatim, creating variation among the care managers and education was not always provided during postpartum calls. The expectation is that call consistency and referrals will improve over time with education and the use of the care pathway. The project opened doors for communication with other disciplines related to the continuation of assessments and ongoing evaluation of members identified with postpartum depression. The goal is to provide accurate and consistent evaluation and referrals for all members. This will improve outcomes not only for the member but for her entire family.
Leadership role: This fellow has learned to adopt the five Kouzes and Posner leadership principles in her role as researcher and project leader. She is committed to being an example of professionalism by modeling the way and serving as a resource for her colleagues. This fellow has enabled others to act by forming teams for the educational project and data collection. Along with my mentor we have shared an inspired vision to improve the outcomes for members and challenge the process of encouraging a change in practice for the care managers in the telephonic maternity program. This fellow has encouraged the heart of the team by listening to concerns, offering support and encouragement along the way.
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