PM Reporting tool Instructions

Attachment 5c. Instructions for Performance Measures Reporting Tool

19-1902 NOFO Performance Measure Reporting Instructions

Purpose

These instructions augment the information provided in the performance measure profiles. Performance measures are not expected to reflect all activities and accomplishments of the recipients. Recipients are encouraged to develop additional program-specific performance measures as needed and to provide additional detail in the narrative portion of their annual report.

For these performance measures, the term ‘state’ or ‘statewide’ refers to the recipient’s jurisdiction (e.g., state, territory, city, etc.).

Questions regarding the performance measures should be directed to email/name.

Information about the SharePoint reporting tool, such as site features, access requests, data submission, etc. can be found here.

Funding Years

Funding Year	1	2	3	4	5
Start	September 1, 2019	September 1, 2020	September 1, 2021	September 1, 2022	September 1, 2023
End	August 31, 2020	August 31, 2021	August 31, 2022	August 31, 2023	August 31, 2024

Performance Measure A: Analysis and Use of Core Data Sets

Performance Measure: Number and percentage of core measures updated, analyzed and disseminated/used during the reporting period.

Purpose: To monitor and document the collection and analysis of core data sets and to assure the reporting and use of the required core measures that are used to guide strategic actions focused on improving asthma control, thus reducing asthma-related hospitalizations, emergency department visits and deaths.

Core data sets required under this NOFO:

• Hospital Discharge

• Emergency Department Visits

• BRFSS Core

• BRFSS Child Prevalence Module

• BRFSSS Random Child Selection Module

• Asthma Call-back Survey (adult)

• Asthma Call-back survey (child)

• Vital statistics/mortality

Most recent year of data analyzed, corresponding core measures, whether the measure has been updated and reported, and most recent result should be completed for all data sets.

Performance Measure B: Linking Activities and Outcomes

Performance Measure: Documented activities of the recipient, and outcomes achieved, to establish and/or expand linkages between components of the EXHALE technical package at the organizational level (e.g., linkages that promote reimbursement or referrals; systems to share information across providers; mechanism to link health plans with home-based services or schools, data sharing across sectors).

Purpose: To monitor and document success of asthma programs and their partners in facilitating coordinated care for people with asthma.

For each activity, recipients should check all linkages that apply. Recipients should select corresponding status, additional information (associated payors, community services, state-level program or organization, and mechanism or organization for care coordination), and relevant associated outcomes.

Types of linkage activities are listed here:

• Linkages around coverage or reimbursement of services – The recipient worked with a payor(s) to provide or reimburse for asthma self-management education and/or home visits.

• Linkages between health care and community services – The recipient facilitated linkages between health care systems, providers or payor(s) and other services in the community, including health department services (other than coverage or reimbursement).

• Linkages with other state-level programs or agencies – The recipient engaged other state-level programs or agencies to expand access to and coordination of EXHALE strategies.

• Linkages between asthma programs and health care systems/providers providing coordinated care – The recipient engaged health care systems or health care providers to promote clinical care coordination.

If a linkage activity is still in development or has not yet been implemented, do not include here.

Performance Measure C: Comprehensive Service Expansion in High Burden Areas

Performance Measure: Number and description of existing, new, and discontinued services supported by the recipient and their partners, by geographic area and intervention type; and alignment of services with high burden geographic areas.

Purpose: To document program services and resources.

Recipients should select the type of intervention and all EXHALE strategies to which this intervention corresponds. If the intervention does not fall into one of the types listed, the title or name of the intervention should be entered in the ‘Title of Intervention Other’ field.

Both the intervention status (optional) and implementation status can be selected from the drop-down menu.

Recipients should select their state prior to selecting the county where the intervention is located. When selecting the county, please keep in mind the following:

• If an intervention is located in County A and residents from Counties A and B are eligible for services, select County A. Then create another entry for the intervention and select County B.

• If an intervention is potentially available statewide (e.g., statewide policy or virtual AS-ME available to anyone in the state) then select ‘statewide.’

Start and end date fields can be completed with at least the year the intervention started or ended, and if available month and day can be included. If the intervention is currently active or ongoing, recipients can select the ‘active’ box.

Performance Measure D: Quality of Guidelines-Based Care

Performance Measure: Documented improvements in the quality of care or health outcomes (e.g., asthma control; emergency department visits; hospitalizations; asthma self-management education) as a result of Quality Improvement (QI) initiatives.

Purpose: To encourage asthma programs to partner with health care providers and organizations serving populations with a disproportionate burden of asthma (as defined by the state asthma program) and to improve quality of care as defined by commonly used quality measures.

Recipients should not report QI initiatives that do not include any health outcomes or QI initiatives without baseline and follow-up data for at least one process or outcome measure. These activities can be documented in annual progress reports.

Recipients should enter the name of the healthcare organization (HCO) or entity conducting QI and select the type of HCO.

Recipients should select their state prior to selecting the county where the intervention is located. When selecting the county, please keep in mind the following:

• If the QI initiative is potentially available statewide (e.g., all FQHCs in a state are participating, working with Medicaid managed care organizations) then select ‘statewide.’

Recipients should enter the following demographic information:

• Approximately what number of patients with asthma are children (0-17 years of age) in this setting?

• Approximately what number of the patients are children (0-17 years of age) in this setting?

• Approximately what number of the patients are adults in this setting?

For each process measure collected and listed below, recipients should use the drop-down menu to indicate whether follow-up data indicated an improvement, no significant change, or worsening. A QI initiative does not need to include all process measures listed:

• Assessment of asthma severity

• Assessment of asthma control

• Use of spirometry

• Provision of asthma action plans

• Teach or review correct inhaler technique

• Provide AS-ME

• Influenza vaccination

• Refer to AS-ME program

• Referral to smoking cessation services

• Referral to other home or community services, including home visit programs

For health outcomes collected, recipients should indicate whether follow-up data indicated a significant improvement (>20%), good improvement (10-19%), improvement (0-9%), no significant change, or worsening.

• Asthma control using a standardized test

• Asthma medication ratio (AMR)

• Asthma hospitalizations

• Asthma ED visits

• Other asthma-related urgent or unscheduled visits

  • Urgent or unscheduled visits can include visits to urgent care or same-day visit to primary care provider due to an asthma exacerbation

• Other

Performance Measure E: Use of Evaluation Findings

Performance measure: Actions taken or decisions made during the reporting period to improve program activities and increase program effectiveness as a result of evaluation findings.

Purpose of measure: To document how recipients use evaluation data in program decision-making.

Recipients should not include evaluation findings that do not demonstrate a clear relationship to programmatic action or actions taken to revise the evaluation process when reporting on this measure.

Recipients should enter the evaluation and select the type of action taken as well as the appropriate evaluation topic. The evaluation question(s), findings, and programmatic action(s) should also be entered.

Performance Measure F: Asthma Self-management Education Completion Rates

Performance measure: Number and demographics of people with asthma who initiated and attended at least 60% of sessions of guidelines-based asthma self-management education (AS-ME); and description of the setting and curriculum of AS-ME courses.

Purpose of measure: To monitor and document enrollment and retention of people with asthma in AS-ME.

Performance Measure G: Improvement in Asthma Control among AS-ME Completers

Performance measure: The number of participants with poorly controlled asthma on enrollment (a subset of the previous measure) who report their asthma is “well-controlled” one month or more after attending at least 60% of asthma self-management education sessions.

Purpose of measure: To monitor and document whether participants completing AS-ME programs are improving asthma control and to document progress towards reducing the number of asthma-related hospitalizations and ED visits.

Reporting for performance measures F and G has been combined for ease of data entry.

Recipients should not report AS-ME that includes less than 2 sessions.

Recipients should list the partner delivering AS-ME and select both the program used and delivery setting. Each setting is unique, and the most appropriate option(s) should be selected. If the curriculum was delivered in more than one setting, select all options that apply.

Recipients should select their state prior to selecting the county where the program is delivered. Recipients can select up to 4 counties in which the program was delivered. When selecting the county, please keep in mind the following:

• If a program is located in County A and residents from Counties A and B are eligible for services, select County A. Then create another entry for the intervention and select County B.

• If a program is potentially available statewide (e.g., virtual AS-ME available to anyone in the state) then select ‘statewide.’

The address of the program should also be entered. This refers to where the program or partner delivering AS-ME is based (e.g., if AS-ME is delivered as part of a home-visiting program, respondents should list the headquarters or mailing address of the group conducting home visits).

The number of participants initiating AS-ME should be entered as well as asthma control status on enrollment:

• Number of participants with well-controlled asthma

  • Upon enrollment, the term well-controlled refers specifically to individuals who score within the well-controlled range on a validated, age-appropriate asthma control test

• Number of participants with poorly controlled asthma

  • Poorly controlled asthma is defined as an aggregate term to include two classifications in the National Asthma Education and Prevention Program guidelines: “not well controlled” and “very poorly controlled” asthma. A person has poorly controlled asthma if their scores on a validated, age-appropriate asthma control questionnaire fall outside the well-controlled range.

• Number of participants with unknown asthma control status

Participants with hospitalizations or ED visits for asthma in the 12 months prior to enrollment should also be recorded:

• Number of participants (upon enrollment) with any hospitalizations or ED visits for asthma in the 12 months prior to enrollment

• Number of participants (upon enrollment) without any hospitalizations or ED visits for asthma in the 12 months prior to enrollment

Recipients should select whether follow-up data are available or not.

Of participants that attended at least 60% of sessions, the following information should be entered:

• Number of participants at enrollment whose asthma is “well-controlled”

• Number of participants at enrollment whose asthma is poorly controlled

• Number of participants at enrollment with no information on asthma control

The number of participants (person with asthma) that fall into each of the age categories listed should be entered as well as the number of participants attending at least 60% of sessions who had poorly controlled asthma at enrollment who reported improved asthma control one month after completion of the program.

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Last updated: January 27, 2020