Form 1 Small Health Care Provider Quality Improvement Program P

Small Health Care Provider Quality Improvement Program Performance Improvement and Measurement System Database

Quality Program PIMS Measures

Small Health Care Provider Quality Improvement Program Performance Improvement and Measurement System Database

OMB: 0915-0387

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Office of Rural Health Policy: Rural Health

Community-Based Grant Programs


Performance Improvement and Measurement System (PIMS) Database


Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The OMB control number for this project is 0915-XXXX. Public reporting burden for this collection of information is estimated to be 8 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.


Small Health Care Provider Quality Improvement Grant Program


Table 1: ACCESS TO CARE

Information collected in this table provides an aggregate count of the number of people served through the program. Please refer to the detailed definitions and guidelines in answering the following measures. Please indicate a numerical figure.


Direct Services are defined as an interaction between a patient/client and a clinical or non-clinical health professional. Please include the number of patients served through this program, funded by Federal Office of Rural Health Policy (ORHP) grant dollars. Examples of direct services include (but are not limited to) patient visits, counseling, and education.


For the purposes of this data collection activity, indirect services will be limited to:

  1. billboards,

  2. flyers,

  3. health fairs and

  4. mailings/newsletters.

  5. Other mass media (e.g., radio, television, social media)


1

Direct Services

Please provide the number of patients or clients your organization serves through direct services (e.g., patient visits, counseling, and education) 

Number

2

Indirect Services
Please provide the number of individuals your organization reaches through the following indirect services: billboards, flyers, health fairs, mailings/newsletters, other mass media

Number






Table 2: POPULATION DEMOGRAPHICS

Table Instructions:

Please provide the total number of people served by race, ethnicity, and age. The total for each of the following questions should equal to the total of the number of people served through Direct Services provided in the previous section. If the total number in any category is zero (0), please put zero in the appropriate section. Do not leave any sections blank. There should not be a N/A (not applicable) response since all measures are applicable.


Number of people served through program by ethnicity is defined as:

  • Hispanic or Latino origin includes Mexican, Mexican American, Chicano, Puerto Rican, Cuban and other Hispanic, Latino or Spanish origin (i.e. Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard etc.)


3

Number of people served by ethnicity:

Number


Hispanic or Latino


Not Hispanic or Latino


Unknown


4

Number of people served by race:

Number

 

 

 

 

 

 

American Indian or Alaska Native


Asian


Black or African American


Native Hawaiian or Other Pacific Islander


White


More than one race


Unknown


5

Number of people served, by age group:

Number

 

 

 

 

Children (0-12)


Adolescents (13-17)


Adults (18-64)


Elderly (65 and over)


Unknown




Table 3: INSURANCE STATUS/COVERAGE

Table Instructions:

Please respond to the following questions based on these guidelines:


  • Uninsured is defined as those without health insurance.

  • Medicare is defined as Federal insurance for the aged, blind, and disabled (Title XVIII of the Social Security Act).

  • Medicaid is defined as State-run programs operating under the guidelines of Titles XIX (and XXI as appropriate) of the Social Security Act.

  • The Children’s Health Insurance Program (CHIP) provides primary health care coverage for children.

  • Other state-sponsored or public assistance program includes State and/or local government programs.

  • Private insurance is health insurance provided by commercial and not for profit companies. Individuals may obtain insurance through employers or on their own.


Each patient should be counted once. The total for this table should equal to the total number of people served through Direct Services.


6

Number of uninsured people

Number

7

Number of people covered through Medicare

Number

8

Number of people covered through Medicaid

Number

9

Number of people covered through the Children’s Health Insurance Program (CHIP)

Number

10

Number of people covered through other state-sponsored insurance or public assistance program

Number

11

Number of people covered by private insurance

Number

12

Unknown

Number



Table 4: STAFFING

Table Instructions:

Please provide the number of clinical and non-clinical positions funded by this grant. Please indicate a numerical figure. There should not be a N/A (not applicable) response since all questions are applicable.


Clinical staff includes, but is not limited to, physician (general or specialty), physician assistant, nurse, nurse practitioner, dentist, dental hygienist, psychiatrist, social worker, pharmacist, technician (medical, pharmacy, laboratory, etc.), therapist (behavioral, physical, occupational, speech, etc.), health educator, community health worker, promotora, case manager, interpreter/translator.


Non-clinical staff includes management (CEO, CFO, CIO, etc.), support staff, fiscal and billing staff, information technology (IT).


NOTE: Please report each staff person who is funded by this program only once. In the case of an individual whose time is split between clinical and non-clinical activities, please report them in the category that reflects the majority of their time.


13

Number of positions funded by grant dollars

Full-Time (1.0 FTE)

Part-Time (less than 1.0 FTE)


Clinical




Non-Clinical




14

How many staff received continuing education or training?

Number



Table 5: SUSTAINABILITY

Table Instructions:

  • The definition of sustainability is “programs or services continue because they are valued and draw support and resources”.

  • Select your sources of sustainability and sustainability activities.

  • Please indicate if any of your program’s activities will sustain after the grant period.

  • Use HRSA’s Economic Impact Tool provide the ratio for Economic Impact vs. HRSA Program Funding.


15

Annual program award
Please provide the annual program award based on box 12a of your Notice of Award (NOA). 

Dollar amount

16

Annual program revenue
Please provide the amount of annual program revenue made through the services offered through the program. Program revenue is defined as payments received for the services provided by the program that the grant supports. These services should be the same services outlined in your grant application work plan. Please do not include donations. If the total amount of annual revenue made is zero (0), please put zero in the appropriate section. Do not leave any sections blank.

Dollar amount




17

Additional funding secured to assist in sustaining the project

Dollar amount


18

Sources of Sustainability
Select the type(s) of sources of funding for sustainability. Please check all that apply.


Selection list


Network/Consortium revenue



In-kind Contributions (In-kind contributions are defined as donations of anything other than money, including goods or services/time.)



Membership fees/dues



Fundraising/Monetary donations



Contractual Services



Other grants



Fees charged to individuals for services



Reimbursement from third-party payers (e.g. private insurance, Medicare, Medicaid)



Product sales



Government (non-grant)



Other – specify type 



None



19

Sustainability Activities:
Which of the following activities have you engaged in to enhance your sustainability?  Please select all that apply.

Selection list


Local, State and Federal Policy changes


Media Campaigns


Community Engagement Activities


Other – Specify activity


20

Have you developed any of the following:

Please select all that apply.

(Y/N)


Sustainability Plan


Business Plan


Communications Plan


Fundraising Plan



21

What is your ratio for Economic Impact vs. HRSA Program Funding?
Use the HRSA’s Economic Impact Analysis Tool (http://www.raconline.org/econtool/) to identify your ratio.

Ratio

22

Will the network/consortium sustain, if applicable?
If you are participating in this program as a network or consortium, please indicate if your current network/consortium will continue after the grant period is over

(Y/N)

23

Will any of the program’s activities be sustained after the grant period?

All/Some/None



Table 6: CONSORTIUM/Network (optional)

Table Instructions:

If you are participating in this program as a network or consortium, please complete this section.


Please provide information about the consortium or network members, if applicable. A consortium or network is defined as collaboration between two or more separately owned organizations.


24

Number of member organizations in the Consortium/Network

Number


Area Agency on Aging



Area Health Education Center (AHEC)



Business



Community Health Center/ Federally Qualified Health Center (FQHC)



Critical Access Hospital



Emergency Medical Service



Faith-Based Organization



Health Department



HIT Regional Extension Center



Hospice



Hospital, not Critical Access



Long Term Care Facility



Mental Health Center



Migrant Health Center



Pharmacy



Private Practice (Medical and/or Dental)



Professional Association



Public Health Department



Rural Health Clinic



School District



Social Services Organization



Tribal Entity



University/College/Community College/Technical College



Other – Specify Type:




Table 7: HEALTH INFORMATION TECHNOLOGY

Table Instructions: Health Information Technology (HIT)

Please select all types of technology implemented, expanded or strengthened through this program.


25

Type(s) of technology implemented, expanded or strengthened through this program: (Please check all that apply)

Selection list


Computerized provider order entry (CPOE)


Electronic entry of prescriptions/e-prescribing


Electronic medical records/electronic health records

 

Health information exchange (HIE)

 

Patient/disease registry

 

Telehealth/telemedicine

 

None

 

Other – please specify

 

26

Have your organization and/or any of your organization’s providers attested to Meaningful Use?

If yes, please select all that apply.

Y/N


Stage 1


Stage 2


Stage 3


If no, is your organization and/or providers planning to attest in the next 12 months?


If yes, have your organization and/or providers received incentive payments?




Table 8: QUALITY IMPROVEMENT

Table Instructions:

Please report on quality improvement activities and initiatives implemented, expanded or strengthened through this program.

.


  • An Accountable Care Organization (ACO) is a group of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to Medicare patients.

  • A Medical Home is defined as comprehensive and continuous medical care to patients with the goal of obtaining maximized health outcomes. To become a medical home an organization generally gains a level of certification from an accrediting body.

  • Care coordination is defined as the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services.

  • The Partnership for Patients is a public/private partnership focused on making hospital care safer, more reliable, and less costly through two goals: reducing preventable hospital-acquired conditions and improving care transitions. (http://partnershipforpatients.cms.gov/)

  • Million Hearts is a national initiative to prevent 1 million heart attacks and strokes by 2017. (http://millionhearts.hhs.gov/index.html)

  • The Medicare Beneficiary Quality Improvement Project (MBQIP) is a Flex Grant Program activity within the core area of quality improvement for Critical Access Hospitals (CAH). (http://www.hrsa.gov/ruralhealth/about/hospitalstate/medicareflexibility_.html)


27

Participation in Accountable Care Organization (ACO)

Is your organization participating in an ACO? (If yes, please check all that apply)

Yes/No

(Selection List)


Medicare Shared Savings Program


Advanced Payment ACO Model


Pioneer ACO Model


Other – specify


28

Participation in Medical Home

Is your organization participating in a Medical Home or Patient Centered Medical Home (PCMH) initiative?

Yes/No


If yes, have you achieved or are you pursuing certification or recognition? (If yes, please check all that apply)

Yes/No

(Selection List)

National Committee for Quality Assurance (NCQA)


Accreditation Association for Ambulatory Health Care (AAAHC)


The Joint Commission


State/Medicaid Program


Other – specify


29

Care Coordination Activities

Yes/No

(Selection List)


Referral tracking system


Patient support and engagement


Integrated care delivery system (agreements with specialists, hospitals, community organizations, etc. to coordinate care)


Case management


Care plans


Medication management


Other – specify


30

Participation in Partnership for Patients

Yes/No

31

Participation in Million Hearts

Yes/No

32

Critical Access Hospitals: Participation in Medicare Beneficiary Quality Improvement Project (MBQIP)

Yes/No

33

Other – please specify





Table 9: CLINICAL MEASURES

Table Instructions:

Please use your health information technology system to extract the clinical data requested. Please refer to the specific definitions for each measure.


Measure 1: The percentage of patients 18 - 75 years of age with diabetes (type 1 and type 2) whose most recent HbA1c level is <8.0% during the measurement year.

Numerator: Patients whose HbA1c level is <8.0% during the measurement year.

Denominator: Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.  



Measure 2: The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) whose most recent LDL-C test is <100 mg/dL during the measurement year.

Numerator: Patients whose most recent LDL-C test is <100 mg/dL during the measurement year.

Denominator: Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.


Measure 3: Percentage of patients aged 18 years and older with a documented BMI during the current encounter or during the previous six months AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the encounter. (Normal Parameters: Age 65 years and older BMI > or = 23 and < 30; Age 18 – 64 years BMI > or = 18.5 and < 25)

Numerator: Patients with a documented BMI during the encounter or during the previous six months, AND when the BMI is outside of normal parameters, follow-up is documented during the encounter or during the previous six months of the encounter with the BMI outside of normal parameters

Denominator: All patients aged 18 years and older


Measure 4: The percentage of patients 18 to 85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90) during the measurement year.

Numerator: The number of patients in the denominator whose most recent BP is adequately controlled during the measurement year. For a patient’s BP to be controlled, both the systolic and diastolic BP must be <140/90 (adequate control). To determine if a patient’s BP is adequately controlled, the representative BP must be identified.

Denominator: Patients 18 to 85 years of age by the end of the measurement year who had at least one outpatient encounter with a diagnosis of hypertension (HTN) during the first six months of the measurement year.


Measure 5: Percentage of patients aged 18 years and older who were screened for tobacco use at least once during the two-year measurement period AND who received cessation counseling intervention if identified as a tobacco user

Numerator:

Patients who were screened for tobacco use* at least once during the two-year measurement period AND who received tobacco cessation counseling intervention** if identified as a tobacco user

*Includes use of any type of tobacco

** Cessation counseling intervention includes brief counseling (3 minutes or less), and/or pharmacotherapy

Denominator: All patients aged 18 years and older who were seen twice for any visits or who had at least one preventive care visit during the two year measurement period


Measure 6: Percentage of patients aged 12 years and older screened for clinical depression using an age appropriate standardized tool AND follow-up plan documented

Numerator: Patient’s screening for clinical depression using an age appropriate standardized tool AND follow-up plan is documented

Denominator: All patients aged 12 years and older


Measure 7: Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization

Numerator: Patients who received an influenza immunization OR who reported previous receipt* of an influenza immunization

*Previous receipt can include: previous receipt of the current season’s influenza immunization from another provider OR from same provider prior to the visit to which the measures is applied (typically, prior vaccination would include influenza vaccine given since August 1st).

Denominator: All patients aged 6 months and older seen for a visit between October 1 and March 31





Numerator

Denominator

Percent

1

NQF 0575: Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Control (<8.0%): The percentage of patients 18 - 75 years of age with diabetes (type 1 and type 2) whose most recent HbA1c level is <8.0% during the measurement year.




2

NQF 0064: Comprehensive Diabetes Care: LDL-C Control <100 mg/dL: Percent of adult patients, 18- 75 years of age with diabetes (type 1 or type 2) who had LDL-C less than 100 mg/dL




3

NQF 0421: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up: Percentage of patients aged 18 years and older with a documented BMI during the current encounter or during the previous six months AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the encounter.




4

NQF 0018: Controlling High Blood Pressure: The percentage of patients 18 to 85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90) during the measurement year.




5

NQF 0028: Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention: Percentage of patients aged 18 years and older who were screened for tobacco use at least once during the two-year measurement period AND who received cessation counseling intervention if identified as a tobacco user




6

NQF 0418: Screening for clinical depression: Percentage of patients aged 12 years and older screened for clinical depression using an age appropriate standardized tool AND follow-up plan documented




7

NQF 0041: Influenza immunization: Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization






OPTIONAL CLINICAL MEASURES

The following clinical measures are OPTIONAL. You are encouraged to include them, especially if your program has a focus on pediatric populations.


Please use your health information technology system to extract the data requested. Please refer to the specific definitions for each measure.


Optional Measure 1: Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents

Numerator: Body mass index (BMI) percentile documentation, counseling for nutrition and counseling for physical activity during the measurement year.

Denominator: Patients 3-17 years of age with at least one outpatient visit with a primary care physician (PCP) or OB-GYN.


Optional Measure 2: Hemoglobin A1c (HbA1c) Testing for Pediatric Patients

Numerator: Patients who had an HbA1c test performed during the measurement year.

Denominator: Patients aged 5-17 years old with a diagnosis of diabetes and/or notation of prescribed insulin or oral hypoglycemic/antihyperglycemics for at least 12 months.


Optional Measure 3: Blood Pressure Screening by 13 Years of Age

Numerator: Children who had documentation of a blood pressure screening and whether results are abnormal at least once in the measurement year or the year prior to the measurement year.

Denominator: Children with a visit who turned 13 years old in the measurement year.





Numerator

Denominator

Percent

1

NQF 0024: Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents: Percentage of patients 3-17 years of age who had an outpatient visit with a primary care physician (PCP) or an OB/GYN and who had evidence of the following during the measurement year:

- Body mass index (BMI) percentile documentation

- Counseling for nutrition

- Counseling for physical activity




2

NQF 0060: Hemoglobin A1c (HbA1c) Testing for Pediatric Patients: Percentage of pediatric patients aged 5-17 years of age with diabetes who received an HbA1c test during the measurement year.




3

NQF 1552: Blood Pressure Screening by 13 Years of Age: The percentage of adolescents who turn 13 years of age in the measurement year who had a blood pressure screening with results








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