• Access to Care and Health-Related Social Needs QI Application

  • Format: (000) 000-0000.

  • Chronic Disease Quality Improvement Project Information

    Eligibility

    All applicants must employ or partner with primary care providers (MD, DO, PA, and/or NP) and currently have an operational ambulatory electronic health record (EHR). Eligible facilities include, but are not limited to, Tribal Health Clinics, Rural Health Clinics, Community Health Centers, hospitals, school-based health clinics, local public health departments, and primary care clinics in Montana. 

    Award amount

    Each awarded facility is eligible to complete up to two projects per grant period which can last from 12 to 18-months, depending on which project you choose to participate in. Please see the project selection portion of this application for specific award amounts. Awards will be given contingent on availability of grant funding.

    Deadlines

    Some projects have specific application deadlines, depending on the focus and funding source. Please see the attached table for current application deadlines. Once an application in received, the site will undergo the readiness process and discuss next steps. Please submit no more than one application per facility.

    All project deliverables must be completed by the agreed-upon end of the project, within 12 to 18 months from the start. 

    Deliverables and Payment 

    All projects, besides the social-related needs training, will have an interim/ baseline report, and a final report, templates are provided by DPHHS, and the due dates of these deliverables will be based off the awarded date. Upon completion of these deliverables, the site will invoice DPHHS in two intervales, one for completion of the interim report and one for completion of the final report.  

    For the social-related needs training, only one deliverable will be due to DPHHS upon completion of the project, and the site will invoice DPHHS subsequently.  

    Use of Funds

    The sub-award funds may be used to develop/enhance a chronic disease registry; cover staff time toward implementing and evaluating the QI project; or train clinical staff on effectively using the EHR for reporting, setting up alerts in the EHR, and providing decision supports. 

     NOTE: Funds may not be used for 1) providing direct patient care; 2) purchasing food; 3) purchasing equipment; 4) lobbying or political activities.  

  • 1. Does your organization have staff who work in a clinic or community pharmacy setting in Montana and can implement this project in person?*
  • 2. What chronic disease-related QI project are you interested in?*
  • If choosing the cardiovascular health-related social needs project, does your organization provide services in the higher priority areas (Tier 1 or Tier 2) depicted in the map at www.montanacardiovascular.mt.gov?
  • 3. Are you familiar with using a PDSA for quality improvement?*
  • 4. Have you already conducted a chronic disease-related quality improvement project?*
  • 6. Have you already conducted a quality improvement project related to addressing social needs?*
  • 8. Are you able to get current and historical data from your EHR for clinical quality measures (CMS/NQF/MIPS/UDS, etc.) or other required data for the corresponding chronic disease you are selecting below? (see details on this clinical quality measure here: https://ecqi.healthit.gov/ep-ec?qt-tabs_ep=1)*
  • 10. Do you administer a social determinant of health (SDOH) screener to your patients outside of the Medicare Annual Wellness questionnaire?*
  • 11. Do you document SDOH data in your EHR?*
  • 12. Does your EHR have the ability to track, analyze, report, and utilize this data to address access to care encountered by your patient population?*
  • 13. Are you and your staff willing to participate in staff training related to the grant that you are applying for? This could be health-related social needs training, asthma and spirometry training, implicit bias and cultural competency training, training related to use of a retinopathy camera, or other relevant training.*
  • 14. Are you able to identify populations of patients within your EHR? This includes: people living with disabilities, veterans, American Indians/ Alaska Natives, patients on Medicaid, patients on Medicare, low-income, older adults, and patients living in rural/ frontier areas?*
  • 15. Are you able to identify specific patient populations through your EHR based on diagnoses and chronic disease conditions including patients with a diagnosis of asthma, diabetes, hypertension, hyperlipidemia, chronic kidney disease, and diabetes-related retinopathy?*
  • 16. Are you able to track outgoing and incoming referrals in your EHR?*
  • 16. Are you able to track outgoing and incoming referrals in your EHR?*

  • Staffing

  • 17. Do you have provider and medical director support for this project?*
  • 18. If your clinic receives a sub-award and the lead staff person on the project is unable to continue working on the project, do you have a transition plan to assign another person as the lead?*

  • Electronic Health Record Information

  • 19. Which of the following EHR functions does your clinic use for chronic disease management? (check all that apply)*
  • 21. Do you have a system outside of your EHR that you are utilizing for patient referrals?*

  • Application Attestation

  • I attest that all the above information is correct and that if my facility receives this award, I will complete the project and deliverables as outlined in this application by the applicable timeframe they are due. I understand Montana Chronic Disease Prevention and Health Promotion Bureau’s responsibilities in the Quality Improvement Project, and the deliverables and responsibilities of the health system applying for the project. 

  • Thank you!

  • Thank you for applying for the Health Improvement Quality Improvement Project! Upon review of this application, DPHHS will send out a readiness questionnaire for sites to fill out detailing the required data elements and next steps. If sites do not qualify, they will receive correspondence from DPHHS stating this. 

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