Quick Finds: Quality Improvement

Leading with Optimism in Challenging Times (2021). In this national webinar you will hear New York Times Best Selling Author, Shawn Achor, talk about his research in positive psychology, Jordan Voigt, president of Genesis Medical Center, Davenport, who will share the story of Genesis Health System, recently featured in Harvard Business Review, and we will explore “what leading with optimism really looks like” in times of significant challenge. More Details...

Bridging Patient Access: Best Practices for Community Health Workers (2021). As telehealth services continue to bridge patient access to health services, it is important for health centers to focus on best practices that ensure excellent delivery of care. Thisguideincludeshelpful information about telehealth service delivery, tips for providing good virtual care, and how Community Health Workers(CHWs)can engage in telehealth. More Details...

Clinical Quality Measures for Eligible Professionals: 2021 Update: A Crosswalk Comparison of Clinical Quality Measures from The HITEQ Center (2021). This spreadsheet developed by the HITEQ Center provides a crosswalk of Clinical Quality Measures and their electronic specifications as defined in the 2021 update for Eligible Professionals (Clinicians). Fields include the crosswalk of measures, with related information about MIPS ID, Telehealth Eligiblity, as well as inclusion in CY2021 UDS, Million Hearts, NCQA eCQM, CMS Adult / Child Medicaid Core Measures Set, HEDIS 2021, and CPC+ eCQMs. Both a PDF and spreadsheet are available for download below. More Details...

Memorandum of Understanding Template: A Partnership-Building Resource for Community Health Centers and Domestic Violence Programs (2021). The purpose of this model Memorandum of Understanding is to provide a model that contains best practices for building and sustaining health center and domestic violence program partnerships. More Details...

Past, Present, and Future: HCCNs and Health Centers Using Data to Drive Clinical Care Series: The Future State: Data Integrity (2021). This is the third webinar in a three-part series -- Past, Present, and Future: HCCNs and Health Centers Using Data to Drive Clinical Care. During these webinars, hear how HCCNs and health centers are collecting and aggregating data on patient populations and leveraging data to support clinical quality improvement initiatives. More Details...

Public Housing Primary Care (PHPC) COVID-19 Dashboard (2020). This dashboard by NCHPH provides the latest COVID-19 statistics in Public Housing Primary Care (PHPC) Health Centers, including race and ethnicity data and additional resources. More Details...

Supporting Implementation of Smoking Cessation Programs in Public Housing Primary Care Settings: Learning Collaborative (20; Session 2 11). During this learning collaborative health center staff learned about different aspects for implementation of smoking cessation programs. More Details...

Culturally Competent Care: Learning Collaborative (20; Session 2 11). This is a learning collaborative series of 4 sessions where Health Center staff learned about standards for providing culturally and linguistically appropriate services (CLAS) to their patients. Slides and recordings for all sessions are available here as well as resources to facilitate the implementation of CLAS in health center settings. More Details...

Creating a Safer Environment for Patients and Staff: Architectural Design and Engineering Solutions – Part Two (2020). Part Two of this series focuses on engineering solutions as we explore best practices in building systems design and management as well as facility maintenance. Strategies for addressing challenges in HVAC and air flow, room/space capacity and equipment selection (air scrubbers, filtration, UV lights, HEPA filters) as well as key factors in disinfection including the role of negative pressure and temperature setting will be presented by senior engineers. More Details...

Creating a Safer Environment for Patients and Staff: Architectural Design and Engineering Solutions – Part Two (2020). Part Two of this series focuses on engineering solutions as we explore best practices in building systems design and management as well as facility maintenance. Strategies for addressing challenges in HVAC and air flow, room/space capacity and equipment selection (air scrubbers, filtration, UV lights, HEPA filters) as well as key factors in disinfection including the role of negative pressure and temperature setting will be presented by senior engineers. More Details...

Emergency Preparedness: Infectious Disease Risk: Risk Communication: Infectious Disease (2019). Sarah Darcy, Media Relations Manager for South Shore Health System, speaks on risk communication and how it relates to infectious disease. More Details...

Leveraging the Electronic Health Record to Link Health Center Patients with Medical-Legal Partnership Services (2020). This issue brief provides concrete examples of how health centers in Iowa, Montana, and Texas are leveraging the EHR to complement their screening for the social determinants of health as well as to increase their capacity to deliver targeted MLP-related interventions. More Details...

Guide to Improving Care Processes and Outcomes in Health Centers: An approach to quality improvement (2016). The quality improvement QI approach outlined in this Guide can be used to augment current QI approaches used in your health center, or can serve as a placeholder QI methodology when there isn’t already a robust QI process in place. It provides a framework and tools for documenting, analyzing, sharing and improving key workflows and information flows that drive performance on high-stakes care performance measures, and related improvement imperatives. This webpage provides strategies and tools that health centers and their partners can use to enhance care processes and outcomes targeted for improvement, such as hypertension and diabetes control, preventive care, and many others.   This webpage provides strategies and tools that health centers and their partners can use to enhance care processes and outcomes targeted for improvement, such as hypertension and diabetes control, preventive care, and many others. For authorship and acknowledgement for this Guide, see the bottom of this guide. The quality improvement QI approach outlined in this Guide can be used to augment current QI approaches used in your health center, or can serve as a placeholder QI methodology when there isn’t already a robust QI process in place. The approach provides a framework and tools for documenting, analyzing, sharing and improving key workflows and information flows that drive performance on high-stakes care performance measures, and related improvement imperatives.  The diagram to the left illustrates the data-driven, health IT-enabled continuous quality improvement approach that this Guide supports.  For an overview of the information contained herein access this recorded webinar and companion materials including transcript and slides for reference.     Background to Guide Guide Context and Approach This section includes guidance on leveraging Health IT to improve quality and clinical performance including data validation tools, Clinical Decision Support Quality Improvement worksheets, and change packages for recommended approaches related to various quality of care measures. Read More...   The diagram below illustrates the Guide’s focus on helping health centers adapt to the intensifying performance improvement imperatives they face pyramid tip. The Guide does this by providing strategies and tools to help analyze and improve critical workflows and information flows layers beneath the pyramid tip. For an introduction to the Guide that was presented as part of a webinar, see here the pertinent discussion is between these times/markers on the recording: 43:46-58:44     Audience The strategies and tools in this Guide are designed for quality, clinical and other health center staff, and health center partners that support quality improvement efforts. Read More... Everyone in a health center has a stake in successful quality improvement, and many different staff roles might be the first to encounter this Guide. For initial review, roles including QI/clinical/data/operations team members or leads are likely most appropriate. To drive substantial improvements, these tools and strategies should then be shared and used more widely with pertinent health center team members responsible for the organization’s clinical, operational and other activities key to successful QI. A QI team is typically the driving force behind the cross-stakeholder work outlined in this Guide. For more on building QI teams, see here.   Various organizations that support or depend on information from QI efforts within health centers can also become better QI partners by understanding and applying the strategies and tools in this Guide. These partners include:   Support organizations such as HCCNs, PCAs, payers and others   Organizations that supply health centers with technology that play a critical QI role, such as EHR and population health software vendors    Why Using this Guide is Important for Health Centers Quality improvement has traditionally been a core health center activity as health centers try to continually maximize value and efficiency. Dramatic healthcare payment reforms, increasingly tying payment to QI efforts and results, make effective QI a business imperative for all provider organizations. Wherever your organization is on the QI journey – from beginning through highly sophisticated – this Guide uses tools such as the CDS/QI Worksheets -- see under 'Document/ Analyze Flows; Identify Improvements' and strategies such as the CDS 5 Rights Framework that can enhance your QI efforts and results. Read More... Payment reforms seek to transform healthcare to achieve 3 key goals often referred to as the ‘Triple Aim’ or ‘Three-part Aim’:   Better care for individuals   Better health for populations   Lower cost   Key stakeholders assert that to achieve these goals, it’s important to also improve work life for clinicians and staff. Adding this dimension to the 3 goals above is referred to as the ‘Quadruple Aim.’ This shift to value-based payment is driven by both the public and private sector, and directly affects FQHC financial health. For example, the Merit-based Incentive Payment System is transforming Medicare by tying provider payments to performance on quality measures, clinical performance improvement activities, costs, and use of health IT. Medicaid and private payers are also driving transformation through increasing use of value and/or risk-based contracts that require successful QI.   Many health centers already use robust QI approaches such as those outlined in this quality improvement primer as part of UDS measure reporting and improvement efforts. Many likewise leverage powerful health IT capabilities such as population health management tools including disease/condition registries; EHR tools to enhance ordering, documentation and data review; and SMS texting with patients in this QI work. The drivers noted above, however, require increasingly sophisticated and effective approaches to health IT-enabled Quality Improvement health IT/QI. Other closely related terms include eCQI used by ONC and CMS and CDS-enabled QI CDS/QI, so those are terms referenced in some materials in this Guide as well.   The framework, strategies, and tools in this Guide can help your organization enhance its health IT/QI approach and results. In addition to the benefits this delivers in addressing payment drivers noted above, it can also improve staff satisfaction by streamlining care workflows, improve health center business strength by avoiding duplicated efforts and decreasing costs, and improve patient satisfaction by meeting their care needs more efficiently and effectively. How to Use this Guide The next main section of this resource, Health IT-Enabled QI Guide Details provides a step-by-step approach and tools for analyzing and enhancing care processes targeted for outcome improvement. The steps are outlined in the pathway under the first heading in that section, Approach to health IT-enabled QI. Read More... The Essential CDS/QI Worksheet is a core resource for analyzing and improving target-focused care. A preliminary workflow analysis and enhancement brainstorming exercise can be accomplished in as little as an hour by one or more health center staff reviewing the tutorial and using this worksheet. More comprehensive QI projects addressing all the steps in the pathway typically take up to a year or longer. In any case, the QI work should be a collaborative process involving all stakeholders within the health center, and ideally key partners as well such as the HCCN or PCA working with the health center, and their EHR and population health software vendors. Scanning these evidence-based strategies and tools will give health centers and their partners a sense for whether/how they can augment your current QI work. Users can then apply these approaches and resources with their team to the depth that would be most valuable and feasible given available time and resources. For a “quick win” exercise to identify potential high-yield, target-focused care process improvement opportunities, see this presentation Health IT Enabled QI: A Guide to Improvement. For additional ideas on introductory QI exercises, see the brief slide set, Five Minutes of Quality Improvement: Tackling Small QI Tasks. Contact the HITEQ Center for support on implementing the QI approach in this Guide.   Strategies and tools from this Guide in action:   CDS Learning Session ‘Quick Win’ Exercise: Sixteen community health centers in New Orleans conducted a valuable ‘Quick Win’ exercise using an earlier version of the Essential CDS/QI worksheet see here for further details about this exercise and results. In this activity, small teams from each health center e.g., a clinician and administrator were given a 20-minute overview of several key health IT/QI concepts and tools outlined in this Guide the broad CDS definition, CDS 5 Rights framework, and an earlier version of the CDS/QI Worksheet, each of which is explained later in this guide.   Immediately following, for just 20 minutes, each team independently used an enlarged version of the Essential CDS/QI Worksheet on a flip chart to document key workflows and information flows for their improvement target e.g., lipid or diabetes control. During this time, they also brainstormed refinements to one or more of the CDS 5 Rights “who, what, when, where, how” dimensions.   During the report-out following this brainstorming, health centers noted excitement about trying these enhancements to improve care processes and outcomes related to their target.   Using the Guide for Yearlong, Target Focused QI: Other QI projects have used the strategies and tools outlined in this Guide in yearlong, target focused QI efforts and have realized benefits for quality improvement and care processes, and increasingly in outcomes. In many cases these efforts involved collaboration with HCCNs and/or HIE/EHR/population management software vendors. These initiatives include:   A network of health centers in CA working on blood pressure control. The lead health center in this project, Petaluma Health Center, is a 2015 Million Hearts Hypertension Control Champion. View project report slides.   Improving blood pressure and diabetes in control in Trenton, NJ that included a health center among the participants. View project report slides .   Health centers in several states working on hypertension diagnosis and management several of which are achieving aggressive blood pressure improvement targets. Link to project overview.   Health IT-Enabled QI Guide Details Approach to Health IT-enabled QI The outline depicted in the figure below provides a step-by-step approach to analyzing and enhancing care processes targeted for outcome improvement. The sections below provide guidance and tools on addressing each of these steps. Read More...   Check/ Reinforce Foundations Successful health IT/QI efforts require a firm foundation of people, process, and technology elements. Read More... Cultivate a shared commitment within your team to improving care delivery and results, including fully leveraging health IT capabilities. Successful QI efforts deliver a ‘win-win-win’ for patients and their care teams, as well as broader organizational goals. This infographic and report examines characteristics of health centers that have achieved high clinical, financial and operational performance.     Ensure that key foundations for successful QI efforts are in place. For example, leadership and team support; stable well-utilized health IT systems such as EHR, population management software; bandwidth and capacity for the QI work; and shared understanding about QI goals and processes.  For some specific resources around ensuring key foundations, see here for Motivating Factors for Engaging in Health IT-enabled QI, and Engaging the Data Creators.  Also, see here for A Buyer’s Guide to Business Intelligence Tools.  Here is a tool to assess analytics capability in health centers, that also provides insights into the nuance of working with data and building a data-driven culture. A brief video introduction to using this tool is here.   Ensure access to and validate data that will underpin the QI efforts. For example, ensure that EHR and/or population management software can deliver needed data and reports, and produce the same values for targeted performance measures and related data as manual review/calculation. See here for questions to consider to help determine if you are fully utilizing your EHR capabilities for population management, and if additional tools are needed. This checklist can help with data validation and interpretation a webinar that includes an introduction to this checklist is here, and the pertinent discussion is between these times/markers on the recording: 8:15- 43:45. See here for a basic auditing tool Excel Template for data reports, and a case study on data validation.   Identify and address barriers to collaboration on effective process improvement such as stakeholder conflicts or conflicting goals among all concerned, including providers, care delivery and quality staff, partners e.g., health IT vendors, and patients.   Layer the approach and tools outlined below onto your general QI methodology, as well as any current target-focused QI activities. If no QI framework is in place, consider using the approach outlined in this Guide as a starting point, and build that out further through options such as those provided in the primer, Continuous Quality Improvement CQI Strategies to Optimize your Practice. Understand Health IT-enabled QI Everyone participating in the QI work should have a shared understanding of key definitions e.g., CDS, frameworks e.g., CDS 5 Rights, strategies e.g., the QI process outlined under the Implement and Evaluate Changes heading., tools e.g., Essential CDS/QI Worksheet, and key QI project success factors.   Read More... ‘Clinical Decision Support’ CDS is a key underpinning for the QI approach outlined in this Guide, but its meaning here might be different than what you have in mind especially if ‘alert’ figures prominently in your definition. In this Guide, CDS is defined as a process for improving health-related decisions and actions with pertinent knowledge and patient information to enhance health and care delivery. Under this definition, CDS is about supporting care decisions and actions, ideally in a manner that makes the appropriate decisions and actions the easy ones to execute. That is, facilitating workflow not interrupting it – as alerts often do. There are many different ways to provide this support e.g., CDS intervention types. See the CMS CDS tipsheet page for more details, including example CDS intervention types e.g., order sets, focused patient data summaries, documentation templates.   The CDS 5 Rights framework is a best practice QI approach recommended by CMS in the tipsheet above to support decisions and actions that drive performance targeted for improvement. It asserts that optimizing care processes and outcomes requires getting the right information to the right people in the right formats through the right channels at the right times see figure below. The tools and approaches outlined in this Guide help organizations implement this framework and enhance the contributions, experience and results for those involved in care delivery.   The Essential CDS/QI Worksheet see excerpt images below is a core health IT/ QI tool best used for initial efforts to map care processes and reveal potential enhancements. That is, to document and analyze target-focused information flows and workflows, and to brainstorm improvement opportunities see figure with excerpts from this worksheet below. The tutorial that follows provides guidance and examples on how the worksheet can be used. to streamline and enhance care processes. The Enhanced CDS/QI Worksheet,  pointed to below under the bullet titled 'For a deeper dive into health IT/ QI Foundations', is a more robust but more complicated tool for those already skilled in using the Essential CDS/QI Worksheet View the Tutorial on how to use the Essential CDS/QI Worksheet   See a completed Outpatient Essential CDS/QI Worksheet Example that uses this tool to illustrate the workflows and information flows that produced very high levels of blood pressure control in a small practice: Ellsworth Hypertension QI Case Study Note: this example used an earlier version of the Essential CDS/QI Worksheet that did not contain the ‘Foundational Activities’ section. This case study was originally developed for ONC and is also posted on here on healthit.gov. Attend to key QI project success factors:   Focus on People, Process, and Technology in that order, recognizing that engaging everyone involved is critical for success.     Focus on ‘the most important things’ when selecting improvement targets, opportunities to enhance care processes for the target, and activities to ensure successful implementation of those process changes.     QI activities involve a chain of stakeholders including health center QI leads, clinicians and staff, and ultimately patients. As the QI project unfolds and each of these groups is touched by the effort, seek to escalate engagement, insights, and momentum toward goals. For a deeper dive into health IT/QI foundations, consider these resources:   Tasks and Key Lessons from each chapter in “Improving Outcomes with Clinical Decision Support, and Implementer’s Guide, 2nd Edition.” These bulleted lists provide detailed guidance on successful CDS-enabled QI programs and interventions.   Enhanced CDS/QI Worksheet: Similar in concept to Essential version, but with additional space to document/review optimal care activities for the target, and the individual CDS 5 Rights dimensions for the current state. Consider using only after you are comfortable with the Essential CDS/QI Worksheet version Note: this example used an earlier version of the Enhanced CDS/QI Worksheet that did not contain the 'Foundational Activities' section.   View the Tutorial on how to use this Enhanced Worksheet [download the PDF and run locally for best results].   See a completed Outpatient Example: CHC Inc. hypertension QI case study   White papers and guides on HIT-CDS/QI:   Qualis Health: Integrating Clinical Decision Support Tools into Ambulatory Care Workflows for Improved Outcomes and Patient Safety   AHRQ: Using Health Information Technology to Support Quality Improvement in Primary Care   ONC: How-To Guides for Clinical Decision Support CDS Implementation Select Targets; Initiate QI Project   Successful QI efforts typically require significant time, energy and resources, so it is important to choose targets where the return will warrant the investment. This requires a clear and accurate understanding of baseline performance on the target.   Read More... Consider targets associated with business imperatives, such as UDS reporting especially for conditions where the health center is under-performing, and value-based payment initiatives from the private sector and CMS e.g., the Quality Payment Program which is radically overhauling Medicare payments to clinicians, and related value/risk-based payment models for Medicaid. Seek QI synergies with pertinent health center initiatives such as PCMH recognition and HRSA Health Center Quality Improvement Grant Awards.   Examine local performance gaps and improvement opportunities when reviewing payment drivers noted above and selecting targets. See the figure below from the HIMSS guidebook on improving outcomes for examples of local factors to consider in selecting targets for quality improvement intervention. Image Reference: Osheroff JA, Teich JM, Levick D, et. al. Improving Outcomes with Clinical Decision Support: An Implementer’s Guide, 2nd ed. Chicago: HIMSS. 2012.   Measure and understand your baseline performance on your targets. The CMS/ONC eCQI Resource Center has information about quality measure specifications for providers. The Checklist for Analyzing Performance Measure Data has detailed information about validating and interpreting these data. Document/Analyze Flows; Identify Improvements   A helpful QI adage is that “systems are perfectly designed to produce the results they deliver.” This truism highlights the importance of understanding current care processes that are driving sub-optimal performance on the targeted measure e.g., diabetes control, preventive care, use of expensive tests so they can be refined to deliver better results. The CDS/QI worksheet supports this analysis through a structured, broadly applicable framework for documenting, analyzing, sharing and improving target-focused care activities. Read More... Use the CDS/QI worksheet to help examine patient-specific and population management information flows and workflows, as well as foundational activities such as EHR configuration, policies, staff training, etc., that are producing sub-optimal performance on the target. For example, if the QI target is hypertension control, consider the current status of staff competency and training on measuring blood pressure appropriately foundational activities; registry use to identify and recall patients with poorly controlled blood pressure population management activities; and optimizing pre-visit huddles, order set use, and patient engagement/care plan adherence tools patient-specific supports.   Walk through the care process with special attention to the patient experience and document results in the Essential CDS/QI Worksheet.   Engage all care team members in the workflow/information flow and improvement analysis– including the patient, if possible.   If you are comfortable with the Essential CDS/QI Worksheet, consider using the Enhanced CDS/QI Worksheet instead of, or in addition to, the Essential Worksheet for a deeper dive into the ‘optimal state’ and the details of each CDS 5 Rights dimension.   Analyze this current state “what is?” to identify opportunities to improve target-focused information flow, workflow and results; i.e., to better address the CDS 5 Rights for the target. Document these potential enhancements in the CDS/QI Worksheet. Review the tutorial for the worksheet you are using i.e., essential vs. enhanced for guidance. For example, consider enhancements such as:   documentation templates, and related workflows for completing them, that make it easier to identify patient barriers to adherence with the care plan foundational activity;   text messages and/or personal calls to patients to decrease no-show rates patient-specific support, and   performance dashboards and related conversations to share target measure results with teams and clinicians as a springboard for brainstorming strategies to accelerate improvement population management activities.   Review evidence-based best care practices for the target “what should be”   Consider available best practice ‘change packages’ for the target:   For hypertension management, the CDC Hypertension Control Change Package presents change concepts, change ideas, and proven tools that outline ‘what should be’ best practices in categories that correspond to the categories on the CDS/QI Worksheets i.e., Foundation Activities, Population Management, and Patient-specific Supports and its subcomponents.   For detecting hypertension that may be ‘Hiding in Plain Sight’ in health centers and diagnosing hypertension so it can be managed appropriately to reduce heart attacks and strokes, see this similarly-structured “HIPS” change package.   For improving colorectal cancer screen rates as called for in the national "80% by 2018" campaign, see this similarly-structured change package   Examine other case examples and best practices for successful target-focused care strategies e.g., QI case studies published by ONC, and other resources:   Case examples on hypertension control:   Ellsworth Medical Clinic hypertension QI case study: narrative discussion and details presented in an earlier version of the Essential CDS/ QI Worksheet.   CHC, Inc.2 hypertension QI case study: narrative discussion and details presented in an earlier version of the Enhanced CDS/QI Worksheet. This study was originally developed for ONC and is also posted here on healthit.gov.   EHR Innovations for HTN Challenge results   Colorectal cancer screening recommendations for community health centers from the Oregon Primary Care Association and the National Colorectal Cancer Screening Roundtable    Case example on tobacco use screening and smoking cessation support at Miramont Family Medicine. This case study was originally developed for ONC and is also posted here on healthit.gov   Define potential workflow and information flow enhancements for the target “what could be here?” by combining ‘top down’ approaches i.e., starting from ‘what should be?’ best practices and ‘bottom up’ approaches i.e., improvement opportunities that emerge from the “what is?” analysis with stakeholders.   Prioritize identified enhancements to implement: Identify several enhancements that are most likely to deliver the greatest benefit in the shortest time with the least effort for initial implementation that is, use the “low hanging fruit” approach – see prioritization tools such as this Prioritization Matrix. Give special attention to changes that could yield strong benefits across multiple targets, or that appear especially promising for strengthening critical workflows and information flows e.g., related to patient engagement, registry use to identify and close care gaps, pre-visit planning, and efficiently executing evidence-based care plans. Implement & Evaluate Changes Implementing enhanced care processes requires that people e.g., health center clinicians, other staff, and patients do things differently. Formal change management approaches can help ensure that these changes are successful and that they produce desired results.   Read More... Use a QI methodology e.g., PDSA cycles to engage frontline staff and other key stakeholders in care processes and results to design, implement and evaluate the prioritized changes. Be sure to do this work with all the stakeholders and not to them i.e., seek and act on team members’ and patients’ input and feedback throughout the process. Be ready to modify patient care and quality improvement activities, CDS intervention details across any of the CDS 5 Rights dimensions, and other parameters if needed as improvement cycles unfold. Monitor implementation activities with structured tools that help you document and manage who’s doing what when, as well as the results. Sample monitoring tools:   Worksheets from Chapter 8: Putting Interventions into Action and Chapter 9: Measuring Results and Continuously Refining the Program in “Improving Outcomes with Clinical Decision Support: An Implementer’s Guide. Second Edition” provided with permission from HIMSS   IHI PDSA Worksheet: http://www.ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet.aspx   Validate and analyze performance measure data to make sure that the results are accurate, and that the team understands what they mean and what to do about them. This checklist can support this process. Harvest/Spread Results Ongoing attention to performance on key targets beyond ‘focused QI projects’ is generally warranted e.g. because performance may backslide for various reasons. In addition, there is a growing list of targets on which improvement is imperative. It is therefore important to ‘harvest’ learning, strategies and tools from each project that can be applied in an ongoing way to the target, and spread to other targets. The CDS/QI Worksheet’s structure can facilitate such cross fertilization among QI targets.   Read More... As the scheduled initiative concludes, review the QI project with stakeholders to better understand what worked well, what could have been done better, and what useful tools were created.   Apply this learning and these results to strengthen ongoing ‘maintenance’ efforts on the current target and other target-focused QI initiatives.   Transition target-related QI efforts from ‘project-focused’ to ‘this is how we do business.’ Build in ability to detect the need for, and implement, tweaks to target-related processes when required because of changes to people/processes/technology.   Incorporate proactively the insights and results from each QI project into subsequent QI initiatives. Although a particular target-focused QI project may be time-limited, the QI and clinical teams should remain alert for ways to continually improve care across all targets. For example, learning from a QI project might indicate opportunities to more broadly modify clinical and quality work and roles, as well as health IT configurations with this latter triggering feedback to developers about broadly needed enhancements.   Contact the HITEQ Center if you are interested in sharing results further with your peers, and opportunities for health IT/QI peer learning.   Acknowledgements Origins and Ongoing Refinement of this Guide: The content in this resource is drawn from and builds on widely used CDS/QI tools and strategies that have evolved over the past decade. The HITEQ Center plans to continue refining this Guide based on input from users like you, so please consider sharing your feedback through the comment form. Read More... The content in this Guide is an adapted and expanded version of care process improvement guidance posted here on healthit.gov. That original material was developed by Jerome Osheroff, MD, TMIT Consulting, LLC in collaboration with ONC and Deloitte, and this version on HITEQ was also developed by Osheroff/TMIT in collaboration with JSI and others.   Guide Reviewers Individuals below each provided helpful feedback on an earlier draft of this guide; those marked with * provided particularly detailed feedback that led to substantial enhancements: Sheila Allen, MPH; Chief Compliance and Quality Officer, HealthNet, Inc. *Daren Anderson, MD; Director of the Weitzman Institute and VP/Chief Quality Officer of Community Health Center, Inc Sasha East, MD; Internal Medicine Resident, Robert Wood Johnson University Hospital Renu George, MD; Internal Medicine Resident, Robert Wood Johnson University Hospital *Meg Meador, MPH, C-PHI;  NACHC Director of Clinical Integration and Education *Jillian Maccini, MBA; Consultant, JSI Laura Methvin, MD; Internal Medicine Resident, Robert Wood Johnson University Hospital Alan Mitchell; Program Director, Performance Improvement, Primary Care Development Corporation PCDC * Nivedita Mohanty, MD; Director of Evidence-based Practice, Alliance of Chicago Rick Reifenberg MD, FAAP, FACP, Associate Medical Director, HealthNet Inc.   Refinements to material on this page to enhance its use and usefulness are planned based on user feedback HITEQinfo@jsi.com.   Recommended citation for this Guide: Osheroff, Jerome A. "Improving Care Processes and Outcomes in Health Centers. HRSA Health Information Technology, Evaluation and Quality Center. JSI. 9 Sept. 2016. Web. 21 Nov. 2016 More Details...

Bringing lawyers onto the health center care team to promote patient & community health: A planning, implementation and practice guide for building and sustaining a health center-based medical-legal partnership (2020). The toolkit has four parts: 1. Outlines nine conversations that a health center team should have with its legal partners to plan for an MLP’s long-term success and to integrate it into the health center’s operations. 2. Is a deep dive into the specifics of how to develop screening, referral, and service delivery workflows. 3. Looks at how integrating legal services can support health center workforce development, with a particular focus on training. 4. Illustrates the types of projects MLPs can engage in to help your health center move upstream to address SDOH and health equity at a policy level. More Details...

Million Hearts Factsheet (2015). This factsheet provides and overview of the Million Hearts Campaign's efforts to improve health of patients through concerted quality improvement (QI) efforts. More Details...

Identifying Hypertensive Patients Hiding in Plain Sight (HIPS) Change Package (2016). This document is a compilation of change ideas that health center teams employed along with associated tools and resources that emerged thru work with the Million Hearts project. More Details...

Leveraging the electronic health record (EHR) to link health center patients with MLP services (2020). This issue brief provides concrete examples of how health centers in Iowa, Montana, and Texas are leveraging the EHR to complement their screening for the social determinants of health as well as to increase their capacity to deliver targeted MLP-related interventions. More Details...

FY2020 Primary Care HIV Prevention Reporting: Crosswalk of FY2020 PCHP reporting to CY2020 UDS Requirements, July 2020 (2020). To support Primary Care HIV Prevention funded health centers, HITEQ has prepared a crosswalk that maps PCHP tri-annual reporting metrics to UDS measures and/ or fields. This assists health centers in leveraging UDS reporting functionality in their EHRs to inform completion of the tri-annual progress report to HRSA. The PCHP metrics listed in the first column crosswalk to specific data definitions in the CY2020 UDS, which are specified in the second column, and then further detail is provided in the third column. More Details...

Using Practice-Based Learning and Improvement (PBLI) to Address Oral Health for Older Adults Living with Diabetes (2020). The purpose of this guide is to provide practical information to interprofessional health center teams using a practice-based learning and quality improvement (PBLI) approach for assessing and continuously improving oral health and diabetes management of older adults. More Details...

Bridging the Digital Divide: Using Technology to Improve Access to Health Care for Public Housing Residents (2020). The purpose of this report is to outline the digital needs and challenges of public housing residents, the risks and benefits of using technology to improve patient care, and recommendations on how to prepare health centers and patients to optimize digital tools, improve access to care, and enhance efforts through partnerships to bridge the digital divide. More Details...

Secondary Traumatic Stress Identification, Mitigation and Improving Work Satrisfaction for Health Center Staff During the COVID-19 Pandemic (2020). Webinar hosted by NCHPH. Recording slides and handouts available. More Details...

Building Resilience in the Midst of a Pandemic: What Health Care Workers and Leaders Can Do During the COVID-19 Pandemic (2020). A lot of energy has been devoted to the critical need for PPE, the lack of respirators, tests, and the pressure on health centers to help “flatten the curve.” This crisis has left little time to address the impact of workplace and personal stressors on providers and other staff as they try to balance the fear of contracting the virus while carrying a heavy, complex workload. This webinar provided tips and recommendations for leadership, health center staff working at clinical sites on how to create a healthy environment and cope with anxiety, depression and other behavioral disorders caused by COVID-19. More Details...

Secondary Traumatic Stress Identification, Mitigation and Improving Work Satisfaction for Health Center Staff During the COVID-19 Pandemic (2020). This webinar educated health center staff on the concept of traumatic stress. It identified terms, risk factors, and symptoms associated with compassion fatigue/secondary traumatic stress and burnout. The concept of self-care is introduce, and participants learned about building skills that can mitigate traumatic stress responses and improve work satisfaction and reslience. More Details...

Rejuvenate Consumer Leadership: Lessons from the Updated Consumer Advisory Board Manual (2020). Consumer Advisory Boards (CABs) are advisory groups of people who use services at a health center and work with the organization to improve program management and service delivery. Based on decades of collective experience participating in CABs, the National Consumer Advisory Board (NCAB) has updated its CAB Manual to provide accessible guidance to develop CABs. During this webinar, NCAB members unveiled the updated manual and shared lessons on how to start a CAB and maximize consumer leadership to take your work to a new level. More Details...

Health Centers as Age-Friendly Health Systems (2020). This webinar explored how health centers can use the 4Ms framework (What Matters, medication, mentation, mobility) to make sure evidence-based care, grounded in What Matters to older adults, is practiced reliably with every older adult, every day. More Details...

HITEQ Highlights: Health Center Defense Against the Dark Web: Strategies for Building Security Awareness, Education, and Compliance in 2020 (2020). This HITEQ Center webinar explored key concepts and best practices that should be followed by Health Centers seeking to develop Defense in Depth and effectively implement hardened security programs at their sites. There are ever-increasing cybersecurity guidelines and protection measures that Health Centers must navigate and digest. This webinar sought to motivate and educate the health center workforce on critical privacy and security concepts and methods for defense. Aspects of Security Risk Assessment, security awareness training, and breach protection were covered with an emphasis on health center-wide information protection. More Details...

Clinical Quality Measures for Eligible Professionals for 2020: A Crosswalk Comparison from The HITEQ Center (2020). This spreadsheet provides a crosswalk of Clinical Quality Measures and their electronic specifications as defined in the 2020 update for Eligible Professionals (Clinicians). More Details...

Diabetes Continuum of Care: Team-Based Care (2020). This webinar is the kick off to the Special and Vulnerable Populations - Diabetes Task Force's 2020 National Learning Series. This session is focused on team-based care and is part one of a four-part webinar series on effective strategies to prevent, treat, and manage diabetes among special and vulnerable health center program patients. More Details...

The FQHC Alternative Payment Methodology (2020). This factsheet provides a snapshot of the FQHC Alternative Payment Methodology (APM). How it works, the different types of APMs, and an overview of the reimbursement methodologies for each state. More Details...

Successful Practices in Accountable Care: Model for Value Based Care and Contracting: Michigan Primary Care Association, Michigan Quality Improvement Network, Michigan Community Health Network (2020). This publication highlights efforts of the PCA and HCCN in Michigan to develop a Clinically Integrated Network. It demonstrates the importance of PCAs and HCCNs collaborating and working together, leveraging the strengths of each organization in a model for value based care and contracting. Included are challenges the organizations faced and lessons learned. More Details...

Developing Cross-Sector Partnerships (2020). This guide provides health center staff with tools and strategies to initiate, develop, and sustain community partnerships to better serve older adult residents of public housing. Content of this publication was developed through a 4-session learning collaborative launched by the SDOH academy with a small cohort of HRSA-funded health centers, HCCNs, and PCAs. More Details...

Financial and Operational Benchmarking Trends and Techniques (2019). How do you assess your performance by looking at your financial metrics? Which metrics are important? How can you benchmark your performance to your peers? In this session, health centers will learn how to assess their health center’s financial and operational performance using benchmarking and comparative metrics from Capital Link’s audited financial database and data from the federal UDS reporting system and referencing Capital Link’s recently updated Federally Qualified Health Centers Financial and Operational Performance Analysis and Performance Benchmarking Toolkit. More Details...

HITEQ Highlights: Documentation Tips when using the Collaborative Care Model for the Treatment of Depression and Anxiety in Primary Care (2020). Join the HITEQ Center, in collaboration with the National Council for Behavioral Health, for a webinar on Documentation Tips when using the Collaborative Care Model for the Treatment of Depression and Anxiety in Primary Care. The webinar provided a brief overview and benefits of the collaborative care model as well as information specific to each of the main staff roles. The role-specific nuances of documentation were highlighted, including considerations for tracking data such as clinical activities accomplished with each patient during the month. More Details...

Root Cause Analysis Training 3 of 3: Prioritizing Root Causes and Creating Action Steps (2020). This webinar focuses on prioritizing root causes, creating action steps, and the importance of using root cause analysis to inform quality improvement. This webinar series was developed to help health centers prepare for the diabetes performance analysis component of their operational site visit. More Details...

Root Cause Analysis Training 2 of 3: The "5 Why's and Fishbone Diagrams" (2020). This webinar focuses on the "5 Why's", Fishbone Diagrams, and the importance of these tools to inform quality improvement. This webinar series was developed to help health centers prepare for the diabetes performance analysis component of their operational site visit. More Details...

HITEQ Highlights: Updates to the HITEQ UDS Clinical Analysis Dashboards (2020). During this HITEQ Highlights webinar, learn about the updated HITEQ Center’s UDS dashboards, available on the HITEQ site for HCCNs, PCAs, and health centers, as well as a nationwide version available to all website visitors. These dashboards show UDS clinical quality measure reporting from calendar year 2018, historical data, and benchmark data from Healthy People 2020 goals. These updated dashboards include a number of new features, to allow users to compare outcomes across various groups to improve the understanding of how certain characteristics correlate with clinical quality outcomes. More Details...

Root Cause Analysis Training 1 of 3: HRSA's Expectations (2020). This webinar focuses on HRSA's expectations and the importance of using root cause analysis to inform quality improvement. This webinar series was developed to help health centers prepare for the diabetes performance analysis component of their operational site visit. More Details...

Cost Per Visit Measuring Health Center Performance (2020). This Issue Brief provides a methodology for health centers to calculate costs across all service lines, and examines the operational factors that most directly influence those costs. Developed in collaboration with the National Association of Community Health Centers (NACHC). More Details...

The Road to Trauma-Informed Care in Primary Care (2020). During this webinar, we heard from the National Council and Zufall Health Center about this program, lessons learned and resources for Health Centers on how to implement a trauma-informed care program on Trauma-Informed Primary Care: Fostering Resilience and Recovery, to educate health care providers on the importance of trauma-informed approaches and to create a change package for implementation of standardized and scalable trauma-informed care practices in the primary care setting. More Details...

Using Financial and Operational Data to Plan for Growth (2019). Develop a framework for identifying strengths, challenges, and opportunities for performance improvement in preparation for growth, including best practices from Capital Link's one-on-one work with health centers. More Details...

Tools and Techniques to Assess Your Health Center’s Market and Community Needs (2020). This session will provide attendees with a review of the resources (many of which are free) available for health centers to assess market opportunities and community needs. More Details...

Financial and Operational Benchmarking Trends and Techniques (2018). In this session, health centers will learn how to assess their health center’s financial and operational performance using benchmarking and comparative metrics from Capital Link’s audited financial database and data from the federal UDS reporting system and referencing Capital Link’s recently released Federally Qualified Health Centers Financial and Operational Performance Analysis 2013-2016, a new resource providing multi-year trends for community health centers on a national basis. More Details...

HITEQ Highlights: Enhancing the EHR for Suicide Prevention (2020). This webinar is the second in a series highlighting the intersection between health information technology and behavioral health services. The webinar explored key components to be built into an electronic health record in order to better address suicide prevention in health care. Decision support considerations, documentation and communication enhancements, as well as population health management strategies were discussed. More Details...

Successful Practices in Accountable Care: Building Capacity to Support Accountable Care: Washington Association for Community Health (2019). This publication highlights Washington Association for Community Health efforts in supporting health center capacity around accountable care. It explores change areas within three domains of NACHC’s Value Transformation Framework (Infrastructure, Care Delivery, People) to provide concrete examples of successful capacity-building strategies. Readers will also gain insight into what it takes to support health center transformation from volume to value. More Details...

Improving Diabetes Outcomes: Curated Expert Guidance, Tools, and Resources, Updated September 2019 (2019). As of CDC's 2017 National Diabetes Statistics Report, 30.3 million people, or 9.4% of the total U.S. population, have diabetes. Of these 30.3 million, only 23.1 million are diagnosed—while the other estimated 7.2 million are undiagnosed. This illustrates the need for targeted quality improvement and implementation of promising practices to address diabetes and needs of diabetic patients. This toolkit includes curated expert guidance, tools, and resources for enhancing care processes and outcomes for diabetes control, preventive care, and others targets for improvement. More Details...

EHR-Related Resources for 330 and RWHAP Dually Funded Health Centers: Resources curated from TargetHIV.org and other sites in October 2019 (2019). Health centers funded by the Ryan White HIV/AIDS Program (RWHAP) must submit the Ryan White Services Report (RSR) annually and often maintain separate databases from their EHR to do so, which is less than ideal in many situations. This document summarizes resources related to integrating RWHAP data reporting requirements into EHRs, including specific vendors, as well as those related to improving HIV service delivery using technology. More Details...

Diabetes Self-Management: Education and Support (2019). Diabetes self-management education and support (DSMES) is a critical element of care for all people with diabetes. DSMES is the ongoing process of facilitating the knowledge, skills, and ability necessary for diabetes self-care, as well as activities that assist a person in implementing and sustaining the behaviors needed to manage his or her condition on an ongoing basis, beyond or outside of formal self-management training. More Details...

The National Diabetes Prevention Program: Where We Are, Where We're Going (2019). To provide an overview of the Primary Care Association (PCA) environmental scan and results. More Details...

Working with the HRSA Diabetes Quality Improvement Initiative (2019). The HRSA Diabetes Quality Improvement Initiative is an agency-wide effort to improve diabetes outcomes and lower health care costs. MCN is working in support of the Improvement Initiative by assisting you to access resources and develop performance improvement skills that will enable you to address diabetes care in your mobile and agricultural worker populations. Diabetes care is a complex mix that includes medication, as well as education, self-care behaviors and continuity of care. Adding the factors of mobility, immigration status and culture takes the challenge to another level. More Details...

Recruiting, Training, and Retaining LGBTQ-Proficient Clinical Providers: A Workforce Development Toolkit (2019). As lesbian, gay, bisexual, transgender, and queer (LGBTQ) people increasingly access care at health centers, the clinical workforce needs to be prepared to meet the unique health needs of LGBTQ patients. Finding LGBTQ-proficient providers, however, can present a challenge, especially outside major metropolitan areas.In this toolkit, we provide tips and strategies for: 1)Recruiting providers who are either already proficient in LGBTQ health care, or who demonstrate an interest in, and capacity for proficiency in LGBTQ health care; 2) Developing the knowledge and skills of providers to care for LGBTQ patients through training and other professional development opportunities, and; 3)Implementing changes to workplace culture, policies, and processes in order to retain LGBTQ-proficient providers. More Details...

Increase Access to Care Self-Assessment (2019). Our Migrant Health Program Self-Assessment tool will provide your health center with the framework to assess and document current status of your MSAW program, and to identify gaps and areas of improvement to better reach and serve your MSAW population. More Details...

Data Driven Programming to Maximize Care for Residents of Public Housing: Presented for National Nurse Care Consortium (NNCC) for health centers serving public housing patients (2018). This presentation walks public housing-focused health centers, such as those with public housing primary care grants, through available UDS reports and tools that can be used for informing services and planning. A number of specific examples are shown of how information from the UDS can be used for improvement. Other information provided serves as a reference for reporting of public housing on Table 4 of the UDS.  More Details...

Creating a Transgender Health Program at Your Health Center: From Planning to Implimentation (2018). In this guide, we provide a framework for building a health program for transgender and gender diverse patients at your health center. There is no “one size fits all” approach to this work, but there are certain building blocks from which to create your own program that supports the gender diverse people in your community. More Details...

Addressing Diabetes Risk Factors in Elementary School Children Through Community Partnerships (2019). Health centers, in collaboration with schools and other community partners, can play a powerful role in performing appropriate screening, prevention, and management of elementary-aged children with obesity and other pre-diabetic indicators. This resource highlights ways health centers (such as federally qualified health centers) can enhance these efforts through school partnerships. More Details...

Ransomware Guidance Presentation for Health Centers: Updated with Ransomware Strategies from CISA (2019). This ransomware guidance presentation for health centers, updated with ransomware strategies from CISA, provides information about ransomware, HIPPA implications, recent examples from the news, and suggested resources. More Details...

Office Hour: Quality Management for Clinical Leaders (2019). In this Office Hour, Cheryl Modica, Director of NACHC's Quality Center, presents evidence-based and promising practices, including NACHC's Value Transformation Framework tool, to guide and accelerate your health center's transformation and improvement in achieving value-based care. The aim of this Office Hour is to increase a Clinical Leader's ability to actively participate and engage other clinical team members in effectively executing health center Quality Management activities, use bench-marking to actively identify clinical improvement opportunities, and support health center accreditation and Patient Centered Medical Home (PCMH) recognition. More Details...

NNOHA Operations Manual - Quality Chapter (2019). Health centers strive to deliver quality care that leads to positive patient outcomes. This chapter of the NNOHA Operations Manual will explore quality improvement for oral health programs. More Details...

Promoting CDC Tips from Former Smokers to Public Housing Residents (2018). This webinar provided background on the smoking rates for public housing residents, the recent requirement for public housing buildings to implement a smoke-free policy, and an overview of CDC Tips materials and resources (such as Tips print ads and videos) tailored for health care providers and organizations that serve public housing residents. It also provided details on the pilot project and information on how to apply. More Details...

Health Behaviors and Public Housing: Interactive Map (n.a.). Health behaviors are detrimental actions that heightened the odd of illness and impede recovery. This map depicts some health behaviors by county and the location of PHPC health centers in the nation. More Details...

Cervical Cancer Screening Strategies in Public Housing Primary Care Settings: Findings from the NCHPH Learning Collaborative (2018). A cervical cancer prevention and control program comprises an organized set of activities aimed at preventing and reducing morbidity and mortality from cervical cancer. The program provides a plan of action with details on what work is to be done, by whom and when, as well as information about what means or resources will be used to implement the program. More Details...

Cervical Cancer Prevention Strategies in Public Housing Primary Care Settings: Findings from the NCHPH Learning Collaborative (2018). The National Center for Health in Public Housing (NCHPH) engaged in discussions with clinical directors from Public Housing Primary Care grantees and other Health Centers located in or immediately accessible to public housing to determine successful strategies to promote cervical cancer prevention among their patient population. More Details...

Increasing Access to Healthy Food and Exercise in Public Housing Communities: Examples From Public Housing Primary Care Grantees (2019). Public housing residents face the challenge of living in communities with poor access to healthy foods and safe places to exercise. Addressing access to healthy food and improving diet and exercise are critical components in improving the health of public housing residents. This report provides examples of Public Housing Primary Care Grantee strategies and programs that have increased access to healthy food, exercise and weight control models for public housing residents. More Details...

Center of Excellence for Protected Health Information: FOCUS: PHI is a SAMHSA-funded source for clear and accurate information about patient privacy and confidentiality (2019). Clear and accurate information about confidentiality is important to ensure that patient privacy is protected and that privacy laws are not erroneously interpreted to prevent disclosure of patient information. Individuals living with mental illness or substance use disorders may not seek care without guarantees of confidentiality and privacy protections. Clarifying privacy protections and promoting communication of patient records is critical for improving patients’ access to care and quality of treatment once in care. The Center for Excellence for Protected Health information is supported by SAMHSA and includes key resources around privacy and confidentiality. More Details...

Building and Sustaining a Data Driven Culture: HITEQ Webinar (2019). The HITEQ Center conducted a webinar on building and sustaining a data driven culture for Community Health Care Association of New York State. This webinar introduced concepts, tools and examples to help manage data as a strategic asset, align data strategy with organizational strategy, and explored ways to implement a data services function. More Details...

Panel Management in the Age of Value-Based Care: Health Center Case Studies Developed with Chiron Strategy Group, June 2019 (2019). This downloadable HITEQ resource offers guidance on improving panel management activities, including real-life examples from two health centers of the challenges and successes in managing panels. More Details...

Successful Practices in Accountable Care: Change Management and Service Delivery (2019). Ammonoosuc Community Health Services, Inc. (ACHS) has achieved an 81.67% colorectal cancer screening rate (compared to the Uniform Data System screening rateof 42% in 2017) making them one of the top in the nation addressing this critical need consistently. This document explores the crucial elements of their success including an organizational culture of improvement, patient engagement strategies, and changes to testing. More Details...

Team as Treatment - Driving Improvement in Diabetes (2019). This webinar will share evidence-based models that will provide a framework for health centers to optimize the team in primary care. More Details...

Key Resources for Managing Diabetes in Primary Care (2018). Given the prevalence of diabetes among health center patients, the impact that poor control has on quality of life, health outcomes, mortality, and costs, and the salutary effects better management yields, the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA BPHC) has launched a diabetes quality improvement strategy to support advancement of diabetes prevention and management. This strategy is designed to improve diabetes prevention efforts through increases in the percentage of adults and children who receive weight screenings and counseling. With respect to diabetes treatment and management, HRSA BPHC’s strategy aims to reduce the proportion of patients with poor diabetes control as measured by hemoglobin A1c (HbA1c) greater than 9% and increase the proportion of health centers that meet the Healthy People 2020 goal for uncontrolled diabetes for each racial/ethnic group. The American Diabetes Association’s (ADA) Standards of Medical Care in Diabetes grounds this improvement strategy in sound clinical evidence More Details...

Health Center Emergency Management Plan - Template (2019). This document is to be used as a guide for the development of a health center emergency management (EM) plan, or EMP. Health centers should modify suggested language, policies, and/or protocols to reflect current operations and organizational approach to the EM program’s structure and ongoing maintenance. The yellow, highlighted text that appears in brackets provides direction/placeholders for customizing this plan to align with your health center’s policies and procedures. More Details...

Health Center Communications Plan - Template (2019). This document is to be used as a guide for the development of a health center Communications Plan. It may be maintained as a free-standing document, or as an annex to your organization’s Emergency Management Plan (EMP). The yellow, highlighted text that appears in brackets provides direction/placeholders for customizing this plan to align with your health center’s policies and procedures. More Details...

How has the ACA Medicaid Expansion Affected Providers Serving the Homeless Population?: Analysis of Coverage, Revenues, and Costs (2016). The Affordable Care Act (ACA) Medicaid expansion to adults closed a longstanding gap in eligibility in the 32 states, including DC, that have adopted it to date, providing a new coverage option for millions of uninsured adults. In Medicaid expansion states, many people experiencing homelessness are newly eligible for coverage since this population includes many single adults who were excluded from Medicaid prior to the expansion. Coverage is particularly important for this population given that they have poor health and intensive health care and social service needs. More Details...

HITEQ Highlights: Addressing Childhood Obesity in Health Centers (2019). This webinar focused on how to improve child weight screening, nutrition and physical activity counselling, and design appropriate and meaningful interventions according to health center peers. A number of tools that support this quality improvement around addressing child weight and potential for obesity were discussed, including Bright Futures guidance and data validation tools from HITEQ. More Details...

Addressing Intimate Partner Violence Series: Session 1: CREATING A SUPPORTIVE CLINICAL ENVIRONMENT TO ADDRESS INTIMATE PARTNER VIOLENCE (2019). Intimate partner violence (IPV) occurs in all segments of our society, but vulnerable populations like migrant women may encounter additional disparities and barriers to care that make intervention and treatment of IPV more complex. In these two sessions, Migrant Clinicians Network provides specific and effective action items to better serve women who have experienced IPV in the exam room, and to make our communities safer by engaging men in the community. More Details...

Environmental and Occupational Screening Questions for the Primary Care Setting: Preguntas para sondear en los lugares de atencion a la salud (2007). Three concise and effective environmental/occupational health screening questions for the primary care provider. English/Spanish resource More Details...

Environmental and Occupational Health Screening Questions for the Primary Care Setting: Preguntas para sondear en los lugares de atension a la salud (2017). Three concise and effective environmental/occupational health screening questions for the primary care provider. Electronic Health Record Version English/Spanish resource. More Details...

Adding Mobile Dental Services to a Pediatrics Clinic: Promising Practice (2019). Harbor Health Services in Massachusetts identified the need for dental services at a primary care location at their health center that did not have a dental clinic. The health center decided to add portable dental equipment to the medical site. This promising practice will discuss how the program was developed and lessons learned. More Details...

Using Non-Billable Staff in Care Teams for Quality Outcomes (2018). Non-traditional support staff are critical to a care team and can add efficiencies to workflows for improved patient care. This webinar explores different care team formations with non-billable staff working at the top of their licensure, with special attention on workflows related to pre-visit planning and standing orders. The webinar centers on NCQA 2017 PCMH Standards, specifically the Team-Based Care and Practice Organization concept, which measures how practices provide continuity of care, communicate roles and responsibilities of the medical home to patients/families/caregivers, and organize and train staff to work to the top of their license and provide effective team-based care. More Details...

Emergency Preparedness: Secondary PPE Training (2019). Lt. Brian Pomodoro, Sr. Program Mgr. of Disaster Response Training for DelValle Institute for Emergency Preparedness- Boston EMS, speaks on PPE donning and doffing. More Details...

Emergency Preparedness: Primary PPE Training: PPE Donning and Doffing Exercise (2019). Lt. Brian Pomodoro, Sr. Program Mgr. of Disaster Response Training for DelValle Institute for Emergency Preparedness- Boston EMS, speaks on PPE donning and doffing. More Details...

Emergency Preparedness: Personal Protective Equipment: PPE Donning and Doffing Exercise (2019). Lt. Brian Pomodoro, Sr. Program Mgr. of Disaster Response Training for DelValle Institute for Emergency Preparedness- Boston EMS, speaks on PPE donning and doffing. More Details...

Emergency Preparedness: Infectious Disease Risk: Risk Communication: Infectious Disease (2019). Sarah Darcy, Media Relations Manager for South Shore Health System, speaks on risk communication and how it relates to infectious disease. More Details...

Health Center Data Validation Tool: Tool to Validate Adult BMI UDS Clinical Measure Reporting from EHR (2019). This Excel-based tool is designed to support validation of EHR reporting for the Adult BMI clinical measure by comparing results from EHR to results from chart reviews or examination of underlying data. This assists in identifying specific data elements that are not being captured appropriately, either as a result of workflow or EHR report logic, and thereby effecting compliance rates. More Details...

Update on the HRSA UDS Sealant Measure - December 2018 (2018). In 2015, HRSA introduced the first oral health clinical quality measure to the UDS, with the UDS Sealants Measure. This session will highlight the 2017 UDS data results for the dental sealants measure. Topics to be included: common challenges health centers have experienced in developing, modifying, and/or implementing clinical workflows and procedures to report on the measure. Best practices and work-arounds to address data collection and reporting challenges will be shared for those health centers that are not yet using the EDR vendor-developed solutions for reporting on the measure. More Details...

Addressing Violence in Public Housing Communities: Case Examples of Violence Prevention and Intervention Strategies from Public Housing Primary Care Grantees (2019). The purpose of this report is to provide Health Centers located in or immediately accessible to public housing with best practices and examples of violence prevention and intervention programs that can be implemented in their communities. NCHPH conducted background research on violence and crime statistics from the Federal Bureau of Investigation Uniform Crime Reporting Program, interviewed four Health Center staff, and analyzed the interviews to identify overlapping themes, lessons learned, and successful strategies used to address and prevent violence. More Details...

Leveraging National Diabetes Prevention Programming for Your Health Center (2018). Miriam Bell from the Centers for Disease Control, Jen Lee from the Association of Asian Pacific Community Health Organizations, Nena Tolenoa from Kosrae Community Health Center, Alicia Rivera and Donna Winston from the Neighborhood Health Centers of the Lehigh Valley, and Gina Trignani from Health Promotion Council discuss how to leverage national diabetes prevention programming for your health center. More Details...

Addressing Childhood Obesity in Health Centers: Promising Practices and Lessons Learned: January 2019 (2019). The HITEQ Center interviewed ten health centers and health center partners to identify solutions and promising practices for addressing childhood obesity across the health center program. The focus included how health centers are meeting the Uniform Data System UDS measure and how they are taking further steps to identify and intervene with those at risk of obesity leveraging health information technology, electronic health records, and the data they have. Seven key areas are identified in the resulting issue brief. In the Fall of 2018, the HITEQ Center interviewed ten health centers and health center partners to identify solutions and promising practices for addressing childhood obesity across the health center program. The focus included how health centers are meeting the Uniform Data System UDS measure, Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents CMS155v6, and how they are taking further steps to identify and intervene with those at risk of obesity by leveraging health information technology, electronic health records, and resulting data. Seven key areas of improvement from interviews are identified in the resulting issue brief: Key 1. Embed Needed Data Capture in Workflow Key 2. Implement Successful Monitoring to Support Decision Making Key 3. Understand the Evidence Base Key 4. Identify Key Data and Metrics Key 5. Target Interventions Appropriately Key 6. Consider Alternative Appointment Types and Locations Key 7. Create Comprehensive, Accessible Interventions Download the issue brief below to see health center examples, related research, and health IT tools for each of these keys. More Details...

Carequality and CommonWell — What matters to health centers (2019). In early 2018, KLAS researchers issued a report stating that the CommonWell-Carequality connection is the key to interoperability value. It is believed that when vendors fully embrace CommonWell and Carequality “instant value” will be created for users. This is an appealing promise to all healthcare providers, including health centers. So what should health centers know about this effort, and how should they prepare to capture the benefits? More Details...

Health Center Expansion Opportunities & Community Needs (2018). This webinar outlines expansion opportunities for health centers to leverage resources, identifies potential for growth, and work with patients and community partners to improve care. You will learn about special considerations for serving residents of public housing, identify strategies to expand services for vulnerable populations, and understand how to position themselves strategically for expansion regardless of funding availability. More Details...

Using Health Center Needs Assessments To Address Legal Needs (2016). This fact sheet outlines how health centers can use community needs assessments to understand and meet their patients’ health-harming civil legal needs. More Details...

UDS Sealant Measure FAQ (2019). Find answers to Frequently Asked Questions (FAQ) about the HRSA UDS Sealant Measure for children ages 6-9 for dental caries. Developed in consultation with oral health specialists and HRSA staff. More Details...

Three Domains to Improve Performance: Immunization Coverage Case Study (2016). Improving performance can be boiled down to three approaches: improving the completeness and accuracy of data, decreasing missed opportunities, and improving the quality of services. Determining which of these is appropriate for your circumstance requires doing some data validation to assess where the issue lies. If you have not taken that step yet, please visit that section of the HITEQ site. Improving performance can be boiled down to three approaches: improving the completeness and accuracy of data, decreasing missed opportunities, and improving the quality of services. Determining which of these is appropriate for your circumstance requires doing some data validation to assess where the issue lies. If you have not taken that step yet, please visit that section of the HITEQ site. This case study walks through improving performance on immunization coverage using one continuous quality improvement process, the AFIX program, and highlights strategies in each of the three approaches to improve performance. More Details...

Successful Practices in Accountable Care: Community Health Centers, Inc. (2017). This papers describes Community Health Centers, Inc., work with their electronic health record vendor to better understand their patient population and provide better care. More Details...

Strategies to Improve Provider Productivity Post EHR (2016). This issue brief aims to help health centers overcome provider productivity loss after implement a new electronic health record system. More Details...

Staff Orientation to the use of Health Information Technology (HIT) to achieve the Triple Aim - Part I: Part 1 of 3: Effectively Using Data to Improve the Patient Experience (2017). A custom, health-center focused eLearning module for onboarding and orienting clinical and administrative health center staff to the Triple Aim and their important role in collecting accurate and timely information to support informed decision-making.  The first aim – Patient Experience – is addressed in this module with a focus on the many staff a patient interacts with during a visit who impact the patient’s care.  ** Please note that viewing issues have been identified when using the Internet Explorer 11 browser. The series is best viewed in either Chrome, Firefox, or IE Edge browsers. The series is best viewed in either Chrome, Firefox, or IE Edge browsers. More Details...

Screening, Brief Intervention, and Referral to Treatment in Urban FQHCs (2014). This webinar describes a randomized clinical trial of a brief intervention (SBIRT) against a 2-6 session intervention of brief treatment in three urban federally qualified healthcare centers (FQHCs), focusing on screening and onsite brief intervention / brief treatment. More Details...

Quality Improvement Theory Burst: Process Mapping (2016). No annotation provided by the authoring organization. More Details...

Providing Civil Legal Aid Through Medical-Legal Partnerships: A Critical Enabling Service for Health Centers Serving Asian Americans, Native Hawaiians and Pacific Islanders (AA&NHPIs) (2016). This case study highlights how a health center serving a high immigrant and limited English proficient patient population, including Asian Americans, Native Hawaiians and Pacific Islanders (AA&NHPIs) integrated civil legal aid into its services through a medical-legal partnership (MLP) approach in order to address the social determinants of health (SDOH). Lessons learned in conducting this case study show that the MLP approach is essential to health care transformation and quality improvement. The approach encourages collaboration between health care providers and legal teams to work together to improve clinical practice and institutional policies to better respond to patients’ needs. More Details...

Prioritization Matrix: A framework for selecting QI activities or project (2017). It is sometimes difficult to know what target metric to focus on when beginning a quality improvement project. A prioritization matrix is a management tool that uses a simple framework to compare multiple options side-by-side using standard criteria. This version includes four criteria and can be adapted for your purposes. What is it and how can it help me? It is sometimes difficult to know where to start when approaching several opportunities to improve care process that emerge from a quality improvement project. A prioritization matrix is a management tool that uses a simple framework to compare multiple options side-by-side using standard criteria.   Download one of the prioritization matrix tools below. One is for selecting a target for a QI Project (e.g., hypertension control, colorectal cancer screening, immunizations, etc.) The other is for selecting among potential improvements identified. These are word documents that you can further edit for your own purposes.   Prioritization Matrix for Selecting Target for QI Project Using the Guide to Improving Care Processes and Outcomes in Health Centers or beginning another QI project, a number of potential targets will be identified (e.g., hypertension control, diabetes control, colorectal cancer screening, no show rate, etc.) List those potential enhancements in the Opportunities to improve target performance column in this matrix. Rate each possible target according to the scale provided. You can also leave a column blank if you don’t find it relevant, just be sure to leave it blank for all options. When rating External requirement consider whether this target metric is related to required reporting, such as UDS, or even more that one reporting requirement? If yes, rate it a 3, otherwise, rate as a 2 for something that is desired or is tangentially related, or a 1 if it is not required for external reporting. When rating Cost consider how substantial the financial investment would be for addressing the target being considered? If the financial investment is relatively low, then rate it a 3. Rate a 2 if a moderate financial investment would be required, and rate a 1 if the activity would require a substantial financial investment, (i.e., the cost is high). When rating Difficulty, you may consider whether you currently have the staff, referral relationships, or other key components that are critical to addressing that target. For example, if you do not have an OB/GYN or someone appropriate to conduct pap tests on staff, and you don’t have an existing referral relationship with a provider who completes pap tests in your community, then targeting cervical cancer screening for improvement would be difficult. When rating Impact, consider how large of an impact addressing the target could have. For example, are there a large number of patients with the condition or in need of the screening? Is current performance particularly low such that a change could result in significant improvement? Once all potential enhancements are listed and ratings are in each column, add all columns together to identify the items that are likely to have the biggest greatest impact with the most efficiency. Those potential enhancements that have the highest score (=external requirement + cost + difficulty + impact) may be the best enhancements to try first.   Prioritization Matrix for Selecting Improvement to Test Using the Guide to Improving Care Processes and Outcomes in Health Centers or beginning another QI project, a number of potential targets will be identified (e.g., hypertension control, diabetes control, colorectal cancer screening, no show rate, etc.) List those potential enhancements in the Opportunities to improve target performance column in this matrix. Rate each possible target according to the scale provided. You can also leave a column blank if you don’t find it relevant, just be sure to leave it blank for all options. When rating External requirement consider whether this target metric is related to required reporting, such as UDS, or even more that one reporting requirement? If yes, rate it a 3, otherwise, rate as a 2 for something that is desired or is tangentially related, or a 1 if it is not required for external reporting. When rating Cost consider how substantial the financial investment would be for addressing the target being considered? If the financial investment is relatively low, then rate it a 3. Rate a 2 if a moderate financial investment would be required, and rate a 1 if the activity would require a substantial financial investment, (i.e., the cost is high). When rating Difficulty, you may consider whether you currently have the staff, referral relationships, or other key components that are critical to addressing that target. For example, if you do not have an OB/GYN or someone appropriate to conduct pap tests on staff, and you don’t have an existing referral relationship with a provider who completes pap tests in your community, then targeting cervical cancer screening for improvement would be difficult. When rating Impact, consider how large of an impact addressing the target could have. For example, are there a large number of patients with the condition or in need of the screening? Is current performance particularly low such that a change could result in significant improvement? Once all potential enhancements are listed and ratings are in each column, add all columns together to identify the items that are likely to have the biggest greatest impact with the most efficiency. Those potential enhancements that have the highest score (=external requirement + cost + difficulty + impact) may be the best enhancements to try first. More Details...

Practice Transformation and Implications for Health Centers Serving AA&NHPIs - Part 5: Ensuring Culturally and Linguistically Appropriate Services in Practice Transformation Initiatives (2015). This webinar reviews DHHS' Office of Minority Health’s enhanced standards for culturally and linguistically appropriate services (CLAS) and how these standards can guide practice transformation for diverse patient populations. It highlights why it is particularly important for health centers serving medically-underserved Asian Americans, Native Hawaiians, and other Pacific Islanders (AA&NHPIs) to continuously measure and improve their culturally and linguistically appropriate services. More Details...

Practice Transformation and Implications for Health Centers Serving AA&NHPIs - Part 2: Health Information Technology: Implications for Community Health Centers Serving Asian Americans, Native Hawaiians, and Pacific Islanders (AA&NHPIs) (2015). This webinar examines how health centers have implemented and used health information technology (HIT). It reviews the requirements for HITECH incentive payments that support quality improvement. The webinar also describes opportunities for health centers and other health care providers to improve patient engagement through health information technologies, such as the use of patient portals. More Details...

Practice Transformation and Implications for Health Centers Serving AA&NHPIs - Part 1: Quality Improvement: Implications for Community Health Centers Serving Asian Americans, Native Hawaiians, and Pacific Islanders (AA&NHPIs) (2015). This webinar provides an overview of basic quality improvement frameworks from the Institute of Medicine and the U.S. Department of Health and Human Services. It highlights how quality improvement is a central part of the health care reforms being implemented under the Affordable Care Act (ACA). Lastly, it reviews the evidence for effective quality improvement activities specifically in health centers and among Asian American, Native Hawaiian and Pacific Islanders (AA&NHPI) populations. More Details...

Optimizing Team Resources: Patient/Provider Scheduling and Panel Size (2018). Health centers continue to devote significant resources to the transition to a team-based model of primary care delivery. This session goes "back to basics" to take a fresh look at techniques designed to expand capacity, utilizing existing resources within a sustainable structure. From defining target outcomes to simplifying scheduling templates to aligning panel size, participants will learn a replicable process for moving forward with each of their primary care teams through what is often a divisive operational imperative. More Details...

Needs Assessment in Action Profiles (2016). A community health needs assessment is a major undertaking for any health center. The Needs Assessment in Action Profiles: Innovative Approaches to Identifying the Needs of Underserved Communities is a resource for health centers to learn about effective strategies utilized by their peers. This resource offers examples of three innovative approaches that have been successfully implemented by health centers across the country. Each profile includes information on the population assessed, data collection methods, how findings were shared and applied, and lessons learned. Health centers can use this resource to apply proven strategies to the planning and implementation of their own needs assessment. More Details...

Motivating Factors for Engaging in Health IT Enabled QI: Guidance for Health Center Leadership and Partners (2016). This white paper explores what is bringing a health center to the world of Health IT Enabled QI and lays out some motivating factors and barriers as well as what skill areas may need further consideration in planning next steps. Health centers across the country have a high EHR adoption rate and most have been using an EHR for several years. However, we know that the proliferation of EHRs and their companion reports have not always lead to accurate and robust data that can be used for quality improvement. Many challenges have been identified, including provider workflow and training issues, challenges with scalability, and limitations to data that can be extracted from various EHR systems. In response, a need has been identified for tools and resources that can guide health centers and those working with health centers through some key skill areas in the pursuit of Health IT Enabled QI. More Details...

Interprofessional Practice and Education in FQHCs (2016). Barbara F. Brandt, PhD, Director of the National Center for Interprofessional Practice and Education, leads a discussion about the National Center’s work in relation to Federally Qualified Health Centers. More Details...

Integrating Team-Based Care to Improve Clinical Outcomes (2018). This publication serves as a primer on care team formation for community health centers, specifically as a means of treating chronic diseases. More Details...

Increasing Access To Care Through Contracting for Dental Services: Promising Practice (2017). This promising practice describes how a community health center in Wisconsin utilized contracting with local dentists to expand dental services at the health center. More Details...

Improving Diabetes Outcomes: Curated Expert Guidance, Tools, and Resources (2017). According to 2016 UDS data, an estimated 14.3% of Federally Qualified Health Center patients nationwide have diabetes. Of these 2 million plus patients living with diabetes, approximately 32% have uncontrolled diabetes, with HbA1c equal to or above 9% or have had no test in the prior year. These statistics bring forth the need for improvement in the care of diabetes; several resources and research outcomes are profiled here with specific takeaways for health centers. As of CDC's 2017 National Diabetes Statistics Report, 30.3 million people, or 9.4% of the total U.S. population, have diabetes. Of these 30.3 million, only 23.1 million are diagnosed - while the other estimated 7.2 million are undiagnosed. Additionally, more than 1 in 3 adults or 84.1 million people in the U.S. have prediabetes. Among adults age 65 and older, nearly half have prediabetes. More Details...

Impact of Enabling Services Utilization on Health Outcomes: Enabling Services Accountability Project (2009). This factsheet highlights the impact of enabling services (ES) on diabetes and childhood immunizations at four health centers, Waianae Coast Comprehensive Health Center in Waianae, HI, Charles B. Wang Community Health Center in New York, NY, International Community Health Services in Seattle, WA, and Kalihi-Palama Health Center in Honolulu, HI. The results indicate that ES utilization is associated with better diabetes outcomes and child immunization. More Details...

High-Performance Health Centers: Learning, Measuring, Achieving (2014). This guide explores the transition from data to information to knowledge to action with the goal of achieving a high level of performance. It discusses the difference between calculating outputs and measuring outcomes, and reviews the basics of “change management,” explaining how to identify what’s important and how to transform limited resources into significant improvements. It also describes the importance of measuring, benchmarking, and evaluating all organizational activities, providing an introduction to the tools needed to attain high performance. More Details...

Health IT-Enabled Quality Improvement: A Guide to Improvement: 10/4 HITEQ Highlights Webinar Transcription (2016). A transcription of the October 4th HITEQ Highlights webinar. A transcription of the October 4th HITEQ Highlights webinar.  Improving care delivery is a business and mission imperative for health centers, and the HITEQ Center offers a growing collection of tools and services to support this journey. The foundation for these particular offerings is the "Guide for Improving Care Processes and Outcomes in FQHCs."  This web-based resource provides step-by-step guidance on understanding and improving workflows and information flows that drive performance on key targets such as hypertension control and colorectal cancer screening. Guide centerpieces include worksheets for documenting, analyzing, sharing and improving care processes for such targets. Strategies and tools in the Guide have been used successfully in various quality improvement (QI) initiatives, and a HITEQ Center focus is spreading this value more quickly and widely among health centers. This introductory training session introduces health centers and their partners to the Guide's proven approaches, worksheets and other health IT-enabled QI tool More Details...

Health IT Staff Resume Screening Tool: A template for Human Resources and Hiring Managers (2016). This is a list of key words and phrases that can be used to pre-screen resumes for HIT/QI jobs to help quickly identify candidates for an additional screen. More Details...

Health IT Staff Recruitment Strategies: A template for Human Resources and Hiring Managers (2016). This resource provides ideas about the latest recruiting tips used by community health centers as well as leading organizations from other industries. Review the strategies and identify ones that could work in your organization.  Adapt them as necessary to fit your particular needs and resources. This resource provides ideas about the latest recruiting tips used by community health centers as well as leading organizations from other industries. Review the strategies and identify ones that could work in your organization.  Adapt them as necessary to fit your particular needs and resources. More Details...

Health IT Interviewing Questions: Examples for Human Resources and Hiring Managers (2016). This resource provides a list of sample questions that can be used to interview job candidates. The questions are organized into four categories: 1) questions for HIT staff positions; 2) questions for quality improvement staff positions; 3) questions for either position; and 4) questions for senior HIT or Quality positions.   This resource provides a list of sample questions that can be used to interview job candidates. The questions are organized into four categories: 1) questions for HIT staff positions; 2) questions for quality improvement staff positions; 3) questions for either position; and 4) questions for senior HIT or Quality positions.   These questions are intended to be a menu of items that an organization can pick or choose from, adapt to meet their organization’s needs, or use to generate additional/new questions. More Details...

Health IT enabled Quality Improvement Project Charter: The first step in a QI project. (2017).  A Project Charter serves as a reference of authority for the future of the project. Creating a Project Charter and getting sign off from all participants gives all involved the authority to begin the work outlined therein. The task of developing the Project Charter builds understanding, consensus, and clarity about purpose, expectations, roles and responsibilities, and communications. Why develop a Quality Improvement Project Charter? Formalizes authority to dedicate resources (such as staff time) to the QI project Defines the purpose and expectations for the QI project Identifies key stakeholders to engage in QI project Clarifies roles and responsibilities of the QI Lead and QI Team members Assures commitment and support for QI project from leadership and QI Team members Provides a sustainable framework for any QI Project A Project Charter serves as a reference of authority for the future of the project. Creating a Project Charter and getting sign off from all participants gives all involved the authority to begin the work outlined therein. The task of developing the Project Charter builds understanding, consensus, and clarity about purpose, expectations, roles and responsibilities, and communications. Download the Project Charter (Word document) below to use with your QI team. It is important that this be completed with your QI team and leadership. Also, be sure to be as specific as possible when completing your QI charter, as this will be your reference for all things related to your project.  For example, rather than say you will hold monthly meetings, be specific that meetings will be the third Wednesday of the month at 9am. Another example, for the communication plan, be specific as to exactly who needs to be communicated with at what frequency, and through what channels. More Details...

Health IT and QI Workforce Development: Onboarding for Success: 11/29 HITEQ Highlights Webinar Transcription (2016). A transcription of the November 29th HITEQ Highlights webinar.  After a brief introduction to HITEQ and this Resource Set, this webinar will highlight two specific tools for onboarding new staff into your health center with a focus on speeding the onboarding of Health IT and QI staff. The webinar will delve into the two onboarding tools - the Calendar and the Sample of a Staff Member’s Dashboard for Required Tasks, showing how they are meant to be used and how you can customize them for your needs. More Details...

Health Center Investments in Enabling Services Associated with Better Outcomes (2017). This factsheet provides analysis of the health center data from the 2015 Uniform Data System (UDS). The data highlights that enabling services staffing and costs are associated with better national quality measures, including higher rate of HbA1c < 8%, higher rate of controlled hypertension, higher cervical cancer screening, and higher child immunization rate. More Details...

Health and Housing Partnerships: Making the Work: Online Tutorial: Step by Step Strategies for Health and Housing Partnerships (2017). This self-paced online class explores the importance and value of partnering with supportive housing providers, partner perspectives and goals, how to assess your organization and your partner organization, and how to make partnerships last. More Details...

Examination of Health Conditions of Enabling Service Users: Enabling Services Accountability Project (2005). This factsheet outlines results from a study conducted examining the health conditions of enabling service (ES) users. The study provides an essential foundation for future ES studies that examine health outcomes for specific conditions. By examining ES and their measurable effects on health, we can begin to develop funding and reimbursement strategies to pay for these essential and currently non-reimbursed services at health centers nationwide. More Details...

Engaging the Data Creators: Involving Front-Line Staff in the Health IT Enabled QI Process (2016). This brief discusses the importance of including frontline staff such as front desk, intake staff, and medical assistants in Health IT Enabled QI process, as they are often the &lsquo;data creators&rsquo; or the ones entering the information into the system. Real world examples as well as suggested approaches and further resources are included. The data that is generated within health centers through entry into the EHR or practice management system and used for myriad purposes such as decision support, reporting, and quality improvement is often input by front-line staff. This may include front desk staff who enter information on intake forms, medical assistants who enter height, weight, and vital signs, among others. Another way to look at it is the information that health center leadership, providers, and payers are using to make decisions is often &lsquo;created&rsquo; by entry level staff that may have less training and higher turnover. For these reasons, it is critically important to consider these &lsquo;data creators&rsquo; in quality improvement activities that are undertaken. More Details...

Enabling Services Data Collection Implementation Packet: Enabling Services Accountability Project (2017). This toolkit includes tools and recommendations for how health centers can better capture data on enabling services (ES). This will help health centers provide a better understanding of the role of ES in health care access, utilization and outcomes for Asian Americans, Native Hawaiians, and Pacific Islanders (AA&NHPIs), and useful information to appropriately address these needs. More Details...

Enabling Services at Health Centers: Eliminating Disparities and Improving Quality: Challenges and Opportunities for Health Centers in Collecting Data on Enabling Services (2006). This report describes a pilot study conducted by AAPCHO and four member health centers. Through this project, a uniform dataset on enabling services was created and a standardized method for collecting data was implemented. The data demonstrates that a high percentage of patients at health centers utilize enabling services (ES), and each user receives more than one ES. The data is able to provide information on the variations in utilization of enabling services and user characteristics at each health center. More Details...

Diabetes Improvement Toolkit (2017). A website that hosts toolkits, guides, and other resources to support data collection, quality, and performance improvement with the use of Health IT tools More Details...

Demystifying Predictive Analytics: Factsheet on Predictive Analytics for Health Centers (2017). Using predictive analytics in health care is an emerging field, especially for health centers. This tool will provide a brief explanation of the purpose of predictive analytics, the ingredients necessary to apply these methods, and ways that health centers are using this approach to improve results. The objective of this resource is to help health center leadership and staff understand how and when predictive analytics can help them, and to think about how predictive analytics might fit into their data-driven QI program. This one-page brief outlines the basics of this complex topic. We define predictive analytics and describe how health centers are adopting this innovation. Sources and uses of data for making predictions are discussed, and specific applications of predictive analytics are described.&nbsp; Specific health center examples are offered to illustrate the potential of predictive analytics for health centers. More Details...

Data Dictionary Tool and Template: Organizational tool for your EHR and analytics platform data indicators (2017). This&nbsp;Data Dictionary provides a single point of reference for data mapping and interpretation for all of the indicators in your quality reports. Organization of the data definitions in this tool provides a reference for the team of all such definitions that impact reports and alerts in the analytics application. This&nbsp;Data Dictionary provides a single point of reference for data mapping and interpretation for all of the indicators in your quality reports. Organization of the data definitions in this tool provides a reference for the team of all such definitions that impact reports and alerts in the analytics application. For example, it provides a format to document all items in a given report, and related EHR data. That application may be the EHR or an analytics platform that is tied to the EHR. Anyone with questions about where data is being pulled from for any indicator can reference the Data Dictionary without analyst security privileges or expertise within the analytics tools. The Data Dictionary should be curated by analysts and made available on a shared drive or company intranet. Download the Excel tool below to see a full example and additional instructions.&nbsp; Also, see the companion Quality Report Inventory tool here. More Details...

Creating a Culture of Safety: A Guide for Health Centers (2017). Responding to the findings of a recent survey conducted by the HCH National Consumer Advisory Board, this resource provides recommendations for developing physical spaces that promote well-being, considerations for vulnerable populations, and strategies for providing staff support. More Details...

Collecting Data On Asian Americans, Native Hawaiians, And Pacific Islanders For Community Health Center Needs Assessments: A Learning Series - Part 2: Data Resource Training: Using Community Commons to Map & Visualize the Needs of AA&NHPIs For Community Needs Assessments (2018). This webinar introduces the Community Commons resource and how it can serve as a great tool to help health centers collect disaggregated data on Asian Americans, Native Hawaiians, and Pacific Islanders (AA&NHPIs). It provides a live demonstration of Community Commons’ mapping technology features and their Needs Assessment Toolkit. Speakers demonstrate how these tools can be used to inform a health center’s community health needs assessment and increase knowledge of available data resources. This will help to improve health center capacity to monitor and track the needs of medically underserved areas and populations. More Details...

Coffee Break Webinar: Clinical Performance Improvement (2015). Health Outreach Partners presents “Leveraging Outreach to Support Clinical Performance Improvement”. In this webinar, we first review what constitutes clinical performance improvement for health centers. Then, we provide several examples of how outreach and health center staff can collaborate to improve the delivery of clinical care to patients.Health Outreach Partners presents “Leveraging Outreach to Support Clinical Performance Improvement”. In this webinar, we first review what constitutes clinical performance improvement for health centers. Then, we provide several examples of how outreach and health center staff can collaborate to improve the delivery of clinical care to patients. More Details...

Civil Legal Aid 101 for Health Care (2016). This new tool provides an overview of the composition, role, limitations, and impact of civil legal aid for health care partners. There is also an accompanying messaging guide to help HRSA-funded health centers understand medical-legal partnership. More Details...

Building Data Teams and Skills: Maximizing Data Literacy and Data Governance for a Data Driven Culture: A compendium of references and tools, created in October 2018 (2018). This compendium of references and tools is intended to support Quality Improvement efforts and to build skills across health center staff, in particular those who may be tasked with leading data literacy and data governance activities or are new to the health center world.  More Details...

Annual UDS Clinical Measure Data Dashboard: Excel Tool for Data Monitoring (2019). This Excel file dashboard was shared by an existing health center and is used to depict performance on UDS measures over time. It was recently updated 2018 reporting requirements and clinical measures. More Details...

Advancing Health Care Through Care Coordination (2017). Care coordination emphasizes collaboration between providers to increase quality of care and ultimately improve patient outcomes. In addition, this model can help reduce the overall cost of care by reducing medication errors, repetitive tests, and prevent hospital admissions. During this webinar, panelists share information about their care coordination efforts and offer important considerations for health centers hoping to start, improve, or expand care coordination programs. More Details...

Accessing your Data: Questions to Consider with your EHR Vendor (2016). Intended to assist in ensuring full use and understanding of capabilities of current system and assessing the need for additional population health management or data integration tools, this checklist describes the steps health center quality improvement and IT staff can take to ensure they are maximizing the population health management and other capacity of current systems. It Included are questions around the system itself, report generation, training, and resulting data, as well as considerations before and after you contact your vendor. This checklist describes the steps health center quality improvement and IT staff can take to ensure they are maximizing the population health management capacity of their current EHR system. It is intended to assist health centers in ensuring they are utilizing the full capabilities of the current system and assessing the need for additional population health management tools. Included are questions around the system itself, report generation, training, and resulting data, as well as considerations before and after you contact your vendor.&nbsp; It&rsquo;s important to note that these questions are just meant for consideration. Not all of the features or aspects discussed will be relevant for your health center, and no system nor approach will check all the boxes. Use this to guide your thinking and discussions so you are able to get a robust understanding of what your EHR is capable of, and what you may need to find elsewhere or find other ways to address. Download the&nbsp;checklist below. More Details...

A Closer Look At Health Center-Based MLPs: Where They Are, How They Work, and How They are Funded (2018). This issue brief from the National Center for Medical-Legal Partnership describes how and where these partnerships operate, and how state primary care associations are supporting these programs. It also discusses how health-center based medical-legal partnerships are financed, with a spotlight on four states that integrate financing for legal services in Medicaid payment arrangements. More Details...