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The Health Center Program:

Policy Information Notice 2001-07: Health Disparities and Patient Visit Redesign Collaboratives

 
 

 

I. INTRODUCTION

This document provides supplemental application guidance and performance expectations for the Health Disparities and Patient Visit Redesign Collaboratives. Activities under these collaboratives will cover the period April 1, 2001 to March 31, 2002. During fiscal year (FY) 2001, the Bureau of Primary Health Care (BPHC) has $7.2 million available for the 3rd year of the health disparities initiative that focuses on diabetes mellitus, cardiovascular disease, cancer, prevention and pesticides as well as depression and asthma. Of the $7.2 million, $100,000 will be made available on a one-time basis, to support activities for each National Clinical Network (CNs). National CNs must apply for this funding opportunity through one of the five lead cluster Primary Care Associations (PCA) and CNs. In addition, $770,155 is available for the transition of Together for Tots (TOTs) into the Health Disparities Collaboratives.

In addition, BPHC will make available $650,000 to support the Patient Visit Redesign Collaborative for FY 2001. There will be one award nationally to one cluster’s lead PCA and CN.

Major directions for the coming year include: (1) a new health disparity collaborative for cardiovascular disease and a third diabetes collaborative; (2) development of collaborative for cancer and prevention; (3) development of web-based depression module and a web-based asthma module; (4) a second asthma collaborative; (5) an additional half day at the kick-off for information system training and the addition of a training session on cognitive and problem solving therapy in a minimum of one Learning Session per collaborative; (6) integration of the TOTs program into the health disparities collaboratives; (7) strengthening and expanding the role of the cluster steering committees and (8) identifying National and State partners with expertise in our collaborative activities to assist health centers using Centers for Disease Control and Prevention and the State-based Diabetes Control Program as a model. The BPHC Health Disparities Collaborative National Director and the Institute for Healthcare Improvement (IHI) Health Disparities Collaborative National Director will provide leadership and assistance in the coming year's activities.

Major capacity building initiatives include: (1) additional resources for lead cluster PCA and CN to support teams; (2) opportunity to align and train current PCA clinical staff; (3) opportunity to build State capacity for clinician involvement in health disparity support activities; (4) strengthening the clinical focus of the PCA by having the PCA provide evidence of a CN or committee with a documented track record of activities that have improved clinical practice and outcomes and a governance structure with significant representation by a group of clinicians with active practices in health centers or National Health Service Corps (NHSC) sites, or have a plan to phase into such a structure within the next 12-18 months; and, (5) transition for community and
migrant health centers from clinical measures to health disparities performance and improvement. As health centers successfully participate and complete a health disparity collaborative, they will continue to measure and improve on a core number of health disparity measures.

Health centers participating in collaboratives will be expected to continue to report on core collaborative measures after completing the collaborative. They will not be required to report on clinical outcome measures, although they are encouraged to use some or all of these measures for internal improvement efforts and for documenting clinical performance for payers.

SECTION I HEALTH DISPARITIES COLLABORATIVES

To be eligible to participate in this project, the lead PCA and CN must present a project plan consistent with performance expectations (attached) and the following issues in the application for support:

  1. Have a steering committee with representation from other PCAs in their cluster, including those PCAs with TOTs Coordinators, multidisciplinary CNs, health center senior leadership and clinicians, and the Health Resources Services and Administration (HRSA) Field Office; have completed two strategic planning sessions, and submit an annual report with the budget request.
  2. Have bylaws and charter or plan that opens membership to all BPHC-supported organizations, and have a policy and plan to share all collaborative information and opportunities with all BPHC-supported organizations including Health Care for the Homeless, Public Housing Primary Care and Healthy Schools, Healthy Communities grantees and NHSC free-standing sites.
  3. Include both a lead PCA and multidisciplinary CN. The CN may be part of the PCA or may be independent. The PCAs and independent CNs are ineligible for this project if they apply separately. Requests for support of the additional State-based collaborative coordinators must be included as part of the request from the lead PCA and CN and be included in the budget from the lead PCA and CN. Individual State requests will not be accepted.
  4. Site visit plan for information system coordinators and cluster and State coordinators, including the number and frequency of anticipated visits to health centers and NHSC sites per year, training and mentoring activities, Technical Assistance to sites, faculty support in other cluster learning sessions and collaboration with other agencies.
  5. A process to monitor whether activities are in fact improving health outcomes and shared national goals at a cluster level, utilizing monthly health center reports and information available from partner agencies, should be included.
  6. Principal activities to be performed by the Executive Director of the PCA and the CN to support the aims and performance of cluster teams, and to facilitate partnerships and communication.
  7. The cluster mission statement and strategic plan.
  8. Agreement by the lead PCA Executive Director and the CN to participate in the quarterly meetings with BPHC, the cluster steering committee meetings and the BPHC cluster site visits.
  9. Description of partnership building activities that support collaborative goals.
  10. A plan, coordinated by the cluster steering committee, for spread to all States and BPHCsupported
    sites should be included as well as a process to monitor whether activities are in fact improving care.
  11. Principal activities to be performed by the manager of the CN.
  12. Role of a CN or committee in strategic planning and implementation of the health disparities collaborative with a documented track record of activities that have improved clinical practice and outcomes.
  13. A PCA governance structure with significant and meaningful representation by a group of clinicians with active practices in health centers or NHSC sites, or proposal to phase into such a structure within the next 12-18 months
  14. Prepare a budget in accordance with PHS 5161-1 along with a one to three page justification. It should describe personnel and travel costs as appropriate, and should clearly define resources for the lead CN. If appropriate, it should include contractual arrangements with other organizations, PCAs and/or CNs.
  15. Plan to distribute the BPHC and IHI produced marketing and training videos to health centers, health departments, other PCAs and other partners as appropriate.

NATIONAL CNs APPLICATION REQUIREMENTS

The Health Care for the Homeless Clinicians' Network, Migrant Clinicians Network and National Network for Oral Health Access (NNOHA) are invited to submit a proposal for the Health Status and Performance Improvement Collaborative. The proposal should not exceed 10 pages in length. Awards will be $100,000.

To be eligible to participate in this project, these organizations must apply through one of the lead cluster PCAs. Health Care for the Homeless Clinicians' Network must apply for a grant through BPHC Homeless Branch, Migrant Clinicians Network to apply through the Migrant Branch, NNOHA to apply through Michigan PCA.

Copies of National grant applications should be included in PCA applications and should reflect integration with the lead PCA activities.

National CNs will work with BPHC, IHI, HRSA Field Office and their lead PCA when developing any materials for the collaborative to assure integration with the collaborative models.

  1. National CNs activities will support collaborative infrastructure in their work with health centers to maximize national goals.
  2. Budget and justification for all costs.

EVALUATION CRITERIA

All applications submitted under this funding announcement will undergo a review based on the following criteria. There will be one PCA and CN team funded per cluster.

  1. Performance in the diabetes collaborative during the past year.
  2. Quality of the proposed approach and its effectiveness in meeting or exceeding the performance goals for the coming year. See attached timeline and operational guidance.
  3. Evidence of partnership building activities supportive of collaborative goals.
  4. The degree of collaboration in the development and design of the proposed approach.
  5. Capacity of the PCA and CN to engage in these activities.
  6. Evidence of a PCA governance structure with significant representation by a group of clinicians with active practices in health centers or NHSC sites, or have a plan to phase into such a structure within the next 12-18 months.

Application due dates for these funding opportunities are March 19, 2001. The original application must be submitted to: BPHC Office of Grants Management, 4350 East-West Highway, 7th floor, Bethesda, Maryland 20814 with a copy to the appropriate HRSA Field Office.

SECTION II - PATIENT VISIT REDESIGN COLLABORATIVE

I. Introduction

This section provides supplemental application guidance for the Patient Visit Redesign Collaboratives. Activities under these collaboratives will cover the period April 1, 2001 to March 31, 2002. During FY 2001, the BPHC will make available $650,000 to support the Patient Visit Redesign Collaborative for FY 2001. There will be one award nationally to one cluster’s lead PCA and CN.

Resources will be available for the 3rd year of the Quality Center’s cluster-specific reengineering collaboratives, engaging approximately 15 BPHC sites in each of the 2-6 month collaboratives planned for this fiscal year.
This year will be a transition year for the applications for the bureau’s Quality Center initiatives including sponsorship of the Patient Visit Redesign Collaboratives. Complimentary and related Quality Center activities will be outlined in the Excellence in Practice Policy Information Notice to be issued separately.

II. Eligibility

Eligible Organizations: One lead PCA and CN nationally. To be eligible to participate in this project, the lead PCA and CN must:

  • Have a participated or been the lead in a Cluster-specific Patient Visit Redesign Collaborative in the past 2 years.
  • Include both a lead PCA and CN. The PCA’s and independent CN’s are ineligible for this project if they apply alone.
  • Have bylaws/charter or other governing guidance that clearly opens membership to all BPHC-supported organizations; allows for special populations program representatives on the board; states commitment to representing all BPHC-supported organizations in State and community level issues and share information with all BPHC-supported organizations.

III. Guidance for Application Content

To be eligible to participate in this project, the sponsoring PCA and CN must present a project plan consistent with performance expectations (attached) and address the following issues in the application for support:

  1. Identification and management of Cluster-Specific Applicant Review Panel in cooperation with Health Disparities Cluster Steering Committee.
  2. Formation and support of the Cluster-Specific Redesign Expert Team for each collaborative in conjunction with National Redesign Expert team.
  3. Coordination, planning and implementation of learning sessions in conjunction with National Redesign Expert Team.
  4. Documentation of learning session evaluations and results.
  5. In collaboration with the National Redesign Expert Team, development of strategy and ongoing support and spread of redesign efforts.
  6. Prepare a budget in accordance with PHS 5161-1 along with a one to three page justification. It should describe personnel and travel costs as appropriate, and should clearly define resources.

EVALUATION CRITERIA
All applications submitted under this funding announcement will undergo a review based on the
following criteria:

  • Performance in the 1998-2000 Redesign Collaboratives.
  • Quality of the proposed approach and its effectiveness in meeting or exceeding the performance goals for the coming year.
  • The degree of collaboration in the development and design of the proposed approach.
  • Capacity of the PCA and CN to engage in these activities.
  • Evidence of a CN or committee with a documented track record of activities that have improved clinical practice and outcomes, and a governance structure with significant representation by a multi-disciplinary group of clinicians with active practices in health centers or NHSC sites, or have a plan to phase into such a structure within the next 12-18 months.
  • Application due dates for these funding opportunities are March 19, 2001. The original application must be submitted to: BPHC Office of Grants Management, 4350 East-West Highway, 7th floor, Bethesda, Maryland 20814 with a copy to the appropriate HRSA Field Office.

FISCAL YEAR 2001 – 2002
PERFORMANCE EXPECTATIONS

I. INTRODUCTION

For several years, the Bureau of Primary Health Care (BPHC) has focused its efforts on the compelling vision of achieving 100% Access and 0 Health Disparities. All BPHC activities are driven by and designed to move towards this vision, both through direct interventions with Bureau resources and by leveraging other resources through partnerships with others committed to the same vision.

One of the key strategies being employed by the Bureau is "Quality Improvement.” This strategy derives from the concept that we must strive to do all things in the best and most effective way possible; all of our "products" must be of the highest quality if we are going to achieve our vision. Quality includes more than clinical practice, and encompasses administrative, financial, and operational aspects of what our supported sites and we do every day. Through Quality Improvement across all objectives in the Strategic Plan (Strengthening the Safety Net, Mobilizing the Workforce, Creating New Access, and Excellence in Practice), access can be increased through more efficient and effective systems of care and disparities can be reduced, bringing us closer to our vision.

The Quality Improvement Model is a key mechanism the BPHC has chosen to implement this overall Quality Improvement strategy. A number of organizations have developed or adapted this basic model for bringing about change and improving their organizations. The Institute for Health Care Improvement developed a Collaborative Model for focusing on clinical practices, and this model has become the core of the BPHC Quality Improvement strategy. The model may vary from place to place and among various target issues, but the key elements remain the same:

  • There is a focus on a specific problem or issue to be addressed.
  • There is a focus on a specific outcome or objective to be achieved.
  • An Interdisciplinary Learning Team from the Site serves as the "change agent."
  • A curriculum is provided that offers possible solutions and options to address the chosen problem.
  • Periodic working/learning sessions bring several teams together to learn relevant content, share experiences, offer support.
  • There is a continual assessment of progress towards the defined objective and adjustment of approaches; rapid change model.
  • It includes tracking and reporting of performance.
  • There will be a long-term impact on the organization though the institutionalization of both the changes made and the learning process itself into their everyday work; they will pursue applications to other areas to implement additional improvements.

This collaborative model forms the foundation for the BPHC Quality Improvement efforts. Thus far, it has been implemented in two key areas: chronic disease management and patient visit redesign. While these two initiatives vary in some details of implementation, they each have the elements of the model described above. In addition, implementation of the model in each area requires a level of infrastructure support (i.e., data systems, staff and logistics, etc.) to succeed. Each of the current efforts has linkages for infrastructure support with BPHC partners such as Primary Care Associations (PCAs) and Clinical Networks (CNs). These partners assist in the implementation of the actual learning/improvement team process in some fashion for each collaborative.

To accomplish these aims, the goal is to involve all health centers and a significant number of National Health Service Corps (NHSC) sites during the next 5 years in at least one collaborative learning experience dedicated to one or more health disparities with a similar 3-year plan to assimilate key redesign principles into all Bureau activities and programs. Priority will be given to health centers that have not participated in any previous collaboratives. The term "health center,” throughout the document, refers to community, migrant, homeless and public housing primary care health centers and Healthy Schools, Healthy Communities grantees. Through this process, each BPHC-supported site has the opportunity to apply evidence and population-based care to
their patients and community, and to document improved health status. In addition, once the care and improvement models are established in a health center or NHSC site, they can be applied to other clinical issues or used to improve administrative systems.

Yet, the goal for eliminating health disparities and increasing access extends beyond Federal policy. It is also a key strategy for success in the current and future health care marketplace. Employers, public and private insurers, and consumers seek health systems that manage health, are accountable, share cost and quality measurements, focus on communities and populations, and are patient centered. The design and implementation of the health disparities and redesign strategies supports these goals.

Health Disparities Collaborative

National Project Goals and Activities: April 1, 2001 to March 31, 2002

I. SUSTAINING AND DISSEMINATION: BUILDING THE COLLABORATIVE COMMUNITY

Goal: Health centers and NHSC sites in Diabetes I (88) continue progress with: (1) 100 percent of the 12 monthly reports completed by January 2002; (2) 90 percent of health centers reaching the national goal by January 2002; (3) maintaining or exceeding an average team score of 4.0; (4) documenting the integration of the care model into on-going clinical and management systems in additional health center sites (spread) and patients (registry enrollment); and, (5) demonstrating an increase of 25 percent or more in the health center patients with diabetes enrolled into a registry information system by May 2001.

Goal: Health Centers and NHSC sites in Diabetes II (120) continue progress with: (1) 100 percent of the monthly reports completed by January 2002; (2) 50 percent of health centers meeting the national goal by October 2001; (3) maintaining or exceeding an average team score of 4.0; (4) documenting the integration of the care model into on-going clinical and management systems in additional health center sites (spread) and with additional patients (registry enrollment); and, (5) demonstrating an increase of 25 percent or more in the health center patients with diabetes enrolled into a registry and information system by October 2001.

Goal: Health centers in Depression and Asthma continue progress with: (1) 100 percent of the monthly reports completed by March 2001; (2) with 50 percent of the health centers reaching the national goal(s) by October 2001; (3) maintaining or exceeding an average team score of 4.0; (4) documenting the integration of the care model into on-going clinical and management systems in additional health center sites (spread) and additional patients (registry enrollment); and, (5) demonstrating an increase of 25 percent or more in the health center patients with depression or asthma enrolled into a registry and information system by October 2001. (A Post-collaborative Expert Panel will meet in March 2001.)

Goal: Select health centers and NHSC sites in the HIV-Bureau sponsored HIV Collaborative continue progress with (1) 100 percent of the quarterly reports completed by January 2002; (2) 50 percent of the health centers reaching the national project goal(s) for HIV by January 2002; (3) maintaining or exceeding an average team score of 4.0; and, (4) demonstrating an increase of 25 percent or more in the health center patients with HIV enrolled into a registry and information system by January 2002. (See support system for additional related goals and activities.)

Goal: In collaboration with lead cluster PCA and CNs, National Association of Community Health Centers NACHC), Center for Disease Control and Prevention (CDC), Institue for Healthcare Improvement (IHI), Substance Abuse Mental Services Health Administration (SAMSHA), National Cancer Institute (NCI), environmental Protection Agency (EPA) and other national partners, plan a health disparities congress for March or April 2002.

Performance Expectations:
PCA and CN:

  1. Design and implement a cluster-wide strategy to support Diabetes I, II, Asthma, Depression and HIV teams that have completed the first year of the collaborative. This may include one or more cluster and State learning sessions for teams and senior leaders, mentoring of new cluster coordinators, regular conference calls, listserv, and site visits.
  2. Establish and implement a cluster strategy to sustain and promote high performing teams and improve performance for lower performing teams.
  3. Identify high performing teams and senior leaders to participate as faculty and mentors to sustain and accelerate positive change. Travel high performing teams to national conferences.
  4. Develop relationships among health centers and State Diabetes Control Programs (DCP) and other appropriate State agencies to help sustain the work of health center teams. Support and facilitate implementation of State DCPs and health center team aims. Explore existing State or regional telecommunication systems, and form appropriate partnerships, for more effective and cost efficient communication and learning.
  5. Establish and implement a data distribution and communication protocol to share monthly data with sites, cluster and national steering committees and partners, utilizing the standard cluster and national report formats. The protocol should include a monthly conference call schedule for cluster steering committees.
  6. National CNs to act as faculty for collaborative activity and help support the spread of the collaborative (e.g., school-based health clinic, homeless or public housing primary care, migrant population) within the same organization.

In support of these national Goals, the BPHC plans to:

  1. Provide resources to PCA budgets for support of an additional collaborative coordinator, including travel, as well as assistance in developing and implementing an orientation and training strategy for the new coordinator. The new coordinator, location to be determined in partnership with the cluster steering committee and located in a cluster partner PCA and CN, will receive programmatic oversight by the cluster collaborative director. Recognizing the organizational titles may differ, “cluster directors” shall have uniform components in job descriptions and be responsible for the programmatic management of the collaboratives at the cluster level.
  2. In collaboration with IHI and NACHC develop two communication and training videos, one focused on a general audience, and the other focused on orienting new health center team members.
  3. In collaboration with IHI and NACHC disseminate breakthrough change concepts developed during previous BPHC-sponsored collaboratives and IHI Breakthrough Series. This may be through published and web-based vehicles.
  4. In collaboration with NACHC, lead cluster PCAs and CNs, IHI, CDC, SAMHSA, NCI, EPA and other national partners, plan a health disparities congress for March or April 2002.
  5. Support the national CN in sustaining and spreading collaboratives to maximize the health
    outcomes of migrant and seasonal farmworkers and homeless populations and assist to
    maximize oral health in all populations.