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Migrant-Specific Performance Measures. Midwest Migrant Stream Forum November 19 th , 2010 Austin, Texas . Karen Mountain, MBA, MSN, RN Chief Executive Officer Migrant Clinicians Network . Outline. Performance measures—what are they? BPHC required performance measures

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migrant specific performance measures

Migrant-Specific Performance Measures

Midwest Migrant Stream Forum

November 19th, 2010

Austin, Texas

Karen Mountain, MBA, MSN, RN

Chief Executive Officer Migrant Clinicians Network

  • Performance measures—what are they?
  • BPHC required performance measures
  • Migrant-specific measures
    • The process
    • Recommended measures
what is a performance measure
What is a performance measure?
  • Tool for documenting performance
      • Designed to serve as a yardstick on which to measure quality. In order to measure a particular element of care, process, or outcome, indicators are selected to assess performance within a particular area of focus. Indicators are quantitative measures that can be used to assess and improve performance.
      • Although measurement in and of itself does not lead to improvement, assessing current performance allows an organization to understand exactly where it is relative to where it wants to be
characteristics of a good measure
Characteristics of a good measure
  • Relevance
    • Does the indicator relate to a condition that occurs frequently or has a great impact on the patients at your facility?
  • Measurability
    • Can the indicator realistically and efficiently be measured given the facility’s finite resources?
  • Accuracy
    • Is the indicator based on accepted guidelines or developed through formal group-decision making methods?
  • Improvability
    • Can the performance rate associated with the indicator realistically be improved given the limitations of your clinical services and patient population?
bphc clinical performance measures
BPHC clinical performance measures

BPHC clinical performance measures are a sub-set of a larger set of HRSA performance measures

Selected from measures used by the National Quality Forum and other national quality groups

Balanced and comprehensive representation of:

Health Center services

Clinically prevalent conditions among the underserved

Population across life cycles

Commonly used by Medicare, Medicaid and other insurance/managed care organizations to assess quality


purpose of required measures
Purpose of required measures
  • Measurement of health center performance on evidence-based practices
  • Collection of aggregate health center data for reporting to stakeholders
  • Evaluation of individual and collective trends over time
  • Identification of areas that may require improvement
integrating measures into your cqi program
Integrating measures into your CQI program

When you determine that the outcome of a Performance Measure is unacceptable you can focus on that measure through the CQI program


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


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


clinical performance measures
Clinical performance measures

BPHC requires these measures in SAC (Service Area Competition), BPR (Budget Period Renewal) and NAP (New Access Point) grant applications

Grantees are establishing baselines and setting (realistic!) goals for improvement

BPHC staff review submissions and progress reports


six required clinical measures aligned with the uds report
Six required clinical measures: Aligned with the UDS report

Outreach/Quality of Care Indicators

Trimester of entry into perinatal care

Childhood (2 year old) immunization


Pap tests for adult (21 – 64 year old)


Health Outcomes and Disparities

Infant birth weight (normal vs. low)

Hypertension (controlled vs. uncontrolled)

Diabetes (adequate control vs. inadequate control)


outreach quality of care
Outreach/Quality of Care

Early entry into prenatal care

If women enter care in their first trimester then probability of adverse birth outcome will be reduced

Childhood immunizations

If children receive their vaccinations in a timely fashion then they will be less likely to contract vaccine preventable diseases or to suffer from the sequela of these diseases

Pap tests

If women receive Pap tests as recommended then they can be treated earlier and will be less likely to suffer adverse outcomes from HPV and cervical cancer


outcome disparities measures
Outcome/Disparities Measures

Low Birth weight

If there are fewer low birth weight children born, then there will be fewer children who suffer the multiple negative sequelae of low birth weight


If there is less uncontrolled hypertension, then there will be less cardiovascular damage, fewer heart attacks, less organ damage later in life.


If there is less uncontrolled diabetes then there will be fewer amputations, less blindness, less organ damage later in life.


two or more additional clinical measures
Two or more additional Clinical Measures:

Required two additional measures

One Oral Health

One Behavioral Health




optional supplemental measures
Optional/Supplemental Measures
  • Special populations (if receiving special funding)
    • Migrant measures: MCN
    • Homeless/Public Housing
  • Others
    • Special initiatives
    • Measures monitored over

time: HDC, program specific

  • Reporting not required
core financial measures
Core Financial Measures
  • Working capital to monthly expense ratio
    • Liquidity in # of months - ability to pay bills on time - current financial condition
  • Long-term debt to equity ratio
    • Portion of net assets tied up in long-term debt - long-term financial condition
  • Change in net assets as a percent of expense
    • Financial results from operations in relationship to total expenses
  • Total cost per patient
    • Annual average cost per patient served - value of service provided based on costs
  • Medical cost per medical encounter
    • Average cost per billable medical encounter (less: lab & pharmacy) - cost efficiency
development of migrant specific measures
Development of Migrant-Specific Measures


To develop supplemental performance improvement measures specific to the unique features of Migrant Health Programs (MHPs)

why migrant specific measures
Why Migrant-Specific Measures?
  • Migrant Health Programs are reporting on clinical and financial measures
  • UDS reporting of required measures does not require separate reporting on migrant patients
  • Programs with large or majority migrant populations feel that features such as enabling services are not reflected in the core measures
  • MHPs are encouraged to include supplemental measures focused on their special population
summary of activities
Summary of Activities
  • Phase I (June-September 08):
    • Meeting of 6 voucher programs
  • Phase II (April-September 09):
    • Expanded Work Group membership to 11 MHPs
    • 4 conference calls
    • 1 face-to-face meeting
    • 2 presentations for wider audiences
    • Extensive email correspondence for discussion and selection of measures
    • Pilot of selected measures 9-10 & 11 in NC
how many of you have already identified something that you will remember and use
How many of you have already identified something that you will remember and use?

Show of hands:

Slide to be inserted mid-way through your presentation:


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

Focus on three categories:

  • Enabling services
  • Environmental/

occupational health

  • Financial
the process27
The Process…
  • What’s already out there?
    • Measures used by MHPs
    • Measures used by others
  • What’s the evidence?
    • Support from scientific/public health literature
the process28
The Process…
  • What do our experts say?
    • Other organizations
    • Expert consultants
    • Survey of Work Group members and wider migrant health audience
  • What is most relevant to health of migrant farmworkers?
the process29
The Process…
  • Preferred measure selected in each category with 2-3 additional alternatives
the process30
The Process…
  • Will they work?
    • Each of the preferred measures was piloted with the North Carolina Farmworker Health Program in Raleigh, NC
preferred enabling services measure
Preferred Enabling Services Measure
  • Percent of migrant patients ≥ 18 years of age with blood pressure ≥ 140/90 who are successfully referred for care. Would reflect the effectiveness of enabling services by documenting the identification of patients outside of the clinic setting with uncontrolled hypertension who are entered into care. “Successfully referred” = referred and clinic visit documented.
  • Calculation:Farmworker patients seen outside of the clinic setting with documented BP of ≥140/90 who are 1) referred for care and 2) are seen by a provider/Total farmworker patients seen outside of the clinic setting with documented BP of ≥140/90.
pilot findings
Pilot Findings
  • Measure includes multiple calculations: 1)# pts with documented elevated BP, 2)Of those, # referred, 3)Of those, % seen.
  • Assumes that BP screenings are routinely taking place in the field AND are being documented
  • Study site educating outreach staff on BP measurement, HTN education
  • Requires a reliable system for making referrals for care and following up on whether appts take place—currently not well documented at study site
  • Study site is designing outreach EHR that will include necessary documentation and tracking of referrals
additional enabling services measures
Percent of migrant women who have documented screening for sexual and intimate partner violence during the measurement year

Percent of migrant patients ≥12 years who have documented tobacco use status during the measurement year

Additional Enabling Services Measures
preferred envir occ health measure
Preferred Envir/Occ Health Measure
  • Percent of registered farmworker patients who receive pesticide prevention education. This measure would document how many farmworker patients receive education regarding the prevention of pesticide exposure, such as the use of personal protective equipment (PPE), proper storage and handling of pesticides, prevention of take-home exposure to family members, etc.
  • Calculation:Farmworker patients with documented pesticide prevention education/Total registered farmworker patients.
pilot findings35
Pilot Findings
  • Study site used this measure for the past 3 years
  • Standardized protocol for outreach staff regarding content of pesticide education
  • For comparison among MHCs, universal definition of “pesticide prevention education” would need to be developed
    • Recommendations regarding content and length of session were made by EOH consultants
additional envir occ measures
Percent of registered farmworker patients screened for Environmental/Occupa-tional Health (EOH) risk

Percent of registered farmworker patients who receive eye protection education

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

(or - Average Hours per Patient X Average Cost per Hour)

pilot findings38
Pilot Findings
  • Simple calculation using numbers reported in UDS:

Total cost for enabling services = UDS Table 8A, Line 11C, Column C

Unduplicated number of enabling patients UDS Table 5, Line 29, Column C

additional financial measures
Additional Financial Measures
  • Average Cost per Hour for Enabling Services
  • Overhead Rate – Administration and Facilities
  • Average Hours per Patient for Enabling Services
where do we go from here
Where do we go from here?
  • Not meant to replace the BPHC required performance measures.
  • Not required for MHCs--intended only as suggested supplemental measures for MHCs.
  • Presented to the National Advisory Council on Migrant Health and BPHC leadership.
  • Webcast and presentations, Streamline
  • Purpose of performance

measurement is to assure

and IMPROVE Quality of


    • Appropriateness of care for the population
    • Effectiveness of care for the population
    • Improve customer/patient satisfaction
    • Include goals in CQI program


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

1: Sprince NL, Zwerling C, Whitten PS, Lynch CF, Burmeister LF, Gillette PP, Thu K, Alavanja MC. Farm activities associated with eye injuries in the Agricultural Health Study. J Agromedicine. 2008;13(1):17-22. PubMed PMID: 19042689.

2: Lacey SE, Forst LS, Petrea RE, Conroy LM. Eye injury in migrant farm workers and suggested hazard controls. J Agric Saf Health. 2007 Jul;13(3):259-74. Review. PubMed PMID: 17892069.

3: Peate WF. Work-related eye injuries and illnesses. Am Fam Physician. 2007 Apr 1;75(7):1017-22 Review. PubMed PMID: 17427615.

4: Forst L, Noth IM, Lacey S, Bauer S, Skinner S, Petrea R, Zanoni J. Barriers and benefits of protective eyewear use by Latino farm workers. J Agromedicine. 2006;11(2):11-7. PubMed PMID: 17135138.

5: Cameron L, Lalich N, Bauer S, Booker V, Bogue HO, Samuels S, Steege AL. Occupational health survey of farm workers by camp health aides. J Agric Saf Health. 2006 May;12(2):139-53. PubMed PMID: 16724790.

6: Mackiewicz J, Machowicz-Matejko E, Sałaga-Pylak M, Piecyk-Sidor M, Zagórski Z. Work-related, penetrating eye injuries in rural environments. Ann Agric Environ Med. 2005;12(1):27-9. PubMed PMID: 16028862.

7: Forst L, Lacey S, Chen HY, Jimenez R, Bauer S, Skinner S, Alvarado R, Nickels L, Zanoni J, Petrea R, Conroy L. Effectiveness of community health workers for promoting use of safety eyewear by Latino farm workers. Am J Ind Med. 2004 Dec;46(6):607-13. PubMed PMID: 15551366.

8: Villarejo D, Baron SL. The occupational health status of hired farm workers. Occup Med. 1999 Jul-Sep;14(3):613-35. Review. PubMed PMID: 10378979. 9: Weinbaum Z, Schenker MB, O'Malley MA, Gold EB, Samuels SJ. Determinants of disability in illnesses related to agricultural use of organophosphates (OPs) in California. Am J Ind Med. 1995 Aug;28(2):257-74. PubMed PMID: 8585522.

other resources
Other Resources
  • Healthy People 2010: www.healthypeople.gov
  • National Quality Center—Improving HIV Care: http://www.nationalqualitycenter.org/index.cfm/22
  • AHRQ Effective Health Care: http://effectivehealthcare.ahrq.gov/
  • National Quality Forum: http://www.qualityforum.org/
  • State Primary Care Associations: http://www.bphc.hrsa.gov/technicalassistance/pcadirectory.htm
hrsa resources
HRSA Resources
  • HRSA/BPHC: www.bphc.hrsa.gov
  • Performance Measures http://bphc.hrsa.gov/about/performancemeasures.htm
  • UDS Website: http://www.hrsa.gov/data-statistics/health-center-data/index.html
    • Detailed information on required measures
    • Sampling methodology
    • 2010 trainings http://www.bphcdata.net/html/bphctraining.html



What do you think about this effort?

Slide to be inserted at the end of your presentation:



Karen Mountain