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.
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
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
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
Hinweis der Redaktion
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