Form 8 2012 Health Care Organization Staff Interview Guides

ATTACHMENT I

2012 Health Care PROVIDEr INTERVIEW GUIDEs

• Form Approved

• OMB No: 0935-0190

• Exp. Date 02/28/2015

CHIPRA QUALITY DEMONSTRATION Evaluation

2012 Interview Guide

PARTICIPATING PROVIDERS

Thank you for speaking with us today. In the email we sent confirming this interview, we provided information on who we are, why we’re here, what topics we’re interested in talking about, and we assured you that your responses will be kept confidential. Do you have any questions before we start the interview? If not, may we begin recording the conversation?

If the respondent did not receive or does not remember the confirmation email or if they have questions about the information provided in the email, review the introduction to the study on next page.

• Public reporting burden for this collection of information is estimated to average 45 minutes per response, the estimated time to complete the interview. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attn: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Rd., Rm. 5036, Rockville MD 20850.

Introduction to Study

We are from the Urban Institute and Mathematica Policy Research, and we are part of the team conducting the cross-state evaluation of the CHIPRA Quality Demonstrations. The evaluation is federally funded by the Agency for Healthcare Research and Quality (AHRQ). The Centers for Medicare & Medicaid Services (CMS) provides the demonstration grants to the states.

We are now conducting our first round of visits to the 18 demonstration states. We are meeting with people who are closely involved in the design, management, and day-to-day operations of each state’s demonstration initiatives, as well as other people who care about how the demonstrations affect children’s care quality in Medicaid and CHIP.

We are particularly interested in your thoughts and insights on several topics, including:

1. Your experience to date implementing your state’s quality demonstration.

2. Evidence to date that your strategies may be having the desired impact.

3. Key issues for the coming year.

Our interview will take 45 minutes. Your responses will be kept confidential to the extent permitted by law, including AHRQ’s confidentiality statute, 42 USC 299c-3(c). We will share everyone’s comments with members of the evaluation team and we will report to AHRQ and CMS on the general themes that emerge from all of our discussions. Our reports will list the people we spoke to in each state, but we will not attribute specific comments or quotes to named individuals without permission. We would like to record our discussion in case we miss something in our notes and want to go back and listen. But, we do not plan to transcribe the recording.

Do you have any questions before we start? May I begin recording?

CORE QUESTIONS

I. Introduction/Background

1. What is your role in the [practice/ clinic/ FQHC/ CME/ SBHC], and how long have you worked here? Are you on salary or are you a partner/owner?

2. Besides patient care, what other responsibilities (formal or informal) do you have? For example, do you lead a care team or a committee?

3. Please tell me about this [practice/ clinic/ FQHC/ CME/ SBHC].

   • Who owns this [practice/ clinic/ FQHC/ CME/ SBHC] (if it is not privately owned or free-standing)?

   • Are you a single-specialty or multi-specialty group? If single-specialty, what is that specialty (e.g., pediatric, family practice)?

   • About how many clinicians work here?

   • How many pediatric patients overall does your [practice/ clinic/ FQHC/ CME/ SBHC] see? How about Medicaid/CHIPRA?

• What is the predominant way your [practice/ clinic/ FQHC/ CME/ SBHC] is paid? For example, is it discounted fee-for-service plus some case management fees, or perhaps partial capitation?

4. What are your responsibilities in connection with the state’s CHIPRA quality demonstration grant?

5. In your own words, describe the major goals of theCHIPRA quality demonstration in your state over the next 4 years.

• What did the state, and participating providers like you, hope to achieve in the first year of the project (since December 2010)?

II. Provider Context

1. What type of health information technology, or “health IT,” did your [practice/ clinic/ FQHC/ CME/ SBHC] have in place before this demonstration began?

• Do you use an electronic health record (EHR)?

• What functions does it have or support?

• Electronic prescribing?

• Disease registries?

• Clinical decision support?

• Ordering and/or viewing lab tests electronically?

• Providing standard order sets for a particular condition or procedure?

• Displaying quality measure performance?

• Electronic reporting to immunization registries?

• Exchanging emails with patients?

• Providing patients with clinical summaries for each visit?

2. Was your [practice/ clinic/ FQHC/ CME/ SBHC] engaged in any pediatric medical home efforts before you began implementing activities under this demonstration? If so, what were they?

3. What quality measure reporting efforts, if any, was your [practice/ clinic/ FQHC/ CME/ SBHC] engaged in before this CHIPRA demonstration began?

• For what measures (if any) were you reporting on, and to whom?

• Were you just reporting on these measures, or also getting performance reports back and using these results to change the way you deliver care?

4. Besides the CHIPRA Quality Demonstration, is your [practice/ clinic/ FQHC/ CME/ SBHC] currently participating in other major initiatives related to quality measures, using health IT, or medical homes? (These could be efforts led by the state, Medicaid MCOs, private payers or plans, professional associations, or some other group.)

III. Strategies

Cross-Category

1. Why did your [practice/ clinic/ FQHC/ CME/ SBHC] decide to participate in this [quality demonstration]?

2. In your own words, how would you describe what your [practice/ clinic/ FQHC/ CME/ SBHC] is doing as part of this CHIPRA quality demonstration?

Probe as appropriate:

• What new quality measures are you reporting? What systems or methods are you using to report them?

• What new health IT tools are you adopting?

• What changes are you making to the way you deliver care?

• Are you participating in a learning collaborative? Can you tell us about it?

• Are you educating patients about the changes you’re making and what roles and responsibilities you want them to take on?

1. What type of compensation, or changes in how you are paid, are being implemented by your state’s Medicaid [program / MCO(s)] as part of this demonstration, if any?

2. For your own [practice/ clinic/ FQHC/ CME/ SBHC] -- how has implementation of this project gone to date?

   • What has gone well?

   • What has gone less well?

3. How has [the state/this learning collaborative] helped your [practice/ clinic/ FQHC/ CME/ SBHC]? What has been less helpful or could they do better?

4. To date, what are the costs and benefits to you and your [practice/ clinic/ FQHC/ CME/ SBHC] of participating in this CHIPRA demonstration?

5. Are you aware of involvement from provider associations or other stakeholder groups in your state in the planning and implementation of this project?

Provider-Based Initiatives (Category C) [moved up]

[NOTE: Use category C module if state has a category C project]

1. Returning to one of our earlier questions, could you please elaborate on what specific changes you will be making to how your [practice/ clinic/ FQHC/ CME/ SBHC] delivers care as part of this demonstration (for example, to increase your “medical homeness”)?

   • Will you be hiring or working with new staff?

2. As you make these changes to your [practice/ clinic/ FQHC/ CME/ SBHC], what has gone relatively well? What challenges have you experienced as you try to make these changes?

3. To what extent have your patients and their families been made aware of the new care delivery model you are implementing (e.g., the medical home model) and the specific changes you are making to your [practice/ clinic/ FQHC/ CME/ SBHC]?

   • How were they made aware of this?

Quality Measurement Initiatives (Category A)

[NOTE: Use category A module if state has a category A project.]

1. What quality measures is your [practice/ clinic/ FQHC/ CME/ SBHC] being asked to collect and report on as part of this CHIPRA-funded demonstration?

• When [did/will] you start reporting on these quality measures?

• How often are you being asked to report this quality measure data?

• What changes, if any, are you making to your data infrastructure or reporting systems to facilitate reporting these new measures?

• Have these measures been added to previously-required measures? Have they replaced some measures or displaced other quality measurement activities?

1. [If facility has an EHR]: Are data from your EHR system being used to populate some or all of the new CHIPRA quality measures being submitted by your [practice/ clinic/ FQHC/ CME/ SBHC] to the state?

   • Please describe your experience in using EHRs to collect and report quality measures.

   • Did you have to make any changes to your EHR or how you interact with your EHR (hardware, software, staffing, workflow)?

   • What do you see as the pros and cons of using EHRs to collect the data?

2. [If no EHR]: Please briefly describe how you collect and report quality measure data without an EHR.

B. Health IT Initiatives (Category B)

[NOTE: Use category B module if state has a category B project.]

1. What new health IT programs, systems, or networks are being implemented that you will use?

• How far along are the entities that are responsible for implementing these systems?

• What have been the barriers to, or facilitators of, implementing these systems?

2. How is your [practice/ clinic/ FQHC/ CME/ SBHC] changing the way it delivers care as a result of using these new health IT tools, if at all at this stage?

• What features of [the new health IT tool or system] work best to improve clinical care?

• Are the data in [the new health IT tool or system] accurate and complete enough to use them for their intended purpose?

3. How is participation in this demonstration affecting your ability to qualify for Medicare and Medicaid incentive payments for “meaningfully using” health IT?

   • When do you think your [practice/ clinic/ FQHC/ CME/ SBHC] will meet the requirements to qualify as a “meaningful user” of health IT?

IV. Lessons Learned

1. In general, what are the biggest issues your [practice/ clinic/ FQHC/ CME/ SBHC] has encountered in [reporting the new quality measures / using the new health IT tool / increasing your “medical homeness” / changing the way you deliver care / etc.]?

2. What do you think has gone smoothly so far, in implementing these projects?

3. Given your early experience, what are the biggest insights or pieces of advice you might have for other [practices/ clinics/ FQHCs/ CMEs/ SBHCs] implementing similar types of activities?

4. What are your [practice’s/clinic’s/FQHC’s/SBHC’s/CME’s] goals and plans for the coming year related to the CHIPRA quality demonstration?

5. As you continue to implement these projects in the coming year, what do you see as the most critical factors that will determine your success?

Thank you very much for making time to speak with us.

SUPPLEMENTAL QUESTIONS

Interviewer: Select the most relevant questions as time permits.

1. How would you characterize your [practice/ clinic/ FQHC/ CME/ SBHC]?

   • [If information not already available]: When was it started?

   • Who currently owns it? What other providers are affiliated with it, if any?

   • How many clinicians are part of it?

   • Roughly how many patients are part of your [practice/ clinic/ FQHC/ CME/ SBHC]’s panel?

   • In terms of payer mix, what percent of your patients are insured through Medicaid/CHIP?

   • What are the characteristics of the Medicaid/CHIP patients you generally serve, in terms of race/ethnicity, level of poverty, language(s) spoken, etc.?

   • What is the predominant way your [practice/ clinic/ FQHC/ CME/ SBHC] is paid? For example, is it discounted fee-for-service plus some case management fees, or perhaps partial capitation?

   • To what extent do various payers reward you for improving quality and/or holding down costs? Conversely, are there any risks for poor performance on quality or cost?

2. In what ways is your [practice/ clinic/ FQHC/ CME/ SBHC] similar or different from other child-serving health care facilities in your state?

• Does your [practice/ clinic/ FQHC/ CME/ SBHC] have a unique history or culture?

• Is it independently owned or affiliated?

• Is it smaller or larger than the typical child-serving health care facility in your state?

• Is it more or less specialized than these other facilities?

• Is it located in a more urban or more rural area than these other health care facilities?

• Do you see a higher or lower percentage of Medicaid or CHIP patients?

• Are the demographics of your patients different from those of the typical child-serving health care facility in your state? Do you see more or less children with special health care needs?

3. How did your [practice/ clinic/ FQHC/ CME/ SBHC] coordinate care with other health care providers that were seeing your patients before you began implementing activities under this demonstration?

• How did you send and receive patient records? (e.g., by mail? fax? email? electronic health records? hard copies conveyed to other providers through patients?)

• Now that you are beginning to implement activities under this demonstration, has this changed?

• Similarly, how did you communicate with other providers – particularly specialists – before or after they saw one of your patients on a referral? (e.g., by mail? fax? email? electronic health records? hard copies conveyed to other providers through patients?)

• Has this changed?

• How did you find out if one of your patients has been seen in the local hospital? (e.g., from the patient telling you during a visit afterward? from the hospital notifying you about this?)

  1. Has this changed?

4. What kinds of information on pediatric patients enrolled in Medicaid/CHIP do you typically receive from your state's Medicaid [program / MCO(s)]?

• Do you receive basic demographic information for these patients? Any data on their utilization or cost? Any quality information? Other?

• How up-to-date is it? How often do you receive it or is it updated?

• What would make it more useful?

5. To what extent do you feel your [practice/ clinic/ FQHC/ CME/ SBHC] has the infrastructure in place to measure the impact on care quality and patient outcomes of the changes you are making?

6. Since you started implementing activities under the CHIPRA grant, have there been any major changes in your local market, region, or state that will affect your ability to implement the CHIPRA quality demonstration? If so, briefly describe them.

7. What relationship, if any, is there between these new activities that you are pursuing under this CHIPRA demonstration?

• In your [practice/ clinic/ FQHC/ CME/ SBHC], do you think these various activities are interdependent or are they independent of each other?

• How are you using your new health IT tools to support quality measurement?

• How are you using your new health IT tools to support changes in the way you deliver care?

• How are you using quality measures to support changes to the way you deliver care?

• How integrated or independent do you think the state sees these activities as being?

8. So far, how has participating in this demonstration changed the way you deliver care, if at all? Please describe.

• When do you anticipate or hope so see improvements in care quality and patient outcomes?

9. Which staff members of your [practice/ clinic/ FQHC/ CME/ SBHC] have been involved in this demonstration, and what roles have they played?

• To what extent do you or your colleagues have previous knowledge, skills, or experience that has helped you effectively implement the various activities that are part of this demonstration? (e.g., related to medical homes, other quality improvement approaches, health IT, quality measure development, etc.)

10. Moving ahead, how confident are you in your ability to implement the desired changes at your [practice/ clinic/ FQHC/ CME/ SBHC]?

• What will facilitate making these changes?

• What barriers do you think might make it harder to make these changes?

11. Are you aware of any major changes your state's Medicaid [program/ MCO(s)] have made to their implementation plans so far? If so, what changes?

• What caused them to make these changes?

• Has implementation proceeded as planned?

• What has gone well and what has gone less well?

12. How does your state's Medicaid [program/ MCO(s)] monitor implementation of your projects under this demonstration?

• How is your own [practice/ clinic/ FQHC/ CME/ SBHC] monitoring its progress?

4. In your own words, what do you think is the goal of the quality measurement component of the CHIPRA quality demonstration?

5. To date, which measures, have you been unable to collect and report on?

   • What specific obstacles have you encountered in collecting and reporting on these measures?

   • What might help you overcome these obstacles?

6. Has the state provided you with any technical assistance to help with reporting on these new quality measures? If so, please describe.

   • How helpful has this assistance been? In what way could it be improved?

7. Have you received any technical assistance in addition to the help received through this demonstration? If so, please describe.

   • Who is providing this assistance? How is it funded?

   • How helpful has this assistance been?

8. From talking to other [practices/ clinics/ FQHCs/ CMEs/ SBHCs] participating in this demonstration, do you think your [practice’s/ clinic’s/ FQHC’s/ CME’s/ SBHC’s] experience with reporting these measures has been similar or different from other [practice/ clinic/ FQHC/ CME/ SBHC]'s experiences? How so?

9. Have you integrated reporting for these new measures with other quality measure reporting activities? If so, how?How is measure data collection and reporting going?

   • What has been your experience collecting the data for these new measures to date?

   • Which measures [have been / do you anticipate being] relatively easy to collect and report on?

   • How difficult or burdensome are they?

   • How useful are they in your view?

• To benchmark your [practice/ clinic/ FQHC/ CME/ SBHC] against other [practices/ clinics/ FQHCs/ CMEs/ SBHCs]?

• To identify areas for improvement?

10. Are data from your EHR system being used to populate any kinds of registries? If so, what kinds of registries?

11. [If no EHR]: Please briefly describe how you collect and report quality measure data without an EHR.

12. As part of the quality measurement component of this CHIPRA demonstration, what information [is / will] your state’s Medicaid [program/ MCO(s)] be providing you with on your Medicaid/CHIP patients?

13. How is your [practice/ clinic/ FQHC/ CME/ SBHC] using new CHIPRA quality measure data that are being fed back to you from the state, if at all at this stage?

    • What are your plans for using them in the future?

    • As far as you know, how are other intervention [practices/ clinics/ FQHCs/ CMEs/ SBHCs] using new CHIPRA quality measure data, it at all at this stage?

4. In your own words, what do you think is the goal of the health IT component of the CHIPRA quality demonstration?

• What is the “information” in your health information technology project—in other words, what type of information will be communicated or captured more readily once your project is implemented?

• For what purpose will the information be communicated or captured? To reduce error or redundancy, to increase coordination or continuity

5. What hardware or software are you adopting as part of this initiative, if any?

• What functionality does this new software possess? (What does it do?)

• What systems are being electronically connected? Is information being reported from one system to another, or is two-way exchange of information happening?

• How much will it cost your [practice/ clinic/ FQHC/ CME/ SBHC] to make these data infrastructure changes?

6. At what stage is your [practice/ clinic/ FQHC/ CME/ SBHC] in implementing these new health IT tools?

• What has gone well?

• What has gone less well? Probe as needed on technical difficulties, privacy and security concerns, work flow issues, and cost overruns.

7. Has the state provided you with any technical assistance to help with implementing new health IT tools? If so, please describe.

• How helpful has this assistance been? In what way could it be improved?

8. Have you received any technical assistance in addition to the help received through this demonstration? If so, please describe.

• Who is providing this assistance? How is it funded?

• How helpful has this assistance been?

9. What changes are being made to existing health IT networks, systems, or programs as part of the state's health IT intervention under this CHIPRA grant?

• How far along are the entities responsible for making these changes?

• What have been the barriers to, or facilitators of, making these changes?

10. Are providers at your [practice/clinic/FQHC/CME/SBHC] using the new health IT tools and/or systems routinely?

    • If not, what issues do you view as most important to increasing the use of the new tools/system?

11. How easy or hard has your [practice/ clinic/ FQHC/ CME/ SBHC] found it to use the new health IT tools or systems?

• Which of the health IT tools or systems are causing you problems? Are you encountering bugs or technical glitches?

12. Has the state provided you with any technical assistance to help with using the new health IT tools? If so, please describe.

• How helpful has this assistance been? In what way could it be improved?

13. Have you received any technical assistance in addition to the help received through this demonstration? If so, please describe.

• Who is providing this assistance? How is it funded?

• How helpful has this assistance been?

14. How are these health IT tools changing the roles and responsibilities of clinicians and staff in your [practice/ clinic/ FQHC/ CME/ SBHC]?

15. What have been patients’ and families’ reactions to your [practice/ clinic/ FQHC/ CME/ SBHC]’s use of the new health IT tool or system?

16. If there is a patient-facing component to the new health IT tool(s) or system(s) you are implementing, are your patients actually using this?

    • Roughly what share of your Medicaid/CHIP patients are using this?

    • What do they use [the new health IT tool(s) or system(s)] to do?

    • What kind of feedback do you hear from your patients about this [tool / system] in terms of its usefulness and user-friendliness?

    • Do you think patients are making more informed decisions about their care as a result of having access to this [tool / system]? What evidence do you have?

17. In your [practice/ clinic/ FQHC/ CME/ SBHC], who enters data into the [name of any new health IT tool(s) being implemented under the CHIPRA grant]?

    • How has the [new health IT tool] affected the efficiency of your [practice/ clinic/ FQHC/ CME/ SBHC]?

18. How are these health IT tools helping with the pediatric quality measure reporting?

4. In your own words, what do you think is the goal of the [medical home / Care Management Entity / School-Based Health Center] component of the CHIPRA quality demonstration?

5. Which of these changes has your [practice/ clinic/ FQHC/ CME/ SBHC] made so far?

6. Has the state provided you with any technical assistance to help you make changes to your practice? If so, please describe.

• How helpful has this assistance been? In what way could it be improved?

7. Have you received any technical assistance in addition to the help received through this demonstration? If so, please describe.

• Who is providing this assistance? How is it funded?

• How helpful has this assistance been?

8. What will you be focusing on next?

   • What do you anticipate will help or hinder your [practice/ clinic/ FQHC/ CME/ SBHC] in making these changes?

9. What have been patients’ and families’ reactions to the changes you have made to your [practice/ clinic/ FQHC/ CME/ SBHC] to date?

1. Could you describe for us what your involvement has been in [the state-specific Category E activity]?

• What specific activities will you be engaged in as part of this activity?

• What activities have you completed as part of this initiative so far?

  • Have you encountered any difficulties associated with implementing these activities? What were they? How did you get around these difficulties?

• [If applicable]: What technical assistance have you received related to this activity, and from whom?

• What will you be focusing on next?

  • What do you anticipate will help or hinder your [practice/ clinic/ FQHC/ CME/ SBHC] in making these changes?

Learning Collaboratives

1. Do you participate in [name of the learning collaborative in this state] activities?

   • If so, which ones so far?

     • Have you participated in in-person meeting(s)? Conference calls? Webinars? Email conversations? Have you read any documents produced by them?

   • On a scale of 1 to 5, how would you rate your [practice's/ clinic's/ FQHC's/ CME's/ SBHC's] level of participation in [name of the learning collaborative in this state] activities, where 1 is “not active at all” and 5 is “very active”?

2. As part of these [name of state's learning collaborative] activities, what topics have been presented or discussed, so far?

3. What are your thoughts on the usefulness of the [name of state's learning collaborative]?

   • What do you feel are its strengths?

   • What do you feel are its weaknesses?

   • How could it be improved?

4. What changes has your [practice/ clinic/ FQHC/ CME/ SBHC] made as a result of participation in the [name of state's learning collaborative], activities / interactions with the [practice coaches / medical home coordinators] you are working with, or other forms of assistance available through this CHIPRA quality demonstration?

   • Have these changes improved care? In what way?

     • How have they affected the quality of care?

     • How have they affected your patients’ outcomes?

     • How have they affected your [practice/ clinic/ FQHC/ CME/ SBHC]’s efficiency?

5. What other learning collaboratives or professional development activities do you participate in? What entities sponsor these activities (e.g., the state Medicaid program or MCO(s), the local AAP chapter, HRSA, a local research or quality improvement network)?

6. At this point in the project, how optimistic are you that the changes you are making to your [practice/ clinic/ FQHC/ CME/ SBHC] will translate into positive impacts on patients’ care? Please explain.

7. To your knowledge, what are the state’s goals for the CHIPRA quality demonstration in the coming year?