The document summarizes activities of the Philadelphia Department of Public Health's AIDS Activities Coordinating Office (AACO). It discusses the Client Services Unit (CSU) which provides intake, case management, and housing services. It also reviews quality management activities including monitoring performance measures for outpatient medical care and medical case management. The AACO tracks over 25 measures for both areas and provides bi-monthly feedback to improve client outcomes.

1. Philadelphia Department of
Public Health
AIDS Activities Coordinating Office
Comprehensive Planning Meeting
February 6, 2013

2. Client Services Unit
CSU

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 Intakes
Calendar 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 182 280 150 239
Percent 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 CHANGE
A1 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 Measures
Retention 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 CSU
Linkage 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 Management
Performance Measures
Performance
2008 2009 2010 2011 2012 (1/1-9/30)
measures
Retention in
MCM (< or = 10
weeks after 76% 81% 80% 78% 82%
intake)
Retention in HIV
medical care for
clients 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 Measures
Unmet 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 Measures
Mental 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 Measures
Substance 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 Measures
Secondary 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 Measures
Medication 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 Measures
Medical 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 Measure
Medical 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 for
MCM
*Data as of 10/31/12

39. Process for Monitoring Medical and
MCM 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 and
MCM 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 Care
Performance 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 Quality
Improvement 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