Clinical Performance Measures & New Access Point (NAP) Applications

Transcription

1 Clinical Performance Measures & New Access Point (NAP) Applications Kameron L. Wells, ND, RN Vice President, Clinical Quality Initiatives

2 Clinical Performance Measures Outline realistic goals to be accomplished during the (2) year NAP project period Baseline data must be established for each measure Should only address the service area and target population of the proposed NAP(s)

3 Applicant Type and Completion of Clinical Performance Measures New start applicants: complete the Clinical Measures based on the entire proposed scope of the project Satellite applicants: complete the Clinical Measures based on the proposed new service delivery site(s) only Multiple sites, populations and/or service areas: the Clinical Measures should represent the total targeted population within the proposed service area (except for special populations ) Special Populations: can identify additional population-specific Clinical Measures (i.e., migrant farmworkers, people experiencing homelessness) All applicants: must complete a minimum of (1) Behavioral Health and (1) Oral Health Clinical Measure

4 Required Clinical Measures Based on Outreach & Quality of Care: 1. Percentage of pregnant women beginning prenatal care in first trimester 2. Percentage of children with 2nd birthday during the measurement year with appropriate immunizations 3. Percentage of women age who received one or more Pap tests during the measurement year or during the two years prior to the measurement year.

5 Required Clinical Measures Based on Health Outcomes and Disparities: 4. Percentage of births less than 2,500 grams to health center patients 5. Percentage of adult patients with diagnosed hypertension whose most recent blood pressure was less than 140/90 mmhg 6. Percentage of diabetic patients whose HbA1c levels are less than or equal to 9 percent

6 Oral Health (1) Additional Required Clinical Measure Some examples: Percent of dental patients with a Phase I treatment plan completed within a 12 month period Percent of pregnant women with a comprehensive dental exam completed while pregnant Percent of children months with a dental evaluation completed in last 12 months Source:

7 Behavioral Health (1) Additional Required Clinical Measure Some examples: Percent of patients with a PHQ-9 screening score >9 who receive counseling from a BH Specialist Percent of diabetes patients who have received depression screening Percent of patients at least 18 years old who received a PHQ-2 with documentation in the patient s EMR

8 Elements of Clinical Performance Measures Form Focus Area Performance Measure and Applicability Target Goal Description Numerator and Denominator Description Baseline Data and Projected Data Data Source and Methodology Key Factor and Major Planned Action Comments

9 DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration ocus Area: Diabetes CLINICAL PERFORMANCE MEASURES Grant Number Project Period Date FOR HRSA USE ONLY OMB No.: Expiration Date: 08/31/2010 Application Tracking Number Performance Measure: Percentage of diabetic patients whose HbA1c levels are less than or equal to 9 percent Is this Performance Measure Applicable to your Organization? [_] Yes [_] No Target Goal Description Numerator Description Number of adult patients age 18 to 75 years with a diagnosis of Type 1 or Type 2 diabetes whose most recent hemoglobin A1c level during the measurement year is <= 9%, among those patients included in the denominator. Denominator Description Baseline Data Data Source & Methodology Key Factor and Major Planned Action #1 Number of adult patients age 18 to 75 years as of December 31 of the measurement year with a diagnosis of Type 1 or Type 2 diabetes, who have been seen in the clinic at least twice during the reporting year and do not meet any of the exclusion criteria Baseline Year: Measure Type: Numerator: Denominator: Projected Data (by End of Project Period) Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description: Key Factor and Major Planned Action #2 Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description: Key Factor and Major Planned Action #3 Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description: Comments

10 Resources Clinical Performance Measures: HRSA/BPHC: NAP website: Appendix B of NAP guidance (detailed description of performance measures) NAP User Guide for Grant Applicants UDS Data and Manual:

11 Resources National Quality Center Improving HIV Care: National Quality Forum: National Committee for Quality Assurance: Institute for Healthcare Improvement: