CDPH Ryan White Part A Early Intervention Services (EIS)

Learning Collaborative Series Kick-Off Meeting

Tuesday, June 28, 2016

Agenda

• Welcome • PHIMC & CDPH QM Collaboration• Learning Collaborative History, Structure, & Requirements• EIS Site Visit Recap & Data Overview • EIS Quality Improvement Projects: Standards, Indicators, & Goals• PDSA Overview• Talk to Your Partner • Meet Your Coach & Team Discussion• Close

Goals for Today’s Meeting

1) Review the CDPH Learning Collaborative structure and purpose.

2) Brainstorm quality improvement projects ideas.

3) Agency introductions to assigned coaches and teams.

4) Leave with developed quality improvement projects ideas.

The Learning Collaborative Binder

• Agenda

• LC Agency Contact List

• Coaching Assignments & Teams

• Quality Improvement Projects

• HRSA EIS Program Monitoring Standards

• CDPH EIS Standards of Care

• NHAS Indicators

• QM EIS Audit Tool

• PHIMC Aggregate Data Presentation

• TRN’s EMA Aggregate Data Report

• LC Evaluation

PHIMC Mission and Vision

Public Health Institute of Metropolitan Chicago (PHIMC) enhances the capacity of public health and health care systems in Illinois to promote health equity and expand access to services.

How We Work

PHIMC leads efforts to strengthen the public health infrastructure in Illinois through:

• Organizational Development

• System Transformation

• Fiscal Management

• Program Implementation

How does PHIMC fit into Ryan White Part A?

• Technical assistance provider partnering with CDPH to implement Ryan White Quality Management (RW QM) across the Chicago EMA.

• Prior to March 2015, MATEC was lead on this project for 14 years.

• MATEC contracted primarily with Training Resources Network- Ms. Susan Thorner’s consulting agency.

The CDPH RWQM Program is….

A partnership between PHIMC and the Chicago Department of Public Health’s Quality Management (QM) Unit to provide training, technical assistance, and capacity building support to Ryan White Part A funded agencies in an effort to maintain sustainable internal QM infrastructure across the Chicago EMA.

How is RWQM Implemented?

• QM Site Visit Implementation

• Learning Collaboratives

• Webinars

• Support core MATEC Trainings

• Generating QM Newsletter/Online QM Resources

• Participation in Community Planning Efforts, i.e. CAHISC and the MAG

• Updating CDPH Standards of Care

• Audit Tool Creation & Data Collection

• Sub-recipient and CAHISC member surveys

• Conflict Resolution Training & Grievance Access

PHIMC and CDPH collaborate on the following items:

What is Quality Management (QM)vs.

Quality Assurance (QA) or Quality Improvement (QI)?

• Quality Management: All functions to evaluate and improve quality

i.e. QM committee + QM plan + QM site visits from funder, etc.

• Quality Assurance: Checking Boxesi.e. Program Monitoring Site Visits

• Quality Improvement: Enhancing Servicesi.e. Increasing percentage of AOMC clients receiving STI screening

What is a “Learning Collaborative”?

• Model developed by the Institute for Healthcare Improvement (IHI) in 1994, later adopted by NQC & HRSA

• Since 2000, NY State Health Department has tested LC model with RW Parts A-D

• In 2008, NQC published LC guide for RW providers nationwide

• Implementing quality improvement & identifying best practices

• Designed for clinical carehttp://nationalqualitycenter.org/files/planning-and-implementing-a-successful-learning-collaborative-pdf/

What is a CDPH Ryan White Part A Learning Collaborative (LC)?

• One Ryan White core service category selected based on CDPH Quality Management site visits from previous year.

• At least four LCs occur in given grant period (March 1st- Feb 28th).

• Agencies that received QM site visit in previous year are required to attend.

• Open to all CDPH RW Part A funded agencies.

Who should attend an CDPH RW Part A LC?

• CDPH Ryan White Part A-funded agencies

• Designated members of RW quality improvement team ORagency staff implementing the service category in question

• For 2016 EIS focused series, this may include:- Member of RW QI team

- Program Managers

- EIS specialists

- LTC staff

- Anyone else instrumental in implementing EIS

What are the requirements for LC participants?

• Register and attend four Learning Collaboratives.

• Complete and present on one quality improvement project for your agency by January 25, 2017.

• Work with and report to assigned coach as necessary.

Translating Ryan White Service Category into an Learning Collaborative Format

1) Review standards of care

2) Evaluate data

3) Convene planning session that includes providers for input

4) Identify quality improvement project areas (measurable indicators)

5) Create space for providers and experts to share best practices

6) Solicit provider input throughout

2016 Early Intervention Services (EIS) Learning Collaborative Series: Foundation

Note: This is the first CDPH Part A EIS focused Learning Collaborative.

• Partially informed by 2015 QM EIS site visits.

• Planning session convened on 5/24/16 including providers from 5 agencies.

• Local provider input and focus.

This year’s number one goal is to structure a learning collaborative that allows RW providers to be the experts.

2016 Early Intervention Services (EIS) Learning Collaborative Series: Structure

• Four provider meetings

• Quality Improvement Tips, Tricks, Trends

• Best Practices Presentations from EIS Providers

• Built in time to meet with coaches & team

CDPH 2015 EIS Site Visit Overview

• 20 agencies site visited in 2015

• 4/20 previously funded by CDPH

• 16/20 newly funded

• Pilot Year

• Not required: EIS Quality Improvement Plan

• Required: 1 EIS Quality Improvement Project

Before We Review the Data….

• EIS is brand new!

• Site visit audit tool has room for improvement.

• Training Resources Network (TRN) led audit tool creation and data report generation.

• Site visit data scores are not punitive measures, but indicators of potential areas of improvement.

Katie Morin, PHIMC Data Strategist

Tuesday, June 28, 2016

EIS Technical Assistance Site VisitAggregate Data Report Back

TA Site Visit Overview

• TA Site Visits September to October 2015• Conducted by CDPH, PHIMC, & TRN

• 20 Agencies (4 Previously Funded 16 Newly Funded)• 222 Charts Reviewed

• For Sites funded prior to 3/1/2015 the review covered March 1, 2014 to February 28, 2015.

• For Sites funded after 3/1/2015 the review covered March 1, 2015 to August 31, 2015.

• Final Report and figures compiled by TRN • All compilations are based on the average of the percentages in the

EMA report, not the raw data.

Quality Assurance Measures

QA Measures:• Largely a compliance check

• Does not have the most direct impact on linkage, retention and suppression.

CQI Measures:• More direct impact on linkage, retention and suppression.

84%

51%

61%

96%

63%

30%

Documentation of Consent Forms Documentation of Initial Intake Documentation of Signed Service Plan Documentation of Completed and SignedMedical Assessment/Evaluation

Documentation ofRisk Assessment

Documentation ofCase Closure

Chicago EMA Documentation of Completion of Forms

QA Data Conclusions

QA Highlights• 96% Completed and Signed Medical Evaluations• 84% Signed Client Consent Forms

QA Opportunities for improvement• 51% Documentation of Initial Intake• 61% Signed Service Plans • 63% Documentation of Risk Assessment • 30% Documentation of Case Closure

Quality Improvement Measures

• All compilations are based on the average of the percentages across all providers in the EMA report, not the raw data.

Data is divided into the following: • Documentation of HIV Testing and Counseling

• Documentation of Referral Services

• Documentation of Health Education and Literacy

• Documentation of Linkage & Retention

94%

80%

93%

65%

Documentation of confirmed HIV status in the chart Documentation that the meaning of a positive HIV test wasexplained to the patient

Documentation of referral for appointment with medicalprovider discussed and provided

Documentation of referral for medical case managementdiscussed and provided

Documentation of HIV Testing and Counseling

83%

CHICAGO EMA AGGREGATE

57%60%

70%

33%

28%

54%

Documentation of referral plan completedwithin 5 business days of initial intake

Documentation of referral to medical casemanagement services

Documentation of referral to medical care Documentation of referral to specialtycare

Documentation of referral to dental care Documentation of referrals monitored

Documentation of Referrals

33%

40%

22%

34%

Documentation of referral to substance abuse treatment Documentation of referral to Mental health Documentation of referral to partner notification Documentation of referral to other supportive services

Documentation of Referrals

83%

57%

Documentation of HIV Testing and Counseling Documentation of Referrals

CHICAGO EMA AGGREGATE

89%

80%76%

57% 57%

52%

Adherence counseling aboutHIV medications and treatment

Labs and their meaning HIV Rx side effects Importance of early initiation oftreatment

How to cope with living withHIV

Disclosure

Documentation of Health Education and Literacy

60%

40%

23%

48%

11%

26%

Nutrition Oral health/hygiene Exercise Tobacco cessation [only iftobacco use]

Alternative Therapy Legal issues

Documentation of Health Education and Literacy

36% 36%

55%

34%

63%

57%

Hep B Hep C STD/STI TB Condom use/sexual riskmanagement

IDU/drug or alcohol use

Documentation of Health Education and Literacy: Risk Reduction

83%

57%

51%

Documentation of HIV Testing and Counseling Documentation of Referrals Documentation of Health Education and Literacy

CHICAGO EMA AGGREGATE

65%

72%

Reasons the patient did not have at least two medical visits Follow-up telephone calls, letters &/or home visit) for missed appointments

Linkage and Retention Efforts

85%

64% 64%61%

Client received 1st clinical visit with a clinical provider within 3months after a confirmed HIV test result

2 medical appointments within the review period - 90 daysapart.

Client successfully retained 3 mo Client successfully retained 6 mo

Documentation of Linkage and Retention in Care

83%

57%

51%

69%

Documentation of HIV Testing and Counseling Documentation of Referrals Documentation of Health Education and Literacy Documentation of Linkage/ Retention in Care

CHICAGO EMA AGGREGATE

Quality Improvement Data: Highlights

HIV Testing and Counseling • 93% Referral for appointment with medical provider discussed and

provided • 80% Documentation that the meaning of a positive HIV test was

explained to the patient

Health Education and Literacy • 89% Adherence Counseling Provided • 80% Meaning of Labs Explained

Linkage and Retention in Care• 85% Attended Clinical Visit within 3 months

Quality Improvement Data: Opportunities for Improvement

HIV Testing and Counseling:• 65% Referrals to medical case management

Referrals • Documentation of referrals overall fell short of the 80% or the “good”

measure• Example 54% Monitoring of referrals

Quality Improvement Data: Opportunities for Improvement

Health Education and Literacy• Documentation of health education and literacy fell short of the 80% or

“good” measure in several areas. • Example 57% Importance of early initiation of treatment

Linkage and Retention in Care • 64% client successfully retained 3 months.

Questions?

Acknowledging the challenges with utilizing EIS in an LC format

• Brand new service category• Limited data • Standards of care do not include measurable indicators• Intervention contains non-clinical/social components

What We Know: The 4 Buckets of Early Intervention Services (EIS)

• HIV Counseling and Testing

• Linkage to Care

• Referrals

• Health Literacy

Applying the NHAS Indicators to EIS

NHAS Indicator 4: Increase percentage of newly diagnosed person

linked to HIV medical care within one month of their diagnosis to at

least 85%.

NHAS Indicator 5: Increase the percentage of person with diagnosed

HIV infection who are retained in HIV medical care to at least 90%.

NHAS Indicator 6: Increase the percentage of persons with diagnosed

HIV infection who are virally suppressed to at least 80%.

Steps to selecting an EIS Quality Improvement Project

Step 1: Select an NHAS indicator.

Step 2: Select one of the buckets of EIS.

Step 3: Identify small-scale projects.

Step 4: Conduct PDSA.

Break

The PDSA Cycle or

How Can We Accelerate Improvements in

HIV Care?

The Quality Academy

Tutorial 13

48

The PDSA Cycle

for Learning and Improvement

The PDSA Cycle

49

Plan

The PDSA Cycle

1. Clarify your Objective

2. Make a prediction

• Formulate theory

• Objective + specificity

3. What is to be done

• Who

• What

• Where

• When

• How

50

Do

The PDSA Cycle

1. Carry out the plan

2. Document your

observations

• Expected

• Unexpected

3. Begin analysis

51

Study

The PDSA Cycle

Complete

Compare

Summarize

52

Act

The PDSA Cycle

1. Adjustments

• Changes to previous test?

• What adjustments?

• Expand last cycle?

2. New cycles

• What are you planning?

• What are you going to test?

53

At the Beginning, Test on a Small Scale

• “What change could you implement by next Tuesday?”

• Use the “Rule of 1”:

• 1 facility

• 1 office

• 1 provider

• 1 patient

Applying PDSA

54

Scale Down the Time Frame

• Years

• Quarters

• Months

• Weeks

• Days

• Hours

• Minutes

Drop down two

levels! (years to

months, weeks

to hours)

Applying PDSA

55

Keep the First Tests Simple

• Volunteers at first

• Useful, not perfect, data

• Use “huddles” to report

Applying PDSA

56

Build Each Cycle on Its Predecessor

“The shorter the timeframes between test cycles, the more tests can be conducted and therefore, more opportunities for learning will emerge.”

HIVQUAL Workbook

Applying PDSA

57

Key Points

The PDSA Cycle:

• Helps “test your hunches”

• Adapt these changes to your own

environment.

• Start small

• Lead to more complex cycles

Key Points

58

Resources

• http://www.IHI.org/IHI/Improvement/ ImprovementMethodsprovides information on improvement methods, strategies, and changes.

• Moen, Ronald, Thomas Nolan; “Process Improvement” Quality Progress, 1987, p62.

• Langley, Gerald, Kevin Nolan and Thomas Nolan; “The Foundation of Improvement,” Quality Progress, June 1994, p. 81.

• Langley, Gerald, Kevin Nolan, Thomas Nolan, Cliff Norman, and Lloyd Provost; The Improvement Guide. San Francisco, CA; Jossey-Bass, 1996.

• Nolan, Kevin; “ASQs Accelerating Change Collaborative Series: A Challenge for Industry,” Quality Progress, Jan 1999, p55.

Resources

59

The Quality Academy

For further information, contact:

National Quality Center

New York State Dept. of Health

90 Church Street, 13th floor

New York, NY 10007-2919

Work: 212.417.4730

Fax: 212.417.4684

Email: Info@NationalQualityCenter.org

Or visit us online at NationalQualityCenter.org

In Closing

60

QUESTIONS?

Talk to Your Neighbor

• EIS Challenges and Successes

• Quality Improvement Project Brainstorm

Meet with Your Coach & Team

Team 1: Charlotte Detournay

Austin CBC

Michael Reese

Regional Care Association

Team 2: Silas Hyzer

Loyola Medical Center

Lurie Children’s Hospital

Mount Sinai

Team 5: Katie Morin

Access Community Health Network

Erie Family Health Center

Heartland Health Outreach

Howard Brown Health Center

Team 6: Barbara Schechtman

South Suburban HIV/AIDS Regional

Clinics

Provident Hospital

Core Center

Team 3: Rod Kaup

AIDS Healthcare Foundation

Lawndale Christian Community Health

Center

Open Door Clinic

South Shore Hospital

Team 4: Laura Kuever (Jenny Epstein)

Lake County Health Department

University of Illinois, Chicago

University of Chicago

Small Group Discussion Questions

1. Introductions & Outstanding Questions

2. Share one productive Ryan White quality improvement project experience you've had. What made it productive?

3. What do you find is the biggest challenge in implementing quality improvement projects at your agency? Why?

4. Brainstorm and share potential EIS QIPs.

5. How can coach be most supportive to you and your agency?

Upcoming Learning Collaboratives

• Tuesday, September 20th, 9:30 AM- 12:30 PM

• Thursday, November 17th, 9:30 AM- 12:30 PM

• Wednesday, January 25th, 9:30 AM- 12:30 PM

Other Upcoming CDPH QM activities

• QM Webinar 1 “Conducting Quality Improvement Projects for Ryan White Part A Early Intervention Services (EIS) in the Chicago EMA” coming up on Tuesday, July 26th 12:00 pm- 1:00 pm

• Online QM Resource Hub in progress

• 2016 QM site visits: mental health, psycho-social, and substance abuse residential

• QM site visit orientation in August 2016

Questions?

Thank You!

Ayla Karamustafa, Quality and Prevention Manager

Public Health Institute of Metropolitan Chicago

Ayla.Karamustafa@phimc.org

Katie Morin, Data Strategist

Public Health Institute of Metropolitan Chicago

Katie.Morin@phimc.org

Barbara Schechtman, Quality Management Consultant

Public Health Institute of Metropolitan Chicago

Barbaraschechtman@gmail.com