1. FQHC Look-Alike Health Care Plan April 28, 2010 Twyla Adams, MHS, Branch Chief Valerie Kolick, Public Health Analyst Art Stickgold, Consultant Charles Daly, Public Health Analyst Department of Health and Human Services Health Resources and Services Administration Bureau of Primary Health Care

2. Objectives To become familiar with the Clinical Measures, Quality of Care Indicators, and Outcome Measures of the Health Care Plan To understand how to collect and use an organization’s patient data to create a Health Care Plan 2

3. Reporting Reminders Organizations should only report on sites within their HRSA-approved FQHC Look- Alike scope of project The reporting year (or measurement year) is based on the prior Calendar Year, regardless of the organization’s current project period 3

4. 4 Health Care Plan  Built around quality improvement measures which document applicants attention to clinical quality  Consists of:  Three Quality of Care measures  Three Outcome measures  Two targeted applicant selected measures

5. 5 Clinical Measures  Six clinical measures form the core of the health care plan: Early entry into prenatal care Complete immunization of two year olds Current Pap test for adult women Birth weight for children of perinatal patients Controlled hypertension Controlled diabetes

6. 6 Clinical Measures  Two additional required measures are to be selected by the FQHC Look-Alike: Behavioral health Includes Mental Health and Substance Abuse Required even for those which do not provide service Dental Required even for those who do not have dental services  Additional optional measures may be created by applicant

7. 7 Clinical Measures  Details can be found in the manual for Community Health Center reporting:  Uniform Data System Manual  Tables 6B and 7  http://www.hrsa.gov/data-statistics/health-center- data/reporting/2009udsreportingmanual.pdf http://www.hrsa.gov/data-statistics/health-center- data/reporting/2009udsreportingmanual.pdf  FQHC Look-Alike agencies do not submit the UDS report!

8. 8 Clinical Measures – Medical Home  The Clinical Measures are based around the concept that the Applicant must be considered the medical home for all of its patients.  Often requires that if a service is not provided directly, the clinic must obtain the data from the other entity that provided the service.

9. 9 Quality of Care Indicators Measures commonly seen as indicators of overall community health

10. 10 Quality of Care Indicators  These are all “process measures”: If patients receive timely routine and preventive care, then we can expect improved health status: Early entry into prenatal care: If women enter care in their first trimester then the probability of adverse birth outcome will be reduced Childhood immunizations: If children receive their vaccinations in a timely fashion then they will be less likely to contract vaccine preventable diseases or to suffer from the sequela of these diseases Pap tests: If women receive Pap tests as recommended then they can be treated earlier and will be less likely to suffer adverse outcomes from HPV and cervical cancer

11. 11 Clinical Measures –Trimester  Universe is all women who were provided perinatal services: Measured from conception, not LMP “Entry” is at initial comprehensive physical exam, not earlier points All women with an initial visit are included even if they drop or transfer Includes women who start in prior year or deliver in subsequent year as long as they were served in the reporting year.

12. 12  Trimester of entry into care: Compliance is considered to be entry into care during the first trimester. First trimester is measured from date of conception and is DOC to DOC+13 weeks Clinical Measures –Trimester

13. 13 Clinical Measures – Immunization  Universe is two year olds who Had a medical visit during 2009 May have been before their last shots were due to be given Entered the practice prior to their second birthday Even though may not have had enough time to fully immunize

14. 14  Compliance = Fully immunized on second birthday: Standards are those of NQF and listed in the UDS manual, not CDC or AAP Shortage of any given vaccine (such as the HIB shortage last year) may result in low numbers Non-compliance includes: Lost to follow-up Religious objections to vaccines “Conscience” objections based on beliefs Immunization must be documented Cannot accept statement from parents Clinical Measures – Immunization

15. 15 Required Vaccines  Fully complaint means compliant for each of 11 diseases normally vaccinated against with: 4 DTP/DTaP, 3 IPV, 1 MMR, 3 Hib, 3 HepB, 1VZV (Varicella) 4 Pneumococcal conjugate  Or evidence of the disease  Or allergic reaction to a vaccine or its components ICD-9: 999.4

16. 16 Clinical Measures – Pap Test  Universe includes: All women who were 24 to 64 during the measurement year Who were seen at least once for medical care in a clinical setting Includes women who receive their “women’s health services” elsewhere Includes women who were current when last seen, but failed to return for test. Reported even by FQHC Look-Alikes which refer out all or some of their Pap tests

17. 17  Compliance:  Tested in the reporting year or the prior two years. Compliance is documented by: A copy of a Pap test done by the FQHC Look-Alike Report of another provider’s findings Not a self-report by patient Compliance does not include: Lost to follow up Documented referral without results Statement from patient saying she is current Patient refusal to be tested Clinical Measures – Pap Test

18. 18 Outcome Measures Measures commonly seen as indicators of overall community health

19. 19 Health Outcomes  These are all “intermediate outcome measures”: If this measurable intermediate outcome is improved, then later negative health outcomes will be less likely. Normal Birthweight: If there are fewer low birthweight children born, then there will be fewer children who suffer mental or physical delays or organ damage Controlled Hypertension: If there is less uncontrolled hypertension, then there will be less cardiovascular damage, fewer heart attacks, fewer strokes, less organ damage later in life Controlled Diabetes: If there is less uncontrolled diabetes then there will be fewer amputations, less blindness, less organ damage later in life

20. 20 Outcome Measures – Birth Weight  Universe includes: All children born to prenatal care patients who delivered during the measurement year Includes women commonly lost who: Were risked out after first visit Were risked out during course of treatment Were routinely referred during 3 rd trimester Were routinely referred for delivery

21. 21 Outcome Measures – Birth Weight  Birth Weight: Ideally obtained from hospital discharge or birth certificate. May accept mother’s report of weight  Compliance  Those children with a birth weight equal to or greater than 2500 grams

22. 22 Outcome Measures – Hypertension  Universe includes: Patients 18 – 85 Diagnosed as hypertensive ever – ideally look at three years of data but prior to June 30 in measurement year Seen twice in medical clinic Includes patients who may not have ever had a primary diagnosis of hypertension Includes hypertensive patients who may never have been seen for hypertension during the reporting year

23. 23 Outcome Measures – Hypertension  Compliance: Is based on the last recorded blood pressure for measurement year Patients are considered in compliance if their BP is under 140/90 – (i.e., systolic is under 140 and diastolic is under 90.)

24. 24 Outcome Measures – Diabetes  Universe includes: Patients 18 – 75 Diagnosed as diabetic ever – ideally look at three years of data Seen twice in medical clinic Includes patients who were not seen with a primary diagnosis of diabetes Includes diabetic patients who may never have been seen for diabetic during the reporting year

25. 25 Outcome Measures – Diabetes  Compliance is based on hemoglobin A1c (HbA1c) reading: Last recorded for measurement year No measurement is coded as out of compliance – should not be replaced Must have test results or copy – may not accept Patient’s understanding of their results from another provider Based on lab test in chart or reported to FQHC Look-Alike by another provider Compliant = those less than or equal to 9% May have been done elsewhere as long as report is recorded in chart when review is done

26. 26 Reporting on patients: Sample or “Universe” Sampling for the FQHC Look-Alike Clinical Measures

27. 27 Clinical Measures Data  Data may be reported in two ways: Report on the universe (total population meeting criteria) Required for both perinatal care measures Either universe or sample is OK for other four + 2 measures Report on a random sample of 70 patients  Neither method is considered to be preferable or superior when it comes to immunizations, Pap tests, hypertension, diabetes or the other 2  Universal reports may be based on: A chart review of all patients meeting criteria Automated reports from an EHR which includes data on 100% of the center’s patients

28. 28  Common EHR misconceptions: Disease registries from collaboratives (PC- DEMS, PECS) may be used as the universe Usually excludes the very people being looked for EHRs may be used as soon as they are installed. for reporting purposes, EHR data may be used only after the EHR has been installed for an entire calendar year – preferably for three years EHRs are necessary Many if not most CHCs found using a sample to be as easy and more accurate Clinical Measures Data

29. 29  Common sampling misconceptions: Data may be sampled from just one site You must include data from all in-scope sites An equal number of charts may be pulled from each FQHC Look-Alike site or for each provider Will bias the sample FQHC Look-Alikes may decide to use a sample size greater than or less than 70 For consistency we have standardized at 70 or at 100% if you have fewer than 70 in the universe Clinical Measures Data

30. 30 Reporting on a Sample  Unless a center is quite small it will generally report on a random sample of 70 charts: …a part of the universe where each member of the universe has the exact same chance of being selected as every other member of the universe. Reporting is simple, requiring A numbered list of all patients in universe Use of a web site to generate random numbers http://www.randomizer.org/form.htm http://www.randomizer.org/form.htm Identification of the charts in the numbered list of patients Review of the identified patients

31. 31 Getting 70 Random Numbers Sets of numbers = 1 Numbers per set = 70 Number range = 1- “n” (enter last sequence number in your numbered list) Unique numbers – Yes Sort numbers – Yes: Least to Greatest

32. 32 Data From Other Sources  Before charts are actually pulled and reviewed, other sources may be queried for the “answer” on compliance: EHRs, PMSs (Practice Management Systems) May not cover all patients or be in place for a long enough time, but may still be used to review patients and periods which are recorded Immunization registries maintained by the state. Collaborative registries which include some, but not all of the patients who meet the criteria (or which include patients who do not meet the criteria) Logs or other “off line” lists

33. 33 Reviewing the Charts  Eventually, some or all charts in the sample for one or more of the measures will need to be reviewed.  With multiple locations: All charts may be brought to a central point Single reviewer may travel to each site Multiple reviewers may review at each site  Tools are available from BPHC

34. Creating the FQHC Look-Alike Health Care Plan Charles Daly, Public Health Analyst Office of Quality and Data Department of Health and Human Services Health Resources and Services Administration Bureau of Primary Health Care 34

35. 35  The health care plan is not a stand-alone part of the proposal or CQI plan.  It needs to be integrated into all aspects of the organization’s evaluation processes.  When designated, it is the clinical quality roadmap. The Health Care Plan

36. 36 Clinical Measures Reporting  There are six UDS Clinical Measures included in those to be reported by FQHC Look Alikes:  Prenatal access to care  Low birth weight babies  Children age 2 immunizations  Pap tests for adult women  Diabetes HbA1c tests  Hypertension blood pressure under control  Specifics of current UDS measures are at http://bphc.hrsa.gov/about/performance measures.htm http://bphc.hrsa.gov/about/performance measures.htm

37. 37 Health Care Plans  BPHC is now requiring these clinical measures to be included in the health care plan for FQHC Look-Alike Designation (Initial/Renewal) and Annual Recertification applications  FQHC Look-Alikes are establishing baselines and setting goals for improvement in their initial and renewal applications (5 year horizon)  FQHC Look-Alike annual recertification reports based on data, where available  BPHC staff will review submissions and progress reports

38. 38 Setting Goals for Improvement  Demonstrate improvement over time or maintain high rate  Ideally 100% of patients in compliance with measure–NOT realistic!  FQHC Look-Alike trends  330 Program grantee performance rates (national, state)  available on HRSA UDS Web site at http://www.hrsa.gov/data-statistics/health-center- data/index.html http://www.hrsa.gov/data-statistics/health-center- data/index.html

39. Initial and Renewal of Designation Applications  Baseline: Baselines are set using data from the calendar year prior to the application submission.  Goal: Goals are set to be accomplished by the end of the project period (5 Years). Baseline and Goal Year 39

40. Baseline and Goal Year Recertification Applications  Baseline: Carried over from most recent initial or renewal of designation application. If the organization has never submitted a Business Plan, the organization will create a new baseline from the prior calendar year.  Goal: Goals are set to be accomplished by the FQHC Look-Alike’s renewal of designation application due date. 40

41. A Word About Benchmarks…  The most important comparisons are internal  Most relevant when patient populations are similar  Benchmarks useful in setting feasible and challenging goals  Data will reveal state and national trends over time 41

42. A Word About Benchmarks…  National and State data from 330 agencies are available from: http://www.hrsa.gov/data-statistics/health-center-data/index.html http://www.hrsa.gov/data-statistics/health-center-data/index.html 42 National Data State Data

43. 43 Designation Health Care Plan Format

44. 44 Focus Area: Name and Description  States the focus area  Six pre-selected topics and two selected by the FQHC-LA  States the specific measure that will be used  States the targeted multi-year goal  A numeric target for the performance measure  Five years out or until end of project period

45. 45 Focus Area: Calculation  Describes the numbers that will be used to calculate the measure  Numerator:  Portion of target population that is in compliance  Denominator:  Description of all persons in the “universe”  Criteria for the six required measures are set by BPHC and must be used

46. 46 Focus Area: Data  Baseline Data:  Year: Year “0”  Measure Type: Percent (all are percents)  Numerator: Value in the base year  Denominator: Value in the base year  > Baseline percent  Target: Percent at end of year X (5)  Data source & Methodology  Where the baseline data come from

47. 47 Focus Area: Key Factors  Name and description of key factors  Will factor contribute toward or constrain success  Description of factor  How factor enhances ability to succeed or  What can be done to minimize restricting effect

48. Recertification Health Care Plan Performance Measure: Percentage of diabetic patients whose HbA1c levels are less than or equal to 9 percent Is this Performance Measure Applicable to your Organization? [_] Yes [_] No Target Goal Description Numerator DescriptionNumber of adult patients age 18 to 75 years with a diagnosis of Type 1 or Type 2 diabetes whose most recent hemoglobin A1c level during the measurement year is ≤ 9%, among those patients included in the denominator. Denominator DescriptionNumber of adult patients age 18 to 75 years as of December 31 of the measurement year with a diagnosis of Type 1 or Type 2 diabetes, who have been seen in the clinic at least twice during the reporting year and do not meet any of the exclusion criteria Baseline DataBaseline Year: Measure Type: Numerator: Denominator: Projected Data (by End of Project Period) Data Source & Methodology Progress Toward Goal Quantitative: Qualitative: Comments 48

49. 49 Restatement of Variable  Information included in the initial or renewal of designation application is restated

50. 50 Progress Report  Quantitative: Calculated percent for the last calendar year.  Qualitative: Discussion of key elements which led to your success or lack thereof.  Include any indication that goal will be met early or not be met at end of project period

51. 51 Recertification HCP Clinical Measures  Plans built around a QI model  FQHC Look-Alikes asked to comment on their progress toward their goals — quantitative and qualitative  Quantitative progress  Report a single percent based on one year up to 3 year trended data, if available  Qualitative progress statements recommended

52. 52 Summary  Purpose of performance measurement is to assure and IMPROVE Quality of Care:  Appropriateness of care for the population  Effectiveness of care for the population  Include health care plan goals in QI program

53. Resources PIN 2009-06, “FQHC Look-Alike Guidance and Application”: http://bphc.hrsa.gov/policy/pin0906/ Specifics of current UDS measures: http://bphc.hrsa.gov/about/performance measures.htm http://bphc.hrsa.gov/about/performance measures.htm Web site to generate random numbers: http://www.randomizer.org/form.htm http://www.randomizer.org/form.htm 330 Program grantee performance rates (national, state) : http://www.hrsa.gov/data-statistics/health-center-data/index.html Uniform Data System Reporting Manual: http://www.hrsa.gov/data- statistics/health-center-data/reporting/2009udsreportingmanual.pdfhttp://www.hrsa.gov/data- statistics/health-center-data/reporting/2009udsreportingmanual.pdf 53

54. Contact Information Twyla Adams Branch Chief Health Center Systems Branch Office of Policy and Program Development 301.594.4300 Twyla.Adams@hrsa.hhs.gov 54

55. Contact Information Valerie Kolick Public Health Analyst Health Center Systems Branch Office of Policy and Program Development 301.594.4300 Valerie.Kolick@hrsa.hhs.gov 55

56. Questions?