Quality Data Initiative (QDI)

The Quality Data Initiative (QDI) is a quality reporting process braided with current and emerging best practice learnings. QDI is designed to leverage existing best practices at Montana health centers and enable the replication of these best practices at other centers across the state. The goal of QDI is to improve clinical outcomes in all health centers.

Key Components:

Monthly data reporting of the nine core measures: Diabetes Management, Colorectal Cancer Screening, Cervical Cancer Screening, Breast Cancer Screening, Depression Screening and Follow-Up, Hypertension Control, Screening for Social Drivers of Health, and Number of Patients Receiving MOUD for Opioid Use Disorder.
Monthly workgroup learning calls which include data review of the past month’s data reporting and a multidisciplinary call that explores a different topic each month.

QDI Data is self-reported by clinics monthly. As the Azara project develops, we will work to validate the accuracy of the QDI/Azara data. All health centers participate in the Quality Data Initiative. Health centers that are not included in the data below either have not consented to have their data shared or missed the monthly data reporting deadline.

Cervical Cancer

Percentage of women 21–64 years of age who were screened for cervical cancer using either of the following criteria:

Women age 21-64 who had cervical cytology performed every 3 years.
Women age 30-64 who had cervical cytology/human papillomavirus (HPV) cotesting performed every 5 years.

Denominator: Women 23 through 64 years of age with a medical visit during the measurement period.
Numerator: Women with one or more screenings for cervical cancer. Appropriate screenings are defined by any one of the following criteria:

Cervical cytology performed during the measurement period or the 2 years prior to the measurement period for women who are at least 21 years old at the time of the test.
Cervical cytology/HPV co-testing performed during the measurement period or the 4 years prior to the measurement period for women who are at least 30 years old at the time of the test.

QDI 2023 Statewide Goal: 65%

Diabetes

Diabetes Management: Hemoglobin A1c (HbA1c) Poor Control (>9 percent) (CMS122v7)
Percentage of patients 18–75 years of age with diabetes who had hemoglobin A1c (HbA1c) greater than 9.0 percent during the measurement period.

Denominator: Patients 18 through 75 years of age with diabetes with a medical visit during the measurement period.
Numerator: Patients whose most recent HbA1c level performed during the measurement year is greater than 9.0 percent and patients who had no test conducted during the measurement period.

QDI 2023 Statewide Goal: 15%

Colorectal Cancer

Colorectal Cancer Screening (CMS130v7)
Percentage of adults 50–75 years of age who had appropriate screening for colorectal cancer.

Denominator: Patients 50 through 75 years of age with a medical visit during the measurement period.
Numerator: Patients with one or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the following criteria:

Fecal occult blood test (FOBT) during the measurement period.
Fecal immunochemical test (FIT)- deoxyribonucleic acid (DNA) during the measurement period or the 2 years prior to the measurement period.
Flexible sigmoidoscopy during the measurement period or the 4 years prior to the measurement period.
Computerized tomography (CT) colonography during the measurement period or the 4 years prior to the measurement period.
Colonoscopy during the measurement period or the 9 years prior to the measurement period.

QDI 2023 Statewide Goal: 55%

Colorectal Cancer FIT Kit Resources.

Breast Cancer

Depression Screening and Follow-up

Depression Screening and Follow-up (CMS 2v9)
Patients aged 12 years and older screened for depression on the date of the qualifying encounter or 14 days prior to the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the qualifying encounter.

Denominator:

All patients aged 12 years and older at the beginning of the measurement period with at least one eligible encounter during the measurement period.

Age >= 12 at the start of the measurement period.
Measure qualifying visit in the last 12 months (See value set tab and technical specifications for qualifying visit codes).

Numerator:

Patients screened for depression on the date of a qualifying encounter or 14 days prior to the date of a qualifying encounter using an age appropriate standardized depression screening tool AND if positive, a follow up plan is documented at the qualifying encounter.

Standardized depression screening in the last 12 months at, or within 14 days of, a qualifying encounter.*
- Negative Depression Screening Result (PHQ-2 < 3 or PHQ-9 < 10 or negative result from a standardized screening tool) in the last 12 months.

Positive Depression Screening Result (PHQ-2 >= 3 or PHQ-9 >= 10 or positive result from a standardized screening tool) in the last 12 months.

AND

Follow-up at a qualifying depression screening encounter must include one or more of the following:
- Additional evaluation for depression such as: psychiatric interview, psychiatric evaluation, or assessment for bipolar disorder.
- Suicide Risk Assessment.
- Referral to a practitioner who is qualified to diagnose and treat depression.
- Pharmacological interventions (prescription of medication).
- Other interventions or follow-up for the diagnosis or treatment of depression, e.g. depression self-management.

*This measure looks for the most recent depression screening, which is defined as a depression screening at or within 14 days of a qualifying encounter. Depression screenings that are conducted at a non-qualifying encounter and are not performed within 14 days of a qualifying encounter are not counted toward this measure and have no impact on the numerator compliance of a patient.

QDI 2023 Statewide Goal: 80%

MOUD Patients and Providers

Cancer Survivorship Resources

Cancer Survivorship Webinar Series

March 18, 2021 – Financial Toxicity and Cancer | Slides | Recording
April 15, 2021 – Health Insurance Needs of Cancer Survivors | Recording
May 20, 2021 – Addressing Needs Missed During COVID | Recording
June 17, 2021 – Tobacco Use and Treatment Among Cancer Survivors | Slides | Recording
July 15, 2021 – Suicidality Among Cancer Survivors | Slides | Recording

Narrative Medicine

Narrative Medicine
Using Narrative Medicine for Care Team Resilience and Patient Engagement Webinar Recording
Flexibility among health care workers is a critical part of patient engagement. This previously recorded Regional Chronic Disease Collaborative event helps viewers learn strategies to help stay present and compassionate in a time of crisis and learn about using Narrative Medicine – a story that can be analyzed for meaning – as a groundwork for patient engagement. Presenters and participants shared ways to help recognize your own needs and increase the skills needed to set an environment for sharing stories that support care team flexibility and that are foundational to authentic patient engagement. This recording and presentation is made possible by the Regional Chronic Disease Collaborative, whose partners include Mountain-Pacific Quality Health, American Heart Association, Montana Primary Care Association, Montana Department of Health and Human Services, Hawaii State Department of Health, State of Alaska Department of Health and Social Services, Alaska Primary Care Associations, and the Wyoming Department of Health.

Resources

Mountain West HPV Project Resources:

National Association of Community Health Centers Transforming Care Resources:

NACHC Value Transformation Framework Action Guide

Care management services are an essential population health service under value-based care. Health centers are in a position to offer care management services to a wide range of people who have higher risks for some of the most common chronic conditions. Many of these patients clinically qualify for, and would benefit from, care management. This guide and companion set of Reimbursement Tips (below) are designed to support health centers in the process of establishing and obtaining reimbursement for care management and virtual communication services.

NACHC Payment Reimbursement Tips: FQHC Requirements for CMS Virtual Communication Services (VCS)

Virtual Communication Services (VCSJ support providers who engage in “virtual check-ins” via telephone or evaluate and interpret images/audio submitted by patients for over five (5) minutes for condition(s) unrelated to recent visits and that do not result in an immediate visit.

NACHC Payment Reimbursement Tips: FQHC Requirements for Medicare Chronic Care Management (CCM)

The Chronic Care Management (CCM) model of care refers to personalized and supportive services for individuals with multiple (two or more) chronic conditions to coordinate care and develop a care plan to achieve health goals.

Breast Cancer Awareness Month Toolkit