Ryan White Indianapolis Part A Quality Management Overview
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This document summarizes quality improvement (QI) initiatives and projects conducted by an organization from 2008-2016. It provides an overview of various QI projects implemented each year, including improving cervical cancer screenings, case management redesign, and collecting data on barriers to care. It also presents retrospective data on inactive clients from 2014 and identifies challenges around data management, workforce retention, and service access and delivery. Finally, it outlines stretch goals for the future, including implementing a shared data system, conducting needs assessments, and continuing to integrate QI across all levels of services.
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Ryan White Indianapolis Part A Quality Management Overview
- 1. Part A Quality Management A Summary of QI Initiatives and Projects 2008-2016 Presented by: Dana D. Hines, PhD, MSN, RN March 18, 2016
- 2. 2008 New TGA capacity building initiative Group 1 HAB measures QM committee becomes standing committee on PC Formed perinatal workgroup to evaluate rate of perinatal transmission in the TGA
- 3. 2009 Training of the Trainer and Total Quality Leadership SOC & QM committees develop local monitoring standards CAREWare goes live at most agencies “Get Papped” QI project to improve cervical cancer screenings
- 4. 2010-2011 Acuity assessments for CM agencies Capacity building, training, and redesign Collaborative CM QM Plan Case management redesign Launch of the floating medical case manager QM-led medical transportation survey
- 6. 2013-2015 Collected data on client’s concerns regarding access to care Rolled out CAREWare case notes templates on a limited basis QM committee-led survey on barriers to RWSP recertification All agencies began developing and implementing their own QM Plan
- 7. 2016 Retrospective review of 2014 inactive RWSP clients 415 415 RWSP Parts A & C case management manual Now until June 1st
- 8. 2014 Inactive Clients by Race/Ethnicity 81, 40% 101, 49% 7, 3% 16, 8% AA White Asian/PI Hispanic N=205
- 9. 2014 Inactive Clients by Gender 33, 16% 171, 83% 1, 1% Number female male MTF N=205
- 10. 2014 Inactive Clients Last CD4 Count December 2014 or earlier Jan-June 2015 July-Dec 2015 Missing CD4 count 86/205 (42%) 41/205 (20%) 53/205 (26%) 25/205 (12%) may be lost to care, deceased, or OOJ Of the 86, 10 died during this timeframe (December 2014 or earlier) Of the 41, 2 died during this timeframe (Jan-Jun 2015) 76/205 (37%) Lost to care 39/205 (19%) Lost to care N=20556% (n=115) of the 205 cases reviewed thus far are lost to care
- 11. Systems Level Challenges Data Management & Integration Retiring workforce of HIV community leaders Service Access & Delivery
- 12. Data Management & Integration • Multiple, uncoordinated data management systems • Ryan White funded providers using multiple data systems – CAREWare – Case manager – Gopher or G3 (Soon to be EPIC) – iSalus – Other hospital-based EMRs
- 13. Service Access & Delivery • Lack of universal RWSP application • Overlapping role definitions for care coordination (ISDH) and case management (CM) (MCPHD) • Lack of clarity regarding medical and non- medical CM
- 14. Service Access & Delivery • Confusion regarding service definitions – Psychosocial and outreach • Recertifying eligible clients for RWSP • No standardized process for identifying and reengaging clients lost to care • Lack of Hispanic/Latino service providers
- 15. Stretch Goals for the TGA and State • Implement a shared state and county data management system for dually funded service providers • Activate data sharing among agencies with shared clients • Facilitate quarterly meetings between state-funded CC and MCPHD-funded CM • Conduct a state-wide needs assessment of the transgender population in Indiana • Engage in succession planning to maintain a pool of competent and capable HIV leaders in the community • Continue to integrate QI at every level of service entry and across all steps of the Care Continuum • Explore and apply for grant opportunities that provide unrestricted dollars for HIV services across the Continuum
- 16. Food for Thought • “The most damaging phrase in the language is: ‘It’s always been done that way.'” ~ Grace Hopper
Editor's Notes
- Goals for my portion of the presentation are to: Highlight the major QI initiatives and projects that the Part A QM program has been involved in since Indianapolis became designated as a TGA Describe major systems-level challenges facing the TGA Present stretch goals for awardees and sub-awardees in the TGA to consider going forward Core Functions Quality management across all levels: Awardee/administrative Internal CQI projects Formalized minute-taking for staff meetings to document, monitor, and track programmatic activities, goals, and updates Internal policies and procedures QA committee for the MCPHD (past) Sub-awardee Site visits/chart audits Use of case note templates to improve documentation of service delivery and to ensure that services provided meet the National Monitoring Standards definitions Coaching on QM plan development Coaching on service program monitoring HAB measures evaluation Coaching/guidance on agency-led CQI projects LPAP Advisory Board facilitator Staff liaison for the goals and objectives workgroup for the integrative plan of care Internal reviewer for sub-awardee grant applications 2011 introduced the concept of writing reviewer’s comments for sub-awardees to guide improvements of future grant applications and program service delivery Support the Part A Director in writing the Part A & MAI grant, progress report and implementation plan, and all other major reports Develop, implement, and update TGA-wide QM Plan Contributing writer for 8 grants, 8 progress reports and implementation plans Participated in over 84 planning council meetings Reviewed approximately 85-90 RFPs from sub-awardees submitted over a 7 year period
- New TGA Initiative: Indianapolis, Nashville, New Orleans, Memphis, and Charlotte, NC First year of data collection was labor intensive. Involved manual chart reviews and hand counting. (November 6, 2008) The Ryan White Part A Planning Council in full session on November 6, 2008 approved, in principle, the establishment of a Quality Management Committee and designated it as a Standing Committee of the Council. Formed informal perinatal work group to evaluate the rate of perinatal transmission in the TGA This group eventually secured funding to formally implement the Fetal Infant Mortality Review (FIMR)/HIV project in Marion County. FIMR is an enhanced perinatal transmission prevention program that uses formal case reviews and community action to investigate cases of exposure and to prevent future perinatal transmissions. Lead to One Test Two Lives Campaign and practice changes for HIV testing during pregnancy.
- 2011 First publication: Using quality improvement principles and concept analysis to refine the role of HIV case management published in Care Management along with co-author Michael Wallace.
- Client concerns: ACA/state-funded insurances-namely how to navigate those new systems Frequency of recertifying for the RWSP Length of time for processing referrals Having to complete two applications, one for the state and one for the county Access to “good” transportation Job placement, utilities, and food Case notes Medical transportation Psychosocial Mental health Substance abuse Outreach EIS Problems with recerts Missing required documentation Recertification after expired date-client driven No client response Moved out of TGA Client no showed for recert appointment Client missed recert window Had other insurance
- QM committee-led survey led to a larger, internal QA project to further examine reasons why clients did not recertify for our program in 2014. Will provide up-to-date numbers
- We used last CD4 count because until recently it was the gold standard for immune system monitoring. Now replaced by VL 115 (28%) of the 415 that went inactive lost to care. Numbers are likely higher. We’ve reconciled 205 cases, 210 to go…
- Data Management and Integration (Ongoing) Prior to July 2009, the process for collecting client-level performance management data was fragmented and variable. The lack of consistent data collection and reporting processes resulted efficiency losses and unreliable data. In FY2009, the QM Program collected data only from the HAB Group 1 measures. The Part A recipient transitioned to CAREWare in an effort to resolve these data challenges. Providers funded by Ryan White and ISDH challenged with entering data into multiple data management systems that are not integrated
- Lack of universal application for all RW Services. One separate app for the state and another one for the county Lack of a standardized process and mechanism to identify clients lost to care and reengage them in care at a community-level. Concerns regarding confidentiality/privacy, when and to whom to refer these clients have added to this overarching challenge Service Access and Delivery (Ongoing) Lack of universal application for all Ryan White Services Overlapping service definitions for the state-managed care coordination system and the county managed medical/non-medical case management systems Ongoing confusion regarding the activities/services that distinguish medical case management from non-medical case management Ongoing confusion regarding the activities that meet the HRSA service definition of outreach and when to appropriately use outreach services Ongoing challenges with recertifying eligible clients for the RWSP Lack of a standardized process and mechanism to identify clients lost to care and reengage them in care at a community-level. Concerns regarding confidentiality/privacy, when and to whom to refer these clients have added to this overarching challenge Gaps in service to the Latino community
- Lack of universal application for all RW Services. One separate app for the state and another one for the county Lack of a standardized process and mechanism to identify clients lost to care and reengage them in care at a community-level. Concerns regarding confidentiality/privacy, when and to whom to refer these clients have added to this overarching challenge Change in HIV leadership….Michael Wallace followed by Tom Bartenbach, Betty Wilson, and Paula French.
- Continue to explore options for a universal, integrated data management system that is shared by ISDH and the MCPHD. Continue to explore options that will allow data sharing for shared clients among stated and county-funded service providers. Will enhance monitoring and progress of the continuum of care at a local level Facilitate quarterly care coordinator and case management case review meetings to investigate trends such as clients who: a) never initiate care, b) are lost to care, c) who fail to achieve HIV viral load suppression, d) who could benefit from, yet do not access mental health or substance abuse services. Complete a state-wide needs assessment of the transgender population Engage in succession planning by developing an AIDS service/public health residency/institute that provides support and ongoing mentoring for up and coming leaders in the TGA-wide HIV community This will ensure quality and continuity of HIV leadership in our community as our current and most senior leaders prepare for retirement Continue to integrate quality improvement at every level of service entry and across all steps of the care continuum Explore grant opportunities that provide unrestricted dollars for HIV services program delivery across all steps of the continuum
- Lack of universal application for all RW Services. One separate app for the state and another one for the county Lack of a standardized process and mechanism to identify clients lost to care and reengage them in care at a community-level. Concerns regarding confidentiality/privacy, when and to whom to refer these clients have added to this overarching challenge