Key Lessons from the National Evaluation of the CHIPRA Quality Demonstration Grant Program

Transforming service delivery to promote quality of care

Program objectives

CMS asked States to develop projects that would test new or improved provider-based models for providing health care services to children and their families. Fourteen States fielded projects in this topic area,7 examining service delivery models in settings such as pediatric and family practices and school-based health centers (SBHCs).   

State strategies

To accomplish their objectives, these demonstration States used varying combinations of the following strategies:

  • Learning collaboratives, including group instruction with peer-to-peer learning opportunities, in-person meetings, and web-based learning sessions.
  • Intensive one-on-one support (such as technical assistance or practice facilitation) to help practices and SBHCs develop QI teams, identify QI activities, collect and analyze data (including from EHRs) to track progress, and/or improve care coordination functions.
  • Addition of new staff to perform a broad set of functions related to care coordination (such as facilitating and tracking referrals or administering screening and assessment tools) and QI (such as overseeing data collection and chart reviews or creating and maintaining registries).
  • Stipends or other payments to support staff time and compensate practices’ loss of billable hours while working on QI activities.
  • Training and certification, such as providing credit toward maintenance of certification (MOC) requirements for participation in learning activities.
  • Guidance in the steps needed to obtain recognition as a patient-centered medical home (PCMH).  
  • Efforts to engage families in QI activities, such as financial support for parent advisors whose role was to assist practices’ in their QI efforts.

Lessons learned

To make progress in transforming service delivery systems, States will need a combination of strategies, such as learning collaboratives, direct facilitation of practice-level changes (for example, technical assistance to help practices develop performance data), and payments to practices to support staff time for implementing new QI efforts.

Specifically, analysis of the projects implemented by the 14 demonstration States working in this area yielded the following insights:

  • Learning collaboratives can be a useful means for supporting practice transformation, but only when providers play major roles in selecting topics and structuring the sessions.
  • Practices need a variety of supports to remain engaged in learning collaboratives and other QI activities (for example, technical assistance, practice facilitators, stipends, MOC credits). States also can use web-based learning sessions to supplement or replace in-person meetings to make attendance easier, especially for practices in rural or frontier communities.
  • With encouragement from the State, practices used a self-administered assessment of medical homeness that tracked changes over time and helped focus QI activities on areas most in need of attention.
  • Most practices lack the technical competencies to gather the data needed to implement and track practice-level QI efforts. Although learning collaboratives can help build providers’ capacity, not all practices want to improve data collection and measurement skills; some view the burden of data collection and measurement activities as outweighing the benefits.
  • Some States hired practice facilitators (sometimes called QI specialists or coaches) to help practices and SBHCs develop QI teams, identify and undertake QI activities, and collect and analyze data to track progress. To be effective, practice facilitators need to: (1) possess strong interpersonal skills that support practice engagement; (2) have technical knowledge in quality measurement, QI strategies, and clinical content areas; and (3) have caseloads that permit them to spend sufficient time with a practice or SBHC.
  • SBHCs may have limited experience in engaging youth in discussions about their own health and health care. States can help SBHCs by hiring youth engagement specialists who can assist in hosting workshops for youth and health literacy training for SBHC staff, and practice facilitators who can help gather and review data to inform SBHCs’ clinical services.
  • Developing sustainable methods for systematically engaging families and youth is challenging. For example, four States used demonstration funds to find and pay parent advisors to help practices with their QI activities but did not continue financial support for this effort after the demonstration period.
  • Allowing practices to hire care coordinators directly (instead of the State hiring them centrally) better supported integration of these staff into daily operations; practices could select individuals with the credentials, demeanor, and communication style that best fit their needs and culture. States and practices raised concerns about their ability to fund care coordinator and practice facilitator positions or to continue their participation in QI activities after the demonstration grant period ends. New grant or demonstration funds or payment mechanisms that include reimbursement for care coordination and QI related activities may help practices and SBHCs sustain these activities.

Colorado and New Mexico hired QI coaches and provided stipends to help SBHCs carry out QI projects. While working with the first of three cohorts of SBHCs, demonstration staff realized that supporting the SBHCs took more time and resources than anticipated. As a result, each State worked with 11 SBHCs instead of 17, as originally planned. The participating SBHCs pursued a variety of QI activities including increasing the percentage of adolescents receiving all recommended Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services and implementing new youth engagement strategies.

Oregon, West Virginia, and Alaska used learning collaboratives, one-on-one practice facilitation, and stipends to help a total of 21 practices enhance their medical home features. As a result, all participating practices implemented new care coordination strategies such as routinely following up with caregivers of children who were referred for specialized care or developing condition-specific care plans. Seventeen of the 21 practices hired new care coordinators to accomplish these tasks. Practices highly valued the new care coordination staff and functions. However, many practices are concerned about sustaining them after the demonstration ends because reimbursement for care coordination services for children is not currently available. 

South Carolina convened a learning collaborative to help 18 child-serving practices build their QI capacity. Demonstration staff used in-person learning sessions, conference calls, and one-on-one support to help practices select, implement, and monitor QI initiatives of their choosing. Practices reported that they appreciated the flexibility to establish their own QI priorities and placed a high value on learning from other practices. As a result of their participation, practices reported using additional developmental and psychosocial screenings, providing oral health preventive services more regularly, and improving adherence to care guidelines for chronic conditions.

Page last reviewed September 2015
Page originally created September 2015
Internet Citation: Transforming service delivery to promote quality of care. Content last reviewed September 2015. Agency for Healthcare Research and Quality, Rockville, MD.
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