Migrant-Specific Performance Measures

1. Migrant-Specific Performance Measures Midwest Migrant Stream Forum November 19th, 2010 Austin, Texas Karen Mountain, MBA, MSN, RN Chief Executive Officer Migrant Clinicians Network

2. Outline • Performance measures—what are they? • BPHC required performance measures • Migrant-specific measures • The process • Recommended measures

4. What is a performance measure? • Tool for documenting performance • Designed to serve as a yardstick on which to measure quality. In order to measure a particular element of care, process, or outcome, indicators are selected to assess performance within a particular area of focus. Indicators are quantitative measures that can be used to assess and improve performance. • Although measurement in and of itself does not lead to improvement, assessing current performance allows an organization to understand exactly where it is relative to where it wants to be

5. Characteristics of a good measure • Relevance • Does the indicator relate to a condition that occurs frequently or has a great impact on the patients at your facility? • Measurability • Can the indicator realistically and efficiently be measured given the facility’s finite resources? • Accuracy • Is the indicator based on accepted guidelines or developed through formal group-decision making methods? • Improvability • Can the performance rate associated with the indicator realistically be improved given the limitations of your clinical services and patient population?

6. BPHC clinical performance measures BPHC clinical performance measures are a sub-set of a larger set of HRSA performance measures Selected from measures used by the National Quality Forum and other national quality groups Balanced and comprehensive representation of: Health Center services Clinically prevalent conditions among the underserved Population across life cycles Commonly used by Medicare, Medicaid and other insurance/managed care organizations to assess quality 6

7. Purpose of required measures • Measurement of health center performance on evidence-based practices • Collection of aggregate health center data for reporting to stakeholders • Evaluation of individual and collective trends over time • Identification of areas that may require improvement • TO IMPROVE QUALITY OF CARE

8. Integrating measures into your CQI program When you determine that the outcome of a Performance Measure is unacceptable you can focus on that measure through the CQI program 8

9. When improvement is needed • Discrepancy between goals or standards and reality • Solve the problem! 9

10. Where are these measures used? • Grant Applications • Clinical and financial performance measures • Agency Monitoring • UDS • Performance Improvement • Budget Period Renewal • ORO • Internally 10

11. Clinical performance measures BPHC requires these measures in SAC (Service Area Competition), BPR (Budget Period Renewal) and NAP (New Access Point) grant applications Grantees are establishing baselines and setting (realistic!) goals for improvement BPHC staff review submissions and progress reports 11

12. Clinical Performance Measures What are they? 12

13. Six required clinical measures: Aligned with the UDS report Outreach/Quality of Care Indicators Trimester of entry into perinatal care Childhood (2 year old) immunization rate Pap tests for adult (21 – 64 year old) women Health Outcomes and Disparities Infant birth weight (normal vs. low) Hypertension (controlled vs. uncontrolled) Diabetes (adequate control vs. inadequate control) 13

14. Outreach/Quality of Care Early entry into prenatal care If women enter care in their first trimester then probability of adverse birth outcome will be reduced Childhood immunizations If children receive their vaccinations in a timely fashion then they will be less likely to contract vaccine preventable diseases or to suffer from the sequela of these diseases Pap tests If women receive Pap tests as recommended then they can be treated earlier and will be less likely to suffer adverse outcomes from HPV and cervical cancer 14

15. Outcome/Disparities Measures Low Birth weight If there are fewer low birth weight children born, then there will be fewer children who suffer the multiple negative sequelae of low birth weight Hypertension If there is less uncontrolled hypertension, then there will be less cardiovascular damage, fewer heart attacks, less organ damage later in life. Diabetes If there is less uncontrolled diabetes then there will be fewer amputations, less blindness, less organ damage later in life. 15

16. Two or more additional Clinical Measures: Required two additional measures One Oral Health One Behavioral Health Supplemental measures 16

17. Optional/Supplemental Measures • Special populations (if receiving special funding) • Migrant measures: MCN • Homeless/Public Housing • Others • Special initiatives • Measures monitored over time: HDC, program specific • Reporting not required

18. Core Financial Measures • Working capital to monthly expense ratio • Liquidity in # of months - ability to pay bills on time - current financial condition • Long-term debt to equity ratio • Portion of net assets tied up in long-term debt - long-term financial condition • Change in net assets as a percent of expense • Financial results from operations in relationship to total expenses • Total cost per patient • Annual average cost per patient served - value of service provided based on costs • Medical cost per medical encounter • Average cost per billable medical encounter (less: lab & pharmacy) - cost efficiency

20. Development of Migrant-Specific Measures Objective: To develop supplemental performance improvement measures specific to the unique features of Migrant Health Programs (MHPs)

21. Why Migrant-Specific Measures? • Migrant Health Programs are reporting on clinical and financial measures • UDS reporting of required measures does not require separate reporting on migrant patients • Programs with large or majority migrant populations feel that features such as enabling services are not reflected in the core measures • MHPs are encouraged to include supplemental measures focused on their special population

22. Summary of Activities • Phase I (June-September 08): • Meeting of 6 voucher programs • Phase II (April-September 09): • Expanded Work Group membership to 11 MHPs • 4 conference calls • 1 face-to-face meeting • 2 presentations for wider audiences • Extensive email correspondence for discussion and selection of measures • Pilot of selected measures 9-10 & 11 in NC

24. How many of you have already identified something that you will remember and use? Show of hands: Slide to be inserted mid-way through your presentation: 24

25. Migrant Measures Work Group • Eastern, Midwest and Western locations; large and small health centers; voucher and non-voucher programs; and combined Migrant/Community Health Centers and “pure” Migrant Health Centers. • Joan Altenbernd, Migrant Health Services, Inc., Moorhead, MN • Lorena Ayala-Lawless, United Health Centers, Parlier CA • Susan Bauer, Community Health Partnerships of Illinois, Chicago IL        • Hilda Ochoa Bogue, National Center for Farmworker Health, Buda TX • Elizabeth Freeman, NC Farmworker Health Program, Raleigh, NC • Mitch Garcia, Valley-Wide Health Systems, Alamosa CO • Barbara Ginley, ME Migrant Health Program, Augusta ME • Mary Ellen O’Driscoll, CT River Valley Farmworker Health Program, Boston MA • Nancy Pealing, Borrego Community Health Foundation, Borrego CA • Claudia Stephens, MT Migrant and Seasonal Farmworker Council, Inc., Billings MT   • Bob Witt, Proteus Health Centers, Des Moines IA • Mary Ann Zelazny, Finger Lakes Migrant Health Program, Pen Yan NY

26. The Process… Focus on three categories: • Enabling services • Environmental/ occupational health • Financial

27. The Process… • What’s already out there? • Measures used by MHPs • Measures used by others • What’s the evidence? • Support from scientific/public health literature

28. The Process… • What do our experts say? • Other organizations • Expert consultants • Survey of Work Group members and wider migrant health audience • What is most relevant to health of migrant farmworkers?

29. The Process… • Preferred measure selected in each category with 2-3 additional alternatives

30. The Process… • Will they work? • Each of the preferred measures was piloted with the North Carolina Farmworker Health Program in Raleigh, NC

31. Preferred Enabling Services Measure • Percent of migrant patients ≥ 18 years of age with blood pressure ≥ 140/90 who are successfully referred for care. Would reflect the effectiveness of enabling services by documenting the identification of patients outside of the clinic setting with uncontrolled hypertension who are entered into care. “Successfully referred” = referred and clinic visit documented. • Calculation:Farmworker patients seen outside of the clinic setting with documented BP of ≥140/90 who are 1) referred for care and 2) are seen by a provider/Total farmworker patients seen outside of the clinic setting with documented BP of ≥140/90.

32. Pilot Findings • Measure includes multiple calculations: 1)# pts with documented elevated BP, 2)Of those, # referred, 3)Of those, % seen. • Assumes that BP screenings are routinely taking place in the field AND are being documented • Study site educating outreach staff on BP measurement, HTN education • Requires a reliable system for making referrals for care and following up on whether appts take place—currently not well documented at study site • Study site is designing outreach EHR that will include necessary documentation and tracking of referrals

33. Percent of migrant women who have documented screening for sexual and intimate partner violence during the measurement year Percent of migrant patients ≥12 years who have documented tobacco use status during the measurement year Additional Enabling Services Measures

34. Preferred Envir/Occ Health Measure • Percent of registered farmworker patients who receive pesticide prevention education. This measure would document how many farmworker patients receive education regarding the prevention of pesticide exposure, such as the use of personal protective equipment (PPE), proper storage and handling of pesticides, prevention of take-home exposure to family members, etc. • Calculation:Farmworker patients with documented pesticide prevention education/Total registered farmworker patients.

35. Pilot Findings • Study site used this measure for the past 3 years • Standardized protocol for outreach staff regarding content of pesticide education • For comparison among MHCs, universal definition of “pesticide prevention education” would need to be developed • Recommendations regarding content and length of session were made by EOH consultants

36. Percent of registered farmworker patients screened for Environmental/Occupa-tional Health (EOH) risk Percent of registered farmworker patients who receive eye protection education Additional Envir/Occ Measures

37. Preferred Financial Measure • Average cost per patient for enabling services. This cost measure would provide a basis to value each enabling service individually and/or in total, allowing each grantee to determine the baseline, trends, and goals for their program. Increases in service levels per patient may result in increased “average cost per patient”, while increases in the total number of patients served within the same staffing and cost structure will result in lower “average cost per patient” indicating improved efficiency. • Calculation: Total Cost for Enabling Services / Unduplicated Enabling Patients (or - Average Hours per Patient X Average Cost per Hour)

38. Pilot Findings • Simple calculation using numbers reported in UDS: Total cost for enabling services = UDS Table 8A, Line 11C, Column C Unduplicated number of enabling patients UDS Table 5, Line 29, Column C

39. Additional Financial Measures • Average Cost per Hour for Enabling Services • Overhead Rate – Administration and Facilities • Average Hours per Patient for Enabling Services

40. Where do we go from here? • Not meant to replace the BPHC required performance measures. • Not required for MHCs--intended only as suggested supplemental measures for MHCs. • Presented to the National Advisory Council on Migrant Health and BPHC leadership. • Webcast and presentations, Streamline

41. Summary • Purpose of performance measurement is to assure and IMPROVE Quality of Care: • Appropriateness of care for the population • Effectiveness of care for the population • Improve customer/patient satisfaction • Include goals in CQI program 41

43. Resources for Supplemental Measures • Enabling Services Measures: • MCHB: Healthy Start: Eliminating Racial/Ethnic Disparities (https://perfdata.hrsa.gov/MCHB/DGISReports/PerfMeasure/PerfMeasureReports.aspx?Report=ProgramPerfMeasures • Healthy People 2010 • AAPCHO Enabling Services Accountability Project Utilization Fact Sheetshttp://www.aapcho.org/site/aapcho/content.php?type=1&id=10292 • Prevention Collaborative Measures 2006http://www.healthdisparities.net/hdc/hdcsearch/isysquery/66a67aa0-3585-4929-bd28-1c872ec3352f/1/doc/ • Migrant Health Promotion—Program Resultshttp://migranthealth.org/our_programs/programs_results/ (studies related to effectiveness of promotores--no measures) • Financial measures: Cynthia Prorok, MSCG • Environmental/Occupational health measures: Matthew Keifer, MD, University of Washington and Amy Liebman, MCN • Suggestions from MHPs, Southern Poverty Law Center

44. Resources for Supplemental Measures, cont’d. 1: Sprince NL, Zwerling C, Whitten PS, Lynch CF, Burmeister LF, Gillette PP, Thu K, Alavanja MC. Farm activities associated with eye injuries in the Agricultural Health Study. J Agromedicine. 2008;13(1):17-22. PubMed PMID: 19042689. 2: Lacey SE, Forst LS, Petrea RE, Conroy LM. Eye injury in migrant farm workers and suggested hazard controls. J Agric Saf Health. 2007 Jul;13(3):259-74. Review. PubMed PMID: 17892069. 3: Peate WF. Work-related eye injuries and illnesses. Am Fam Physician. 2007 Apr 1;75(7):1017-22 Review. PubMed PMID: 17427615. 4: Forst L, Noth IM, Lacey S, Bauer S, Skinner S, Petrea R, Zanoni J. Barriers and benefits of protective eyewear use by Latino farm workers. J Agromedicine. 2006;11(2):11-7. PubMed PMID: 17135138. 5: Cameron L, Lalich N, Bauer S, Booker V, Bogue HO, Samuels S, Steege AL. Occupational health survey of farm workers by camp health aides. J Agric Saf Health. 2006 May;12(2):139-53. PubMed PMID: 16724790. 6: Mackiewicz J, Machowicz-Matejko E, Sałaga-Pylak M, Piecyk-Sidor M, Zagórski Z. Work-related, penetrating eye injuries in rural environments. Ann Agric Environ Med. 2005;12(1):27-9. PubMed PMID: 16028862. 7: Forst L, Lacey S, Chen HY, Jimenez R, Bauer S, Skinner S, Alvarado R, Nickels L, Zanoni J, Petrea R, Conroy L. Effectiveness of community health workers for promoting use of safety eyewear by Latino farm workers. Am J Ind Med. 2004 Dec;46(6):607-13. PubMed PMID: 15551366. 8: Villarejo D, Baron SL. The occupational health status of hired farm workers. Occup Med. 1999 Jul-Sep;14(3):613-35. Review. PubMed PMID: 10378979. 9: Weinbaum Z, Schenker MB, O'Malley MA, Gold EB, Samuels SJ. Determinants of disability in illnesses related to agricultural use of organophosphates (OPs) in California. Am J Ind Med. 1995 Aug;28(2):257-74. PubMed PMID: 8585522.

45. Other Resources • Healthy People 2010: www.healthypeople.gov • National Quality Center—Improving HIV Care: http://www.nationalqualitycenter.org/index.cfm/22 • AHRQ Effective Health Care: http://effectivehealthcare.ahrq.gov/ • National Quality Forum: http://www.qualityforum.org/ • State Primary Care Associations: http://www.bphc.hrsa.gov/technicalassistance/pcadirectory.htm

46. HRSA Resources • HRSA/BPHC: www.bphc.hrsa.gov • Performance Measures http://bphc.hrsa.gov/about/performancemeasures.htm • UDS Website: http://www.hrsa.gov/data-statistics/health-center-data/index.html • Detailed information on required measures • Sampling methodology • 2010 trainings http://www.bphcdata.net/html/bphctraining.html 46

47. Questions??? What do you think about this effort? Slide to be inserted at the end of your presentation: 47

48. Contact: Karen Mountain KMountain@migrantclinician.org www.migrantclinician.org 48