Small Health Care Provider Quality Improvement Grant: A Cultural Shift in Quality for Providers

by Zachary Toliver

The Northeast Oregon Network, located in Wallowa County, had sought for years to increase healthy behavior in their small, geographically isolated, and aging frontier community.

"There wasn't any readily accessible help and support for motivation, patient activation, and persistence of lifestyle behavior change," stated the Network's Executive Director, Lisa Ladendorff.

There wasn't any readily accessible help and support for motivation, patient activation, and persistence of lifestyle behavior change.

The network applied for, and received, a Small Health Care Provider Quality Improvement grant through the Federal Office of Rural Health Policy (FORHP). They are using the grant funds to create a Patient Activation Project that places master's-level mental health counselors in primary care settings. These counselors are trained as health coaches and work with patients to support lifestyle behavior changes. The goal is to help patients better manage chronic diseases, such as diabetes and cardiovascular disease.

Since the project's launch in 2013, the network has succeeded in lowering hemoglobin A1C levels to under 8 percent in 70 percent of the diabetic population. In addition, the network has seen body mass index (BMI) drop among patients.

Building a Quality Program

FORHP first funded the Small Health Care Provider Quality Improvement Grant Program in 2006. What started as a two-year pilot program has evolved into a significant funding resource supporting numerous rural programs across the nation. Every three years, the Quality Grant Program funds rural organizations that seek to improve the quality of care for their patients and communities. This year, $4 million will be available through FORHP to fund approximately 20 programs. While the projects funded have differed in their creative approaches to improving rural health, they all share a common objective. The Quality Grant Program promotes coordinated care and the development of an evidence-based culture in the primary care setting. This includes improved health outcomes for patients, enhanced chronic disease management, and better engagement of patients and their caregivers.

Over a three-year period, grantees implement an evidence-based quality improvement model to improve the health of a chosen population. Previous recipients have addressed a variety of different health issues, but regardless of the focus, the best projects have similar traits.

"FORHP has found that the most effective projects funded through this program contain common elements," stated Ann Ferrero, Program Coordinator for the Small Health Care Provider Quality Improvement Grant Program. "Some things we see in successful programs include care coordination, using multidisciplinary teams, participating in payment programs, and integrating the social determinants of health into the project."

Ferrero also noted that collaboration, and the ability to collect, report, and use data for quality improvement, were signs of effective project models. Grant recipients are required to implement health information technology (HIT) by year 1 of the program. This ensures that the data is available for observing health care quality and costs. She added that "the program emphasizes collection and reporting of clinical data to show improvement in patient outcomes."

Encouraging Collaboration and Promoting Sustainability

While the Quality Grant Program does not require applicants to form consortia or networks, "organizations are encouraged to work together as the health care system becomes increasingly collaborative," Ferrero said.

For example, nearby Winding Waters Clinic and the Wallowa Valley Center for Wellness partnered with the Northeast Oregon Health Network to form a consortium that now coordinates three systems to manage population health.

We're actually pulling data from the electronic health record in real time to measure our progress. That's a huge accomplishment that took a ton of work that wouldn't have happened without the grant.

"We now have the quality assurance infrastructure needed to mount three different systems, which has really added to the program's sustainability. We're actually pulling data from the electronic health record in real time to measure our progress. That's a huge accomplishment that took a ton of work that wouldn't have happened without the grant," stated Ladendorff.

The program also encourages grantees to plan for sustainability from day one.

"A lot of the time, the initiative goes away once the grant goes away" said Helen Royal, Behavioral Health and Quality Improvement Director of the Summit Community Care Clinic (SCCC), a current grantee. "In such a small center, no one had the time to measure PDSA [Plan, Do, Study, Act] cycles or program changes."

Since becoming a grantee, this has changed for SCCC, which went from struggling to finish quality reports to hiring a full-time quality assurance department. By adding a quality manager and data coordinator, SCCC now attaches quality to every aspect of what the organization does. Rather than focusing on a specific program or population, the SCCC's approach to quality improvement assisted with a cultural shift and overall sustainability of new habits.

"Anything we do, we can now look at it to see if it can be done better and we can do that in a more systematic way. We give feedback to staff and share observations with our community members," said Royal.

The Northeast Oregon Network saw similar results in sustainability. Ladendorff stated that some project initiatives created with the grant may have happened on their own, but not with the same emphasis on quality improvement.

"I think mental health would have been provided in the primary care setting. However, I don't think those mental health services would have made the transition to health coaching. I don't think we would have seen integration between the behaviorist and the RN Care Manager, which has been a huge success in this project," said Ladendorff. "We definitely would not have seen the application of the quality improvement techniques and its growth at the clinic site. We would not have seen the data and analytics change."

Looking Ahead

This year, several changes have been made to the program, such as recognizing the U.S. Department of Health and Human Services (HHS) Delivery System Reform initiative. HHS constructed the reforms as a part of the larger transitioning of health care systems to a value and quality-driven system. In addition, FORHP is asking grantees to demonstrate an improvement in health status, and show a reduction in emergency department visits due to chronic disease.

Learn more about the Small Health Care Provider Quality Improvement Grant Program in RHIhub's Funding and Opportunities.