Ryan White Title I – St. Louis EMA Grantee: City of St. Louis, Department of Health

1. Ryan White Title I – St. Louis EMAGrantee: City of St. Louis,Department of Health

2. About the St. Louis EMA • Urban & rural; St. Louis city, & 6 MO counties; 5 IL counties • Popl: 2.6 million; 76% Caucasian, 18% African American (AA) • HIV popl: 5,174 persons; 80% from urban core; • AA represent 77.4% of HIV+ women; 8% are IDU • AIDS incidence: 60.5% AA; 82.5% male; 60.5% MSM • CM clients: ~ 2,513 clients • Title I primary care clients: ~500 clients • 61.2% of Title I service budget funds health care in ’06 • (medical, dental, drugs, & healthcare continuation)

3. Priorities of Clinical Quality Management Initially • Initiating, & maintaining positive relations with Title I primary care providers (PC MDs) Now • Seeking ways to improve clinical behavior of PC MDs, • Decreasing communication gap between case managers & PC MDs about clients • Decreasing communication gap between Title I fiscal subcontractor & PC MDs about services available

4. Challenges in Setting Up Clinical QI Program • No baseline clinical data prior to 2003 • No previous relationship between Grants Administration (GA) & PC MDs • Fiscal subcontractor is funded by Title I to contract with PC MDs for clinical services • Thus, GA can not directly implement some key clinical improvements, which slows pace of improvement • Most PC MD sites are private offices

5. Challenges in Clinical Data Collection & Use Data Collection • Reviewing charts is like reviewing the cleanliness of MD’s home • Charts are often quite disorganized • Level of documentation is often poor & difficult to interpret Use of Data • How to report poor results to proud, under-funded PC MDs? • For many PC MDs, cost of providing HIV primary care > benefit • Thus, there is low to no incentive to change behavior • For clients, relationship with PC MD is very important • Grant emphasizes importance of keeping clients engaged in care • How to prevent PC MDs from “opting out” of HIV care?

6. Approach to Setting Up Clinical QI Program • Called other EMAs: Asked for advice & chart review instruments • Decided to use an established instrument: HIVQUAL • Didn’t hesitate to contact HIVQUAL for help • Asked PC MDs for their feedback on instrument & methodology • Adopted “here to help” vs. “auditor” attitude in communicating & working with PC MDs

7. Approach to Clinical Data Collection & Use • Developed second instrument to collect data from PC sites regarding their strengths & needs • Provided instruments in letter notifying about chart reviews • Focused on care received vs. quality of documentation • Provided PC sites with their results & results for all charts reviewed • Solicited PC MD questions, concerns about results • Adopted non-defensive attitude: “Negative feedback is better than no feedback”

8. Example of Results Sent to Providers

9. Client-level graph:Effects of HARRT started June 20

10. Clinical Quality Improvement Projects • Conducted desk-side audit using clinical service dB • Collected contact info (i.e. emails) to notify PC MDs of local & on-line HIV-related training and CMEs • Coordinated HIV training for PC MDs and their clinical staff via state & regional AETCs • Solicited input from PC MDs about quality improvement • Implemented policy requiring PC MDs are “HIV Specialists” based on NY AIDS Institute HIV specialist criteria or obtaining AAHIVM credentials

11. Lessons Learned • Data collection • Define specific terms for each variable measured • Don’t take behavior of PC MD and their staff personally • If possible, provide results to PC MDs & staff ASAP • Use of Data • Put yourself in the PC MDs shoes • Just providing poor results will NOT motivate improvement • Review charts at all PC sites, including those with <5 clients • Provide de-identified results from all sites to all PC MDs