A QI project to assess the feasibility of using One Key Question® in retail health clinics
One goal of Healthy People 2020 is improving pregnancy planning, increasing spacing between pregnancies, and decreasing unintended pregnancy.1 As the situation stands now, almost half of all pregnancies in the United States are unintended.2 Only 14% of ambulatory care encounters with women of reproductive age include provision of contraception and preconception services,3 which, if offered on a broader basis, would go a long way toward reducing the rate of unintended pregnancies and improving women’s health and pregnancy outcomes.
In 2006, the CDC recommended reproductive life planning (RLP) as an approach that could be introduced at healthcare visits.4 RLP is a process in which healthcare providers (HCPs) and female patients or couples engage in discussions that serve to identify their family planning goals and then make healthcare plans collaboratively in order to safely and realistically meet those goals.5 Key components of RLP include consideration of the desire for children, number of children desired, spacing of children, and timing of children. Preconception and contraceptive counseling are provided as appropriate, and referrals are made as needed.5
One Key Question® (OKQ) is an evidence-based intervention used to help initiate the discussion between HCPs and female patients concerning reproductive desires and goals.6 Developed by the Oregon Foundation for Reproductive Health, OKQ uses a simple prompt— Would you like to become pregnant in the next year?—in order to move the health visit conversation toward these goals. The ensuing conversation then focuses on patients’ desire for pregnancy rather than their specific plans. The OKQ algorithm includes three response categories: yes, no, and I’m not sure or I’m okay either way (Algorithm). This non-confrontational approach focuses on each woman’s desire for pregnancy, with the aim of opening the RLP dialogue with the HCP, which will then, under ideal circumstances, connect the woman to the most appropriate healthcare services.7 The OKQ screening tool has been piloted in multiple settings in Oregon and one setting in Missouri. Three clinical trials are now under way to study the impact of screening and the service delivery patterns for preventive reproductive healthcare (i.e., contraception and preconception care).8
Finding non-traditional avenues for HCPs and women to engage in RLP discussions is important, particularly in terms of reaching women who do not regularly see a primary care or ob/gyn provider for reproductive healthcare. Retail health clinics (RHCs) commonly used for episodic acute care may provide such an avenue. RHCs offer convenience, including accessible locations, walk-in service, and ease of obtaining appointments for morning, evening, and weekend hours. HCPs at RHCs conduct comprehensive health assessments, make diagnoses, and develop care plans that include education and referrals as needed. These HCPs have an ideal opportunity to screen reproductive-aged women for pregnancy intention and to increase awareness about contraception options and healthful preconception behaviors. Folic acid supplements can be recommended or prescribed on site. Appropriate referrals can be made to primary care and ob/gyn providers in the community to meet reproductive healthcare needs.
Four RHCs identified in Maricopa County, Arizona, were not currently screening for pregnancy intention. The authors determined that the absence of such screening in these clinics offered them an opportunity to pilot the use of the OKQ screening tool/algorithm in the clinics.
The purpose of this quality improvement (QI) project was to assess the feasibility of implementing the OKQ screening tool/algorithm at four RHCs. Desired QI project outcomes included the following: (1) 75% of all eligible women aged 18-50 years who visited one of the RHCs, regardless of their visit reason, would be screened; (2) 90% of women who answered yes to the OKQ, indicating a desire for pregnancy in the next year, would be referred to an ob/gyn provider; (3) folic acid would be prescribed or recommended to 100% of all screened women, regardless of their answer to OKQ; (4) 100% of patients whose answer was no or I am not sure/I’m okay either way would be assessed for current contraception use and referred to a primary care or ob/gyn provider, if desired, for comprehensive birth control counseling, including being provided with information about long-acting reversible contraceptives; and (5) feasibility of use of the OKQ screening tool/algorithm in RHCs would be assessed.
The DNP project is a QI project and, as such, does not meet the definition of human subjects research as defined by the Common Rule and the Federal Policy for Protection of Human Subjects. Therefore, Institutional Review Board (IRB) approval was not needed, which is a reflection of more contemporary definitions of research (language about IRB approval per Duke DNP program guidelines).
Six family nurse practitioners (FNPs) working at the aforementioned four clinic sites were recruited to participate in the project. Women aged 18-50 years who visited one of the sites during the project were eligible for OKQ screening, regardless of the reason for their visit to the clinic. Women who indicated that they had undergone permanent sterilization or a hysterectomy were excluded from screening.
An in-service was conducted with all participating FNPs as a group so that consistent education and messaging about the project were delivered. A paper screening tool was provided to allow for tracking algorithm use. Anonymity was maintained by not including any identifying information on the form. After the education/ messaging session was completed, implementation of OKQ screening at the project sites began.
During the 6-week project period, the FNPs screened eligible women for pregnancy intention and implemented educational interventions based on the algorithm. When obtaining a current sexual history, FNPs asked eligible women, Would you like to become pregnant in the next year? as well as the date of their last menstrual period. For a woman who answered yes to the OKQ, the FNP recommended folic acid supplements and smoking/ alcohol cessation as indicated. The FNP encouraged the woman to follow up with an ob/gyn provider for a preconception visit. For women who indicated they did not desire a pregnancy or were unsure/okay either way, the FNP asked about current contraception use and satisfaction with the method, with encouragement to follow-up with a primary care or ob/gyn provider as needed. The FNPs did not provide any written information about contraceptives because of restrictions from the RHCs where the pilot study was performed. Following the 6-week project period, the primary author led a focus group meeting with the FNPs to assess their perceptions about the feasibility of using the OKQ screening tool/algorithm in an RHC setting.
A total of 275 women seen at the RHCs during the 6-week project period were eligible for pregnancy intention screening. Among them, 194 (71%) were screened using the OKQ tool. For the 8 women who answered yes, all (100%) were referred to primary care or ob/gyn providers to discuss preconception care. For the 186 women who answered no or I am not sure/I’m okay either way, all (100%) were assessed for current contraception use and/or referred to primary care or ob/gyn providers for further discussion and provision of contraception. Folic acid was prescribed or recommended to all 194 screened women (100%).
Six FNPs participated in the project and attended the focus group. The FNPs agreed that the OKQ screening tool/algorithm was helpful and allowed for provision of better care for reproductive-aged women. They felt that an RHC setting was appropriate for use of this screening tool/algorithm for patient awareness purposes, with referrals provided when indicated. They noted that use of the screening tool/algorithm helped fill a gap for women who might not otherwise receive reproductive health information if they did not regularly see a primary care provider. Stated barriers to use of the screening tool/ algorithm included not enough time and not being able to prescribe and manage contraception in the RHC setting. The FNPs did recommend that the screening tool/ algorithm be incorporated in the electronic health record (EHR) rather than using a paper format.
Limitations included the short time interval for the project and small number of providers participating in the project. Also, providers did not have adequate time in busy daily schedules to follow up on referrals made for reproductive healthcare.
Implications for women’s health
The project fell just short of meeting the desired outcome to screen 75% of eligible women and to assess and refer them as needed for contraception. All other desired outcomes were met. Overall, the FNPs felt that use of the screening tool/algorithm was feasible and positive for increasing women’s awareness concerning reproductive health and resources within the community.
Although RHCs provide an opportunity to improve access to care, they may have an adverse impact on continuity of care and on the use of preventive healthcare services.9 However, using a simple screening tool can help support both continuity of care and prevention through appropriate referral, as demonstrated with this project. The next step to help strengthen this continuity would be to ascertain whether patients do, in fact, seek the referral. Future plans include presenting the data to RHC companies and working to include this screening tool/algorithm into the EHR, which would make the information part of the permanent record. Interventions can then be billed and recorded so that quality metrics can be obtained.
Rachel E. Curry is a Family Nurse Practitioner (FNP) and Retail Health Clinic (RHC) provider; Anne L. Derouin is Associate Professor at Duke University School of Nursing in Durham, North Carolina; Katherine Kenny is Associate Dean of Academic Affairs at Arizona State University College of Nursing and Health Innovation in Phoenix; Debra Goulding is an FNP and RHC provider; and Julie A. Thompson is Statistical Consultant and Eleanor L. Stevenson is Associate Professor, both at Duke University School of Nursing in Durham, North Carolina.
1. U.S. Department of Health and Human Services. Family Planning. Site last updated April 11, 2019. healthypeople. gov/2020/topics-objectives/topic/family-planning ?topicid=13
2. CDC. Reproductive Health. Page last reviewed January 30, 2019. cdc.gov/reproductivehealth/index.html
3. Bello JK, Rao G, Stulberg DB. Trends in contraceptive and preconception care in United States ambulatory practices. Fam Med. 2015;47(4):264-271.
4. Johnson K, Posner SF, Biermann J, et al. Recommendation to improve preconception health and health care—United States. A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR Recomm Rep. 2006;55 (RR6):1-23.
5. Edmonds SW, Ayres L. Evolutionary concept analysis of reproductive life planning. J Obstet Gynecol Neonatal Nurs. 2017;46(1):78-90.
6. Oregon Foundation for Reproductive Health. One Key Question® Implementation Manual. 2015.
7. Allen D, Hunter MS, Wood S, et al. One Key Question®: first things first in reproductive health. Matern Child Health J. 2017;21(3):387-392.
8. Oregon Foundation for Reproductive Health. One Key Question®. July 10, 2017.
9. Villasenor S, Krouse HJ. Can the use of urgent care clinics improve access to care without undermining continuity in primary care? J Am Assoc Nurse Pract. 2016;28(6):335-341.