This document provides supplemental application guidance and performance expectations for the Health Disparities Collaboratives. Activities under these collaboratives will cover the period April 1, 2002 to March 31, 2003. During fiscal year (FY) 2002, the Bureau of Primary Health Care (BPHC) has one-time funding of $8.9 to $9.3 million available for the 4th year of the health disparities collaboratives initiative that focuses on diabetes mellitus, cardiovascular disease, cancer, prevention, diabetes prevention, asthma, and depression. Of the $9.1 to $9.6 million, $250,000 will be made available on a one-time basis, to support activities for the migrant and homeless National Clinical Networks (CN). National CN must submit a Memorandum of Agreement (MOA) with each of the lead cluster Primary Care Associations (PCA). The National Network for Oral Health Access must submit an application with the Michigan Primary Care Association.

Major directions for the coming year include:

1. a national health disparities collaborative including diabetes, cardiovascular disease, asthma and depression and office redesign for open access;
2. implementation of a prototype developmental collaborative for cancer and prevention and diabetes prevention;
3. development and implementation of training manuals related to diabetes, cardiovascular, depression and asthma collaboratives;
4. integration of depression screening into all chronic care collaboratives;
5. strengthening the role of the cluster steering committees;
6. development and implementation of a flexible, integrated clinical information system that includes diabetes, asthma, depression, and cardiovascular disease, cancer, and prevention;
7. strengthening the support of health centers as they work to sustain and spread the improvements made during the first year of the collaborative learning model, and
8. identifying national and State partners with expertise in our collaborative activities to assist health centers using Centers for Disease Control and Prevention (CDC) and the State-based Diabetes Control Program as a model. The BPHC Health Disparities Collaborative National Director, the BPHC Clinical Information System Coordinator, and the Institute for Healthcare Improvement (IHI) Health Disparities Collaborative National Director will provide leadership and assistance in the coming year's activities.

For this project, the lead PCA and CN must present a project plan consistent with performance expectations (attached) and the following issues in the application for support:

1. Have a steering committee with representation from other PCAs in their cluster, multidisciplinary CNs, health center senior leadership and clinicians, and the Health Resources Services and Administration (HRSA) Field Office; have completed two strategic planning sessions, and submit an annual report with the budget request.
2. Have bylaws and charter or plan that opens membership to all BPHC-supported organizations, and have a policy and plan to share all collaborative information and opportunities with all BPHC-supported organizations including Health Care for the Homeless (HCH), Public Housing Primary Care and Healthy Schools, and Healthy Communities grantees.
3. Include both a lead PCA and multidisciplinary CN. The CN may be part of the PCA or may be independent. The PCAs and independent CNs are ineligible for this project if they apply separately. Requests for support of the additional State-based collaborative coordinators must be included as part of the request from the lead PCA and CN and be included in the budget from the lead PCA and CN. Individual State requests will not be accepted.
4. Site visit plan for cluster infrastructure, including the number and frequency of anticipated visits to health centers and National Health Service Corps (NHSC) sites per year, training and mentoring activities, Technical Assistance (TA) to sites, faculty support in other cluster learning sessions and collaboration with other agencies.
5. A process to monitor whether activities are in fact improving health outcomes and shared national goals at a cluster level, utilizing monthly health center reports and information available from partner agencies, should be included.
6. Principal activities to be performed by the Executive Director of the PCA and the CN to support the aims and performance of cluster teams, and to facilitate partnerships and communication.
7. Include the cluster mission statement and strategic plan.
8. Agreement by the lead PCA Executive Director and the CN to participate in the bi-annual meetings with BPHC and the cluster steering committee meetings.
9. Description of partnership building activities that support collaborative goals.
10. A plan, coordinated by the cluster steering committee, for spread to all States and BPHC-supported sites, should be included as well as a process to monitor whether activities are in fact improving care.
11. Role of a CN or committee in strategic planning and implementation of the health disparities collaborative with a documented track record of activities that have improved clinical practice and outcomes.
12. A PCA governance structure with significant and meaningful representation by a group of clinicians with active practices in health centers.
13. Prepare a budget in accordance with PHS 5161-1 along with a one to three page justification. It should describe personnel and travel costs as appropriate, and should clearly define resources for the lead CN. If appropriate, it should include contractual arrangements with other organizations, PCAs and/or CNs. (Please submit a separate budget for the redesign for open access collaborative-20 teams total-4 teams per cluster)
14. Plan to distribute the BPHC and IHI produced marketing and training videos and training manuals to health centers, health departments, other PCAs and other partners as appropriate

NATIONAL CNs APPLICATION

The Health Care for the Homeless Clinicians' Network should submit their request to the BPHC HCH Branch and the Migrant Clinicians Network to the BPHC Migrant Health Branch with copies to the BPHC Clinical and Professional Development Branch. The proposal should not exceed 10 pages in length. Awards will be $125,000 each.

National CN must submit an MOA with each of the lead cluster PCAs. The National Network for Oral Health Access must submit an application with the Michigan Primary Care Association.

National CNs will work with BPHC, IHI, HRSA Field Office and the lead PCAs when developing any materials for the collaborative to assure integration with the collaborative models.

1. National CNs activities will support collaborative infrastructure in their work with health centers to maximize national goals.
2. Budget and justification for all costs.

EVALUATION CRITERIA

All applications submitted under this funding announcement will undergo a review based on the following criteria. There will be one PCA and CN team funded per cluster and two national clinical networks.

1. Performance in the health disparities collaboratives (Phase 1 and 2) during the past year.
2. Quality of the proposed approach and its effectiveness in meeting or exceeding the performance goals for the coming year. See attached timeline and operational guidance.
3. Evidence of partnership building activities supportive of collaborative goals.
4. The degree of collaboration in the development and design of the proposed approach.
5. Capacity of the PCA and CN to engage in these activities.
6. Evidence of a PCA governance structure with significant representation by a group of clinicians with active practices in health centers.

BPHC HEALTH DSPARITIES COLLABORATIVES
National Project Goals and Activities: Performance Expectation April 1, 2002 to March 31, 2002

I. SUSTAINING AND DISSEMINATION: BUILDING THE COLLABORATIVE

COMMUNITY

Goal: Health centers and National Health Service Corps (NHSC) sites in Diabetes I (88), Diabetes II (119), Depression I (17), Asthma I (23) continue progress with: (1) 100 percent of the monthly reports are completed and submitted; (2) 90 percent of health centers reaching the national goals by January 2003; (3) documenting the integration of the care model into on-going clinical and management systems in additional health center sites (spread) as reflected in the senior leader survey and; (4) 100 percent of patients with diabetes, asthma, and depression are proactively managed through enrollment into an electronic clinical information system by October 2002; (5) demonstrating the integration of the care and improvement models and measures into the organizational quality improvement program.

Goal: Health Centers and NHSC sites in Diabetes III/CVD1 (97) continue progress with: (1) 100 percent of the monthly reports completed and submitted; (2) 50 percent of health centers meeting the national goals by January 2003; (3) documenting the integration of the care model into on-going clinical and management systems in additional health center sites (spread); (4) demonstrating an increase of 25 percent or more in the health center patients with diabetes and cardiovascular disease enrolled into a registry and information system by January 2003; and, (5) demonstrating the integration of care and improvement models and measures into the organizational quality improvement program.

Goal: Health Centers (including) school-based health centers in Asthma II (21) continue progress with: (1) 100 percent of the monthly reports completed and submitted; (2) 50 percent of health centers meeting the national goals by October 2002; (3) documenting the integration of the care model into on-going clinical and management systems in additional health center sites (spread); (4) demonstrating an increase of 25 percent or more in the health center patients with asthma enrolled into a registry and information system by January 2003; and, (5) demonstrating the integration of the care and improvement models and measures into the organizational quality improvement program.

Performance Expectations

PCA and CN shall:

1. Develop a workplan and a timetable for sustain and spread activities and submit to BPHC as part of the Letter of Intent. Plan should include:
   1. Senior leadership engagement,
   2. Alignment with core business strategy of health centers,
   3. Health centers development of organizational plan for spread and communication strategy,
   4. Integration into the organizational quality improvement program.
   5. Engage cluster Primary Care Associations and State infrastructure in sustain and spread strategy.
   6. Collect monthly data and quarterly narrative data from health centers and share aggregate report to BPHC and IHI quarterly.
   7. Provide travel and logistical support for Phase 2 health center teams to attend at least one reunion sustain and spread learning session to include Patient Electronic Care System (PECS) training. (Midwest cluster to provide travel, lodging, per diem for Asthma Phase 2 teams to the Asthma Phase 1 Congress in September. Midwest cluster will pay for 3 team members and an Executive Director or Chief Executive Officer.) Other PCAs to include travel for cluster directors to attend Asthma congress to receive Phase 2 teams into their cluster.
      Collect and facilitate sharing of success stories and information from teams quarterly with clusters and BPHC.
   8. Submit to BPHC a MOA with each National Clinical Network (NCN) to clarify roles and responsibilities.
   9. Be responsible for building an expert faculty in content and the model for sustain and read meetings and for continued mentoring as needed in the cluster. Cluster will be responsible for the travel, per diem, lodging and honoraria of faculty.

Goal: The NCNs, which focus on migrant farmworkers, homeless persons or oral health care integration, as appropriate to the specific NCN, will support the collaboratives in all clusters in both Phase 1 and Phase 2 of the collaboratives through increased participation and improved quality of primary care.

Performance Expectations

NCN shall:

1. Submit to BPHC a MOA with each Cluster to clarify roles and expectations and to ensure the integration of the special needs of homeless, migrant populations and oral health needs into the spread and sustainability of the collaboratives.
2. Communicate resource information and technical assistance through writing, email, and in-person at conferences and national and cluster reunion meetings to centers that serve homeless patients, migrant health centers and oral health care providers.
3. Disseminate information about Collaborative activities via communication channels within each of the three national networks.
4. In concert with the Cluster Directors, identify and collaborate with the oral health care providers, migrant health centers and HCH projects that participate in the Collaboratives.
5. Serve as faculty and resources at sustain and spread cluster meetings (Clusters will provide travel and logistic support).
6. Facilitate sharing of success stories and information from teams providing care to migrant farmworkers and homeless populations.
7. Encourage health centers to assess progress of aims and measures in special population groups within their populations of focus.

BPHC plans to:

1. In collaboration with the IHI, develop change concepts to support sustain and spread of models.
2. Provide resources to PCA budgets for sustain and spread activities identified in the workplan to include a minimum of one Learning Session per Cluster to include PECS training.
3. In collaboration with IHI and National Association of Community Health Centers, (NACHC) BPHC will continue support of the National health disparities web site.
4. In collaboration with IHI and NACHC, BPHC will support the development and distribution of disparities specific training manuals.
5. Support the national CN in sustaining and spreading collaboratives to maximize the health outcomes of migrant and seasonal farmworkers and homeless populations and to assist with maximizing oral health in all populations.
6. Develop and maintain partnerships with national agencies and organizations to support the health disparities collaboratives, e.g., CDC, Substance Abuse and Mental Health Service Administration (SAMHSA), Environmental Protection Agency (EPA), National Institutes of Health (NIH)/National Cancer Institute (NCI).
7. The BPHC will assist in identifying faculty for the sustain and spread meetings.

(Note: All health disparities learning sessions are 3 days)

Goal: Begin the first annual combined BPHC Health Disparities Collaborative (includes Diabetes IV, Cardiovascular II, Depression II, Asthma III, office redesign for open access I) with selection of health centers by April 2002. Prework to begin in May 2002, and a first learning session in July 2002. The health centers will select the disease area to focus and report on while learning and testing changes to implement the care model in the organization. A minimum of 20 health centers nationally is needed to provide a topic area (diabetes, depression, cardiovascular disease or asthma, redesign for open access). Redesign for open access is for health center teams who have gone through a health disparities collaborative. Depression screening concepts will be integrated into each chronic illness collaborative. The second national learning session will be October 2002 and the third national learning session will be in March 2003.

Goal: Health Center teams will complete the collaborative with an average team score of 3.5, meet the shared national project goals, with 90 percent of the monthly reports arriving on time each month, the cluster and national reports shared with all participants and partners by the end of each month, and with 100 percent of the participating sites completing the 12 month collaborative.

Performance Expectations

PCA and CN shall:

1. Recruit health centers and market the annual health disparities collaborative, including educational sessions for health center governing board members (as appropriate) at Annual conferences. Shall encourage the use of the national uniform web-based application form. Recruitment and selection will target health centers that have not previously participated in a health disparities collaborative.
2. With assistance of its Cluster steering committees, select and enroll health centers including migrant, homeless and public housing primary care health centers for participation. The HRSA Field Office lead clinician, as a member of the cluster steering committee, will be involved in the selection process. List of participants will be forwarded to BPHC by April 2002. Uniform Data System number will be used as a unique identifier for participants.
3. Provide travel, $250 registration fee and logistical support for 30 health center teams from each cluster to attend three national learning sessions. (Include support for six dental representatives per cluster or appropriate number to attend with health center team.) Shall provide travel and logistical support for senior leader from each health center to attend the first and third learning sessions and support for one governing board member (as appropriate) to the first learning session. (Submit a separate budget for four teams from each cluster for office redesign for open access)
4. Provide travel and logistical support for two person high performing teams from prior health disparities collaboratives and senior leaders to serve as faculty and to provide a poster session for the three learning sessions.
5. Provide a revised pre-work manual and TA to teams during pre-work phase prior to July 2002 kick-off learning session.
6. Implement the established cluster strategy to sustain and promote high performing teams and improve performance for lower performing teams.
7. Support and facilitate implementation of State-based Diabetes Control Program, Cardiovascular Disease, and asthma program partnership aims with health centers. Facilitate support from State and local initiatives with health center teams working on health disparities collaborative goals.
8. With BPHC and IHI, implement and refine strategy and curriculum to involve senior leaders in pre-work and monthly test cycles and assure that senior leader attends first and third learning sessions.
9. Facilitate and market the depression training provided at learning sessions and integration of depression screening in all collaboratives.
10. With national infrastructure and partners, develop a strategy to support travel and honorarium for faculty used in the cluster sustain and spread meetings and expand trained faculty available to each cluster. This includes organizations such as Area Health Education Centers.
11. Promote participating sites enrollment in and use of the cluster listservs.
12. Collaborate with BPHC and national partners (i.e.: CDC) to identify additional State infrastructure and resources to participate in the collaborative.
13. With BPHC, develop and implement a communication/reporting strategy that includes monthly national, cluster and State specific information, highlights successful models and partnerships and is shared on a monthly basis with partners, participating health centers and BPHC. Cluster reports (narrative and cluster data) shared with BPHC and IHI by the 20th of every month.
14. Implement protocol for conference calls with health centers (with distribution of summary minutes), facilitating monthly health center reporting and providing site visits as needed. Utilize existing State or regional telecommunications where feasible. One section of report specifically set aside to address collaboration with Diabetes Control Program and other national partners and HRSA-supported State partners.
15. Incorporate efficient office redesign concepts into learning opportunities and actions periods for teams.
16. Develop cluster strategy to utilize high performing teams in the collaborative.
17. Identify successful team participants to attend harvesting meeting to refine change concepts.
18. Collect and facilitate sharing of success stories and information from teams quarterly with BPHC.

Goal: Health centers will complete Phase one of the Diabetes III/CVD I collaborative by May 2002. Health Center teams will complete the collaborative with an average team score of 3.5, meet the shared national project goals, with 90 percent of the monthly reports arriving on time each month, the cluster and national reports shared with all participants and partners by the end of each month, and with 100 percent of the participating sites completing the 12 month collaborative.

Performance Expectations

PCA and CN shall:

1. Provide travel and logistical support for 20 health center teams, a senior leader and a governing board member (as appropriate) to attend the DMIII/CVDI Congress in May 2002 in St. Louis, Missouri.
2. Provide support for two members of five selected health centers to attend 1 day PECS training on May 1, 2002.
3. Implement a communication/reporting strategy that includes monthly national aggregate information, highlights successful models and partnerships and is shared on a monthly basis with partners, participating health centers and BPHC. Cluster reports (narrative and cluster data) shared with BPHC and IHI by 20th of every month.
4. Identify high performing team members to utilize as future faculty.
5. Implement cluster strategy to sustain and promote high performing teams and improve performance for lower performing teams.
6. Assist health center teams to submit timely storyboards electronically to national directors for distribution by CD-ROM to participants.
7. Support cluster infrastructure to attend congress as faculty support.
8. Shall provide travel and logistical support for one high performing team from prior health disparities collaboratives and senior leaders to serve as faculty and to provide a poster session for the national congress.
9. Identify successful team participants to attend harvesting meeting to refine change
   concepts.

Goal: Health centers will complete Phase one of the Asthma II collaborative by September 2002 and health center teams will be supported in spread and sustaining the work of the collaboratives through their cluster infrastructure. Health Center teams will complete the Asthma II collaborative with an average team score of 3.5, meet the shared national project goals, with 90 percent of the monthly reports arriving on time each month, the cluster and national reports shared with all participants and partners by the end of each month, and with 100 percent of the participating sites completing the 12 month collaborative.

Performance Expectations

PCA and CN shall:

1. Midwest Cluster to provide travel and logistical support for 21 health center teams, one senior leader and a governing board member (as appropriate) to attend Learning Session (LS) #3 in April 2002 and to attend final congress in August 2002.
2. Midwest Cluster to host the advisory committee for integrating reengineering concepts and IHI's open access concepts for the collaborative to start in July and identify faculty for the collaborative in partnership with IHI and BPHC.
3. Support cluster directors and information system specialists to attend LS#3 and congress and facilitate transfer of support of teams to the cluster infrastructure for sustain and spread phase of collaborative.
   Implement cluster strategy to utilize high performing teams in the collaborative.
4. Implement cluster strategy to sustain and promote high performing teams and improve performance for lower performing teams.
5. Implement protocol for conference calls with health centers (with distribution of summary minutes), facilitating monthly health center reporting and providing site visits as needed. One section of report specifically set aside to address collaboration with EPA supported partners.
6. Implement a communication/reporting strategy that includes monthly national aggregate information, highlights successful models and partnerships and is shared on a monthly basis with partners, participating health centers and BPHC. National reports (narrative and cluster data) shared with clusters, BPHC and IHI by 20th of every month.
7. Shall provide travel and logistical support for one high performing team from prior health disparities collaboratives and senior leaders to serve as faculty and to provide a poster session for the national congress.
8. Identify successful team participants to attend harvesting meeting to refine change
   concepts.
9. Shall provide travel and logistical support for three person teams and one leadership person from the Phase two Asthma I Collaborative to the Asthma II National Congress to include PECS training.

Goal: National Clinical Network coordinators (focus on migrant farmworkers, homeless persons and oral health integration) will support the collaboratives in all clusters. Increase participation of HCH projects, Migrant Health Centers, and Oral Health providers in the Health Disparities Collaboratives. By October 2002 collaborate with the Phase one teams to improve the quality of primary care to homeless persons and migrant farmworkers and the quality of oral health care for all patients.

Performance Expectations

NCN shall:

1. Communicate resource information and TA through writing, email, and in person at conferences and meetings to HCH projects, migrant health centers and oral health care providers and encourage participation in the Collaboratives.
2. Disseminate information about Collaborative activities via communication channels within each of the three national networks.
3. In concert with the Cluster Directors, identify and monitor the oral health care providers, migrant health centers and HCH projects that participate in the Collaboratives.
4. Serve as faculty and resources at all national Collaborative Learning Sessions.
5. Facilitate sharing of success stories and information from teams providing care to migrant farmworkers and homeless populations.
6. Provide TA to participating health centers for assessment of progress of aims and
   measures in special population groups within the population of focus.

BPHC plans to:

1. Provide resources to PCA budgets for registration fee and travel support for three national Learning Sessions to include PECS training for 30 teams and Cluster infrastructure.
2. In collaboration with IHI and NACHC, will continue support of the National health disparities web site.
3. In collaboration with IHI and NACHC, will support the development and distribution of disparities specific training manuals.
4. Support the national CN in the collaboratives to maximize the health outcomes of migrant and seasonal farmworkers and homeless populations and to assist with maximizing oral health in all populations.
5. Develop and maintain partnerships with national agencies and organizations to support the health disparities collaboratives, e.g., CDC, SAMHSA, EPA, NIH/NCI.
6. In collaboration with IHI, will convene harvesting meetings to refine future health disparities collaboratives change concepts and training manuals.
7. In collaboration with IHI and the redesign advisory group, refine curriculum for LS#1 in July 2002.
8. With IHI, provide generalized software program that include diabetes, cardiovascular disease, asthma and depression data fields, reports, and visit notes.
9. Distribute health center success stories to partners, government agencies as appropriate.

Goal: In partnership with IHI, begin a Delivery System Redesign Collaborative for Open Access with selection of 20 health centers by April 2002, prework to begin in May 2002 and a first learning session in July 2002. The second national learning session will be October 2002 and the third national learning session will be in March 2003. The learning sessions will be integrated with the health disparities collaborative learning sessions. This collaborative will address clinical office visit efficiencies and increased access.

Goal: Health Center teams will complete the collaborative with an average team score of 3.5, meet the shared national project goals, with 90 percent of the monthly reports arriving on time each month, the cluster and national reports shared with all participants and partners by the end of each month, and with 100 percent of the participating sites completing the 12 month collaborative.

Performance Expectations

PCA and CN shall

1. Recruit and market the Delivery System Redesign Collaborative for Open Access. Recruitment and selection will target health centers that have previously participated in a health disparities collaborative.
2. Provide travel and logistical support for four health center teams from each cluster to attend three national learning sessions. Shall provide travel and logistical support for senior leader from each health center to attend the first learning session.
3. Implement the established cluster strategy to sustain and promote high performing teams and improve performance for lower performing teams.
4. Provide TA to teams during prework phase prior to July 2002 kick-off learning session.
5. Promote participating sites enrollment in and use of the collaborative listserv.
6. With BPHC, develop and implement a communication/reporting strategy that includes monthly information, highlights successful models and partnerships. Cluster reports (narrative and cluster data) shared with BPHC and IHI by 20th of every month.
7. Develop cluster strategy to utilize high performing teams in the collaborative.
8. Identify successful team participants to attend harvesting meeting to refine change concepts.

BPHC plans to:

1. In collaboration with IHI and the redesign advisory group, develop and refine collaborative change concepts to be tested by participating health centers.
2. Provide resources to PCA budgets for registration fee and travel support for three national learning sessions.
3. Provide resources to support faculty for the collaborative.
4. Provide resources to Michigan Primary Care Association to convene redesign advisory group to include IHI open access experts.
5. In collaboration with IHI and the advisory group, convene harvesting meeting to refine future delivery system redesign collaboratives.

Goal: Begin a prototype collaborative in cancer screening and care with selection of 10 health centers by April 2002 and national prototype learning sessions in June 2002 Prototype (PS#1), September 2002 (PS#2), and February 2003 (PS#3). Prototype collaboratives will involve close partnerships and communication with participating health center teams and intense action periods between sessions.

Goal: Begin a prototype collaborative in prevention with selection of five health centers by September 2002 and national prototype learning sessions in November 2002 (PS#1) and February 2002 (PS#2). Prototype collaboratives will involve close partnerships and communication with participating health center teams and intense action periods between sessions.

Goal: Begin a prototype collaborative in diabetes prevention with selection of five health center teams by September 2002 and national prototype learning sessions in November 2002 (PS#1) and February 2002 (PS#2). Prototype collaboratives will involve close partnerships and communication with participating health center teams and intense action periods between sessions.

Performance Expectations

PCA and CN shall:

1. Assist BPHC to identify and recruit high performing Phase two teams to participate in prototypes.
2. Support travel and logistics for at least one cluster director or coordinator and/or Information System specialist to participate in each prototype session.
3. Support travel and logistics for two health center teams in the cancer prototype and one health center team in the prevention prototype and diabetes prevention prototype to participate in three prototype sessions.
4. Participate in conference calls with health center teams and faculty.
5. Take the lead (Southeast Cluster) in the diabetes prevention prototype and be responsible for support including logistical support for the five teams including Travel, lodging, per diem to all sessions.

BPHC plans to:

1. In collaboration with IHI, CDC and NIH/NCI, support the design of the new collaboratives, including software package.
2. Provide resources to PCA budgets for travel support for teams to three national Prototype Sessions to include PECS training. (prototype sessions will be 2 days)

Goal: As part of the care model, health center teams will receive information systems support for the use of the Diabetic Electronic Management System (DEMS), Cardiovascular Diabetic Electronic Management System (CVDEMS) registry, as well as, training and support for their potential transition to the generalized PECS. These tools are part of the broader BPHC information system strategy and consistent with BPHC guidelines. Technical Assistance from IS Specialists (ISS) will be provided in each cluster so that 90 percent of the teams are utilizing a computerized registry program instituted during any health disparities collaborative (Diabetes, Cardiovascular, Asthma, Depression, Cancer and Prevention).

Performance Expectations

PCA and CN shall:

1. Assure that IS work as an operational team with each other and within their Clusters.
2. Provide technical assistance through:
   1. Telephone consultation
   2. Group conference calls
   3. Learning Session Question & Answers, Individual session, Group training
   4. Available technologies at the Cluster PCA
   5. Cost effective innovative technology e.g., Desktop Streaming, etc.
   6. Site visits at PCA or health center
3. Provide readiness assessment for utilization of Information Technology during application and prework process.
4. Continue technical support of DEMS and CVDEMS by Cluster IS through 12/31/03.
5. Communicate phase out strategy and timeline for support to DEMS and CVDEMS.
6. Develop partnerships at local and State level for TA related to Clinical Information Systems.
7. Train Cluster Directors on functions and use of PECS.
8. Train and mentor at least one Cluster Coordinator in the functions and use of PECS through the IS coordinator. This Cluster Coordinator will be able to provide group PECS training to health center staff.
9. Provide PECS training for Phase 2 teams at the Cluster level in coordination with the BPHC Clinical Information System Coordinator.

Goal: In the development and release of the PECS, the national IS team is engaged in several essential processes for the development of the most useful software product and the optimal implementation and training strategy for the health center staff members.

Performance Expectations

PCA and CN shall:

1. Use the IS to assist in the development and implementation of uniform collaborative IS mission and operational guidelines in collaboration with IHI and BPHC.
2. Participate in 4-5 week Alpha-testing periods of PECS.
3. Test all future versions (1.1, 1.2, 2) of PECS before their release, document findings, report to developers (IHI-Jerry Langley), provide recommendations for solutions as needed.
4. Provide technical support to the health center clinicians and technical personnel
   participating in alpha and beta testing for all versions of PECS.
5. Provide input into training curriculum and aids for the implementation of PECS in health centers at Learning Sessions and for local use in collaboration with the BPHC Clinical Information System Coordinator (CIS) and IHI Technical Expert.
6. With BPHC CIS Coordinator and IHI Technical Expert, develop readiness and
   implementation plans for PECS for Phase one and two teams.

Goal: To provide efficient, reliable and uniform reporting templates and technical support for health center teams to produce data displayed over time at a national, State and Cluster level for monthly reporting requirements. National reports (narrative and cluster data) will be shared with clusters, BPHC and IHI by 20th of every month.

Performance Expectations

PCA and CN shall:

1. Support collection and aggregation of health center level key measure data.
2. Provide TA to the health center to ensure timely, accurate and uniform Cluster level reports.

BPHC plans to:

1. In collaboration with IHI, provide resources, training, TA for software development and enhancements.
2. In collaboration with IHI, develop training curriculum and aids for the implementation of PECS in health centers at Learning Sessions and for local use.
3. In collaboration with NACHC, assess and develop strategies and partnerships to address identified health center IS needs. Use the National CIS Coordinator to provide leadership and assistance in the use of the collaborative CIS guidelines.
4. In collaboration with IHI, provide resources and expertise for the PECS Clinical
   Advisory Group.

Goal: The planning and implementation of cluster activities will be strengthened through a PCA governance structure with significant representation by a group of clinicians with active practices in health centers, an active cluster steering committee composed of cluster PCAs, multidisciplinary CNs, health center senior leaders and clinicians, HRSA Field Office clinician, and appropriate partners.

Performance Expectations

PCA and CN shall:

1. Complete at least twice yearly cluster steering committee strategic planning sessions. Cluster strategic planning sessions must include lead cluster PCA and CN, HRSA Field Office, cluster director/coordinators and IS specialist, other PCA CNs, representation from State PCAs and key external partners. The CN will be multidisciplinary or present plan and time-line to become multidisciplinary by March 2003.
2. Submit a cluster mission statement and strategic plan, including plan for sustaining and spread of collaborative work, which forms the basis for the lead PCA and CN proposal to BPHC. The strategy shall align PCA and CN quality improvement activities with BPHC national activities and collaborative goals and engender partnerships at the State and cluster level.
3. Provide training to steering committee members in care and improvement models and orientation to familiarize members to new electronic registry (PECS).
4. Implement and evaluate the on-going communication strategy for the cluster and a process for decision-making within the cluster.
5. Continue the current management structure, and include at least one full-time cluster director in each cluster. The BPHC grantee coordinating committee at the national level will continue its current role.
6. Utilize National CN coordinators as faculty and partners to strengthen the infrastructure, spread the collaborative work, and maximize oral health and health outcomes in migrant and homeless populations.
7. Have or plan to have clinicians in the PCA governance structure by March 2003.

Goal: By May 2002 each lead cluster will have at least one full-time cluster director, at least one IS, and at least two full-time coordinators.

Performance Expectations:

PCA and CN shall:

1. Ensure 100 percent full-time employee capacity for cluster directors, cluster coordinators and IS to work on BPHC-funded collaboratives.
2. Have its cluster steering committee develop a strategy, in partnership with the BPHC to train and mentor new cluster coordinators and IS.
3. Provide travel and logistical support to cluster directors and lead information systems specialist to attend the annual NACHC Community Health Institute in August 2002.
4. Provide travel support for cluster director and IS to attend the IHI National Forum in December 2002.
   Leverage partnerships of existing State infrastructure and private partnerships to expand support to health centers.

BPHC plans to:

1. Provide one “core” training sessions a year for new cluster coordinators, Diabetes Control Programs, and information system specialists. The PCAs and CNs to include travel for cluster infrastructure in submitted budget.
2. Provide leadership training for cluster directors and information systems specialists twice a year.
3. Continue to augment the expertise of the cluster and IS coordinators through training and coaching in partnership with IHI.
4. Meet with the BPHC grantee coordinating committee (lead PCAs) twice per grant cycle. (Travel, lodging, per diem to be included in cluster budget). The purpose of the meeting is communication, reporting related to current and post-collaborative teams, spread, planning e.g., providing input into topics of future collaboratives, and resource allocation.

Goal: By April 2002, each NCN will ensure one full-time employee capacity for coordinators (focus on migrant farmworkers, homeless persons and oral health integration) to support the work and goals of the collaboratives in all clusters.

Performance Expectations

NCN shall:

1. Provide TA, disseminate educational materials and furnish resource information to teams in Phase I and Phase II of the Collaboratives.
2. Participate on conference calls within each Cluster as requested.
3. Monitor national and cluster listservs and facilitate information sharing.
4. Host national conference calls as needed on oral health care or working with homeless or migrant persons.
5. Assure that the coordinator or clinical network member designee participates in
   each Cluster Steering Committee (members include the National Network for Oral Health Access in the Midwest Cluster).
6. Provide clusters and BPHC at least quarterly