AACO's Annual Client Services Unit, Housing, and Quality Management Presentation

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Evelyn Torres and Sebastian Branca presented on Philadelphia's AIDS Activities Coordinating Office's Client Services Unit, Housing Services Program, and Quality Management program at the February 6, …

Evelyn Torres and Sebastian Branca presented on Philadelphia's AIDS Activities Coordinating Office's Client Services Unit, Housing Services Program, and Quality Management program at the February 6, 2013 meeting of the Needs Assessment Committee of the Philadelphia EMA Ryan White Planning Council.

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  • 1. Philadelphia Department ofPublic HealthAIDS Activities Coordinating OfficeComprehensive Planning MeetingFebruary 6, 2013
  • 2. Client Services UnitCSU
  • 3. CSU MissionHelp HIV infected and at-risk individuals understand their needs and make informed decisions about possible solutionsAdvocate on behalf of those who need special supportReinforce clients’ capacity for self-reliance and self-determination through ◦ education ◦ collaborative planning ◦ problem solving
  • 4. CSU ResponsibilitiesIntake services to HIV positive individuals requesting case management servicesMCM & RW eligibility ◦ HRSA Requirement ◦ Every six months ◦ Every RW funded service accessed by a client ◦ Information and verifying documentation must be collected on clients’ ◦ HIV dx ◦ Identity ◦ Household income ◦ Medical insurance ◦ ResidencyNo significant complaints about RW eligibility received through CSU
  • 5. CSU ResponsibilitiesInformation and referral services for all other AACO funded programsProcess individuals’ requests for subsidized housingFeedback about funded providersLocal Case Management Coordination Project
  • 6. CSU Information Health Information Helpline is open 8 a.m. to 6 p.m. Monday through Friday 1-800/215-985-2437 Staffing: ◦ 1 Manager ◦ 1SW Supervisor ◦ 1Housing Supervisor ◦ 4 City Social Workers ◦ 2 Housing Staff ◦ 1 Data Specialist ◦ 1 Training Coordinator Staff speak Spanish
  • 7. CSU Waiting List149 peopleFollowed by CSU Intake Workers ◦ Emergency ◦ UrgentEmergencies and other priority populations are immediately referred to MCM providers ◦ SCI ClientsCSU workers facilitate HIV medical appointments for all clients reporting no HIV medical care in last three months
  • 8. Intake Data
  • 9. MCM IntakesCalendar year Intakes 2007 1873 2008 2092 2009 2356 2010 2310 2011 2087 2012 2038
  • 10. 2012 Intake Demographics
  • 11. 2012 Intake Demographics
  • 12. Calendar Year 2012: Client needs at intake (N=2038) Newly Diagnosed All Clients Latino MSM Afr. Amer. MSM Youth 13-24 (w/in 1 year of intake)Number of intakes 2038 182 280 150 239Percent of total intakes 100.0% 8.9% 13.7% 7.4% 11.7%Service Category          Benefit Assistance 59.0% 71.4% 50.0% 54.7% 55.6%Housing Assistance 51.7% 41.2% 56.1% 41.3% 34.3%Transportation Assistance 31.2% 20.3% 32.5% 24.7% 34.3%Mental Health Treatment 29.1% 22.5% 30.0% 28.0% 32.2%Medical Insurance 27.6% 37.9% 26.1% 40.7% 38.1%Medical Care 23.1% 37.9% 14.6% 48.7% 40.6%Medications 20.3% 37.9% 12.5% 30.0% 28.9%Rental Assistance 17.6% 29.7% 11.8% 11.3% 9.6%Food Bank/Home Delivered Meals 17.2% 8.8% 21.4% 8.7% 13.0%Support Groups 14.4% 13.2% 13.9% 17.3% 16.3%Dental Care 11.0% 17.0% 11.4% 28.0% 23.4%HIV Education/Risk Reduction 10.4% 22.0% 7.5% 33.3% 41.0%Substance Abuse 8.5% 6.0% 5.7% 2.0% 6.3%
  • 13. Housing Services Program (HSP)
  • 14. HSP FundingThe AACO Housing Services Program (HSP) is 100% funded by the Philadelphia Office of Housing & Community Development (OHCD)The HSP receives $0 from Ryan White funds ◦ RW funding can not be used to provide permanent housing ◦ Federal and State funding for housing continues to decline
  • 15. What is HSPCentralized intake for applicants seeking permanent rental assistance (subsidized housing)The main referral source for housing sponsors providing Housing Opportunities for People With AIDS (HOPWA) or HIV/AIDS Shelter Plus Care (S+C) housing
  • 16. What HSP DoesProcess and evaluate individual applications for housingMaintain the waiting listProvide training to southeastern PA service providersProvide ongoing TA to providersAll services at no costDo not provide emergency housing
  • 17. HSP Scope8 housing sponsors663 housing slots out of 1015 slots ◦ 522 HOPWA ◦ 131 S+C89% tenant based11% project based
  • 18. Waiting List293 applicants currently on the waiting list ◦ Priority 1- 8 months wait time (includes homeless folks) ◦ Priority 2 – 3 year wait time ◦ Priority 3 – 4 year wait time
  • 19. Quality Management in the EMA
  • 20. QM ActivitiesCollecting and monitoring data to assess client outcomes ◦ Local and HAB performance measures ◦ Other available dataUsing data to improve client outcomes ◦ Ongoing feedback to providers ◦ QIPs ◦ Quarterly Meetings: scaling these back ◦ Individual TA
  • 21. QM ActivitiesImproving access to HIV medical care ◦ Retention in care measure for core and supportive servicesImproving the HIV system of care ◦ Benchmarking ◦ HRSA Systems Measures ◦ PDPH management team ◦ Planning Council
  • 22. Outcome Monitoring in the EMAPerformance MeasuresSystem MeasuresCare Outreach OutcomesEarly Intervention OutcomesDisparities in Care
  • 23. Performance Measures27 measures for medical (O/AMC) services ◦ 22 HAB Group 1-3 measures ◦ 5 local measures9 (10) MCM measures ◦ 2 HAB measures ◦ 5 Part B measures (extended to Part A) ◦ 2 (3) local measures5 HAB oral health measuresMeasures for all other services
  • 24. Outpatient-Ambulatory Medical Care Measures• AACO collects these measures from providers every two months• The exception to this VL Suppression which is collected once per year• Disparity also calculated once per year
  • 25. O/AMC Performance in the EMA Performance Measure 2011 AUG 2012 YTD CHANGEA1 Percentage with >=2 Viral Load Counts 72% 70% -2%A2 Retention In Care 84% 84% 0%A3 Partner Services Newly Diagnosed 41% 46% 5%A5 Not Recomended ART Regimen 1% 1% 0%A7 MSM Receiving Syphilis Screening 81% 81% 0%A8 Colposcopy After Abnormal PAP 41% 39% -2%HAB01 Two Primary Care visits>= 3mos Apart 82% 82% 0%HAB02 Percentage with >=2 CD4 Counts 73% 71% -2%HAB03 CD4<200 with PCP prophylaxis 82% 81% -1%HAB04 AIDS Clients on HAART 97% 96% -1%HAB05 Pregnant women prescribed ART 99% 96% -3%HAB06 Adherence Assessment 80% 75% -5%HAB07 Cervical Cancer Screening 48% 49% 1%HAB08 Hepatitis B Vaccination 52% 51% -1%HAB09 Hepatitis C Screening 88% 89% 1%HAB11 Lipid Screening 72% 68% -4%HAB12 Oral Exam 20% 18% -2%HAB13 Syphilis screening 76% 74% -2%HAB14 TB Screening 73% 72% -1%HAB15 Chlamydia Screening 61% 65% 4%HAB16 Gonorrhea screening 61% 65% 4%HAB17 Hepatitis B Screening 77% 78% 1%HAB19 Influenza vaccination 52% 55% 3%HAB22 Pneumococcal Vaccination 74% 74% 0%
  • 26. Medical Case Management MCM
  • 27. MCM EmphasisThe coordination and follow-up of HIV medical treatmentMedical case management includes the provision of treatment adherence counselingDelivered by medically credentialed or other health care staffPart of the clinical care team
  • 28. AACO MCM Performance MeasuresRetention in MCM services• Percent of clients referred to an MCM provider who had a face-to-face MCM visit within 8-10 weeks of the referral from CSULinkage to HIV medical care• Percent of clients active in HIV medical case management who are also active in HIV medical care• Numerator includes patients who had a medical appointment up to 120 days prior or 70 days after becoming active in medical case management
  • 29. Medical Case ManagementPerformance MeasuresPerformance 2008 2009 2010 2011 2012 (1/1-9/30)measuresRetention inMCM (< or = 10weeks after 76% 81% 80% 78% 82%intake)Retention in HIVmedical care forclients getting 87% 92% 95% 97% 96%MCM
  • 30. Other MCM MeasuresAdded to CAREWare in April 2012Data collected on 2 HAB and 5 state measures every two months2 (3) measures monitored through CSUCAREWare Simplifies reporting at programs offering both MCM and O/AMCFacilitates multidisciplinary team approachAllows for regular monitoring of performance in our large EMAWill begin sending feedback reports this year
  • 31. RW Part B MCM MeasuresUnmet need• Percentage of clients with HIV infection whose records indicate retention in medical care• Numerator - number of clients whose records indicate CD4 count OR viral load test OR ARV therapy prescribed• Denominator - number of clients who have accessed (MCM) services at least twice during the measurement year• Patient self-reporting not accepted
  • 32. RW Part B MCM MeasuresMental Health History and Treatment Status• Percentage of clients with HIV infection who have documented mental health history and treatment status• Numerator - number of clients who have their mental health history and treatment status documented at least once during the measurement year• Denominator - number of clients who have at least one face-to-face MCM visit during the measurement year
  • 33. RW Part B MCM MeasuresSubstance Abuse History and Treatment Percentage of clients with HIV infection who have their substance abuse history and treatment status documented Numerator - number of clients who have their substance history and treatment status documented at least once during the measurement year Denominator - number of clients who have at least one face-to-face case management visit during the measurement year
  • 34. RW Part B MCM MeasuresSecondary Risk Assessment• Percentage of active MCM clients that do risk reduction plan (counseling) at least once per year• Numerator - number of clients for whom risk assessment was completed• Denominator - number of active clients in case management
  • 35. RW Part B MCM MeasuresMedication Assessment and Counseling Percentage of clients with HIV infection on ARVs who were assessed and counseled for adherence two or more times in the measurement year Numerator - number of HIV-infected clients, as part of their HIV medical and/or MCM care, who were assessed and counseled for adherence two or more times at least three months apart Denominator - number of HIV-infected clients on ARV therapy who had a visit with an HIV medical and/or MCM provider at least twice in the measurement year
  • 36. HRSA MCM MeasuresMedical Case Management: Care Plan Percentage of HIV-infected MCM clients who had a MCM care plan developed and/or updated two or more times in the measurement year Numerator - Number of HIV-infected MCM clients who had a MCM care plan developed and/or updated two or more times at least three months apart in the measurement year Denominator - Number of HIV-infected MCM clients who had at least one [face-to-face] MCM encounter in the measurement year
  • 37. HRSA MCM MeasureMedical Case Management: Medical Visits Percentage of HIV-infected MCM clients who had two or more medical visits in an HIV Care setting in the measurement year Numerator - Number of HIV-infected MCM clients who has a medical visit with a provider with prescribing privileges two or more times at least three months apart in the measurement yea that is documented in the MCM record Denominator - Number of HIV-infected MCM clients who had at least one [face-to-face] MCM encounter in the measurement year
  • 38. EMA’s Baseline Performance forMCM*Data as of 10/31/12
  • 39. Process for Monitoring Medical andMCM PerformanceAACO Reporting Calendar sent annually to all programsReminders with attached instructions for generating reportAACO monitors provider submissionsProgram generates performance reports ◦ AACO Report Generator (O/AMC) ◦ Performance Measure Worksheet (MCM) ◦ Custom Oral Health Database
  • 40. Process for Monitoring Medical andMCM PerformancePerformance measures for O/AMC, MCM and oral health submitted every two monthsISU enters and analyzes data using PMR Master toolFeedback reports sent to programsProviders analyze data and develop QIPsGrantee provides feedback on QIPsOutcome monitoring by provider and grantee
  • 41. Monitoring and FeedbackStrong emphasis on feedbackQuickly highlights trends, strengths and needsData visualization is critical in getting attention of program leadershipBenchmarking contextualizes data and can capitalize on competitiveness of providersAssists in prioritizing QIPs
  • 42. Monitoring and Feedback ToolsPMR Master for Medical and MCM ◦ AACO enters performance data bimonthly ◦ Remaining process is automated ◦ Tool generates aggregate performance data, including city, state and funding ◦ Trend data for both system and provider ◦ Flags all significant improvements and declines ◦ Ranks provider performance for each measure ◦ System and provider trend data on all measures ◦ Generates an individualized Performance Feedback Report for every provider
  • 43. Monitoring and Feedback Tools EMA Aggregate Reports ◦ Sent after analysis of bimonthly submission of data by programs ◦ Identifies upcoming submissions and explains data ◦ Feedback to all O/AMC providers on system performance ◦ Includes EMA trend data and highest-lowest performers ◦ Aggregate for O/AMC sent to MCM programs to aid in identifying regional priorities when coordinating with O/AMC providers
  • 44. Monitoring and Feedback Tools• Performance Feedback Reports o Sent to providers every two months o Number of measures presents challenges for data visualization o Uses a dashboard format o Provides trend data on each measure, including VL Missed Opportunities o Flags improvements and declines o Ranking in the EMA on all HAB/local measures o Flags top and bottom 5 performance in EMA
  • 45. Performance Feedback Reports
  • 46. Performance Feedback Reports
  • 47. Oral Health MeasuresCollected through database created by the EMADatabase similar to CAREWare in its functionality ◦ Data entry form functions as client record ◦ Calculates and generates performance measure reports ◦ Identifies patients who are Not in NumeratorProgram reviews charts based on sample size calculator (5-7% confidence interval)3 (5) HAB oral health measures
  • 48. HRSA/HAB Oral Health CarePerformance Measures CY 2011 Dental and medical history 95% Dental treatment plan 91% Oral health education 66% Completion of Phase 1 treatment plan* Periodontal treatment plan*
  • 49. HAB System Measures-Appointment Availability• Numerator: Number of organizations with a waiting time of 15 or fewer business days for a patient to receive an appointment to enroll in O/AMC• Denominator: Number of Ryan White Program-funded O/AMC organizations in the system/network at a specific point in time in the measurement year
  • 50. HAB System Measures-Appointment Availability• Performance for 2011: 71.1%• AACO made three attempts to contact each program in June 2011• If the program failed to respond to these attempts within 15 business days, it was treated as a failure to meet the measure• 45% of programs that did not meet measure were due to being unresponsive
  • 51. HAB System Measures-Appointment AvailabilityOn average, 1.6 attempts were needed to solicit a response from programsAverage time for appointments in the EMA (for non-emergency patients): o 1st available appt: 4.7 business days o 2nd available appt: 6.9 business days o 3rd available appt: 8.9 business days
  • 52. HAB System Measures-Appointment Availability• Of the programs that responded o 82% indicated a wait of five days or less for newly diagnosed patients o 12% indicated a wait of 10 days or less o 6% were unable to answer the question• All programs that failed to meet the measure were contacted again in December• Only one program failed to meet the measure on the second attempt
  • 53. HRSA System Measures- HIV Test Results for PLWHA• Definition: Percentage of individuals who test positive for HIV who are given their HIV-antibody test results in the measurement year• Performance for 2011: 71%
  • 54. HRSA System Measures- System-Level Performance• Definition: Rate of achievement (percentage of patients) of the performance measurement of interest in the system in the measurement year.• AACO selected the local A2 Retention in Care measure as the measure of interest for the EMA.• Numerator: HIV positive clients who received at least one medical visit in the current measurement year• Denominator: HIV positive clients who received at least one medical visit in the year prior to the current measurement year• Performance for the 2011 Measurement Year: 84%
  • 55. Quality Improvement Projects• Expanded to all core services in 2012• EMA uses form developed by PA’s Part B QM Committee for all core services except O/AMC• All QIPs updated quarterly and submitted• Grantee provides feedback to providers on all plans and requires revisions as needed• In 2012, 126 QIPs were collected and reviewed• Grantee works with programs that will need to submit more than 5 QIPs per year to identify priorities
  • 56. Quality Improvement ProjectsAACO has moved away from regional measures to a more individualized approachValue in working toward common goal- facilitates sharing of best practicesBut number of O/AMC measures makes priority-setting criticalLast regional measure saw providers with high performance doing a QIP at the expense of other key measures with low performance
  • 57. Quality Improvement ProjectsSuccess on one measure is not necessarily predictive of success on other measuresEMA has defined key measures and set automatic thresholds for QIPsPrograms may still select other measures for improvement in addition to any required QIPs
  • 58. Quality Improvement Projects• Triggers for QIP submission o 0% performance on any measure o Greater than 10% gap between VL and Visits o Below 50% on Colposcopies o Below 60% on Cervical Exams o Significantly below EMA (lowest 5 performer)• Significant declines o Viral Load 5% o Syphilis 5% o Cervical Exams 5%
  • 59. Quality Improvement ProjectsNarrative format for O/AMC ◦ QI Committee, including program leadership ◦ Focus on specific performance measure(s) ◦ Root causes for low performance (data-driven) ◦ Action Steps target processes related to root causes ◦ Plan for implementing actions and goal ◦ Quarterly updates
  • 60. Quality Improvement ProjectsQI Storyboard for all other core services ◦ Developed by PA’s Part B QM Committee ◦ Strict adherence to FOCUS PDSA process ◦ Each step mapped out ◦ Particularly useful for new providers or those struggling with CQI ◦ Strong emphasis on incorporating data into the process
  • 61. Criteria For Evaluating QualityImprovement ProjectsFocus on systems and processesAre data-drivenUtilize a sound QI process (e.g. FOCUS PDSA)Investment by program leadershipIncorporation of consumers in the QI processProduces desired improvements
  • 62. Consumers and CQIPDPH emphasizes consumers in the QI process ◦ Consumers on QI teams or committees ◦ Obtain input from Consumer Advisory Boards during key stages of a QI process ◦ Consumer focus groups ◦ Client surveys to obtain client input relating to causes for low performance or proposed action steps
  • 63. QIP Outcomes
  • 64. Questions or Comments