Developing Quality Management Activities from the Ground Up

1. Developing Quality Management Activities from the Ground Up Elizabeth Graves Love, MPH Houston EMA

2. Outline • Houston EMA at a Glance • The CPCDMS • Outcomes Evaluation • Clinical Chart Review • Client Satisfaction Measurement • Resources • Conclusions and Questions

3. I. The Houston EMA at a Glance

5. The Houston EMA • Six county area in southeast Texas, covering 5,921 square miles • General population of 4,290,277 • Estimated number of diagnosed PLWH/A is 20,045

6. Houston EMA

7. The Houston EMA • FY 2003 Title I allocation is $20,526,823 • HIV Services administers 67 service contracts with 27 local providers • Over 7,000 PLWH/A access Title I services each year

8. II. The Centralized Patient Care Data Management System

9. The CPCDMS • The CPCDMS is a real-time, de-identified, client-level database application • The system was implemented in June 2000 • To date over 10,500 clients have been registered in the CPCDMS

10. The CPCDMS • Records are created, accessed and updated by providers via DSL data linking using a unique 11-character client code • No client-identifying information is collected • Client records are stored at HIV Services on a database server in SQL format

11. The CPCDMS • Data collection occurs through one of three processes • Client registration • Service encounter information • Medical updates • Through these processes the data that is essential to QM activities is collected

12. The CPCDMS • Users schedule reports using Crystal Reports software • Providers use reports to generate backup billing documentation and manage programs • HIV Services uses reports to obtain unduplicated data across all providers, service categories and/or grant codes

13. The CPCDMS • 31 local Ryan White-funded providers are online and using the CPCDMS • This includes all providers funded by Titles I, II, III and IV in a 10-county area

14. III. Outcomes Evaluation

15. Background • HRSA began emphasizing the importance of evaluating CARE Act programs in the late 1990’s • The Houston EMA began discussing options in FY 1999

16. Roles and Responsibilities • The RWPC requested that HIV Services develop and implement a comprehensive, ongoing evaluation program • The RWPC determined that its role would be one of general process oversight

17. Getting Ready • In early FY 2000 HIV Services hired an FTE Project Coordinator to manage this and other quality-related initiatives • Job description required a graduate degree and documented evaluation experience

18. Getting Ready • In summer 2000 HIV Services completed necessary background work • Reviewing HRSA materials and existing evaluation models • Setting project goals and timeline • Surveying the level of awareness among providers and RWPC members • Conducting a resource inventory

19. Getting Ready • Project Goals included: • Developing appropriate outcomes and indicators for each funded service • Involving all stakeholders • Minimizing the pain of data collection for providers and clients • Providing accessible, useful data to the RWPC and providers on a regular basis

20. Getting Ready • In fall 2000, HIV Services conducted an orientation meeting for providers, RWPC members and consumers • HIV Services then facilitated work groups to select outcomes and indicators for 27 Title I service categories

21. Selecting the Outcomes • Each group worked through the United Way’s logic model, which provides steps for choosing appropriate outcomes • For each selected outcome the group chose appropriate indicators and data collection methods

22. Selecting the Outcomes • Example – Primary Medical Care • Outcome – Slowing/prevention of disease progression • Indicator – 75% of clients will improve or maintain CD4 counts and viral loads over time • Data Collection Method – CPCDMS

23. Selecting the Outcomes • Example – Rehabilitation • Outcome – Improved ability to perform activities of daily living (ADL) • Indicator – Change over time in the percent of clients who report an improvement in the ability to perform ADL after completing rehabilitation therapy • Data Collection Method – Client survey

24. Selecting the Outcomes • Example – Outreach • Outcome – Entrance into the system of care • Indicator – By the end of the fiscal year, 50% of clients will enter Ryan White primary care • Data Collection Method - CPCDMS

25. Selecting the Outcomes • Once the work groups reached consensus, the RWPC reviewed and approved the outcome measures • The outcome measures are reviewed and revised each fiscal year

26. Background Work • During the RWPC approval process, HIV Services prepared the following: • Data collection tools and analysis reports • Policies and contract language describing requirements for providers • Training for providers

27. Data Collection • Through registrations, service encounters and medical updates, the CPCDMS collects the following data used in outcomes analysis: • Demographics • CD4 counts, viral loads and stage of illness • Opportunistic infections and co-morbidities • Health and support service utilization

28. Data Collection • Through special screens created for certain service categories, the CPCDMS collects the following data used in outcomes analysis: • Provider assessment of client progress • Health data not collected in primary care • Number of hospitalizations and ER visits

29. Data Collection • In general, the CPCDMS cannot provide information about • Quality of life • Cost-effectiveness • Knowledge, attitudes and practices • Client surveys collect this information

30. Data Collection • Client Surveys • HIV Services developed and piloted the pre- and post-test surveys • Virtually all surveys are less than one page in length; most are four questions or less • No demographic information is collected

31. Data Collection • Survey Administration • In FY 01 survey administration and data entry was manual • Since FY 02 survey administration and data entry has been automated through the CPCDMS

34. Provider Requirements • Providers are contractually obligated to participate in evaluation activities • Reimbursements may be withheld if a provider is not in compliance

35. Implementation • Prior to the beginning of FY 2001, providers received instructions and training on evaluation activities • Data collection began March 1, 2001

36. Data Analysis and Reporting • Providers must submit outcomes data to HIV Services each quarter • Data is stored in SQL format and analyzed using Crystal Reports • Each provider and the RWPC receives results on a quarterly basis

37. Using Outcomes Data • Providers use outcomes data to report to their boards, complete RFPs and for internal quality improvement • The RWPC uses outcomes data in all planning processes

38. Using Outcomes Data - Example • Primary Care Outcome 1.1 – Slowing or prevention of disease progression • Indicator - 75% of clients will decrease or maintain their viral load over time • In FY02 79% of Title I primary care clients decreased or maintained their viral load • The RWPC increased the allocation for primary care by 10% for FY04

39. Using Outcomes Data - Example • Household Items Outcome 3.1 – Improved or stabilized living conditions • Indicator - Change in the percent of clients with improved or stabilized living conditions due to receiving furniture or household items • FY01 and 02 data showed that this program had no impact on client living conditions • The RWPC did not fund this service for FY04

40. Successes • From conception to implementation, project development took just six months • The project has support and participation from all key stakeholders • The resulting data has enhanced RWPC decision-making as well as our Title I grant application

41. Challenges • At first providers were wary about the possibility of extra work • RWPC members require ongoing education about understanding and using outcomes

42. IV. Clinical Chart Review

43. Background • In April 2001 HRSA issued its guidance on quality management • One goal is to ensure that medical services are consistent with treatment guidelines • The EMA determined that clinical chart review could best accomplish this goal

44. Roles and Responsibilities • Following HRSA guidance, HIV Services assumed project oversight • The RWPC QA Committee maintains an advisory role

45. Getting Ready • In FY 2001 HIV Services hired an FTE Program Development Coordinator to oversee clinical chart review • Job description required a graduate degree along with documented experience in QA/utilization review

46. Getting Ready • During winter 2001 HIV Services completed all necessary background work • Reviewing PHS Guidelines and HRSA’s Primary Care Assessment Tool • Reviewing tools and methodologies from other EMAs • Determining provider expectations

47. With this information HIV Service determined the scope of the project Each health-related service would undergo an annual review of client records A qualified contractor would perform the chart reviews HIV Services would analyze and report findings Scope of Work

48. Participating service categories include: Primary Care Case Management Oral Health Care Vision Care Professional Counseling Substance Abuse Treatment Rehabilitation Hospice Care Home Health Care Drug Reimbursement Scope of Work

49. Contractor • HIV Services contracted with a masters-level RN to help develop the tools and to conduct the reviews • Reimbursement is on a per-chart basis

50. Tool Development • For each service category a set of core questions was developed • Example – What percentage of primary care clients receive the recommended number of CD4, viral load and CBC tests each year? • These questions drove tool development