Philadelphia Department Philadelphia Department of Public Health of Public Health

AIDS Activities Coordinating Office AIDS Activities Coordinating Office Comprehensive Planning Meeting Comprehensive Planning Meeting February 6, 2013 February 6, 2013

Client Services UnitClient Services UnitCSU CSU

CSU Mission CSU Mission Help HIV infected and at-risk individuals Help HIV infected and at-risk individuals

understand their needs and make understand their needs and make informed decisions about possible informed decisions about possible solutions solutions

Advocate on behalf of those who need Advocate on behalf of those who need special support special support

Reinforce clients’ capacity for self-Reinforce clients’ capacity for self-reliance and self-determination through reliance and self-determination through

◦education education ◦collaborative planning collaborative planning ◦problem solvingproblem solving

CSU ResponsibilitiesCSU Responsibilities Intake services to HIV positive individuals Intake services to HIV positive individuals requesting case management servicesrequesting case management services

MCM & RW eligibility MCM & RW eligibility ◦ HRSA Requirement HRSA Requirement ◦ Every six months Every six months ◦ Every RW funded service accessed by a client Every RW funded service accessed by a client ◦ Information and verifying documentation must be collected Information and verifying documentation must be collected

on clients’ on clients’ ◦ HIV dxHIV dx◦ IdentityIdentity◦ Household incomeHousehold income◦ Medical insuranceMedical insurance◦ Residency Residency

No significant complaints about RW eligibility received through CSU

CSU ResponsibilitiesCSU Responsibilities

Information and referral Information and referral services for all other AACO services for all other AACO funded programs funded programs

Process individuals’ requests for Process individuals’ requests for subsidized housing subsidized housing

Feedback about funded Feedback about funded providersproviders

Local Case Management Local Case Management Coordination ProjectCoordination Project

CSU CSU Information Information

Health Information Helpline is open 8 a.m. to 6 Health Information Helpline is open 8 a.m. to 6 p.m. Monday through Friday p.m. Monday through Friday 1-800/215-985-24371-800/215-985-2437

Staffing: Staffing: ◦ 1 Manager 1 Manager ◦ 1SW Supervisor1SW Supervisor◦ 1Housing Supervisor1Housing Supervisor◦ 4 City Social Workers 4 City Social Workers ◦ 2 Housing Staff 2 Housing Staff ◦ 1 Data Specialist1 Data Specialist◦ 1 Training Coordinator 1 Training Coordinator

Staff speak Spanish Staff speak Spanish

CSU Waiting List CSU Waiting List 149 people149 peopleFollowed by CSU Intake WorkersFollowed by CSU Intake Workers

◦ Emergency Emergency ◦ Urgent Urgent

Emergencies and other priority Emergencies and other priority populations are immediately referred to populations are immediately referred to MCM providers MCM providers ◦ SCI Clients SCI Clients

CSU workers facilitate HIV medical CSU workers facilitate HIV medical appointments for all clients reporting no appointments for all clients reporting no HIV medical care in last three months HIV medical care in last three months

Intake DataIntake Data

MCM Intakes MCM Intakes

Calendar yearCalendar year IntakesIntakes

20072007 18731873

20082008 20922092

20092009 23562356

20102010 23102310

20112011 20872087

20122012 20382038

2012 Intake Demographics2012 Intake Demographics

2012 Intake Demographics2012 Intake Demographics

Calendar Year 2012: Client needs at intake (N=2038)

All Clients Latino MSM Afr. Amer. MSM Youth 13-24Newly Diagnosed

(w/in 1 year of intake)

Number of intakes 2038 182 280 150 239

Percent of total intakes 100.0% 8.9% 13.7% 7.4% 11.7%

Service Category          

Benefit Assistance 59.0%59.0% 71.4%71.4% 50.0%50.0% 54.7%54.7% 55.6%55.6%

Housing Assistance 51.7%51.7% 41.2%41.2% 56.1%56.1% 41.3%41.3% 34.3%34.3%

Transportation Assistance 31.2% 20.3% 32.5% 24.7% 34.3%

Mental Health Treatment 29.1% 22.5% 30.0% 28.0% 32.2%

Medical Insurance 27.6% 37.9% 26.1% 40.7% 38.1%

Medical Care 23.1% 37.9% 14.6% 48.7%48.7% 40.6%

Medications 20.3% 37.9% 12.5% 30.0% 28.9%

Rental Assistance 17.6% 29.7% 11.8% 11.3% 9.6%

Food Bank/Home Delivered Meals 17.2% 8.8% 21.4% 8.7% 13.0%

Support Groups 14.4% 13.2% 13.9% 17.3% 16.3%

Dental Care 11.0% 17.0% 11.4% 28.0% 23.4%

HIV Education/Risk Reduction 10.4% 22.0% 7.5% 33.3% 41.0%

Substance Abuse 8.5% 6.0% 5.7% 2.0% 6.3%

Housing Services Housing Services ProgramProgram

(HSP)(HSP)

HSP FundingHSP FundingThe AACO Housing Services The AACO Housing Services

Program (HSP) is 100% funded by Program (HSP) is 100% funded by the Philadelphia Office of Housing the Philadelphia Office of Housing & Community Development & Community Development (OHCD) (OHCD)

The HSP receives $0 from Ryan The HSP receives $0 from Ryan White fundsWhite funds◦RW funding can not be used to RW funding can not be used to

provide permanent housingprovide permanent housing◦Federal and State funding for Federal and State funding for

housing continues to decline housing continues to decline

What is HSPWhat is HSPCentralized intake for applicants Centralized intake for applicants

seeking seeking permanentpermanent rental rental assistance (subsidized housing)assistance (subsidized housing)

The main referral source for The main referral source for housing sponsors providing housing sponsors providing Housing Opportunities for People Housing Opportunities for People With AIDS (HOPWA) or HIV/AIDS With AIDS (HOPWA) or HIV/AIDS Shelter Plus Care (S+C) housing Shelter Plus Care (S+C) housing

What HSP DoesWhat HSP DoesProcess and evaluate individual Process and evaluate individual

applications for housingapplications for housingMaintain the waiting list Maintain the waiting list Provide training to southeastern Provide training to southeastern

PA service providersPA service providersProvide ongoing TA to providersProvide ongoing TA to providersAll services at no costAll services at no costDo not provide emergency Do not provide emergency

housinghousing

HSP ScopeHSP Scope8 housing sponsors8 housing sponsors663 housing slots out of 1015 663 housing slots out of 1015

slots slots ◦522 HOPWA522 HOPWA◦131 S+C131 S+C

89% tenant based89% tenant based11% project based11% project based

Waiting ListWaiting List293 applicants currently on 293 applicants currently on

the waiting listthe waiting list◦Priority 1- 8 months wait time Priority 1- 8 months wait time (includes homeless folks)(includes homeless folks)

◦Priority 2 – 3 year wait timePriority 2 – 3 year wait time◦Priority 3 – 4 year wait timePriority 3 – 4 year wait time

Quality Management in Quality Management in the EMAthe EMA

QM Activities QM Activities Collecting and monitoring data to

assess client outcomes◦Local and HAB performance

measures◦Other available data

Using data to improve client outcomes ◦Ongoing feedback to providers◦QIPs◦Quarterly Meetings: scaling these

back◦Individual TA

QM Activities QM Activities Improving access to HIV medical care

◦Retention in care measure for core and supportive services

Improving the HIV system of care◦Benchmarking◦HRSA Systems Measures◦PDPH management team ◦Planning Council

Outcome Monitoring in the Outcome Monitoring in the EMAEMAPerformance MeasuresSystem MeasuresCare Outreach Outcomes

Early Intervention Outcomes

Disparities in Care

Performance MeasuresPerformance Measures

27 measures for medical (O/AMC) services◦22 HAB Group 1-3 measures◦5 local measures

9 (10) MCM measures◦2 HAB measures◦5 Part B measures (extended to

Part A)◦2 (3) local measures

5 HAB oral health measuresMeasures for all other services

Outpatient-Ambulatory Outpatient-Ambulatory Medical Care MeasuresMedical Care Measures

• AACO collects these measures from providers every two months

• The exception to this VL Suppression which is collected once per year

• Disparity also calculated once per year

O/AMC Performance in the O/AMC Performance in the EMAEMA

Performance Measure 2011 AUG 2012 YTD CHANGEA1 Percentage with >=2 Viral Load Counts 72% 70% -2%A2 Retention In Care 84% 84% 0%A3 Partner Services Newly Diagnosed 41% 46% 5%A5 Not Recomended ART Regimen 1% 1% 0%A7 MSM Receiving Syphilis Screening 81% 81% 0%A8 Colposcopy After Abnormal PAP 41% 39% -2%HAB01 Two Primary Care visits>= 3mos Apart 82% 82% 0%HAB02 Percentage with >=2 CD4 Counts 73% 71% -2%HAB03 CD4<200 with PCP prophylaxis 82% 81% -1%HAB04 AIDS Clients on HAART 97% 96% -1%HAB05 Pregnant women prescribed ART 99% 96% -3%HAB06 Adherence Assessment 80% 75% -5%HAB07 Cervical Cancer Screening 48% 49% 1%HAB08 Hepatitis B Vaccination 52% 51% -1%HAB09 Hepatitis C Screening 88% 89% 1%HAB11 Lipid Screening 72% 68% -4%HAB12 Oral Exam 20% 18% -2%HAB13 Syphilis screening 76% 74% -2%HAB14 TB Screening 73% 72% -1%HAB15 Chlamydia Screening 61% 65% 4%HAB16 Gonorrhea screening 61% 65% 4%HAB17 Hepatitis B Screening 77% 78% 1%HAB19 Influenza vaccination 52% 55% 3%HAB22 Pneumococcal Vaccination 74% 74% 0%

Medical Case ManagementMedical Case ManagementMCM MCM

MCM EmphasisMCM Emphasis

The coordination and follow-up of The coordination and follow-up of HIV medical treatment HIV medical treatment

Medical case management includes Medical case management includes the provision of treatment the provision of treatment adherence adherence counselingcounseling

Delivered by medically credentialed Delivered by medically credentialed or other health care staffor other health care staff

Part of the clinical care team Part of the clinical care team

AACO MCM Performance AACO MCM Performance Measures Measures

Retention in MCM services• Percent of clients referred to an MCM provider

who had a face-to-face MCM visit within 8-10 weeks of the referral from CSU

Linkage to HIV medical care• Percent of clients active in HIV medical case

management who are also active in HIV medical care

• Numerator includes patients who had a medical appointment up to 120 days prior or 70 days after becoming active in medical case management

Performance Performance measures measures 20082008 20092009 20102010 20112011 2012 (1/1-2012 (1/1-

9/30)9/30)Retention in Retention in MCM (< or = MCM (< or = 10 weeks 10 weeks after intake)after intake)

76%76% 81%81% 80%80% 78%78% 82%82%

Retention in Retention in HIV medical HIV medical care for care for clients clients getting MCMgetting MCM

87%87% 92%92% 95%95% 97%97% 96%96%

Medical Case Management Medical Case Management Performance Measures Performance Measures

Other MCM MeasuresOther MCM MeasuresAdded to CAREWare in April 2012Data collected on 2 HAB and 5 state

measures every two months 2 (3) measures monitored through CSUCAREWare Simplifies reporting at

programs offering both MCM and O/AMCFacilitates multidisciplinary team

approachAllows for regular monitoring of

performance in our large EMAWill begin sending feedback reports this

year

RW Part B MCM MeasuresRW Part B MCM Measures

Unmet need • Percentage of clients with HIV infection

whose records indicate retention in medical care

• Numerator - number of clients whose records indicate CD4 count OR viral load test OR ARV therapy prescribed

• Denominator - number of clients who have accessed (MCM) services at least twice during the measurement year

• Patient self-reporting not accepted

RW Part B MCM MeasuresRW Part B MCM Measures

Mental Health History and Treatment Status

• Percentage of clients with HIV infection who have documented mental health history and treatment status

• Numerator - number of clients who have their mental health history and treatment status documented at least once during the measurement year

• Denominator - number of clients who have at least one face-to-face MCM visit during the measurement year

RW Part B MCM MeasuresRW Part B MCM Measures

Substance Abuse History and Treatment

Percentage of clients with HIV infection who have their substance abuse history and treatment status documented

Numerator - number of clients who have their substance history and treatment status documented at least once during the measurement year

Denominator - number of clients who have at least one face-to-face case management visit during the measurement year

RW Part B MCM MeasuresRW Part B MCM Measures

Secondary Risk Assessment• Percentage of active MCM clients that

do risk reduction plan (counseling) at least once per year

• Numerator - number of clients for whom risk assessment was completed

• Denominator - number of active clients in case management

RW Part B MCM MeasuresRW Part B MCM Measures

Medication Assessment and Counseling Percentage of clients with HIV infection

on ARVs who were assessed and counseled for adherence two or more times in the measurement year

Numerator - number of HIV-infected clients, as part of their HIV medical and/or MCM care, who were assessed and counseled for adherence two or more times at least three months apart

Denominator - number of HIV-infected clients on ARV therapy who had a visit with an HIV medical and/or MCM provider at least twice in the measurement year

HRSA MCM MeasuresHRSA MCM Measures

Medical Case Management: Care Plan Percentage of HIV-infected MCM clients

who had a MCM care plan developed and/or updated two or more times in the measurement year

Numerator - Number of HIV-infected MCM clients who had a MCM care plan developed and/or updated two or more times at least three months apart in the measurement year

Denominator - Number of HIV-infected MCM clients who had at least one [face-to-face] MCM encounter in the measurement year

HRSA MCM Measure HRSA MCM Measure

Medical Case Management: Medical VisitsPercentage of HIV-infected MCM clients who

had two or more medical visits in an HIV Care setting in the measurement year

Numerator - Number of HIV-infected MCM clients who has a medical visit with a provider with prescribing privileges two or more times at least three months apart in the measurement yea that is documented in the MCM record

Denominator - Number of HIV-infected MCM clients who had at least one [face-to-face] MCM encounter in the measurement year

EMA’s Baseline Performance EMA’s Baseline Performance for MCMfor MCM

*Data as of 10/31/12

Process for Monitoring Process for Monitoring Medical and MCM Medical and MCM PerformancePerformanceAACO Reporting Calendar sent

annually to all programsReminders with attached

instructions for generating reportAACO monitors provider

submissions Program generates performance

reports◦AACO Report Generator (O/AMC)◦Performance Measure Worksheet

(MCM)◦Custom Oral Health Database

Process for Monitoring Process for Monitoring Medical and MCM Medical and MCM PerformancePerformancePerformance measures for O/AMC,

MCM and oral health submitted every two months

ISU enters and analyzes data using PMR Master tool

Feedback reports sent to programsProviders analyze data and

develop QIPsGrantee provides feedback on QIPsOutcome monitoring by provider

and grantee

Monitoring and FeedbackMonitoring and FeedbackStrong emphasis on feedbackQuickly highlights trends, strengths

and needsData visualization is critical in getting

attention of program leadershipBenchmarking contextualizes data

and can capitalize on competitiveness of providers

Assists in prioritizing QIPs

Monitoring and Feedback Monitoring and Feedback ToolsToolsPMR Master for Medical and MCM

◦AACO enters performance data bimonthly◦Remaining process is automated◦Tool generates aggregate performance data,

including city, state and funding◦Trend data for both system and provider◦Flags all significant improvements and declines◦Ranks provider performance for each measure◦System and provider trend data on all

measures ◦Generates an individualized Performance

Feedback Report for every provider

Monitoring and Feedback Monitoring and Feedback ToolsToolsEMA Aggregate Reports

◦Sent after analysis of bimonthly submission of data by programs

◦ Identifies upcoming submissions and explains data

◦Feedback to all O/AMC providers on system performance

◦ Includes EMA trend data and highest-lowest performers

◦Aggregate for O/AMC sent to MCM programs to aid in identifying regional priorities when coordinating with O/AMC providers

Monitoring and Feedback Monitoring and Feedback ToolsTools• Performance Feedback ReportsoSent to providers every two monthsoNumber of measures presents challenges

for data visualizationoUses a dashboard formatoProvides trend data on each measure,

including VL Missed Opportunities oFlags improvements and declinesoRanking in the EMA on all HAB/local

measuresoFlags top and bottom 5 performance in EMA

Performance Feedback Performance Feedback ReportsReports

Performance Feedback Performance Feedback ReportsReports

Oral Health MeasuresOral Health MeasuresCollected through database created by the

EMADatabase similar to CAREWare in its

functionality◦Data entry form functions as client record◦Calculates and generates performance

measure reports◦Identifies patients who are Not in

NumeratorProgram reviews charts based on sample

size calculator (5-7% confidence interval)3 (5) HAB oral health measures

HRSA/HAB Oral Health Care HRSA/HAB Oral Health Care Performance Measures CY 2011Performance Measures CY 2011

Dental and medical history 95%

Dental treatment plan 91% Oral health education 66% Completion of Phase 1

treatment plan* Periodontal treatment plan*

HAB System Measures- HAB System Measures- Appointment AvailabilityAppointment Availability

• Numerator: Number of organizations with a waiting time of 15 or fewer business days for a patient to receive an appointment to enroll in O/AMC

• Denominator: Number of Ryan White Program-funded O/AMC organizations in the system/network at a specific point in time in the measurement year

HAB System Measures- HAB System Measures- Appointment AvailabilityAppointment Availability

• Performance for 2011: 71.1%• AACO made three attempts to contact

each program in June 2011• If the program failed to respond to

these attempts within 15 business days, it was treated as a failure to meet the measure

• 45% of programs that did not meet measure were due to being unresponsive

HAB System Measures- HAB System Measures- Appointment AvailabilityAppointment Availability

On average, 1.6 attempts were needed to solicit a response from programs

Average time for appointments in the EMA (for non-emergency patients):o 1st available appt: 4.7 business days o 2nd available appt: 6.9 business dayso 3rd available appt: 8.9 business days

HAB System Measures- HAB System Measures- Appointment AvailabilityAppointment Availability• Of the programs that respondedo 82% indicated a wait of five days or

less for newly diagnosed patientso 12% indicated a wait of 10 days or lesso 6% were unable to answer the question

• All programs that failed to meet the measure were contacted again in December

• Only one program failed to meet the measure on the second attempt

HRSA System Measures- HIV HRSA System Measures- HIV Test Results for PLWHATest Results for PLWHA

• Definition: Percentage of individuals who test positive for HIV who are given their HIV-antibody test results in the measurement year

• Performance for 2011: 71%

HRSA System Measures- HRSA System Measures- System-Level PerformanceSystem-Level Performance• Definition: Rate of achievement (percentage

of patients) of the performance measurement of interest in the system in the measurement year.

• AACO selected the local A2 Retention in Care measure as the measure of interest for the EMA.

• Numerator: HIV positive clients who received at least one medical visit in the current measurement year

• Denominator: HIV positive clients who received at least one medical visit in the year prior to the current measurement year

• Performance for the 2011 Measurement Year: 84%

Quality Improvement Quality Improvement ProjectsProjects• Expanded to all core services in 2012• EMA uses form developed by PA’s Part B QM

Committee for all core services except O/AMC

• All QIPs updated quarterly and submitted• Grantee provides feedback to providers on

all plans and requires revisions as needed• In 2012, 126 QIPs were collected and

reviewed• Grantee works with programs that will need

to submit more than 5 QIPs per year to identify priorities

Quality Improvement Quality Improvement ProjectsProjectsAACO has moved away from regional

measures to a more individualized approach

Value in working toward common goal- facilitates sharing of best practices

But number of O/AMC measures makes priority-setting critical

Last regional measure saw providers with high performance doing a QIP at the expense of other key measures with low performance

Quality Improvement Quality Improvement ProjectsProjectsSuccess on one measure is not

necessarily predictive of success on other measures

EMA has defined key measures and set automatic thresholds for QIPs

Programs may still select other measures for improvement in addition to any required QIPs

Quality Improvement Quality Improvement ProjectsProjects• Triggers for QIP submission

o0% performance on any measureoGreater than 10% gap between VL and

VisitsoBelow 50% on ColposcopiesoBelow 60% on Cervical ExamsoSignificantly below EMA (lowest 5

performer)• Significant declines

oViral Load 5%oSyphilis 5%oCervical Exams 5%

Quality Improvement Quality Improvement ProjectsProjectsNarrative format for O/AMC

◦QI Committee, including program leadership

◦Focus on specific performance measure(s)

◦Root causes for low performance (data-driven)

◦Action Steps target processes related to root causes

◦Plan for implementing actions and goal◦Quarterly updates

Quality Improvement Quality Improvement ProjectsProjectsQI Storyboard for all other core services

◦Developed by PA’s Part B QM Committee

◦Strict adherence to FOCUS PDSA process

◦Each step mapped out◦Particularly useful for new providers or

those struggling with CQI◦Strong emphasis on incorporating data

into the process

Criteria For Evaluating Quality Criteria For Evaluating Quality Improvement ProjectsImprovement Projects

Focus on systems and processesAre data-drivenUtilize a sound QI process (e.g. FOCUS

PDSA)Investment by program leadershipIncorporation of consumers in the QI

processProduces desired improvements

Consumers and CQIConsumers and CQI

PDPH emphasizes consumers in the QI process◦Consumers on QI teams or committees◦Obtain input from Consumer Advisory

Boards during key stages of a QI process◦Consumer focus groups◦Client surveys to obtain client input

relating to causes for low performance or proposed action steps

QIP OutcomesQIP Outcomes

Questions or CommentsQuestions or Comments