CDC CSTLTS Workplan Elements

Source

Data & Information Systems

KM 868-05

A1.  Recruit and onboard and retain  and onboard up to 25 member health centers  organizations to improve immunization rates through quality improvement strategies to include:

·  Provider champions

·  Actionable data feedback

·  Incentives

·  Peer to peer learning

·    Missed opportunities

·  Removing supply chain barriers

· Improving documentation in structured data (IIS and EMR)

· Patient engagement strategies

PM1. Number of partners submitting data to NACHC

OP1. Monthly dashboards summarizing data

KM 876-01

A1. Define the data elements suggestions include: - Vaccine Hesitancy - COVID prevention - COVID treatment - Housing insecurity/ lack of stable housing - Food insecurity - Lack of access to health care - Dental need - Medication access - Referral - Post-COVID syndrome - Substance abuse - Mental health treatment needs

PM1. Number of data elements

OP1. List of data elements and a data dictionary based on the 4 cornerstones of a care plan and Corresponding FHIR standards

SP 862-05

1. Develop a Data Analytic Plan for anemia and Iron Deficiency practices in health centers to with one large HCCNS to include:

a.      Pregnant Women

b.      Children 6-23 months( or age 5)

c.      ICD Codes

d.      Social determinants of health

e.      Lead prevalence

f.       Feeding including breast feeding

PM4. Number of data elements in Data Analytic plan to assess anemia in Iron Deficiency in health center patients.

Q4. Data Analytic Plan for anemia and Iron Deficiency.

Communications

KM 868-05

A1. Implement a communication plan to improve adult immunizations in health centers through sharing best practices and lessons learned to include social media,

PM1.  Number of educational materials, communication materials, social media posts and best practices disseminated to primary care associations, health centers and HCCNs

OM 1.  Comprehensive communication strategy.

OM  Increased capacity in the health center network to use communication and information technology to affect health decisions and actions 

KM 868-05

A2. Harvest of lessons learned and best practices to advance scale and spread. 

PM2. Number of lessons learned and best practices.

OM 2. One national and 3 state presentations presentation highlighting lessons learned and best practices for adult immunization best practices in health centers 

OM  Increased capacity in the health center network to use communication and information technology to affect health decisions and actions 

OM1. The elevation and dissemination of health center best practices and lessons learned in documenting and acting on social risks at the patient, community, and/or systems levels.

A3. Present findings at state and national meetings highlighting adult immunization promising practices for scale and spread in health centers.

PM3. Number of presentations at state and national conferences.

OM 3. One national and 3 state presentations presentation highlighting lessons learned and best practices for adult immunization best practices in health centers 

PCAs

Primary Care Associations (PCAs) provided training and technical assistance to federally qualified health centers, look-alikes, and similar community-based safety net providers in their state or region. The T/TA is based on statewide and regional needs assessment conducted by the PCAs. T/TA help health centers improve clinical outcomes, operations, financial performance. Also, PCAs can help health centers and look-alikes plan develop and grow health centers in their state, as well as develop strategies to recruit and retain staff.

PCAs work closely with partners such as NACHC and HCCNs to provide T/TA that will enable health centers and their patients to improve health outcomes.

Collaborative Work with HCCNs and PCAs from KM 868-05

NACHC will continue to partner with, and will add more, health center controlled networks (HCCNs) and primary care associations (PCAs) and standalone health centers for adult immunization implementation and scale activities.

According to HRSA, health center fundamentals include: 

·        Delivery of high quality, culturally competent, comprehensive primary care, as well as supportive services such as health education, translation, and transportation that promote access to health care. 

·        Provide services regardless of patients’ ability to pay and charge for services on a sliding fee scale. 

·        Operate under the direction of patient-majority governing boards. 

·        These include public and private non-profit organizations and tribal and faith-based organizations. 

·        Develop systems of patient-centered and integrated care that respond to the unique needs of diverse medically underserved areas and populations. 

·        Meet specific federal requirements regarding administrative, clinical, and financial operations. 

HCCNs were established to improve the efficiency and effectiveness of health centers. The formation of networks enabled groups of health centers to collaborate, share, and/or integrate functions that are critical to health center operations (e.g., clinical, fiscal, information management, managed care, human resources).  

The HRSA definition of a HCCN is “a network controlled by and acting on behalf of the health centers, as defined and funded under Section 330(e)(1)(C) of the Public Health Service Act, as amended.” The term “controlled” means that health centers are required to collectively appoint a minimum of 51 percent of the network’s board members.  

HCCN Core Roles are: 

Support for Electronic Health Records (EHRs): A core capacity/competency of many HCCNs/PCAs is the support and assistance they provide their member health centers in the adoption, implementation, and utilization of EHRs.  

Support for Practice Management Systems (PMSs): In addition to supporting member health centers with an EHR product, many HCCNs/PCAs have the capacity to support the “back-office” function of their centers, including the support of practice management systems. This table summarizes PMS vendors supported by HCCNs/PCAs and the major support functions provided to member centers. 

Support for Electronic Dental Records (EDRs): For those HCCNs/PCAs with members who operate oral health programs, support is also available for the adoption, implementation, and utilization of EDRs. 

Support for Data Aggregation, Analytics, and Reporting Tools: Collection and use of clinical data can be a complex task that may be beyond the scope of individual health centers. Data aggregation, analytics, and reporting tools play an important role in using data for a range of purposes. This table summarizes the variety of ways that HCCNs/PCAs are using these tools to support their members. 

Practice Transformation, Quality Improvement, and Health Information Exchange (HIE) Activities: As delivery system transformation continues to evolve and as payment reform moves from “volume to value,” many HCCNs/PCAs are well positioned to support their member health centers in these transformations.  

Support of Quality Reporting and Clinical/Performance Measures: To encourage providers to undertake delivery system transformation efforts and guide the process, a number of incentive programs and clinical/performance measures have been developed. This table summarizes the quality reporting programs, incentive programs, and clinical/performance measure sets that are supported by HCCNs/PCAs. 

Managed Care Activities: As managed care becomes increasingly prevalent, HCCNs/PCAs are frequently engaged in efforts to support their members in managed care activities.  

Support for Administrative and Financial Functions: Beyond their capacity/competency in the areas of Health Information Technology (HIT) and Delivery System Transformation, some HCCNs/PCAs have developed the capacity to support their health center members with a range of administrative and financial functions, including accounting, human resource (HR), and group purchasing.  

PCAs serve as technical assistance leads for the health centers within their state and have been proving valuable in the linkage between community health and public health.  Their ability to convene, outreach to, and collect lessons from health centers within their purview make them a strong collaborator in this work.

Contractual Work from KM 868-05

NACHC has a long history of establishing contracts with vetted expert consultants and vendors to complement staff expertise to support strong program implementation and results. NACHC uses an extensive vetting process including cost/price analysis, contract tracking and approval, sole source justification if sole source is used, and checking contractor’s debarment/suspension status in www.sam.gov. In addition, with the large network of professionals in the field, we check for references regarding consultants’ or contractors’ performance, work ethic, and commitment. The rates charged by consultants and contractors are also compared with other services to make sure they are competitive and reasonable. The average contract can be executed and implemented within 30 days or more rapidly when a need is critical.

For this phase of the work, it is planned that NACHC will continue to work with:

·        Up to 25 health centers

·        At least 4 networks and organizations, including

o   AllianceChicago,

o   Migrant Clinicians Network, 

o   HealthChoice,

o   Alaska Primary Care Association,

·        Curlew Consulting

·        Clinovations Gov+Health

NACHC uses the following criteria for vetting potential contractors: 

·        Strong organization 

·        Leadership intact (no turnover in the previous year or expected turnover) 

·        Reputation for delivering high quality products on time 

·        Strong health IT, informatics, and data analytics capacity to include access to patient-level population data that would enable tracking and reporting on de-identified individual patients over time to assess outcomes 

·        Data aggregation capacity, either in-house or through 3^rd parties such as Azara Healthcare, Arcadia, or i2i Systems 

·        Ability to ensure data integrity and validity 

·        Access to multiple data sets desired (e.g., claims) 

·        Willingness and ability to share data for evaluation, publication, and informing future directions, as well as for others to query for research purposes 

Product/Deliverable

Description

Approximate Cost**

Action Guide

Sample topics could include:

• CHWs

  Medicare Initial Preventive Physical Exam (IPPE) or Annual Wellness Visits (AWV); could focus on immunizations, HTN control, or other focal areas).

  Patient Self-Management

  Obesity Management (Adult)

  SDOH*

  Artificial Intelligence (AI)*

  Many others

Action Guides are concise documents that distill and synthesize the evidence-base, breaking it down into concise action steps for health center systems change. Action Guides address ‘why’ a topic is important, define ‘what’ the topic is, and ‘how’ a health center can make improvements in the focal area. Action Guides are typically 5-7 pages, although those that incorporate clinical guidelines may be in the range of 10-12 pages.

In developing an Action Guide, the Quality Center would work with subject matter lead to define the focal topic, outline the content, draft content for review by project leads, manage review and editing of the document by multiple stakeholders, and oversee formatting and design. The product would be a final, formatted Action Guide in the design template of current VTF Action Guides.

$15,000

Reimbursement Tip

Reimbursement Tips (see sample) provide guidance on program requirements for reimbursement of specific services, along with billing and coding guidance specific to FQHCs. These Tips condense volumes of Medicare regulations and guidelines into concise guidance (typically 2-4 pages) for health center administrators, care team members, and providers. They typically include the following topic areas: Patient Eligibility and Consent; Timeframe & Services; Authorized Providers and Staff; Documentation; Coding and Billing; Exceptions During the Public Health Emergency; and References.

$7,500

Slide Deck: Connecting Project to Systems Approach & the VTF

In consultation with your team, and with consideration of your workplan and activities, the Quality Center would prepare a brief slide deck that can be used in project work, learning communities, etc. to communicate the connection of your project work to a systems approach and the Value Transformation Framework. This set of PowerPoint slides (~5-10) would connect the work of your project to VTF Change Area(s) and, if done across multiple CAD projects, would communicate our collaborative efforts to advance the Quintuple Aim goals.

$5,000

Microlearning module

The Quality Center team would create a microlearning module (10 mins or less) from a webex/zoom recording and slide deck. The Quality Center would take your team’s recording and accompanying slide deck (approximately a dozen or less slides) and crop, clean, and make available as a microlearning module available for posting to the LMS or sharing with the field.

$5,000