Advancing the Health of Underserved Communities:

The Health Center Quality Journey

Montana Primary Care AssociationApril 18, 2018

Suma Nair PhD, MS, RDDirector, Office of Quality ImprovementBureau of Primary Health Care (BPHC)Health Resources and Services Administration (HRSA)

Increasing Access to Primary Health Care

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Health Center Program Quality Journey

• QA/QI Requirements and the UDS• Focus on Outcomes and Improvement

-Introduction of Clinical Measures

-Building & Aligning Systems to Improve Quality

-Transparency & Accountability

-Incentivizing Improvement & Investing in Value

• The Road Ahead-Health Care Landscape & Clinical Priorities

-Building a Learning Health Center System

-UDS Modernization

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Uniform Data System – The Early Years

• HRSA began collection over 20 years ago

• UDS focused on patient demographics, services provided, utilization rates, costs, and revenues

• UDS data was primarily used for program evaluation

• Health center data was not shared widely for quality improvement

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Introduction of Clinical Quality Measures

• In 2008, introduced a small set of 6 clinical quality measures (has grown to 16)

• Collected health outcome measures by race/ethnicity

• Increased focus on alignment – NQF, CMS MU, HP2020

• Focused on quality improvement and the story behind the data/trend

• No negative impact on grant funding

• Built ongoing focus on quality metrics into program oversight activities, including program applications and progress reviews

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Investments to Modernize Primary Care Infrastructure and Service Delivery

Source: Uniform Data System, 2010 and 2016.

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98% EHR at all or some

sites

Patient Centered Medical Home Transformation

0%

20%

40%

60%

80%

100%

2010 2016All Sites

EHR Adoption70% are PCMH

Recognized

Using Data to Support Improvement

• Developed a robust set of performance feedback reports• Grantee Summary Report

• Trend Report (3 yr. grantee trends)

• Comparison Report (grantee vs. similar grantees/state/national)

• Integrated clinical quality metrics and a quality improvement plan into grant applications and annual program reviews

• Shared data with state/national training and technical assistance partners and added quality improvement goals to their work plans

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Data Transparency & Accountability

• Shared data publicly via UDS webpage • National/state/grantee level, includes program compliance

status and adjusted quality rankings

• Set bold QI goals• 93% of health centers met/exceeded at least 1 HP2020 goal

• Continuously raise the bar (% meet/exceed 5 or more HP2020 goals)

• Incorporate UDS performance data in presentations • Maps comparing states

• Charts showing variability in performance

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Incentivizing Improvement

• Recognize success • Highlight high performers during presentations

• Badges for EHR, PCMH, Million Hearts, Quality Awards on website

• Quality Improvement Awards• Focused on: Access, Cost and Quality

• Designed with disparities in mind

• Incorporates design elements to reward both absolute quality scores and improvement over time

• Accounts for patient-mix related differences via adjustment

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Investing to Improve Quality and Value

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Health Center Investments

• New Access Points

• Service Expansions – Behavioral Health, Oral Health, Pharmacy, Enabling Services, Substance Abuse

• PCMH Recognition Support

• Quality Improvement Awards

• Health Information Technology Support

Training & Technical Assistance Investments

• Health Center Controlled Networks

• Primary Care Associations

• National Cooperative Agreements

http://bphc.hrsa.gov/qualityimprovement/strategicpartnerships/index.html

VALUE

Access

Cost

Quality

Patients & Communities

Providers

Payers

Impact on Performance

• Adoption of Electronic Health Records- 25% (2007) to 98% (2016)

• Patient Centered Medical Home Recognition- 1% (2010) to 70% (2017)

• Clinical Quality Measures- 99% improved performance on at least one UDS measure

- 91% meet/exceed at least one HP2020 goals

- 203 Health Centers met/exceed Million Hearts Program goals

- 319 health centers reduced disparities in low birth weight, blood sugar control or blood pressure control

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The Road Ahead…

Increasing Focus on Value and Impact

• Health Care Delivery System

• Managed Care

• Accountable Care

• Alternative Payment Methodologies

• Community-wide

• Community Centered Health Homes

• Accountable Health Communities

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Bureau of Primary Health Care:Strategic Goals

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Increase Access to Primary Health Care

Advance Health Center

Quality and Impact

Optimize Bureau of Primary Health Care

Operations

Mission: Improve the health of the nation’s underserved communities and vulnerable populations by assuring access to comprehensive, culturally

competent, quality primary health care services

Patient-Centered Medical Home (PCMH) Initiative

More Health Centers are delivering patient-centered care as demonstrated by the increase in PCMH recognition from 66% in 2016 to 70% in 2017.

Impact of PCMH Transformation on Quality Health centers with PCMH recognition perform better on clinical quality measures (CQMs), with longer periods of recognition leading to better outcomes on 9 of 11 CQMs.*

*Hu, R. et al. (2018). The Association of Patient-centered Medical Home Designation With Quality of Care of HRSA-funded Health Centers. Medical Care, 56(2), 130-138.

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HRSA Clinical Priorities

Substance Use Disorder and Opioid Treatment

• In 2016, 142,000 SUD patients were seen at health centers – an increase of 41% from 2014

Mental Health Services

• Health centers reported more than 8.5 million mental health visits in 2016

Childhood Obesity

• About 63% of health center patients 17 years old and younger received weight assessments, and preventative services

Diabetes

• Nearly one-third (32.10%) of health center patients have uncontrolled diabetes (HbA1c >9%)

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Mental Health and SUD Capacity (Montana)

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Increase Diabetes Prevention Efforts• Increase the percentage of adults who receive weight screenings & counseling

• Increase the percentage of children who receive weight screenings & counseling

Improve Diabetes Treatment And Management• Reduce the proportion of persons with diabetes with an HbA1c value greater

than 9 percent

• Increase the proportion of health centers that meet the Healthy People 2020 goal for uncontrolled diabetes for each racial/ethnic group

Diabetes Quality Improvement Initiative - Goals

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6.8%

8.8% 8.5%

6.5%

0%

2%

4%

6%

8%

10%

2013 2014 2015 2016

% of HRSA Health Centers that Met the HP 2020 Goal for Uncontrolled Diabetes

37.9%

22.5%

34.4% 33.4%

39.0%42.6%

29.6%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

AmericanIndian/ Alaska

Native

Asian Black/ AfricanAmerican

Hispanic orLatino

NativeHawaiian

Other PacificIslander

White(NonHispanic/

Latino)

% of Uncontrolled Diabetes Patientsby Race/Ethnicity for 2016

Childhood Obesity: National, Region VIII, and Montana

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Diabetes Performance Across Montana

19

17.5 15.718.7

60.3

90.0

64.1

29.1 29.8 31.4

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

2014 2015 2016

Highest Performing Health Center Lowest Performing Health Center State Performance Average

Variance of Uncontrolled Diabetes Patients

*Diabetes: Hemoglobin A1c Poor Control: Change to the denominator: Age 18 through 75 years (previously age 18 through 74), eligibility no longer limited to patients with at least t

wo medical visits during the measurement year. Please see https://ecqi.healthit.gov/ecqm/measures/cms122v4Source: Uniform Data System, 2014-2016. HRSA Electronic Handbooks, 2014-2016.

Per

cen

tage

of

Pat

ien

ts

Addressing Health Disparities in Montana

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*Diabetes: Hemoglobin A1c Poor Control: Change to the denominator: Age 18 through 75 years (previously age 18 through 74), eligibility no longer limited to patients with at least

2 medical visits during the measurement year. Please see https://ecqi.healthit.gov/ecqm/measures/cms122v4Source: Uniform Data System, 2014-2016. HRSA Electronic Handbooks, 2014-2016.

48.6

39.8

34.7

28.8

52.954.5

29.4

0.0

10.0

20.0

30.0

40.0

50.0

60.0

American Indian/Alaska Native

Asian Black/ AfricanAmerican

Hispanic or Latino Native Hawaiian Other PacificIslander

White(NonHispanic/

Latino)

% of Uncontrolled Diabetes Patients by Race/Ethnicity for 2016

Per

cen

tage

of

Pat

ien

ts MT State

Average: 31.4%

Diabetes Quality Improvement Initiative –Implementation Strategies

1. Quality Improvement Priority Alignment• Focus on Diabetes Quality Measures during Oversight Activities

• Quality Improvement Investments and Activities focus on Diabetes

2. Using Data and Evidence to Drive Improvement

3. Developing and Implementing Technical Assistance Resources

4. Establishing and Leveraging Partnerships/Collaborations

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Building a Learning Health Center System

Learning Health System Attributes:

✓ Science and Informatics• Real time access to knowledge• Digital capture of the care experience

✓ Patient-Clinician Relationships• Engaged, empowered patients

✓ Incentives• Incentives aligned for value• Full transparency

✓ Culture• Leadership instilled culture of

learning• Supportive system competencies

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Best Care at Lower Cost: The Path to Continuously Learning Health Care in America http://www.nationalacademies.org/hmd/Reports/2012/Best-Care-at-Lower-Cost-The-Path-to-Continuously-Learning-Health-Care-in-America.aspx

Health Centers

HCCNs

PCAs

NCAsBPHC

Federal Agencies

Other Partners

Learning Health Center

System

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HIT Enabled Quality Improvement

HHS/ONC: Health IT Enabled Quality Improvement -http://www.healthit.gov/sites/default/files/HITEnabledQualityImprovement-111214.pdf

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Uniform Data System Modernization Initiative

Impact• Reduces reporting burden through a standardized UDS submission process – 88%

reduction in time during the pilot• Improves UDS data quality to increase its utility as an administrative data source • Promotes improvements in patient-centered care• Increases efficiency, timeliness, and transparency of the UDS reporting business processes

• UDS Submission Process • Goal: Automate data submission to relieve

reporting burden• Goal: Promote transparency and integrate

stakeholder feedback • UDS Content

• Goal: Ensure UDS reflects improvements in patient-centered care and an evolving primary health care setting

UDS Modernization Landing Page

The purpose of the UDS Modernization Initiative landing page is to:

• Disseminate information to internal and external stakeholders

• Serves as a centralized source of information for stakeholders

Provide feedback to

HRSA on changes to

the UDS

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UDS Modernization Solutions: Completed and Planned

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UDS Reporting Year (CY)

2017 2018 2019 2020

Capture Virtual Visits

Collect Provider Specialties for Substance

Use Disorder Services

Replace Coronary Artery Disease Measure

Add Closing the Referral Loop eCQM

Earlier Release of Reporting Requirements

Exposure of Validation Rules

Performance Data Collection Environment

Process Solutions

Content Solutions

* Solutions being studied 2018-2019

• Expand reporting beyond face-to-face visits

• Expand reporting on provider types and visits to support models of care

• Streamline extraction of countable visits

• Categorize patients by health factors outside of the clinical setting

Reports Modernization

UDS Form Modernization

Participatory Governance

Standard Report Submission File

Off Line Data Collection & Validation

Revise eCQMs

EHR-EHB Integration

Transform Data Configuration &

Submission*

2019 UDS Changes Under Consideration

•Categorize substance abuse treatment providers to better differentiate between providers who deliver such care

Addiction Treatment and Mental Health Services Categorized by

Provider

•Establish a distinct category on for interns and residentsResidents and Interns

• Incorporate an e-specified care coordination to determine whether providers receive a report from a referred patient

Closing the Referral Loop

•Determine the type and range of workforce training capacity

Health Center Facilities and Workforce Dedicated to Training

•Streamline health information technology (HIT) questions Update Questions Regarding Health

Information Technology in Appendix D of The Uniform Data System

•Replace the non-CMS e-specified Coronary Artery Disease measure with an e-specified measure

Statin Therapy (Replace the Coronary Artery Disease Measure)

•Capture telemedicine/virtual visits to better quantify the use of telemedicine/virtual visits

Integrate Granular Telemedicine/ Virtual Visits Information in the UDS

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UDS Modernization Initiative Next Steps

Spring 2018

• Pilot five electronic clinical quality measures (eCQM)

• Pilot three transformational concepts:• Streamlining the extraction of countable visits• Expanding reporting beyond face-to-face visits• Enhancing data granularity with patient-level data

Summer 2018

• Pilot offline data collection and validation

• Release 2018 UDS manual in June

Fall 2018

• Introduce offline data collection and validation

• Introduce a standardized file for easy upload of the final UDS report

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Health Center Program Resources

✓ BPHC Helpline: hrsa.gov/about/contact/bphc▪ EHB questions/issues▪ FTCA inquiries

✓ BPHC Project Officer: ▪ Address specific questions about your health center’s grant or look-alike

designation

✓ National Cooperative Agreements & Primary Care Associations: bphc.hrsa.gov/qualityimprovement/strategicpartnerships

✓ Website: bphc.hrsa.gov▪ Includes many Technical Assistance (TA)

resources

✓ Weekly E-Newsletter: Primary Health Care Digest ▪ Sign up online to receive up-to-date

information

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Thank You!

Suma Nair PhD, MS, RD

Director, Office of Quality Improvement

Bureau of Primary Health Care (BPHC)

Health Resources and Services Administration (HRSA)

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snair1@hrsa.gov

301 594 0818

www.bphc.hrsa.gov

facebook.com/HHS.HRSA@HRSAgov

Connect with HRSA

To learn more about our agency, visit

www.HRSA.gov

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