Optimizing inpatient access to oral contraceptives: A quality improvement approach in behavioral health.

Rachel S. Pierce: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Software, Resources, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization. Devon N. Crews: Writing – review & editing, Writing – original draft. Benjamin J. Pierce: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Project administration, Methodology, Investigation, Formal analysis, Conceptualization. Courtney K. Wulffson: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Resources, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization.

The QI initiative was reviewed and approved by the Research Innovation Council at the Midwestern community hospital. The project was deemed exempt from full Institutional Review Board (IRB) review. All data were deidentified prior to analysis to protect patient confidentiality and securely stored using institutional protocols, including password protection, biometric authentication, and Okta Verify. This QI initiative used a pre–post intervention design to evaluate the implementation of an OC procurement workflow in an inpatient BH)setting. The project was guided by iterative Plan-Do-Study-Act (PDSA) cycles, allowing continuous refinement based on real-time feedback. Each cycle lasted one month, with tests of change conducted in February, March, and April 2025. The initiative was conducted in a 304-bed Midwestern community hospital with a 24-bed adult inpatient BH unit serving medically stable adults admitted for acute psychiatric care. A multidisciplinary team—including pharmacists, BH providers, nursing students, and an obstetrician—collaborated with a local university. The principal investigator (PI), a nurse practitioner, coordinated stakeholder meetings and workflow development. Monthly planning sessions with pharmacy leadership and a pharmacy intern supported implementation. A structured workflow was implemented to ensure timely access to OCs for female BH inpatients. Key components included: • OC availability list with National Drug Codes (NDCs) to identify equivalent brand and generic formulations. • Coordination between inpatient and outpatient pharmacy teams for timely delivery. • Specialist input from an obstetrician as needed. • The workflow launched December 2, 2024, with communication distributed via email and hosted on OneDrive. Data collection occurred January 20–April 30, 2025, with monthly PDSA refinements. OC availability list with National Drug Codes (NDCs) to identify equivalent brand and generic formulations. Coordination between inpatient and outpatient pharmacy teams for timely delivery. Specialist input from an obstetrician as needed. The workflow launched December 2, 2024, with communication distributed via email and hosted on OneDrive. Data collection occurred January 20–April 30, 2025, with monthly PDSA refinements. Female BH inpatients aged 18–49 prescribed an OC prior to admission were included. Exclusion criteria: male patients, age outside range, no pre-admission OC, or Padua Prediction Score ≥ 4. The primary outcome measure was the proportion of eligible BH in-patients who received their pre-admission OCs during hospitalization. Secondary outcomes included the odds ratio of OC administration post-intervention compared to pre-intervention and the rate of missed doses. Pre-intervention data (2022–2023) were collected via retrospective chart review and stored in Excel; post-intervention data (Jan–Apr 2025) were collected daily in REDCap by a pharmacy intern. Variables included OC type, source (patient-supplied, pharmacy-supplied, unavailable, refused), timing of first administration, admission/discharge dates, and length of stay. Data completeness and accuracy were ensured through daily verification by the pharmacy intern and PI. Each record was cross-checked against the electronic health record (EHR) medication administration log and discharge summary. Discrepancies were resolved immediately, and missing data were flagged and corrected before analysis. Both retrospective and prospective datasets were reviewed for consistency in variable definitions. Variation between pre- and post-intervention periods was assessed using Fisher's exact test to compare proportions of OC administration. Odds ratios with 95 % confidence intervals were calculated to quantify the magnitude of change. Descriptive statistics summarized missed dose rates and administration timing across both periods. A p -value <.05 was considered significant. Analyses were conducted using Python (v3.12.7) and SciPy.

A retrospective chart review revealed that 67 % ( n  = 34, N  = 51) of BH patients prescribed OCs during 2022–2023 experienced missed doses, highlighting a significant gap in medication continuity. Following implementation of the OC procurement workflow, continuity improved substantially. Between January and April 2025, 78 % ( n  = 7, N  = 9) of eligible patients received their OCs compared to 33 % ( n  = 17) in the pre-intervention period (see Fig. B1). Missed doses decreased from 67 % to 22 %. Post-intervention, patients were seven times more likely to receive OCs (95 % CI [1.31, 37.40]; p  = .23), indicating meaningful improvement in access and administration.

Women's health faces systemic disparities, particularly among those with behavioral health (BH) diagnoses. Barriers such as gender bias, restrictive policies, logistical challenges, and fragmented insurance limit access to reproductive care. 5 , 6 , 7. , 8 These inequities call for patient-centered quality improvement (QI) initiatives. This gap reflects broader reproductive and psychiatric healthcare disparities, where women with mental health conditions often experience compounded barriers to care. These include stigma, fragmented health systems, and underrepresentation in clinical guidelines, which collectively limit access to timely and appropriate contraceptive management. Inpatient BH settings are particularly vulnerable because reproductive health needs are frequently deprioritized, exacerbating inequities in continuity of care and reproductive autonomy. Continuity of contraceptive care during hospitalization is often overlooked, especially in BH settings. Interruptions in OC use can lead to unintended pregnancies, hormonal imbalances, and exacerbation of conditions such as dysmenorrhea, endometriosis, and menstrual migraines. 9 , 10 , 11 BH patients are particularly vulnerable due to compounded psychiatric and reproductive health risks. Professional guidelines emphasize maintaining contraceptive continuity when clinically appropriate. 12. , 13 , 14 , 15. Despite these recommendations, inpatient workflows rarely prioritize OC continuation, often relying on patient-supplied medications or ad hoc pharmacy procurement. 4 Standardized protocols and pharmacist involvement are critical for safe and timely administration. 16 While OCs may be withheld for venous thromboembolism (VTE) risk, most BH patients are ambulatory and young with few comorbidities. 17 The Padua Prediction Score (PPS) guides VTE risk assessment; patients with PPS <4 are considered low risk and eligible for OC continuation. 18 Prior to this initiative, lack of workflow, limited inventory, and provider uncertainty led to frequent OC discontinuation. A needs assessment revealed that only 33 % of eligible BH inpatients received OCs during hospitalization, despite low VTE risk, underscoring the need for a structured process. Compared to the broader 14–20 % baseline rate of essential medication disruption among BH inpatients, the observed 67 % missed oral contraceptive doses in this setting represents a markedly higher lapse, indicating that OC continuity is disproportionately compromised during BH hospitalization. 19 The problem addressed in this study is the lack of a standardized workflow to ensure timely continuation of pre-admission oral contraceptives in behavioral health inpatient settings, resulting in significant care gaps. Therefore, the purpose of this QI initiative was to design, implement, and evaluate a structured OC procurement workflow to improve continuity of care and support reproductive autonomy for hospitalized BH patients.

This QI initiative addressed a critical gap in OC continuity for BH inpatients by implementing a structured procurement workflow. Leveraging outpatient pharmacy resources and multidisciplinary collaboration significantly improved medication reconciliation and access, reducing missed doses and supporting reproductive autonomy in a vulnerable population. These results demonstrate the effectiveness of systems-based interventions in closing care gaps. This QI initiative aligns with existing literature underscoring the critical role of medication reconciliation and pharmacist involvement in enhancing continuity of care, particularly in BH settings. Prior studies have emphasized the importance of inpatient pharmacists in resolving medication-related issues during transitions 16 and highlighted opportunities for BH providers to address reproductive health needs during hospitalization. 14 However, this project offers a novel contribution by specifically targeting OC access within an inpatient BH unit—a setting where reproductive health is often overlooked. While national data reveal persistent barriers to contraceptive access, 6 , 8 few interventions have focused on inpatient BH environments. The success of this initiative suggests that institutional workflows may be a modifiable barrier to contraceptive continuity. Tailored strategies, such as an OC availability list and collaboration with outpatient pharmacy services, addressed logistical challenges commonly cited in the literature. 4 Moreover, the proactive involvement of a multidisciplinary team reflects best practices in collaborative care and likely contributed to the intervention's effectiveness. Several noteworthy insights emerged during the implementation of the OC procurement workflow. First, despite targeted communication efforts, one BH provider was unaware of the new workflow. This underscored the importance of enhancing provider engagement through more comprehensive dissemination and training strategies. Second, although medication technicians or inpatient pharmacists were instructed to document the specific week of the patient's OC cycle, many patients were unable to recall this information. This reduced the ability to ensure accurate continuation of phasic contraceptive regimens. Outpatient pharmacy inventory constraints, particularly regarding OC formulations and therapeutic equivalents, can limit the overall reach of the intervention. Inventory decisions are informed by a cost-benefit analysis, with outpatient pharmacy staff conducting regular reviews to assess the need for adjustments. The OC availability list was positively received for enhancing clarity and workflow efficiency; however, its utility was limited when prescribed OCs were not stocked or when providers failed to reorder the OC. Additionally, on one occasion, the prescribed OC was not available in the outpatient pharmacy. This QI project has several limitations impacting its generalizability. A small post-intervention sample size and brief data collection period (Jan 20–Apr 30, 2025) limit statistical power and long-term assessment. Additionally, the study may be subject to bias due to manual data collection and reliance on a single site, which could limit the generalizability and reproducibility of the findings across other inpatient BH settings. The initiative remains active, but manual data tracking has ceased due to staffing changes. Reliance on individual champions and manual processes raises concerns about scalability and sustainability. While OC access improved, missed doses persisted due to ongoing systemic barriers, including provider unawareness and outpatient pharmacy stock limitations.

This QI initiative improved reproductive care continuity for female patients in an inpatient BH unit through a structured OC procurement workflow. As the unit expands to 32 beds, more patients may benefit from this approach. By addressing systems-level barriers, the project promoted reproductive autonomy and demonstrated that leveraging outpatient pharmacy resources can close care gaps without expanding inpatient inventory. Sustainability depends on institutional support, and the model is replicable across settings. Future research should explore a broader national patient care gap, electronic medical record (EMR)-integrated solutions, and long-term outcomes. At the project site, efforts continue to embed the workflow into standard procedures. This initiative aligns with the Joint Commission's National Patient Safety Goal on medication reconciliation by reducing missed OC doses during care transitions. The success of this initiative highlights the potential for institutional policy changes and integration into EMRs to standardize contraceptive continuity workflows, offering a scalable model that can be adapted across diverse inpatient settings to improve reproductive health equity.

Rachel S. Pierce reports relationships with University of Wisconsin-Eau Claire and Mayo Clinic Health System that includes employment. Benjamin J. Pierce and Courtney K. Wulffson report relationships with Mayo Clinic Health System that includes employment. The other author declares that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.