Quality Management

Update Ryan White Part A

Atlanta EMA

January 5, 2017

Agenda

• Program Monitoring

• Site Visits

• Desk Audits

• Quality Projects

• CAREWare Project

• Time-Study Project

• Quality Measures

• HAB Performance Measures

• EMA Performance Measures

Program Monitoring

Quality Assurance

- Refers to a broad spectrum of evaluation activities aimed at ensuring compliance with minimum quality standards

• Programmatic Site Visits

• Fiscal

• Programmatic

• Quality Management

• Desk Audits or Chart Reviews

• Review of Client Records

FY 2016 CHANGES • Decrease Site Visits

• Quarterly Annually

• Expand Quality Management Discussion During Site Visits

• Increase Scope and Volume of Chart Reviews

• In addition to eligibility, reviewing charts for compliance in each funded service category

• Random sampling based on client size

• Annually quarterly, ongoing

QM SITE VISITS

QM Site Visits

• Infrastructure

• Quality Management Plan

• Quality Improvement Projects

QM Site Visits- Infrastructure

Quality Management Staff Capacity

Full-time QM Coordinator 29%

Part-time QM Coordinator 65%

QM Team Meeting Frequency

Weekly 6%

Monthly 35%

Quarterly 47%

Biannually 12%

QM Team Size

1- 3 Members 12%

4-6 Members 35%

7-9 Members 24 %

10+ Members 29%

QM Site Visits- QM Plan

• Quality Infrastructure • Roles/Responsibilities

• Goals and Objectives • SMART Objectives in

alignment with goals

• Performance Measurement Process

• Participation of Stakeholders

• Capacity Building

• QI Projects

• Evaluation • Process to evaluate QM

Program

• QM Plan Implementation

Common elements that were missing or vague:

QM Site Visits- Projects

12% 6%

18%

35%

29%

QI Projects

none

1

2

3

4+

Subject # projects # agencies

Care Continuum 13 10

Core Services 8 5

Administrative 6 6

Technology 6 4

Client Satisfaction 5 5

HAB Measures 5 3

Support Services 4 2

Workflows 3 2

Capacity Building 2 2

CHART REVIEWS- 2ND QUARTER

Desk Audits (Chart Review)

• Conducted by Project Officers

• New Chart Review Tool- created Summer 2016

• Chart Review tool is based on language from: • National Monitoring

Standards for Ryan White Part A Grantees: Program – Part A

Chart Review 2016

% of Sample* Number of

Clients Served (Range)

100% 1-50

unduplicated clients

25-50% 51-100

Unduplicated Clients

10% 101-999

Unduplicated Clients

3-5% 1,000

Unduplicated clients or more

• Reviews a random sample of client records based on projected client size

• Sample Size - 1,985

• Chart review visits started at the end of Quarter 2

• Status- Completed 685 chart reviews

Chart Review 2016- Status Funded Service

Categories Sample Size Percentage Completed

Medical Case Management 118 16%

Medical Nutrition Therapy 55 31%

Mental Health 155 43%

OAHS-Primary Care 643 41%

Oral Health 213 12%

Substance Abuse 76 53%

Childcare 28 0%

Food 159 31%

Legal 15 100%

Linguistics 32 22%

Medical Transportation 70 100%

Non-Medical Case Management 284 23%

Psychosocial 137 24%

Chart Review Summary Some findings included:

• Eligibility • Some files were not recertified

within timeframe • SSI amount not listed on letters • Lack of HIV Documentation • Missing supporting

documentation for residency and income claims

• OAHS • Clinical notes were not signed

by a provider

• Mental Health • Treatment plan were not signed

by a provider • Missing documentation of the

existence of a detailed treatment plan for each eligible client that includes ALL of the following: • (1)Diagnosis of mental illness

condition, • (2) Treatment modality (group or

individual), • (3) Start date of mental health

services, • (4) Recommended # of sessions, • (5) Date of reassessment, • (6)Any recommendations for

follow-up, and • (7) The signature of the mental

health professional rendering services is documented

QUALITY IMPROVEMENT PROJECTS

CQI Projects

• CAREWare Project

• Time-Study Project

CAREWare Project: PDSA Cycles

• Cycle 1: Data Verification

• Cycle 2 : Computer System Optimization

• Cycle 3: Data Entry and Reporting Processes • Is CAREWare data entered

the same across the EMA?

• Are CAREWare data report parameters set for data of interest?

PDSA Model

CYCLE THREE: Data Entry and Reporting

• PLAN • Develop CAREWare Survey based on subservice categories

• DO • Distribute surveys during site visits

• Meet with Cross-parts representatives about updating CAREWare dictionary

• STUDY • Summarize and Analyze Results

• Discuss results with Part A, B , C, and D representatives to identify areas of needed clarity and training

• Follow-up with agencies to better understand data entry processes and usage

• Review CAREWare setup with developers for ideal data parameters to improve how data is entered and shared

STUDY: CAREWare Survey

• Which subservice fields should be added, edited, or removed?

• Based on services currently provided, how should we define…

• Units?

• Subservice category?

• Which subservice fields are needed to calculate a quality measure?

• Reviewing survey responses for…

• Most utilized

• Least utilized

• Variations in usage

STUDY: CAREWare Survey

• Medical Nutrition Therapy • Nutritional Assessment

• Nutritional Supplement

• Mental Health and Substance Abuse • Intake

• Assessment

• Intake/Assessment

• Treatment Plan

• Behavioral Health Screening

• Outpatient Ambulatory Health Services

• Medical Procedure Visit • Primary Care Visit • Routine HIV/TB Primary Care Visit • Medication Pick up • Primary Care Prescription (nonHIV

med) • Lab Review

• Oral Health • Alternative Units

• Cost of procedure • Unit per quadrant

• Medical Case Management

• Discharge Linkage • Treatment Adherence • Individual Medication Adherence

Counseling • Medication Adherence Assessment • Case Management Assessment

STUDY: CAREWare Survey

• Linguistics

• American Sign Language

• Other Language

• NonMCM

• Benefits/Financial Counseling

• Face-to-Face Interim Contact

• Update Service Plan-Non Medical

• Psychosocial Support

• Default Psychosocial Support 2

• Group Peer Counseling

• HIV Support Group

• ChildCare

• No Variation

• Food Bank/Home Delivered Meals

• Vouchers

• Legal

• No Variations

• Medical Transportation

• Van

• Public Transportation

• 58% use one-way trip

Time Study Project: Cycle One

• Plan

• Determine the best way to gather information related to appointment data

• Ensure the study takes place during a representative time period

Next Steps…

• CAREWare Project • STUDY

• Discuss results with cross-parts

• Follow-up with agencies

• Act • Revise CAREWare Data

Definitions with Parts B,C, and D

• Distribute and train Quality Management and Data Designees

• Customize CAREWare

• Time-Study Project • Create data collection tool

QUALITY MEASURES

HAB MEASURES- 11.30.16 HAB Performance Measure Part A

Core01 HIV viral load suppression 74%

Core02 Prescription of antiretroviral therapy 89%

Core03 HIV medical visit frequency 62%

Core04 Gap in HIV medical visits 15%

HAB03 CD4<200 with PCP prophylaxis 38%

HAB07 Cervical Cancer Screening 27%

HAB09 Hepatitis C Screening 76%

HAB10 HIV risk counseling 80%

HAB12 Oral Exam 24%

HAB13 Syphilis screening 72%

HAB14 TB Screening 87%

HAB15 Chlamydia Screening 75%

HAB16 Gonorrhea Screening 75%

HAB17 Hepatitis B Screening 73%

HAB21 Mental Health Screening 73%

HAB23 Substance Use Screening 72%

EMA MEASURES- CORE 11.30.16

EMA Performance Measure Target Part A OAHS: Viral Load Suppression 83% 74%

OAHS: Medical Visits Frequency 83% 62%

Oral Health: Medical Visits Frequency 96% 76%

MNT: Medical Visits Frequency 96% 73%

MNT: Referred received MNT screening, education or counseling visit N/A

MCM: Medical Visits Frequency 53% 57%

MCM: Care Plan N/A

MCM: Viral Load Suppression 66%

MCM: Gaps in Medical Visits 23.31%

Mental Health: Medical Visits Frequency 90% 65%

Mental Health: Screening (HAB 21) 83% 73%

Mental Health: Treatment Plan N/A

Substance Abuse: Medical Visits Frequency 92% 64%

Substance Abuse: Treatment Plan N/A

EMA MEASURES- Support 11.30.16

EMA Performance Measure Target Part A Non-MCM: Medical Visits Frequency 86% 66%

Non-MCM: Care Plan N/A

Non-MCM: Viral Load Suppression 88% 72%

Non-MCM: Gaps in Medical Visits 13.30%

Food Bank/ Home Bank: Medical Visits Frequency 85% 56%

Food Bank/ Home Bank: Dietitian Review N/A

Psychosocial Support: Medical Visits Frequency 71% 57%

Psychosocial Support: Linkage to Care N/A

Medical Transportation: Medical Visits Frequency 86% 60%

Legal: Medical Visits Frequency 75% 53%

Linguistics: Medical Visits Frequency 96% 83%

Child Care: Medical Visits Frequency 96% 65%