Second Stage: Installation

The second stage for immediate postpartum LARC implementation is installation, which includes preparations to offer immediate postpartum LARC. Regular communication is essential during the Installation Stage because the steps of implementing immediate postpartum LARC program are interconnected across departments. Regular communication about barriers encountered and steps completed is essential and a communication plan can be particularly helpful to offset staff turnover.

Steps may not progress linearly in the order presented, nor is each step required for successful program implementation. However, an overview of the process may help reduce difficulties caused by unanticipated steps.

Key Steps by Department:

Key steps by task:

1. Clinicians – Policies and Protocols

Policies, guidelines, protocols and supply lists: Creation of these documents often rests with clinicians. Relevant hospital documents may include policies, eligibility guidelines, placement guidelines, or clinical protocols for implant and IUD placement. This step should be tailored to each hospital’s process for new protocols. If you’re interested in receiving sample documents, please submit your request to the ACOG LARC Program Help Desk. Consent forms: Each hospital should align the consent process with their institutional standards. Contraceptive counseling about immediate postpartum LARC should optimally begin during prenatal visits. Patient education materials: Relevant contraceptive counseling materials may include handouts specific to LARC methods focusing on placement timing, breastfeeding education, and/or post-discharge information. The ACOG FAQ #500: Using LARC Right After Childbirth is written for patients and offers answers to common questions about immediate postpartum LARC. Find more information about contraceptive counseling here and patient education and contraceptive counseling resources here.

2. Clinicians – Training and Education

Insertion training: Since postplacental IUD placement technique varies from interval placement, clinicians planning to offer immediate postpartum LARC may benefit from additional training.

See our training resources here and learn more about our onsite training here.

Implant certification: Clinicians planning to offer the implant must undergo a Food and Drug Administration-approved training provided by the manufacturer, who requires that only trained clinicians place the implant. Having documentation of training certification available can facilitate the hospital pharmacy ordering process.

Nurse training, staff in-service, and pharmacy education: Nurse training may include background education, consent verification, medical administration record documentation, and patient education. Mother-baby unit staff may also require a brief introduction to immediate postpartum LARC and the tasks they may perform. Clinicians may be asked to provide information to LARC about pharmacists, or a pharmacy team member may educate the pharmacy department.

3. Pharmacy

Pharmacy and Therapeutics Committee application: Pharmacists and clinicians often work together on their hospital’s process to bring LARC onto the inpatient hospital formulary. The first step may include a Pharmacy and Therapeutics Committee application for each device. Clinicians may need to educate Pharmacy and Therapeutics Committee members about immediate postpartum LARC provision.

Our Immediate Postpartum LARC Resource Digest contains links to helpful educational materials that include evidence and best practices for immediate postpartum LARC provision.

Pharmacy and Therapeutics Committee approval and device on formulary: Pharmacists or clinicians may resolve committee requests. Clarity of responsibilities is important and final approval should be communicated to the implementation team.

Pharmacy planning:

  1. Vendor contracts: Hospital pharmacies may need to establish or negotiate new contracts with device manufacturers.
  2. Inventory system and estimated use: Pharmacists may work with information technology staff to adapt existing inventory systems to immediate postpartum LARC. Clinicians and pharmacists may work together to estimate LARC use for appropriate order volume.
  3. Distribution plan: A LARC distribution and storage plan is critical for success. It is often convenient for IUDs to be stored in electronic medication dispensing systems within the labor and delivery unit for timely access.
  4. Purchase devices: The final pharmacy step is to obtain the devices.

4. Finance and billing

Clarify payment submission: Finance or billing personnel may require communication from payers regarding appropriate charge codes for LARC devices, placement, and any modifiers or additional information to ensure timely payment.

The ACOG LARC Program tracks all state Medicaid reimbursement policies here.

Charge documentation: Finance or billing personnel may work with information technology personnel to update their hospital’s software for charge documentation and charge submission.

5. Information technology and electronic health record

Information technology personnel are involved in preparing the electronic health record and related computer systems for documenting, tracking, and charging for LARC placement.

Clinical documentation: Computer systems adjustments for immediate postpartum LARC may not be extensive. Hospital processes for documenting consent, medication orders, procedural time-outs, medication administration, and clinical procedures can often be adapted to immediate postpartum LARC. Hospitals may consider creating electronic order sets with standard medications and supplies for IUD or implant placement.

Charge capture: This step is tailored to each hospital’s existing charge capture processes and software. Information technology personnel can assist in integrating electronic health records and finance systems to adequately capture charges for devices and their placement. Simulation and close communication between financial and information technology personnel are particularly important to this segment of the revenue cycle.

Inventory notification: Information technology personnel can help adapt existing pharmacy inventory management systems to immediate postpartum LARC. These adaptations may include tracking LARC usage, updating numbers of devices in electronic medication dispensing systems and alerting the pharmacy department about levels of devices in stock.

Device log: Hospitals may consider whether they need to create a log of individual devices that are placed. If so, information technology personnel may be able to streamline this process by capturing lot numbers from medication administration documentation.

Find more implementation resources here.

Citation: Hofler LG, Cordes S, Cwiak CA, Goedken P, Jamieson DJ, Kottke M. Implementing immediate postpartum long-acting reversible contraception programs. Obstet Gynecol 2017;129:3-9. Reprinted with permission from Wolters Kluwer Health, Inc.