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In concert with the quality initiatives occurring
within the broader health care community, the
Health Resources and Services Administration
(HRSA) is incorporating quality-related measures
that place greater emphasis on health outcomes
and demonstrate the value of care delivered
by health centers funded under Health Center
Program. A key component of the success of the
Health Center Program has been its ability to
demonstrate to payers and patients the value
of care delivered to those receiving health
center services. The expansion of the Health
Center Program and the resulting growth in the
number of health center patients and services,
along with technological advances and the development
of provider incentive programs in the private
and public health sector market, have underscored
the importance of demonstrating that health
centers continue to deliver high quality care
to underserved populations. Through the implementation
of these new measures HRSA will be able to publicly
report on key successes of the Health Center
Program in providing quality care to the underserved
community, and individual health centers will
have additional data to support continued performance
and quality improvement.
The Bureau of Primary Health Care (BPHC) recently
obtained approval from the Office of Management
and Budget to collect data on four new standardized
clinical measures, building upon the two existing
clinical measures collected through the Uniform
Data System (UDS). These new measures will be
incorporated in the Calendar Year (CY) 2008
UDS and in the Fiscal Year (FY) 2009 Service
Area Competition (SAC) and Budget Period Renewal
(BPR) funding opportunities. This alignment
across grant application and reporting requirements
presents an opportunity for grantees to enhance
their focus on performance improvement and for
HRSA staff to expand its support to grantees
in this area. This document presents: (1) BPHC’s
rationale for incorporating these quality-related
enhancements into the Health Center Program;
(2) the plan for rolling out these changes;
(3) the processes for collecting these data
elements; and (4) BPHC’s intended use
of these data.
After a year-long period of study, HRSA has
adopted a set of 12 nationally-standardized
(i.e., HEDIS, AQA, NQF, NCQA) clinical core
measures as the basis for an Agency-wide quality
improvement initiative to span grantee delivery
sites that provide clinical care and/or provide
referrals for clinical care. These measures
encompass six key areas that cut across multiple
Bureaus, Programs, and health service delivery
grantees: HIV, pre-natal and perinatal care,
immunizations, cancer, cardiovascular hypertension,
and diabetes.
BPHC selected a subset of four new clinical
measures from these HRSA core measures. The
four new Health Center Program measures are:
1) appropriate childhood immunizations; 2) cervical
cancer screening; 3) blood pressure control;
and 4) diabetes control. They include both process
and outcome measures: childhood immunization
and cervical cancer screening as process measures,
and blood pressure and diabetes control as outcome
measures. Through the annual UDS, health centers
will be asked to report on their overall patient
populations for the process measures as well
as on the racial and ethnic subgroups within
that population for the outcome measures. These
new measures augment clinical quality measure
reporting already underway in health centers
including entry into prenatal care, and birth
weight.
The BPHC selected the four new measures because
together they provide a balanced and comprehensive
representation of health center services, clinically
prevalent conditions amongst underserved communities,
and the population across life cycles. In addition,
the majority of health center grantees have
extensive experience working to improve the
quality of care in diabetes, hypertension, cancer
prevention and childhood immunizations. Finally,
these measures are nationally endorsed by the
National Quality Forum (NQF), and are commonly
used by Medicare and Medicaid and health care
insurance/managed care organizations to assess
quality performance so many health centers already
report these measures to these programs.
To minimize the reporting burden on grantees,
and based on feedback from health center grantees,
BPHC selected only a small subset of the HRSA-wide
measures and pilot tested them with a small
group of health centers to determine whether
it was feasible for health centers to collect
and report on these critical measures. The pilot
study confirmed that the health centers were
able to collect the data and report on them
readily based on chart reviews of a sample of
patients or through an electronic health record.
The four measures selected were among the small
subset that most health centers were able to
collect and report.
The significant growth of the Health Center
Program, the focus on quality and performance
improvement, and the proliferation of information
technology (IT) enhancements within health care
systems, including health centers, provided
the impetus to evaluate and revise the performance
reporting requirements for organizations funded
under the Health Center Program. As health centers
receive reimbursement and support through multiple
funding streams, improved performance reporting
serves to align health center reporting on clinical
performance measures with requirements of major
national quality improvement organizations.
Furthermore, enhanced performance reporting
results in the ability of the Health Center
Program to make evidence-based statements about
the impact of health centers on improving access
to cost-effective primary care for the nation’s
underserved populations. Finally, health centers
will have the ability to measure the quality
of care delivered to their patient populations.
HRSA staff is committed to working collaboratively
with health centers to provide HRSA training
and technical assistance resources to improve
health center performance over time.
The alignment of the measures across the grant
application (SAC and BPR) and grant performance
reporting (UDS) provides grantees with the opportunity
to establish quality and performance goals for
their organization and patient populations,
and then assess their progress against these
established goals. The alignment will also further
HRSA’s objectives to collect data in a
way that minimizes grantee reporting burden,
and to document and demonstrate the value and
successes of the Health Center Program.
As mentioned, HRSA’s purpose for collecting
these data is two-fold: to document the overall
value of the Health Center Program, and to provide
health centers with an assessment of their performance
in these areas so that they can set improvement
goals and track their improvement over time.
HRSA has also established technical assistance
resources at the State and national levels to
support health centers in achieving their quality
improvement goals. In short, HRSA remains committed
to its longstanding history of assisting health
center grantees in improving the quality of
care delivered to low income, uninsured patients.
Starting with CY 2008 UDS, grantees will be
submitting reports on-line, making use of a
web-based data collection system that is completely
integrated with HRSA Electronic Handbooks (EHBs).
BPHC grantees will use their EHB user name and
password to login to the EHB to complete their
UDS submission. BPHC grantees will be able to
submit UDS report data using standard web browsers
through Section 508 compliant interface. The
system will present users with electronic forms
that will clearly communicate what is required
and will guide the users in completing their
reports.
Usability features such as those that pre-fill
data from prior year reports will prevent redundant
data entry while other features such as calendar
controls to enter dates will speed up the data
entry process. Grantees will be able to work
on the forms in part, save them online, and
return to complete them later in a collaborative
manner. The approach will also allow grantees
to distribute the data entry burden amongst
multiple users if desired. Quantitative and
qualitative edit checks will also be applied
to ensure accurate and consistent data entry.
Grantees will be provided with a summary of
what is complete and what is incomplete along
with links to appropriate sections to fix the
identified incomplete parts. An electronic table
of contents for review and printing will be
automatically generated making it easy for the
grantees to organize their submissions per the
requirements.
BPHC has redesigned the Health Care and Business
Plans presented in the FY 2009 SAC and BPR applications
in order to better align the various data requests
based on a continuous quality improvement model.
In the SAC, grantees will establish long-term
project period length performance goals for
their organization and patient populations.
When possible, applicants should also provide
baseline data that directly corresponds to the
four new clinical performance measures, as well
as the two existing clinical measures. All SAC
applicants must also include one behavioral
health and one oral health performance measure
of their choice in the Health Care Plan. Applicants
who have a UDS comparison report which shows
their performance as well as State and national
data may wish to use these data to assist them
in establishing performance goals. Applicants
will also be following a similar model for the
Business Plan.
Applicants will be expected to track performance
against their established goals from the SAC
throughout the entire approved project period,
and to report interim (annual) progress achieved
on those goals in subsequent BPR applications.
When submitting their progress reports (BPR
application) applicants will report quantitative
progress on the related performance measures
(including all required measures). Applicants
will also be able to report supplementary information
that outline qualitative progress such as major
contributing or restricting factors impacting
the grantee’s performance as well as key
strategies or objectives undertaken to date
that contribute to the achievement of their
goals. In addition, project period end goals
may be revised if major accelerated progress
or barriers have been experienced in the previous
budget period. The rationale and comments for
any revisions must be provided in the Health
Care or Business Plan and/or Program Narrative
as applicable.
BPHC is embarking on a year-long process to
communicate to grantees about these changes
and to provide training. BPHC has set aside
resources to help grantees understand these
changes and respond to these new requirements.
Primary Care Associations (PCA) have been trained
on these new measures and are prepared to provide
technical assistance (TA) to grantees in understanding
these measures and how to develop goals and
benchmarks for the SAC and BPR Health Care Plans.
BPHC has also offered two TA calls on the implementation
of the new measures in the SAC opportunity,
with replays available until September 2008.
The slides and replay information for these
calls is available online at: http://www.hrsa.gov/grants/technicalassistance/sac.htm.
BPHC will also offer TA calls to assist grantees
in understanding the new performance requirements
in the FY 2009 BPR opportunity, upon its release.
To assist grantees in developing baseline and
goals for their upcoming SAC and BPR applications,
BPHC will also be sending out trend reports
to health centers with information from their
prior UDS and audit submissions.
For CY 2008, the annual UDS trainings will
include additional sessions focused specifically
on the four new clinical measures and the sampling
and data collection methodology for UDS reporting.
More information about the UDS reporting requirements
for these measures is available online at: http://www.bphc.hrsa.gov/uds/2008manual/.
BPHC will also work with its national cooperative
agreement partners and all State and regional
PCAs throughout the year to continue to communicate
these changes and provide training.
For more information and/or questions on the
implementation of these new measures, please
contact Charles Daly in the Office of Quality
and Data at 301-594-0818.
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