Uniform Data System Calendar Year 2013 Bureau of Primary Health Care - - PDF document

11/8/2013

Uniform Data System Calendar Year 2013

Bureau of Primary Health Care

Agenda

• Brief Introduction to UDS
• Available Assistance
• Definitions used in the UDS report
• Step‐by‐Step Instructions for Completing UDS

Tables

• 2013 Changes; 2014 Changes

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11/8/2013

Questions – Do you know?

• How many patients are served by the health center

program?

• How many visits?
• What % of patients are uninsured? % having Medicaid?
• What is the average cost per medical visit?
• What is the average charge for a visit?
• What percentage of women age 24‐64 get a pap test?
• What percentage of adults received colorectal cancer

screening?

• Where can you get this information?
• How is this information used?
• Why are we here today?

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Health Center Impact

Source: http://bphc.hrsa.gov/healthcenterdatastatistics/index.html Accessed 8/29/13

• Patients

served (85% are medical patients)

• Total

Visits include: medical, dental, MH, SA, Vision, Other Professional, and Enabling services

• Employees

represent FTE – those employ ed 21.1 Million Total are far greater

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11/8/2013

UDS: The Who, What, When, Why, and How

• WHO: 330 Grantees, LALs, and NMHCs who

were “funded” prior to October 2013

• WHAT: “Scope of Project” for the period

January 1, 2013 ‐ December 31, 2013

• WHEN: February 15, 2014 report due;

finalized by March 31 with reviewer

• WHY: Program evaluation, public data and

reports to Congress and the Administration

• HOW: Through “Electronic Handbook” (EHB)

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12 Tables Provide a Snapshot

• f Patients and Performance

What is Reported Table(s)

Patients you serve

Tables 3A, 3B, 4 and Zip

Types and quantities of services you provide

Tables 5 and 6A

Staffing mix and tenure

Tables 5 and 5A

The care you deliver / quality of care

Tables 6A, 6B, and 7

Costs of providing services

Table 8A

Revenue sources

Tables 9D and 9E

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11/8/2013

Who Reports Which Tables

Table 1 BPHC 330‐Funded Program and NMHCs: Universal Report More than 1 BPHC 330‐ Funded Program: Universal + Special Pop. Grant Reports Look‐Alike Health Center: Universal Report

Zip Codes

Yes n/a Yes

3A, 3B, 4

Yes Yes No Agricultural Worker or Health Care for the Homeless detail

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Yes Visits & Patients, only Yes

5A

Yes n/a Yes

6A

Yes Yes Not reported

6B

Yes n/a Yes

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Yes n/a Yes

8A

Yes n/a Yes

9D

Yes n/a No Managed Care or Retroactive details

9E

Yes n/a No 330 or ARRA grants

Available Assistance

• Regional trainings
• On‐line training modules, manual, fact sheets, webinars, and
• ther TA materials available:
• www.bphcdata.net
• http://bphc.hrsa.gov/healthcenterdatastatistics/ reporting/index.html
• PALs
• CY 2013: http://bphc.hrsa.gov/policiesregulations/policies/pal201302.html
• CY 2014: http://bphc.hrsa.gov/policiesregulations/policies/pal201307.html
• Telephone and email helpline: 866‐UDS‐HELP or

udshelp330@bphcdata.net

• Technical support to review submission
• Primary Care Associations/Primary Care Offices
• EHB Support (see handout)

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• HRSA Call Center: 877‐464‐4772
• BPHC Help Desk: 301‐443‐7356

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11/8/2013

Strategies for Success Submission

• Work as a team
• Refer to the manual, fact sheets, and other

resources

• Check your data before submitting
• Refer to last years reviewer

’s letter emailed to the UDS Preparer/Contact

• Address all edits
• Check data trends
• Compare data to benchmarks

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2013 Changes

• Zip code table will ADD patients by primary

third party payor or uninsured.

• Table 4: CHANGE age breaks for insurance.
• Table 6B: Immunizations and Cervical Cancer

measures have been CHANGED.

• Look‐alikes: ADD managed care to table 4 and

race/ethnicity to table 7.

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11/8/2013

2014 Changes

• Table 4: A line will be added to identify Residents
• f Public Housing
• Table 6A: ADD “first time ever” HIV diagnosis
• Table 6B:
• ADD to universe women referred for perinatal care even

when no care was provided

• CHANGE tobacco to one measure
• DELETE CAD process measure
• ADD follow‐up for first time ever HIV diagnosed patients
• ADD depression screening
• Table 7:
• ADD referrals to perinatal outcomes (delivery, birth weight)
• ADD lipid control for CAD patients
• Simplify HbA1c reporting for diabetic patients

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THE TABLES:

Key Definitions and Step by Step Instructions

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11/8/2013

Patient Profile Tables

• Number and socio‐demographic

characteristics of patients served:

– Zip Code Table: zip code by insurance status – Table 3A: by age and gender – Table 3B: by race/ethnicity /language – Table 4: by income, insurance, special populations

• Tables 3A, 3B and 4 are completed for each

additional funding stream.

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Who Counts: Patient Defined

• An individual who has one or more visits

reported on Table 5 during the calendar year is considered a “patient.”

– Medical, dental, behavioral health, vision, other professional and selected enabling services

• Whenever “patients” are counted, it is an

unduplicated count. Each patient is counted

• nce and only once regardless of the number
• r scope of visits.

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11/8/2013

Patient Types: What are the Differences?

• Patient counts are unduplicated counts of

individuals who have one or more visits during the reporting year.

• On Grant Report (only relevant if you receive multiple

330 funding streams) a patient is an individual who receives one or more visits supported by a special population grant.

• Patients reported by Service Category are individuals

who receive one or more documented “visits” of each specific service type: medical, dental, vision, mental health, substance abuse, enabling, other professional.

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ZIP CODE TABLE:

Patients by Zip Code and Insurance

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11/8/2013

Patients by Zip Code

• Report all zip codes with 11 or more patients

– Combine the rest as “other zip codes”

• 2013 CHANGE: Patients from each zip code are reported by

their primary medical insurance

– This is the third party MEDICAL insurance that would be billed first if the patient had a medical visit – Must be reported for ALL patients including those patients who are not being seen for medical services – There is no unknown insurance category – Totals must tie to totals patients on Table 3A and insured patients on table 4

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Patients by Zip Code (continued)

• Additional instructions for Special Populations

– Homeless: Use zip code of location where patient receives services if no better data exist. – Agricultural: Use zip code of the temporary housing they

• ccupy when patient is in the area.

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11/8/2013

TABLES 3A AND 3B:

Patient Demographics

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Table 3A: Patients by Age & Gender

• Report total patients
• Age is calculated as of

June 30

• Count each patient once

and only once

• Total on line 39 is official

total – all

• ther totals

must equal this number

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11/8/2013

Table 3B: Patients by Hispanic or Latino Ethnicity/Race/Language

• Use Column B if patient

does not indicate “Latino” or “Hispanic.”

• Use Line 6 only if patient

chooses two or more listed races.

– “More than one” shouldn’t be a choice; don’t use for Latino + a race to be “more than one race”

• Use unreported, line 7 if

no race was specified.

• Total must equal T3A.

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Table 3B: Patients by Language

• Report all patients who would best be served

in a language other than English including:

– Bilingual persons not fluent in medical English – Persons who are served by a bilingual provider – Persons who receive interpretation services – Persons using sign language – Persons in Puerto Rico or the Pacific where a language

• ther than English is used
• This is the only UDS cell that may be

estimated.

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11/8/2013

TABLE 4:

Other Demographic Data

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Table 4: Patients by Income

• Use income as of your most recent assessment.

– Income may be self‐reported if permitted by your policy

• Income must be from recent patient data

(within the last year) – otherwise count as unknown.

• Total on Line 6 must = total on table 3A.

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11/8/2013

Table 4: Patients by Medical Insurance

• 2013 CHANGE: Break between age 17 and 18
• Report principal 3rd party insurance for MEDICAL

care (even if patient is not a medical patient)

• Insurance is reported as of the last visit

– Even if it did not pay for the visit – Total on Line 12 must = total for ages on Table 3A – Total for each insurance type must equal totals on zip code table

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Table 4: Medical Insurance Reporting Categories

• NONE/UNINSURED – patients

with no insurance: may include patients for whom health center may be reimbursed through grant or uncompensated care funds

• MEDICAID – report

all Medicaid patients including those in managed care programs run by commercial insurers

• MEDICARE – report

all Medicare patients including Medicare Advantage and Medi‐Medi patients

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11/8/2013

Table 4: Reporting Categories Continued

• CHIP‐RA is handled differently from state to state:

– If provided through Medicaid it is reported on Line 8b (Medicaid) – If provided through a commercial carrier outside of Medicaid it is reported on Line 10b (Other public – not private)

• OTHER PUBLIC – Public coverage for patients for a

broad set of benefits – very uncommon

– Do not include family planning, breast and cervical programs, EPSDT, etc.

• PRIVATE INSURANCE
• NOTE: Workers Comp is

not medical insurance

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Test Your Reviewer Skills 1

• How would you check the reasonableness of

these numbers?

• Do they get your seal of approval?

Principle Third Party Medical Insurance Source 0‐17 years old (a) 18 and older (b) 7 None 120 450 8a Regular Medicaid (Title XIX) 632 259 8b CHIP Medicaid 75 8 Total Medicaid (Lines 8a+8B) 707 259 9 Medicare (Title XVIII) 120 8 10a Other Public Insurance Non‐CHIP (Specify: ) 84 37 10b Other Public Insurance CHIP 174 10 Total Public Insurance (Line 10a+10b) 84 211 11 Private Insurance 6 35 12 Total (Sum Lines 7+8+9+10+11) 1037 963

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11/8/2013

Table 4: Managed Care Utilization

• Completed ONLY by health centers with capitated and/or FFS

managed care (HMO) contracts.

– Patient is assigned to health center or their provider(s) – Patient MUST go to health center for listed primary care services – Do not count Primary Care Case Management patients.

• A member month is 1 member enrolled for 1 month. Report the

sum of the monthly enrollments for 12 months (generally from HMO reports to the health center).

– In some cases, “members” might not be “patients.”

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Table 4: Target Populations

All health centers must report total number of targeted patients (if any) on Lines 16, 23, 24 and 25.

• 330(g) MHC Grantees – provide

separate totals for migratory and for seasonal agricultural workers on Lines 14 and 15

• 330(h) HCH Grantees ‐ report patient’s shelter arrangement

as of first visit in 2013 (where they were housed the prior night)

• A veteran is an individual who completed service in the

Uniformed Services of the US

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11/8/2013

Table 4: Agricultural Worker Defined

• An agricultural worker is an individual whose PRINCIPAL

employment is in agriculture on a SEASONAL BASIS, who has been so employed within the last 24 months, and/or their dependents.

• “Migratory” establishes temporary home(s) for such employment
• “Seasonal” workers do not
• Agriculture means farming, including
• Cultivation and tillage of the soil
• The production, cultivation, growing, and harvesting of any

commodity grown on, or in the land, or as an adjunct to or part of a commodity grown on or in the land; and

• Any practice (including preparation and processing for market and

delivery to storage or to market or to carrier for transportation to market) performed by a farmer or on a farm incident to or in conjunction with the above.

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Table 4: Homeless Defined

• A homeless patient is any person

– known to be homeless at the time of any service or who was housed but eligible because of having been a homeless patient within 12 months of the service date.

• Shelter arrangements (at the first visit of the year):

– “Street” includes living outdoors, in a car, in an encampment, in makeshift housing/shelter or in other places generally not deemed “ fit for human occupancy” – Persons who spent the prior night incarcerated, in an institutional treatment, a hospital or in jail should be reported based on where they intend to spend the night after their encounter/release. If they do not know, code as “street” – “Doubled up” must be temporary and unstable

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11/8/2013

Table 4: 2014 Changes

• Residents of Public Housing

– A line will be added to identify Residents of Public Housing. – Required of all health centers, not just 330(i) PHPC grantees. – Public housing will be restricted to geographically defined programs – either high rise projects or 221(d)(3) low rise programs, but not scattered site or Section 8 rent subsidy programs

• Use of patient address will be acceptable to identify the

population.

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TABLES 5 AND 5A:

Staffing, Tenure, and Utilization

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11/8/2013

Staffing and Utilization Profile Tables

• Types and quantities of services provided and

staff who provide these services

– Table 5: Staffing and utilization

• FTEs, visits, and patients
• Columns B and C (only) are completed for each non‐

CHC funding stream for grantees with multiple funding

• streams. (Grant report includes all activity for patients

reported on Grant Tables 3A,3B and 4)

– Table 5A: Tenure for health center staff

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Table 5: Staffing & Utilization

• Col (a) – Staff

full‐time equivalents (FTEs) reported by position

• Col (b) – Clinic visits

reported by provider type

• Col (c) – Patients

reported by service type

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11/8/2013

Full‐time Equivalent (FTE) Defined

• WHO: All staff providing services at approved

locations

– Employees, contracted staff, residents, and volunteers – Do not count paid referral provider FTEs

• WHERE: Report based on work performed

– FTEs can be allocated across multiple categories

• NOTE: Medical director’s corporate time can be allocated to non‐clinical;

do not allocate administrative time of other providers

– See Appendix A in Reporting Manual for staffing categories

• Line 22 Other Professional includes Chiropractic, acupuncture, PT, OT,

nutrition, podiatry, etc.

• Line 29a Other Related include non‐health care staff (e.g., WIC,

childcare, housing, fitness, job training, etc.)

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Calculating FTEs

• HOW: FTE is actual for the year, not as of last

day

– 1.0 FTE is equivalent to one person working full‐ time (as defined by health center) for one year

• Providers: Based on employment contracts
• Based on hours paid including vacation, sick, continuing

education, etc.

– Calculate FTE for persons working part‐time or part‐year (E.g., 6 months full‐time = 0.50 FTE, 9 months half‐time = 0.375 FTE )

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11/8/2013

Calculating FTEs for Hourly Work

• WHO: Volunteers, locums, residents, on‐call

providers, etc. who do not receive PTO benefits.

• HOW:

– Calculate the number of hours the comparable position works

• E.g., Provider receives 160 hours vacation, 96 hours sick, 40

hours continuing education, 80 hours holidays = 1704 hours worked

– Calculate number of hours person being evaluated actually works

• E.g., Volunteer worked 30 days @ 8 hours = 240

– Calculate and report FTE

• hours worked (240) divided by FTE work hours (1704) = .14 FTE

(240/1704 = 0.1408)

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Visit Defined

• WHAT: Face to face, one to one between

patient and provider

• For behavioral health ONLY group and telemedicine
• No group health education, or group medical visits.

– Licensed provider for medical, dental, vision, etc.

• Include volunteer and contracted provider

– The service must be charted – The provider must be acting independently – The provider must be using professional judgment unique to their training and education

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11/8/2013

Visit Defined ‐ continued

• Only 1 visit/patient/provider type/day

– Unless 2 different providers at 2 different sites

• Only 1 visit/provider/patient/day regardless of the

number of services provided

• COUNT paid referrals; visits when following current

patients in a nursing home, hospital or at home

• DO NOT COUNT immunization only, lab only, dental

varnishing, mass screenings, health fairs, outreach or pharmacy visits

• Count visits provided by both paid and volunteer staff

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Patients by Service Category Defined

• Total number of patients of that type of

service seen in the program year

• A patient may be counted ONLY ONCE in EACH

category regardless of the number of visits.

• Patients provided with multiple types of

service MUST be counted in each category.

– E.g. A patient may counted as both a medical and a dental patient.

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11/8/2013

Table 5A: Tenure for Selected Health Center Staff

• Data reported are generally available in health

center Personnel or Human Resource (HR) employment records.

– Starting point will be last year’s work sheet.

• Deleting staff who have left and adding new staff

– No new data over and above that needed for HR management should be necessary. – TENURE may be measured in a form differently than the way SENIORITY information is stated. – Virtually all of the work for this can be done well in advance of the submission date.

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Table 5A: Tenure

• WHO: Individuals working

at the health center

– Full‐ and part‐time, part‐ year, contract, NHSC – Locums, volunteers, on‐ call, residents

• WHAT: Combined tenure

– In months (not FTE) – As of last work day of year – By job title (consistent with T5)

• NOTE: Col B may not = A

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11/8/2013

Who to include in Census

• WHAT: Snap shot of clinical and selected key

management staff who worked at the health center on December 31.

• WHO:
• Clinical staff:
• Key Non‐clinical staff:

– Physicians – CEO / Executive Director – NP, PA, CNM providers – CFO / Fiscal Officer – Nurses – CIO / IT Director – Dental providers – CMO / Medical Director – Mental Health providers – Vision providers

• Note: Line numbers remain the same as those used for Table 5

for all clinical and non‐clinical staff.

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Tenure for Full and Part Time Staff

• Regular employees and persons on regular

contracts, who are employed at the time of the census are each counted as 1 in column A.

– Regardless of when they first started working – Those who are not working that day but who are scheduled to work before and after that day are counted as 1 – Those who are no longer employed on that day are not counted on this table – Those with two jobs (e.g., ObGyn + CMO) are counted as 1 in each category

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11/8/2013

Tenure for Other Service Provider Arrangements

• Volunteers, locums, on‐call providers, residents,
• etc. who are scheduled to work before and

after 12/31 are each counted as 1 in column C.

– Regardless of how much time they work if they are considered to be a part of the regular staff they are

• counted. Some examples include:
• Specialists who are usually present at least once each

month or quarter

• Primary care providers present during a specific season

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Tenure Months

• Months are calculated from the date person was most

recently hired into that position.

– Continuous months from the start date through December

• f the reporting year

– Rounded up to the closest whole number

• E.g., Pediatrician hired 8/1/02, promoted to CMO on 9/15/10, and

serves in both roles ‐ Count 137 months as pediatrician and 40 months as CMO

• E.g., COO is hired 11/10/88, promoted to Deputy Director 7/12/97

and then promoted to CEO 6/22/13, retaining the obligations of the Deputy Director ‐ Count 7 months as CEO only

• E.g., CEO hired 5/15/10 to fill the role of CIO, CFO, and CEO –Count

44 months as CEO, 44 months as CFO, 44 as CIO

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11/8/2013

Test Your Reviewer Skills 2

• How would you check the reasonableness of

these numbers?

Indicator Prior Year Current Year Total Patients 3,599 3,404 Total Visits 15,396 8,342 Medical Patients 2,403 2,789 Medical Visits 6,899 3,418

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TABLES 6A, 6B, AND 7:

Diagnoses, Services and Care Provided, and Quality of Care Indicators

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11/8/2013

Clinical Profile Tables

• Clinical care

– Table 6A: Selected diagnoses and services

• Also completed for each additional non‐CHC funding stream

– Table 6B: “Quality of care” indicators – Table 7: Health outcomes and disparities

• EHR Capabilities and Quality Recognition

– Series of questions on the implementation of EHR, national and/or state quality recognition (accreditation or PCMH) certification of systems, and how widely adopted the system is throughout the health center’s and its providers – (Not a numbered table – at end of the EHB entry)

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The ICD‐10 Transition

• CMS mandates that ICD‐9 codes are to be

used through 9/30/14, and that ICD‐10 codes will be used after that date.

• ICD‐10 codes (only) must be used for the CY

2015 UDS report to be submitted in 2016.

• BPHC is reviewing options for working through

the transition.

– BPHC encourages timely transition in accordance with CMS requirements. – BPHC will release UDS reporting guidance shortly.

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11/8/2013

TABLE 6A:

Diagnoses and Services

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Table 6A: Diagnoses and Services

• Lines 1‐20d: Selected

diagnoses

– NOTE: Report any appearance not just primary

• Lines 21‐34: Selected

services

• Uses ICD‐9 or CPT

codes

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11/8/2013

Visits by Diagnosis and Service: Column A

• Column A – All

visits with the diagnosis or service

– Any given patient may have multiple visits for the specified diagnosis or service during the year and ALL ARE COUNTED HERE – A given visit may have more than one of the reportable diagnoses (e.g., hypertension and diabetes) and EACH is counted. – A given visit may have multiple services or diagnoses that are on the same line and ONLY ONE IS COUNTED. (E.g., with five vaccines or two fillings in a single visit

• nly one visit is counted)

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Patients by Diagnosis and Service: Column B

• Column B – Unduplicated number of patients

with diagnosis or having received service

– Count a patient ONCE AND ONLY ONCE ON EACH LINE where a visit was counted.

• E.g. – a

patient who is seen five times for hypertension will be counted as one patient in column B

– A patient may have a diagnosis and a service on the same day

• E.g. – a

patient seen for their diabetes and provided with a flu shot – both are counted.

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11/8/2013

Table 6A: 2014 Change

• Persons first diagnosed with HIV during the

reporting year.

– Count only individuals who did not know they had HIV / AIDS

• r who had never been formally

diagnosed with HIV / AIDS prior to a visit with your provider – Do not count persons who knew they had HIV / AIDS but who were being seen for the first time at your health center – There are no codes for this measure

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TABLE 6B AND 7:

Reporting Methods

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11/8/2013

Options for Reporting

• Report Universe – All

patients who meet the reporting criteria

– Must report universe when:

• Universe has fewer than 70 patients who meet the

criteria;

• Reporting Prenatal Care and Delivery Outcome

variables

• Report Sample – A

sample of 70 charts from the Universe

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Note: You may choose differently for each measure

TABLE 6B:

Quality of Care Indicators

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11/8/2013

Process Measures

• Access to prenatal care (first prenatal
• “Process

visit in 1st trimester)

• Childhood immunizations

measures”: IF

• Cervical cancer screening

patients receive

• Adolescent weight screening & follow

timely routine and

up

• Adult weight screening & follow‐up
• Tobacco use screening

preventive care,

• Tobacco cessation counseling for

THEN we can

tobacco users

• Asthma drug therapy

expect improved

• Cholesterol treatment (lipid therapy for

coronary artery disease patients)

health

• Heart attack/stroke treatment (aspirin

therapy for ischemic vascular disease patients)

• Colorectal cancer screening

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Section A: Prenatal Patients by Age

• Report all patients who received prenatal care

during the year by age category.

– Section A is ONLY completed by health centers with Prenatal Programs – Report all women served regardless of whether they delivered, including women whose only service in 2013 was their delivery – Include women who transferred or were “risked out”, as well as women who were delivered by another provider – Do not include patients who may have had tests, vitamins, assessments or education, but did not have their initial clinical visit with the clinic’s obstetrical provider

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11/8/2013

Section B: Access to Prenatal Care

• Trimester of entry into prenatal care

– Section B is ONLY completed by health centers with Prenatal Programs – For all prenatal patients reported in Section A, indicate what trimester they began care and whether it was with the health center or another provider – “Entry into prenatal care” occurs when the patient has had a visit with a physician or midlevel provider who initiates prenatal care with a complete physical exam (i.e., not a pregnancy test, nurse assessment, etc.)

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Prenatal Care Count: 2014 Changes

• All Health Centers will report on all pregnant

MEDICAL patients who were provided any of the following required services:

– (2014 Change) no prenatal care BUT REFERRED FOR PRENATAL CARE and delivery, as well as previously reported: – full perinatal services through delivery – some or all prenatal care and then referred for delivery – some prenatal care and then referred out for late prenatal care and delivery – some prenatal care and then transferred because of risk status

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11/8/2013

Prenatal Care Don’t Count: 2014 Changes

• Health Centers will NOT report on pregnant

patients who:

– Were not counted as medical patients during the calendar year (e.g., dental only, health education

• nly, nutrition only.)

– Were known to be pregnant, but who never sought care or referral for pregnancy including those who had their own obstetrical provider and those who choose to terminate their pregnancy – Those who only requested a pregnancy test and did not return for followup

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Section C: Childhood Immunizations

• Col (a) Universe: 2013 CHANGE: All children who

– turned 2 years and 364 days in 2013 (born on 1/2/10 ‐ 1/1/11) AND – who had at least one medical visit in 2013 AND – were first ever seen prior to their 3rd birthday.

• This is the “catch‐up” schedule. Technically –

asks about children who were immunized before they turned 3.

– CDC / AAP still recommends immunization by age 2

(no exclusions)

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11/8/2013

Childhood Immunizations

• Col (b): Universe or sample of 70 patients
• Col (c) Meeting measurement standard: Number
• f children in Col(b) who, by their 3rd birthday

are fully compliant, i.e., for each disease listed on the next slide they (1) received vaccine*, or (2) had evidence of the disease or (3) have a contraindication for vaccine

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* Hepatitis A, Rotavirus, and Influenza immunizations not measured beginning CY 2013.

Required Vaccines

• Fully compliant means meeting measurement

standard for each of 11 diseases normally vaccinated against with:

– 4 DTP/DTaP, – 3 IPV, – 1 MMR, – 3 HIb, – 3 HepB, – 1 VZV (Varicella) – 4 Pneumococcal conjugate

• 2013 CHANGE: Removed HepA, rotavirus and

influenza

– CDC / AAP still recommends these vaccines

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11/8/2013

Assessing Immunization Measurement Standard

• Notes in the medical record indicating that the patient

received the immunization “at delivery” or “in the hospital” may be counted as evidence of meeting the measurement standard.

• A note that “patient is up‐to‐date” with immunizations that

does not list the date of each immunization and the name

• f the provider does not constitute sufficient evidence of

meeting the measurement standard.

• Good faith efforts to get a child immunized which

nonetheless fail remain “non‐compliant” including:

– Parental failure to bring in the patient – Parents who refuse for religious reasons – Parents who refuse because of beliefs about vaccines

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Section D: Cervical Cancer Screening

• Col (a) Universe: All women

– aged 24 – 64 (born 1/1/49 – 12/31/89) AND – with at least one medical visit in a health center clinic during the reporting year AND – who were first seen before age 65. (excluding women with hysterectomy)

• Col (b): Universe or sample of 70 patients

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11/8/2013

Cervical Cancer Screening (2013 CHANGE)

• Col (c) Meeting the Measurement Standard: 2013

CHANGE: Number of women in Col (b) who received

• ne or more documented Pap tests (regardless of

where performed) during the measurement year or during the two years prior to the measurement year OR, for women age 30 and older who received a Pap test accompanied with an HPV test after, the test was done during the measurement year or the four years prior

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Assessing Cervical Cancer Measurement Standard

• Count as meeting the measurement standard a medical

record with

– A copy of the test result (your lab or another lab) – An evidence based entry in the patient’s chart which includes the provider, test date and result, which was entered by your provider or clinic staff

• A note that “patient was referred” or “patient reported

receiving pap test” does not constitute sufficient evidence of pap test measurement standard being met.

• Even if a good faith effort was made to get the patient tested,

she is “non‐compliant,” even if she:

– refused to have test – failed to return for a scheduled test – claims to have had one but cannot document it

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11/8/2013

Section E: Adolescent Weight Screening and Follow Up

• Col (a) Universe: All children and adolescents

– From aged 3 until 17 on December 31st (born 1/1/96 – 12/31/10) AND – with at least one medical visit in a health center clinic during the reporting year AND – were first seen before age 17 (excluding pregnant adolescents)

73

Adolescent Weight Screening and Follow Up

• Col (b): Universe or sample of 70 patients
• Col (c) Meeting the Measurement Standard:

Number of patients in Col (b) who

– had a recorded BMI percentile during 2013 AND – had documented counseling on nutrition (not just diet) AND – had documented counseling on activity (not just exercise)

74

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Assessing Adolescent Weight Screening Measurement Standard

• Just recording that a well child visit was done

does not meet the requirement

• All three criteria: BMI percentile, counseling
• n nutrition, and counseling on activity must

be documented

75

Section F: Adult Weight Screening and Follow Up

• Col (a) Universe: All adults

– aged 18 and older on December 31st (born on or before 12/31/1995) AND – with at least one medical visit in a health center clinic during the reporting year AND – last seen after they turned 18. (excluding pregnant women & terminally ill patients)

• Col (b): Universe or sample of 70 patients

76

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Adult Weight Screening and Follow Up

• Col (c) Meeting the Measurement Standard:

Number of patients in Col (b) who

– had their BMI recorded at their last visit or within 6 months of that visit AND – had a follow‐up plan documented if they were

• under age 65 and BMI was ≥ 25 OR < 18.5 or
• age 65 or older and BMI was ≥ 30 OR < 22

77

Assessing Adult Weight Measurement Standard

• Just recording height and weight is not

adequate – BMI must be visible in chart or on template

78

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Section G1: Tobacco Use Screening

• Col (a) Universe: All adults

– aged 18 and older on December 31st (born on or before 12/31/1995) AND – who have been seen at least twice (ever) in the practice for medical care AND – with at least one medical visit in a health center clinic during the reporting year AND – last seen after they turned 18 (no exclusions)

79

Tobacco Use Screening

• Col (b): Universe or sample of 70 patients
• Col (c) Meeting the Measurement Standard:

Patients in the sample who were queried about their tobacco use one or more times by any provider (e.g. dental, vision) during their last visit or within 24 months of their last visit

80

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Section G2: Tobacco Cessation Counseling for Tobacco Users

• Col (a) Universe: All adults

– who used any form of tobacco within 24 months AND – aged 18 and older on December 31st (born on or before 12/31/1995) AND – who have been seen at least twice (ever) in the practice for medical care AND – with at least one medical visit in a health center clinic during the reporting year AND – last seen after they turned 18 (no exclusions)

81

Tobacco Cessation Counseling for Tobacco Users

• Col (b): Universe or sample of 70 patients
• Col (c) Meeting the Measurement Standard:

Patients in the sample who

– received tobacco use cessation services OR – received an order for cessation medication (Rx or OTC) OR – were on medication

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Tobacco Measure: 2014 Change

• Only one measure will be used, not two
• Measure will reflect the adult weight measure

in structure.

• Will ask if they were assessed and, if they were

found to be users, were they provided with intervention – all in one question

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Section H: Asthma Treatment

• Col (a) Universe: Patients aged 5 through 40

– initially diagnosed with persistent asthma AND – born between 1/1/73 and 12/31/08 AND – last seen while between ages 5 through 40 AND – seen at least twice (ever) in the practice AND – had at least one medical visit in a health center clinic during the reporting year (excluding patients with allergic reaction to asthma meds and intermittent asthma)

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Asthma Treatment

• Col (b): Universe or sample of 70 patients
• Col (c) Meeting the Measurement Standard:

Patients in the sample who

– received or had a prescription for inhaled corticosteroids OR – received or had a prescription for an approved alternative medication OR – was on medication

85

Section I: Cholesterol Treatment (Lipid Therapy for CAD patients)

• Col (a) Universe: All adults

– with an active diagnosis of CAD during current or prior year or had a myocardial infarction (MI) or had cardiac surgery AND – aged 18 and older on December 31st (born on or before 12/31/1995) AND – last seen after they turned 18 AND – seen at least twice (ever) for medical care AND – had at least one medical visit in a health center clinic during the reporting year (excluding individuals whose last LDL lab test was <130 mg/dL or with an allergy to or a history of adverse outcomes from or intolerance to LDL lowering medications)

86

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Cholesterol Treatment

• Col (b): Universe or sample of 70 patients
• Col (c) Meeting the Measurement Standard: Patients

in the sample who received a prescription for, were provided with, or were taking lipid lowering medications

• 2014 Change: This measure will be eliminated from

table 6B. It will be revised and reported on table 7 (the measure will be described on table 7).

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Section J: Heart Attack/Stroke Treatment (Aspirin Therapy for IVD Patients)

• Col (a) Universe: All adults

– with an active diagnosis of IVD during the current or prior year OR had been discharged after AMI or CABG or PTCA between January 1, 2012 and November 1, 2012 AND – aged 18 and older on December 31st (born on or before 12/31/1995) AND – last seen after they turned 18 AND – had at least one medical visit in a health center clinic during the reporting year (no exclusions)

88 AMI: acute myocardial infarction CABG: coronary artery bypass graft PTCA: percutaneous transluminal coronary angioplasty

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Heart Attack/Stroke Treatment

• Col (b): Universe or sample of 70 patients
• Col (c) Meeting the Measurement Standard:

Patients in the sample who had documentation of aspirin or another anti‐ thrombotic medication being prescribed, dispensed, or used

89

Section K: Colorectal Cancer Screening

• Col (a) Universe: Patients aged 51 through 74

– born between 1/1/39 and 12/31/62 AND – had at least one medical visit in a health center clinic during the reporting year (excluding patients who have had colorectal cancer)

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Colorectal Cancer Screening

• Col (b): Universe or sample of 70 patients
• Col (c) Meeting the Measurement Standard:

Patients in the sample who had documentation

• f appropriate colorectal cancer screening:

– Colonoscopy conducted during reporting year or previous 9 years OR – Flexible sigmoidoscopy conducted during reporting year or previous 4 years OR – Fecal occult blood test (FOBT), including the fecal immunochemical (FIT) test, during the reporting year

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2014 Changes – New Process Measures

• HIV Follow‐up

– Patients first ever diagnosed with HIV by clinic staff between October 2, 2013 and September 30, 2014 who received a follow‐up visit within 90 days

• NOTE: This means beginning to track in 2013
• Depression Screening

– Patients aged 12 and older who were screened for depression using a standardized tool and, if found to be depressed, had a follow‐up plan documented

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Test Your Reviewer Skills 3

• How would you check the reasonableness of

these numbers?

• Do they get your seal of approval?

Section D‐ Cervical Cancer Screening Pap Tests Total Number of Female Patients 24‐64 years of age (a) Number Charts Sampled or EHR total (b) Number of Patients Tested (c) 11 Pap Tests 920 70 63

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TABLE 7:

Health Outcomes and Disparities

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47

Intermediate Outcome Measures

“Intermediate

• utcome
• Low birth weight

measures”: IF this

• Blood pressure control

measurable

(hypertensive patients with

intermediate

blood pressure < 140/90)

• utcome is
• Diabetes control (diabetic

patients with HbA1c <=9%)

improved, THEN later negative health outcomes will be less likely.

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Disparities Format

Hispanic/Latino 1a Asian 1b1 Native Hawaiian 1b2 Other Pacific Islander 1c Black/African American 1d American Indian/Alaska Native 1e White 1f More than One Race 1g Unreported/Refused to Report Race Subtotal Hispanic/Latino Non‐Hispanic/Latino 2a Asian 2b1 Native Hawaiian 2b2 Other Pacific Islander 2c Black/African American 2d American Indian/Alaska Native 2e White 2f More than One Race 2g Unreported/Refused to Report Race Subtotal Non‐Hispanic/Latino Unreported/Refused to Report Ethnicity h Unreported/Refused to Report Race and Ethnicity Total

• All outcome data are

reported in a matrix to show ethnicity and race.

• Latino patients are

reported in section 1.

• Patients who report race

but not ethnicity are assumed non‐Hispanic and reported in section 2.

• Patients with neither race

nor ethnicity are reported as Unreported in section 3.

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11/8/2013

HIV Pregnancy and Deliveries by Health Center Clinicians

• Line “0”: Pregnant HIV patients seen in the

clinic, regardless of whether or not they received prenatal care

– All health centers report, including those with no prenatal care program

• Line 2: Total number of deliveries performed

by health center clinicians including deliveries to non‐health center patients

– Only agencies which provide prenatal care report this line

HIV Positive Pregnant Women Blank 2 Deliveries Performed by Health Center’s Providers Blank 97

Section A: Low Birth Weight

Prenatal Care Live Births: <1500 Live Births: 1500‐ Live Births: Patients Who grams 2499 grams =>2500 grams Delivered During the Year (1a) (1b) (1c) (1d)

• Column 1a: All prenatal care patients from Table 6B

who were known to have delivered during the year, even if the delivery was done by another provider

– Column 1a need not / will not / should not equal the sum

• f columns 1b + 1c + 1d except by coincidence
• Columns 1b – 1d: Live births born to prenatal care

patients during the year by weight, including multiples, regardless of who performed the delivery

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11/8/2013

Section A: Low Birth Weight 2014 Change

• All Health Centers will report the outcomes for ALL

pregnant MEDICAL patients who were provided any of the following required services:

– no prenatal care BUT REFERRED FOR PRENATAL CARE and delivery, as well as – full perinatal services through delivery – some or all prenatal care and then referred for delivery – some prenatal care and then referred out for late prenatal care and delivery – some prenatal care and then transferred because of risk status

• Will require the tracking of patients by programs who

never reported in the past.

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Section B: Blood Pressure Control

• Col (2a) Universe: Patients aged 18 to 85

– diagnosed with hypertension prior to 6/30/13 AND – born between 1/1/29 and 12/31/95 AND – seen at least twice during the reporting year for any medical service (excluding pregnant women and patients with End Stage Renal Disease)

Total Hypertensive Charts Sampled or Patients with HTN Patients EHR Total Controlled (2a) (2b) (2c)

100

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Blood Pressure Control

• Col (2b): Universe or sample of 70 patients
• Col (2c) Meeting the Measurement Standard:

Patients in the sample whose most recent blood pressure is less than 140/90

– No documented blood pressure during the reporting year does not meet the measurement standard.

Total Hypertensive Charts Sampled or Patients with HTN Patients EHR Total Controlled (2a) (2b) (2c)

101 102

Section C: Diabetes Control

• Col (3a) Universe: Patients aged 18 to 75

– diagnosed with diabetes AND – born between 1/1/39 and 12/31/95 AND – seen at least twice during the reporting year for any medical service (excluding those with only a diagnosis of gestational diabetes or steroid‐induced diabetes)

Total Patients with Diabetes (3a) Charts Sampled or EHR Total (3b) Patients with HbA1c <7% (3c) Patients with 7% <= Hba1C <8% (3e) Patients with 8%<= HbA1c <=9% (3e) Patients with HbA1c >9%

• r No Test

during Year (3f)

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Diabetes Control

• Col (3b): Universe or sample of 70 patients
• Col (3c‐3f) Test Result: Patients in the sample

whose last HBA1c during the reporting year is in the given range

– No test during the reporting year does not meet the measurement standard and is reported in Column 3f

Total Patients with Diabetes (3a) Charts Sampled or EHR Total (3b) Patients with HbA1c <7% (3c) Patients with 7% <= Hba1C <8% (3e) Patients with 8%<= HbA1c <=9% (3e) Patients with HbA1c >9%

• r No Test

during Year (3f)

103

Diabetes Control: 2014 Change

• HbA1c Result categories will be reduced.

– Instead of four categories, there will be only three:

• less than 8%, 8% through 9%, and greater than 9%

– Failure to test will still be lumped with the “greater than 9%” category and considered failure to meet the measurement standard.

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2014 Change: Add Cholesterol Treatment (Lipid Therapy for CAD Patients)

• Universe will be all patients:

– with an active diagnosis of CAD during current or prior year or had a myocardial infarction (MI) or had cardiac surgery AND – Were aged 18 or older on December 31st (born on or before 12/31/1996) AND – last seen after they turned 18 AND – seen at least twice (ever) for medical care AND – had at least one medical visit in a health center clinic during the reporting year

• Meeting measurement standard will be LDL < 100

mg/dl

105

TABLES 8A, 9D, AND 9E:

Financial Profile

106

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Financial Profile Tables

• Cost of delivering services and sources and

amounts of income

– Table 8A: Financial costs – Table 9D: Income from patient services – Table 9E: Other revenues

107

TABLE 8A:

Financial Costs

108

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Table 8A: Financial Costs

• Accrued costs and

allocation of facility and non‐clinical services

• Exclude bad debt
• Include depreciation
• Report donated (“in‐

kind”) costs on line 18, only

109

Table 8A and Table 5 Crosswalk

FTEs Reported on Table 5, Line: Have costs reported

• n Table 8A, Line:

1‐12: Medical providers and clinical support staff 1: Medical Staff 13‐14: Lab and X‐Ray 2: Lab and X‐Ray 16‐18: Dental (e.g., dentists, dental hygienists, etc.) 5: Dental 20a‐20c: Mental Health 6: Mental Health 21: Substance Abuse 7: Substance Abuse 22: Other Professional (e.g., nutritionists, podiatrists, etc.) 9: Other Professional 22a‐22c: Vision Services (ophthalmologist, optometrist, optometric assistant, other vision care) 9a: Vision 23: Pharmacy 8a: Pharmacy 24‐28: Enabling (e.g., case management, outreach, eligibility, etc.) 11a‐11g: Enabling 29a: Other programs/services (e.g., non‐health related services including WIC, job training, housing, child care, etc.) 12: Other related Services 30a‐30c and 32: Non‐clinical Support Services and Patient Support (e.g., corporate, intake, medical records, billing, fiscal, and IT staff) 15: Non‐clinical Support Services 31: Facility (e.g., janitorial staff, etc.) 14: Facility

110

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Table 8A: Lines 1 ‐ 10

• Line 1: Medical care costs

– Medical staff salaries and benefits – Staff dedicated to use or application of EHR QI programs – Staff on contract and contracted visits

• Excludes Ophthalmologists and Psychiatrists
• Line 2: All medical (not dental) lab and x‐ray costs

including supplies, lab staff, etc.

• Line 3: All other direct medical costs including provider

dues, CME, and travel; supplies, depreciation, EHR system, etc.

• Lines 5,6,7,9,&9a: Other clinical services costs

– Personnel (hired or contracted) and all “other” direct expenses for (5) dental, (6) mental health, (7) substance abuse, 9 (other professional) and (9a) vision

111

Table 8A: Lines 8a and 8b

• Pharmacy Costs

– Line 8b ‐ costs of pharmaceuticals, only – Line 8a ‐ all other pharmacy costs including MIS, staff, equipment, non‐pharmaceutical supplies, etc.

• If you cannot separate non‐drug cost from total cost ‐ report all costs on

line 8b

• All pharmacy overhead is on Line 8a col b
• Note: Do not include donated pharmaceuticals on either line. This is shown on

line 18.

11 2

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Table 8A: Lines 11a ‐ 12

• Line 11a‐11g: Enabling
• Line 12: Other program

― Personnel detail (hired

related costs

• r contracted) and all

– Include costs associated with

“other” direct enabling

staff reported on Table 5 Line

expenses

29a as well as other related direct expenses for non‐health‐ care services such as:

• WIC
• Housing Corporations
• Job training
• Head Start /Early Head Start
• Child care
• Adult Day Health Care
• Shelters
• Fitness programs

– Include any “pass through” funds here

113

Table 8A: Lines 14 – 15 Non‐Clinical Support and Facility

• Line 14: Facility costs include rent or depreciation,

mortgage interest payments, utilities, security, janitorial services, maintenance, etc.

– No CIP or FIP costs, but include appropriate depreciation

• Line 15: Non‐clinical support staff costs include costs

for corporate administration, billing and collections, and medical records and intake staff as well as all associated costs including supplies, equipment, depreciation, travel, etc.

114

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Allocation of Facility

• Facility

– Allocate each building separately

• Captures differences in costs per building such as

improvements, donated space, etc.

– Allocate based on proportion of square footage utilized by each cost center or better data if available – Include allocation to “non‐clinical support” for administrations facility costs

115

Allocation of Non‐Clinical Support

• Non‐clinical support staff and costs

– Allocate based on actual use

• E.g. – allocating billing to cost centers that bill, front

desk costs to those services that use the front desk staff for check in, etc.

– Alternative: straight line method, using the proportion of total costs to the service category excluding all Non‐Clinical Support costs and Facility costs – Can use both methods

116

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Test Your Reviewer Skills 4

• How would you check the reasonableness of

costs as they relate to staffing and visits?

117

TABLE 9D:

Patient Related Revenue

118

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Table 9D: Patient Related Revenue

• Cash basis
• Patient revenues are

reported by payor: Medicaid, Medicare, Other public, Private and Self‐Pay

119

Charges

• Full Charges Col(a):

– Undiscounted, unadjusted charges for services based

• n fee schedule; charges should cover costs

– Include all charges (i.e., medical, dental, pharmacy, mental health, etc.). – Do not include “charges” where no collection is attempted or expected such as charges for enabling services, donated pharmaceuticals, or free vaccines.

120

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Collections

• Collections Col(b):

– Report all amounts collected as payments for health services including capitation payments, payments from patients and third party insurance, FQHC reconciliation payments and contract payments (e.g., schools, jails, etc.) received during the year. – Report by payor. – Do not include “meaningful use” payments.

121

Adjustments

• Adjustments Col(c1‐c4):

Note: Adjustments are included in col(b), but do not = col(b). – Columns (c1) and (c2): reconciliation payments for FQHC

• r CHIP‐RA settlements

– Col (c3): “Other Retroactive Payments” including risk pools, incentives, PFP, withholds and court ordered payments – Col (c4): amounts which are returned to third party (report as positive number)

122

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Allowances

• Allowances Col(d):

– Reductions in payment by a third party based on a contract – Allowances do not include:

• non‐payment for services that are not covered by the third party
• r rejected by the 3rd party
• deductibles or co‐payments that are due from the patient and not

paid by a third party

– Reduce allowances by amount of FQHC payments – For capitated plans, col d = col a – col b

123

Sliding Discounts

• Sliding Discounts Col(e):

– A reduction in the amount charged (paid or owed) for services rendered which

• Is based solely on the patient’s documented income

and family size at the time of service as it relates to the federal poverty level

• May be applied to insured patients’ co‐payments,

deductibles and non‐covered services when the charge has been moved to self pay if consistent with how uninsured patients are treated

• May not be applied to past due amounts

124

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Bad Debt

• Bad Debt Col(f):

– Amounts considered to be uncollectable and formally written off during the current calendar year, regardless of when the service was provided – Only self‐pay bad debt is reported, not third party bad debt – Do not report as a “cost” on Table 8A – Bad debt can never be changed to a sliding discount

125

Payors: Medicaid and Medicare

• Lines 1 ‐ 3: Medicaid

– All routine Medicaid – EPSDT – under any name – Medicaid part of Medi‐Medi or crossovers – CHIP, if paid through Medicaid – May also include fees for other state programs which are paid by the Medicaid intermediary

• Lines 4 ‐ 6: Medicare

– All routine Medicare – Medicare Advantage – Medicare portion of Medi‐Medi or crossovers

126

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Payors: Other Public and Private

• Lines 7 ‐ 9: Other Public

― State or other public insurance programs ― Non‐Medicaid CHIP programs ― State‐based programs which cover a specific

service or disease (i.e., BCCCP, Title X, Title V, TB)

― Does not include indigent care programs ― NOTE: Patients who benefit from services paid for

by “other public payers” are not necessarily counted as “other public insurance” on Table 4

• Lines 10 ‐ 12: Private

― Private and commercial insurance ― Medi‐gap programs, Tricare, Workers Comp. etc. ― Contracts with schools, jails, head start, etc. ― NOTE: Patients benefiting from private contracts

may not be insured in these categories on Table 4

127

Payment Types Reported

• Each of the four third‐party payor

categories has three payment types:

– Fee‐for‐service = Payment for each charge (or global fee) on the charge slip / encounter form / bill – Managed care capitated = Payments for each month the patient is enrolled in the program + in public programs, reconciliations to some prospective payment rate (PPS) – Managed care fee‐for‐service = Patient is assigned to doctor or clinic, but payment is only made when a charge is reported. Reconciliation to PPS rates occur in some public programs

128

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Payors: Self Pay

• Line 13: Self Pay

– Charges for which patients are responsible and all associated collections including:

• Full fee patients
• Patients receiving sliding discounts
• “Nominal fee” or “zero‐pay” patients
• Co payments and/or deductibles
• Services not covered by a patient’s insurance
• Services which form or will form the basis for state or

local safety net (uncompensated care) funds

• Dental patients who only have medical insurance

129

Reclassify Charges

• It is essential to reclassify charges which are

unpaid in whole or in part, not including allowances:

– This includes co‐payments and deductibles as well as charges for non‐covered services which are rejected by third parties

• Deduct unpaid charges or portion of charge from original

payor (Medicaid, Medicare, Private, etc.)

• Add to charges on line for self pay or the secondary (tertiary,

etc.) payor

• Show collections of these amounts on the appropriate line

130

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Test Your Reviewer Skills 5

• How would you check the reasonableness of these

table 4 and table 9D numbers?

131

• Do they get your

seal of approval?

TABLE 9E:

Other Revenues

132

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Table 9E: Other Revenues

• Report non‐patient‐service

income.

• Cash basis – amount

received/drawn down during the year

• Report “last party” to

handle funds before you received them.

• Do not include:

– Capital received as loan – Patient‐related revenue – Value of donated services, supplies, or facilities – Donated “community value”

133

Federal Grants

• Line 1: BPHC Grant drawdowns

– Report all funds received directly from BPHC regardless of their end use. – Include funds received from BPHC and passed through to another agency.

• If you do not report activity for grant, report as cost on Table 8A, Line

12

• Line 3: Other Federal Grants

– Report funds received from Federal government grants management system. – Do not report Ryan White – especially part A or part B – here unless you are an entity that receives the funds directly. – Do not include IHS funds for compacted and contracted services received by a tribe and passed through to the clinic.

134

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Other Government Grants

• Line 3a: Medicare and Medicaid EHR Incentive

Payments for Eligible Providers

– Payments made directly to providers and turned

• ver to the health center are also recorded here
• Line 4a: ARRA – CIP

and FIP drawdowns

• Line 6: State Grants ‐ and ‐ Line 7: Local Grants

– Do not include grant funds which pay for units of service

135

Other Revenue Sources

• Line 6a: Indigent Care Programs

– State and local programs that pay for health care in general and are based on a current or prior level of service, or on a fee per visit, but not fee‐for‐service

– Report full charges on Table 9D as self‐pay charges and everything not due from the patient is written off as a sliding discount – Do not include state insurance plans

• Line 8: Foundation / Private Grants
• Line 10: Other Revenues

– Contributions, fund raising income, rents, sales, patient record fees, etc.

136

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11/8/2013 Thank you for attending this training and for all of your hard work to provide comprehensive and accurate data to BPHC!

Ongoing questions can be addressed to UDSHelp330@BPHCDATA.NET 866‐UDS‐HELP

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