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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%