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1917 Clinic QM Plan

Rev. 2/01/2017

1917 Clinic, a Ryan White Part B & C GranteeQuality Monitoring Plan

QUALITY STATEMENT Quality Goal - The goal of the UAB 1917 Outpatient AIDS/HIV Clinic’s Quality Management (QM) Program is to ensure that patients receiving care at the clinic receive the highest quality medical and supportive services. To accomplish this goal, the UAB 1917 Outpatient AIDS/HIV Clinic QM program will ensure:

1. Adherence to standards and expectations:

Ensure that direct service medical providers adhere to established practice standards, Public Health Service (PHS) & DHHS Guidelines (http://aidsinfo.nih.gov/guidelines) and user expectations to the extent possible;

Relevant Guidelines include but are not limited to the following current DHHS Guidelines:

Adult and Adolescent ARV Guidelines Adult and Adolescent OI Prevention and Treatment Guidelines

Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents

Perinatal Guidelines Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women

for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States

Pre-exposure Prophylaxis (PrEP) Guidelines Clinical Practice Guideline: Pre-Exposure Prophylaxis for the Prevention of HIV

Infection in the United States – 2014 Clinical Providers’ Supplement: Pre-Exposure Prophylaxis for the Prevention of HIV

Infection in the United States – 2014Occupational Post-exposure Prophylaxis (PEP) Guidelines

Updated US Public Health Service Guidelines for the Management of Occupational Exposures to Human Immunodeficiency Virus and Recommendations for Postexposure ProphylaxisNon-occupational Post-exposure Prophylaxis (nPEP) Guidelines

Antiretroviral Post-exposure Prophylaxis After Sexual, Injection-Drug Use, or Other Non-occupational Exposure to HIV in the United States Prevention with Persons with HIV (PWP) Guidelines

Recommendations for HIV Prevention with Adults and Adolescents with HIV in the United States, 2014Sexually Transmitted Diseases (STD) Treatment guidelinesLaboratory Testing Guidelines

Laboratory Testing for the Diagnosis of HIV Infection: Updated Recommendations Suggested Reporting Language for the HIV laboratory Diagnostic Testing Algorithm

Recommendations for Hormonal Contraception HIV Counseling, Testing, and Referral Guidelines

http://aidsinfo.nih.gov/guidelines

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2. Supportive services focus on access and adherence:

Ensure that critical HIV-related supportive services focus on achieving appropriate access and adherence with HIV care; and

3. Available data are used effectively:

Ensure that available demographic, clinical and health care utilization information, as well as available health outcomes data, are used to monitor the spectrum of HIV-related illnesses and trends in the local epidemic.

Scope of Quality Management Program - The UAB 1917 Outpatient AIDS/HIV Clinic’s QM program covers all services funded through Part B & C of the Ryan White Treatment Modernization Act.

Quality Definitions

• Quality is defined as the degree of excellence of a product or service. In terms of Ryan White, the quality of a service is the degree to which a service meets or exceeds professional standards, guidelines and user’s expectations.

• A Performance Measure is a quantitative tool that provides an indication of the quality of a service or process.

• An Outcome is the benefit or other result (positive or negative) for patients that may occur during or after receiving a service.

• Quality Assurance is a program for the systematic monitoring and evaluation (e.g. through performance measurement) of the various aspects of a service to ensure that standards of quality are being met.

• Quality Improvement refers to conducting activities aimed at improving processes to enhance the quality of care and services.

• The term Quality Management Program encompasses all grantee-specific quality activities, including the formal organizational quality infrastructure (stakeholders and resources), quality assurance and quality improvement activities.

• In this document, the word patient is used to describe an individual who is infected with HIV and who receives health and/or support services at the 1917 Clinic.

QUALITY MODEL

Quality Improvement - The 1917 Clinic ascribes to the Plan–Do–Check–Act Cycle of quality management, also called: PDCA, plan–do–study–act (PDSA) cycle, Deming cycle, Shewhart cycle. Briefly, the plan–do–check–act cycle (Figure 1) is a four-step model for carrying out change. Just as a circle has no end, the PDCA cycle is be repeated again and again for continuous improvement. We use the Plan-Do-Check-Act As a model for continuous improvement when 1) starting a new improvement project, 2) developing a new or improved design of a process, product or service; 3) defining a repetitive work process, 4) planning data collection and analysis

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in order to verify and prioritize problems or root causes, and 5) implementing any change. The Plan-Do-Check-Act Procedure is simply:

Plan -- Recognize an opportunity and plan a change. Do -- Test the change. Carry out a small-scale study. Check -- Review the test, analyze the results and identify what you’ve learned. Act -- Take action based on what you learned in the study step: If the change did not work,

go through the cycle again with a different plan. If you were successful, incorporate what you learned from the test into wider changes. Use what you learned to plan new improvements, beginning the cycle again.

QUALITY INFRASTRUCTURE

Leadership - Leadership for the UAB 1917 Outpatient AIDS/HIV QM program resides within the office of the Director in collaboration with appropriate parties including but not limited to:

Alabama Vaccine Clinic Director, Clinic Manager, Consultants (ad-hoc). Coordinator of Social Services, Dental Clinic, Director of IT, Financial Business Officer II, IS Project Leader, Medical Director, Medical providers, andPatient Advisory Board

Quality Program Participants & Stakeholder Groups - The QM program activities incorporate 1917 Clinic staff members, Health Resources and Services Administration (HRSA) HIV Bureau quality indicators, and patient involvement. Group members play an important role in identifying service needs and areas for service improvement. The role of each of these stakeholders is described.

I. 1917 Clinic Leadership Council – maintain a proactive quality focus to promote high level patient outcomes through 1) QM goal setting, 2) linkages to committees within the UAB Health System enterprise, i.e. Department of Medicine’s Clinical Practice Committee & TKC External Clinic group; IMPACT Clinic Expert User Group Meeting, and 3) on-going quality-education/awareness initiatives.

Membership - Director (Chairperson), Medical Director, CFAR Director, 1917 Clinic Manager, 1917 Clinic Cohort Coordinator, 1917 Clinic IS Project Leader, IT Director, 1917 Dental Clinic Director, 1917 Research Clinic Nurse Manager, CFAR Director, CFAR Director of the Behavior Core, CFAR Director of the Clinical Core, CFAR Business Officer.

II. 1917 Clinic Staff - The clinic staff members are primarily responsible for QM activities as described herein (infra).

• As the Quality Coordinator, the Director provides 1) develops and maintains annual quality plan, 2) provides oversight and guidance to staff regarding daily responsibilities and

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those related to quality management, 3) reviews the QM program, including QM plans and quality improvement activities, 4) monitors utilization of grant-funded services by coordinating data collection and compiling reports (e.g. quarterly CQI performance reports), 5) supports ongoing QM projects for Part B activities, 6) develops and implements outcomes for Part B, and 7) provides QM training and mentorship to other members of the QM Team.

• Medical Director: 1) Serves as supporting resource and coach for quality programs and clinic staff, including the subspecialty clinics. 2) Utilizes expertise and knowledge of quality principles and tools to promulgate quality program strategies. Provides direction and assistance in implementation of programs. 3) Assures the implementation of quality improvements and quality tracking reports. Assists with oversight of all major quality program areas and coordinates and identifies requirements for specific area expertise (patient safety, core measures, infection control, accreditation/regulatory compliance, quality assessment and performance improvement program, medical staff professional practice review, etc). 4) Assists on implementation of quality related deficiency action plans.

Coordinator of Social Services: 1) conducts monitoring activities for Part B quality activities by coordinating data collection and compiling reports (e.g. quarterly QM performance reports), 2) works with Quality Coordinator to develop and monitor performance measures related to case management, 3) ensures adherence to state HIV case management service standards through annual chart reviews and monitoring of performance measures, and 4) develops and implements policies and procedures to improve the overall delivery of case management services.

• Nutritionists: monitors adherence to nutritional standards, including but not limited to BMI screening and follow-up plan documentation.

• Women’s health advance practice nurse practitioner: monitors adherence to care standards for pregnant women, contraceptive care and cervical PAP screening.

• Research Informatics Services Center (RISC) Program Manager: monitors suicide risk.

• Linkage & Retention in Care Program Director: monitors adherence to new patient visits and retention in care.

• Data Analyst – 1) provides general analytical support to the QM program and 2) completes monthly and quarterly reports.

• Employees - Job descriptions include a quality component.

IV. Health Resources and Services Administration - HRSA’s HIV/AIDS Bureau (HAB) is committed to improving the quality of care and services and ultimately the quality of life for PLWH/A. To support 1917 Clinic quality assurance and QM activities, HRSA provides:

• Technical assistance • On-line training and resources

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• HAB Performance Measures for Adult/Adolescent Patients (Core medical measures released; draft measures for systems, oral health, medical case management and ADAP recently released for comment)

• Site visits • Program and fiscal monitoring through various reporting requirements

V. Patients - Patient input is a critical piece to delivering high quality services. Patient input is obtained through the grievance process, patient satisfaction surveys and participation on Patient Advisory Board. In addition, information feedback is obtained by patients through ongoing communication with providers and from patient-employees.

VI. UAHSF – integration of 1917 Clinic QM initiatives through the office of the UAHSF Chief Quality/Patient Safety Officer.

Resources - Approximately 3% of the total Ryan White budget is allocated for Planning & Evaluation and Quality Management activities. These funds cover, in part, the activities of the Quality Coordinator and Systems Analyst. Funds are also budgeted for travel to RW Clinical Updates and all Title Meetings. All clinic quality activities are covered by the Ryan White Part C funding.

Quality Management resources provided by the following organizations are consulted frequently:

• Health Resources Services Administration HIV/AIDS Bureau (http://hab.hrsa.gov/special/qualitycare.htm)

• National Quality Academy (http://nationalqualitycenter.org/QualityAcademy/) • Institute for Healthcare Improvement (http://www.ihi.org/IHI/Topics/HIVAIDS/) • New York State Department of Health AIDS Institute

(http://www.hivguidelines.org/Content.aspx) • Target Center: Technical Assistance for the Ryan White Community

(http://careacttarget.org/)

QUALITY GOALS & ACTIVITIES The primary QM goals are to ensure that:

• Funded services adhere to PHS/DHHS guidelines, established clinical practice, and user expectations;

• Program improvement includes supportive services linked to access and adherence to medical care; and

• Demographic, clinical and utilization data are used to evaluate and address characteristics of the local epidemic.

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Annual Utilization/Quality Data (Ryan White Data Report- Client level reporting, 2017)

• Review end-of-year clinic report • Approve final report prior to uploading to HRSA • Report end-of-year data to HRSA, via the ADPH • Make corrections, as identified by Ryan White Coordinator

Performance Measurements – Ongoing quality assurance and quality management activities are summarized in Table 1. These indicators are consistent with and representative of those endorsed by “HIVQUAL” (Table 2). The process for monitoring these nationally recognized clinical indicators involves the systems analyst performing quarterly analysis that surveys the entire patient data base. The preliminary data/findings, along with a listing of all outliers are sent to the QM Coordinator who reviews the data and each instance of discrepancy. The QM manager monitors the data for trends that might negatively impact patient outcomes and simultaneously works with individual providers to reconcile non-adherence to standards of care. Individual providers are notified when a discrepancy is identified and consulted as to how the provider wants to proceed in the care of the individualized patient. (Sometimes it is necessary in the practice of medicine to develop plans of care that may not adhere to nationally accepted guidelines.) A Continuous Quality Improvement segment is incorporated into the medical director‘s quarterly mandatory provider meeting. Data are used as an impetus for improvement and a way to monitor progress to an identified goal.

Table 2: HIVQUAL National Core IndicatorsAdherence Assessment Anorectal Exam and Anal Pap Smear ARV Therapy Management Baseline Resistance Test Clinical VisitsDental Care Gynecology Care Health Literacy Screening Hepatitis C (HCV) Screening HIV Monitoring HIV Specialist Care Lipid Screening MAC Prophylaxis Mental Health Screening PCP Prophylaxis Pneumococcal Vaccination Prevention Education

STI Management Substance Use Screening TB Screening Tobacco Use Screening

Table 1: QM IndicatorsADAP AdherenceCervical Pap ScreeningHBsAB or HBcAB ScreeningHepatitis B Antigen ScreeningHepatitis C ScreeningMAC Prophylaxis (<50 CD4)Nutritional Assessment (<200 CD4)Patients receiving ARTPatients with vRNA <50 copiesPCP Prophylaxis (<200 CD4)Pneumovax vaccinationRetention in Care (CDC project)Suicide ScreeningSyphilis Screening

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EVALUATIONImpromptu, quarterly and annual evaluation is conducted to determine if Quality Goals and performance measures are achieved.

1. Adherence to standards and expectations (see performance indicators): Ensure that direct service medical providers adhere to established practice standards, DHHS Guidelines and user expectations to the extent possible;

2. Supportive services focus on access and adherence (based on RSR statistics): Ensure that critical HIV-related supportive services focus on achieving appropriate access and adherence with HIV care; and

3. Available data are used effectively (measures to insure data integrity are working): Ensure that available demographic, clinical and health care utilization information, as well as available health outcomes data, are used to monitor the spectrum/continuum of HIV-related illnesses and trends in the local epidemic.

Clinical and non-clinical performance measures are evaluated quarterly for trends in outcomes and annually by clinic leadership for their appropriateness of continued monitoring.CAPACITY BUILDING

Assessment of the Quality Improvement capacity of providers is assessed by the degree of involvement in QM activities (see publications, infra).

Assess QM training activities. Assess the feedback mechanisms to providers. Determine if a “Continuous Quality

Improvement” segment was incorporated into the medical director’s quarterly mandatory “provider meeting.”

PROCESS TO UPDATE QM PLAN

The QM Coordinator will initiate an annual review of plan immediately following RW EIS Part C grant submission. However, impromptu revision can be made to address newly identified areas of concern.

The Director and Medical Director approve the annually revised plan.

COMMUNICATIONS

Dissemination of findings – The principle manner to communicate provider feedback is twofold: 1) when a deviation from the guideline is detected and 2) during the “Continuous Quality Improvement” segments of the monthly staff meeting and the medical director’s quarterly mandatory “provider meeting.”

QM IMPLEMENTATION

Most recent REVISION: 2/01/2017

QM Program activities in 2015, 2016 & 2017 YTD (2/01/2017)

Development and implementation of a plan for increasing safety in the workplace

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o This multifaceted activity is being implemented in response to multiple potentially violent incidents (e.g. implied and explicit threatening behavior by patients toward 1917 Clinic providers, staff and visitors; firearms and other weapons brought into clinic, disruptive and disrespectful visitor behavior at the pharmacy requiring law enforcement notification)o In-service education: “Safety and De-escalation” by UAB Police to provide 1917 Clinic personnel with strategies related to:

De-escalation of “upset” individuals When & how to call for the resources of UAB Police Response to a situation involving an active shooter

o Adaptation of UAB Hospital “Code Q” policy for use in the 1917 Clinic.o Review commonly recognized strategies for creating a safe and caring work

environment – nonviolent crisis intervention.o Magnometer proposed, approved and ordered. Installation is pending. o Installation of bullet proof glass proposed, approved and ordered. Installation is

pending.o On-site full time UAB Police Officer proposed and approved (3/25/16). UAB

Police Officer, Alex Pruitt, is now stationed full time in the 1917 Clinic. He makes rounds several times per day. Duty hours are: Monday-Friday, 8AM – 5PM.

o Staff training “How to Deal with Difficult People,” Robert Hudson. Friday, January 20th, 1:15 – 3:15pm.

o Staff training “How to Deal with Difficult People,” Robert Hudson. Friday, January 20th, 1:15 – 3:15pm.

Development and implementation of a social work services plan for comprehensive “case management” (see Case Management Policy).

Development and implementation of 1917 Clinic Policy for “Sick-call / Triage” Implementation of the “1917 Nurse Practitioner Clinical Case Conference (NPCCC) to

enhance NP knowledge and competence in the performance of clinical duties. Database search in response to FDA Warning of Risk to patients prescribed Concomitant

medications: amiodarone with Hepatitis C Antiviral agents (March 2015). Implementation of an on-site Anal Dysplasia Clinic allowing patient with abnormal anal

PAP smears to obtain High Resolution Anoscopy (HRA) with additional diagnostic and therapeutic on-site intervention.

Karen R. Fry, MSN, CRNP (Women’s Health Nurse Practitioner), completed an 18-month clinical mentorship and successfully passed the American Society for Colposcopy and Cervical Pathology (ASCCP) Colposcopy Mentorship Program (CMP) Examination (March 2015). This allows 1917 Clinic female patients to undergo cervical colposcopy and additional diagnostic procedures on-site thereby circumventing the necessity of making additional off-site referral visits.

Ongoing interval “Patient Satisfaction” Survey Implement actions to enhance the patient experience and quality of care for Transgender

patients attending 1917 Clinic.

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o Expanding clinician awareness of the principles for the clinical management of Transgender Patients” and available on-site 1917 Endocrinology Clinic services for the management of HIV-infected persons with “gender identity disorder. Medical provider case conference presented by A. Warriner, MD, endocrinologist.

o Policy for Transgender restroom access (3/14/16). o Mandatory staff training on Transgender issues:

Acknowledging Gender and Sex This interactive video comes from the Center of Excellence for

Transgender Health at UCSF. It’s helpful for all clinic staff. Definitions (sex, gender identity, sex assigned at birth, gender,

gender expression), appropriate language, two step gender and sex differentiation questions, health disparities and outcomes for transgender population

The case studies are issues that we have faced at 1917 Clinic (restroom concerns, welcoming/inclusive language, concern about disclosure).

Easy to access. Don’t need to register, just click the link and follow the prompts – remember to keep clicking next.

Time will vary with each user, but less than 30 minutes. http://transhealth.ucsf.edu/video/story.html

TransTalks This is a new online training series from the National LGBT

Health Education Center at Fenway Institute. Gender Affirmative Health Care (the first in the series) covers

Trans 101, terminology in more detail, sensitivity, research globally and need for more, interaction between HIV and other health/social issues that disproportionately impact trans population, and need for trans community engagement and cultural humility.

About 40 minutes. CME/CEU available. (Complete the evaluation at the end of the survey to receive certificate for 1.0 credits.)

Click the link to log in or register (for new users to create account). I recommend the video (vs just the slides) for best learning. http://www.lgbthealtheducation.org/transtalks/

o Transgender Health Conference (Rachel Hanle, MSW) 2016 marks the 4th year of the Professional Track of the Philadelphia Trans Health Conference, offering comprehensive training courses for professionals to provide trans-competent

http://www.lgbthealtheducation.org/transtalks/

http://transhealth.ucsf.edu/video/story.html

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services . This track will take place on Thursday, June 9th and Friday, June 10th.

Clinic assessment for Gardasil (HPV), Prevnar Pneumo-coccal pneumonia), and Zostavax (VZV) immunizations: analysis revealed the total number of patients eligible for the vaccines in our clinic population & the estimated cost of providing Gardasil, Prevnar, and Zostavax. We also sought to understand the costs of immunizing only new patients in subsequent years assuming that existing patients had already been immunized (see manuscript, “Immunization Costs and Programmatic Barriers at an urban HIV Clinic” for the details). This assessment will serve as the benchmark from which an immunization campaign will be formulated.

Implementation of the “Hand Washing Survey.” Palliative Care Program development

o Implementation of Point-of-Care (POC) urine drug screening (UDS) (April 2015). POC UDS will promote safe opioid prescribing by allowing providers to have the results of random urine drug screens during the patient visit.

o Two clinic providers (J. Merlin, MD & G. Dobbs, CRNP) and J. Murphree, MSW, attended a three day training to gain expertise in “Motivational Interviewing”

o The following clinic personnel attended a 2-day Motivational seminar to gain valuable information and skill to promote behavior change in patients attending the 1917 Clinic (April 2015): Providers : James Raper; Barbara Corley; Crystal Chapman Lambert; Gina

Dobbs; Laura Secord; Jean Thibault; Jodie Dionne-Odom; Greer Burkholder; Ellen Eaton; Jane Mobley; Cynthia Brow and Jacob Graham

Mental health providers: Paige Ingle-Pang; Charles Wright; Patsy Barron; Social workers : Ashley Bartee; Daphne Tice; Vanessa Hudson; Leslie Simons;

Kathy Gaddis; LouAnn Webster; Rashundra Renee' Hopkins; Wes Akins; Brooke Penney; Crystal Berry;

Testing and linkage coordinators : Kelly Ross-Davis; Shyla K Campbell; Kachina Kudroff; Kirema Brown;

o Nutritionists/Registered Dieticians : Donna Yester; Meredith Atwater;

PUBLICATIONS from 1917 Clinic personnel related to QM Activities at 1917 Clinic – national significance

Keep it simple": older African Americans' preferences for a health literacy intervention in HIV management. Gakumo CA, Enah CC, Vance DE, Sahinoglu E, Raper JL. (2015). Patient Prefer Adherence. 2015 Jan 29; 9: 217-23.

Factors Associated with Missed Psychiatry Visits in an Urban HIV Clinic. Ho CP, Zinski A, Fogger SA, Peters JD, Westfall AO, Mugavero MJ, Lawrence ST, Nevin CR, Raper JL, & Saag MS, Willig JH. (2014). AIDS Behavior. [Epub ahead of print]

Viral Suppression Is Associated with Increased Likelihood of Colorectal Cancer Screening Among Persons Living with HIV/AIDS. Burkholder GA, Tamhane AR, Appell LE, Willig JH,

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Saag MS, Raper JL, Westfall AO, & Mugavero MJ. AIDS Res Hum Retroviruses. 2014 Nov 29. [Epub ahead of print]

Venous thromboembolism among HIV positive patients and anticoagulation clinic outcomes integrated within the HIV primary care setting.Modi RA, McGwin G, Westfall AO, Powell DW, Burkholder GA, Raper JL, & Willig JH.Int J STD AIDS. 2014 Nov 20. [Epub ahead of print]

Testosterone replacement therapy among HIV-infected men in the CFAR Network of Integrated Clinical Systems. Bhatia R, Murphy AB, Raper JL, Chamie G, Kitahata MM, Drozd DR, Mayer K, Napravnik S, Moore R, & Achenbach C; Centers for AIDS Research (CFAR) Network of Integrated Clinical Systems (CNICS). AIDS. 2015 Jan 2;29(1):77-81.

Connecting the dots: could microbial translocation explain commonly reported symptoms in HIV disease? Wilson NL, Vance DE, Moneyham LD, Raper JL, Mugavero MJ, Heath SL, & Kempf MC. J Assoc Nurses AIDS Care. 2014 Nov-Dec;25(6):483-95.

The multiple stigma experience and quality of life in older gay men with HIV.Slater LZ, Moneyham L, Vance DE, Raper JL, Mugavero MJ, & Childs G.J Assoc Nurses AIDS Care. 2015 Jan-Feb;26(1):24-35.

Beyond core indicators of retention in HIV care: missed clinic visits are independently associated with all-cause mortality. Mugavero MJ, Westfall AO, Cole SR, Geng EH, Crane HM, Kitahata MM, Mathews WC, Napravnik S, Eron JJ, Moore RD, Keruly JC, Mayer KH, Giordano TP, & Raper JL; Centers for AIDS Research Network of Integrated Clinical Systems (CNICS).Clin Infect Dis. 2014; 59(10):1471-9.

A qualitative study of underutilization of the AIDS drug assistance program. Olson KM, Godwin NC, Wilkins SA, Mugavero MJ, Moneyham LD, Slater LZ, & Raper JL. J Assoc Nurses AIDS Care. 2014 Sep-Oct;25(5):392-404.

Going the extra mile for retention and re-engagement in care: nurses make a difference.Raper JL. J Assoc Nurses AIDS Care. 2014 Mar-Apr;25(2):108-11.

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Point-of-care HIV testing and linkage in an urban cohort in the southern US. Point-of-care HIV testing and linkage in an urban cohort in the southern US. Zinski, A., Dougherty, S.M., Tamhane, A., Ross-Davis, K.L. & Raper, J.L. (2013). AIDS Research and Treatment; 1-12.

The Role of Neuroplasticity and Cognitive Reserve in Aging with HIV: Recommendations for Cognitive Protection and Rehabilitation. Vance, D.E., Fazeli, P.L., Grant, J.S., Slater, L.Z., & Raper, J.L. (2013). Journal of Neuroscience Nursing. 45, 306-316.

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A pilot study of screening, brief intervention, and referral for treatment (SBIRT) in non-treatment seeking smokers with HIV. Cropsy, K.L., Hendricks, P.S., Jardin, B., Clark, C.B., Kativar, N., Willing, J.H. Mugavero, M.J., Raper, J.L., Saag, M.S. & Carpenter, M.J. (2013). Addictive Behaviors, 38(10):2541-2546.

Impact of a computer-assisted, provider-delivered intervention on sexual risk behaviors in HIV-positive men who have sex with men (MSM) in a primary care setting. Bachmann, L.H., Grimley, D.M., Gao, H., Aban, I., Chen, H., Raper, J.L., Saag, M.S., Rhodes, S.D., & Hook, E.W. (2013). AIDS Education Prevention Journal, 25, 87-101.

Providers’ attitudes towards treating depression and self-reported depression treatment practices in HIV outpatient care. Bess, K.D., Adams, J., Watt, M.H., O'Donnell, J.K., Gaynes, B.N., Thielman, N.M., Heine, A., Zinski, A., Raper, J.L., Pence, B.W. (2013). AIDS Patient Care STDs, 27, 171-80.

Assessing and Treating Forgetfulness and Cognitive Problems in Adults with HIV. Vance, D.E., Fazeli, P.L., Moneyham, L.D., Keltner, N.L. & Raper, J.L. (2013). Journal of the Association of Nurses in AIDS Care, 24, S40-S60.

Reasons why people living with HIV include individuals in their chosen families. Grant JS, Vance DE, Keltner NL, Prachakul W, & Raper JL. (2012). Journal of the Association of Nurses in AIDS Care. 2012, Journal of the Association of Nurses in AIDS Care, 24, 50-60.

A low-effort clinic-wide intervention improves attendance for HIV primary care. Gardner LI, Marks G, Craw JA, Wilson TE, Drainoni ML, Moore RD, Mugavero MJ, Rodriguez AE, Bradley-Springer LA, Holman S, Keruly JC, Sullivan M., Skolnik PR, Malitz F, Metsch LR, Raper JL, & Giordano T.P. (2012). Clinical Infectious Diseases. 2012 Jul 24. [Epub ahead of print]

Multimorbidity patterns in HIV infected patients: the role of obesity in chronic disease clustering. Kim DJ, Westfall AO, Chamot E, Willig AL, Mugavero MJ, Ritchie C, Burkholder GA, Crane HM, Raper JL, Saag MS, & Willig JH. (in press). Journal of Acquired Immune Deficiency Syndromes.

Do social support, stigma, and social problem-solving skills predict depressive symptoms in people living with HIV? A mediation analysis. White W, Grant JS, Pryor ER, Keltner NL, Vance DE, & Raper JL (in press). Research and Theory for Nursing Practice. 26 (3).

HIV infection and obesity: where did all the wasting go? Tate T, Willig AL, Willig JH, Raper JL, Moneyham L, Kempf MC, Saag MS, & Mugavero MJ. (In press). Antiviral Therapy.

Pain, Mood, and Substance Abuse in HIV: Implications for Clinic Visit Utilization, ART Adherence, and Virologic Failure. Merlin JS, Westfall AO, Raper JL, Zinski A, Norton WE, Willig JH, Gross R, Ritchie CS, Saag MS, Mugavero MJ. J Acquir Immune Defic Syndr. 2012 Jul 3. [Epub ahead of print]

http://www.ncbi.nlm.nih.gov/pubmed/22766967


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Support, Stigma, Health, Coping, and Quality of Life in Older Gay Men With HIV. Slater LZ, Moneyham L, Vance DE, Raper JL, Mugavero MJ, Childs G. J Assoc Nurses AIDS Care. 2012 Jun 9. [Epub ahead of print]

Cognitive and Everyday Functioning in Older and Younger Adults with and without HIV. Vance DE, Wadley VG, Crowe MG, Raper JL, Ball KK. Clin Gerontol. 2011 Oct;34(5):413-426. Epub 2011 Sep 14.

Childhood trauma and health outcomes in HIV-infected patients: an exploration of causal pathways. Pence BW, Mugavero MJ, Carter TJ, Leserman J, Thielman NM, Raper JL, Proeschold-Bell RJ, Reif S, Whetten K.J Acquir Immune Defic Syndr. 2012 Apr 1;59(4):409-16.

Patient reported outcomes in routine care: advancing data capture for HIV cohort research. Kozak MS, Mugavero MJ, Ye J, Aban I, Lawrence ST, Nevin CR, Raper JL, McCullumsmith C, Schumacher JE, Crane HM, Kitahata MM, Saag MS, Willig JH. Clin Infect Dis. 2012 Jan 1;54(1):141-7. Epub 2011 Oct 31.

Essential components of effective HIV care: a policy paper of the HIV Medicine Association of the Infectious Diseases Society of America and the Ryan White Medical Providers Coalition. Gallant JE, Adimora AA, Carmichael JK, Horberg M, Kitahata M, Quinlivan EB, Raper JL, Selwyn P, Williams SB, Infectious Diseases Society of America, Ryan White Medical Providers Coalition. Clin Infect Dis. 2011 Dec;53(11):1043-50. Epub 2011 Oct 20.

Early retention in HIV care and viral load suppression: implications for a test and treat approach to HIV prevention. Mugavero MJ, Amico KR, Westfall AO, Crane HM, Zinski A, Willig JH, Dombrowski JC, Norton WE, Raper JL, Kitahata MM, Saag MS. J Acquir Immune Defic Syndr. 2012 Jan 1;59(1):86-93.

Temporal trends in presentation for outpatient HIV medical care 2000-2010: implications for short-term mortality. Seal PS, Jackson DA, Chamot E, Willig JH, Nevin CR, Allison JJ, Raper JL, Kempf MC, Schumacher JE, Saag MS, Mugavero MJ. J Gen Intern Med. 2011 Jul;26(7):745-50. Epub 2011 Apr 5.

The role of toxicity-related regimen changes in the development of antiretroviral resistance. Nevin CR, Ye J, Aban I, Mugavero MJ, Jackson D, Lin HY, Allison J, Raper JL, Saag MS, Willig JH. AIDS Res Hum Retroviruses. 2011 Sep;27(9):957-63. Epub 2011 Mar 21.

Underutilization of the AIDS Drug Assistance Program: Associated Factors and Policy Implications. Godwin NC, Willig JH, Nevin CR, Lin HY, Allison J, Gaddis K, Peterson J, Saag MS, Mugavero MJ, Raper JL. Health Serv Res. 2011 Jan 6. [Epub ahead of print]

Substance abuse treatment in an urban HIV clinic: who enrolls and what are the benefits? Pisu M, Cloud G, Austin S, Raper JL, Stewart KE, Schumacher JE. AIDS Care. 2010 Mar;22(3):348-54.













1917 Clinic QM Plan

Rev. 2/01/2017

Anal-rectal cytology: correlation with human papillomavirus status and biopsy diagnoses in a population of HIV-positive patients. Bean SM, Chhieng DC, Roberson J, Raper JL, Broker TR, Hoesley CJ, Eltoum IA, Jin G. J Low Genit Tract Dis. 2010 Apr;14(2):90-6.

Routine, self-administered, touch-screen, computer-based suicidal ideation assessment linked to automated response team notification in an HIV primary care setting. Lawrence ST, Willig JH, Crane HM, Ye J, Aban I, Lober W, Nevin CR, Batey DS, Mugavero MJ, McCullumsmith C, Wright C, Kitahata M, Raper JL, Saag MS, Schumacher JE. Clin Infect Dis. 2010 Apr 15;50(8):1165-73.

Development of a Point-of-Care HIV/Aids Medication Dosing Support System Using the Android Mobile Platform. Sadasivam RS, Gathibandhe V, Tanik MM, Willig JH. J Med Syst. 2010 Nov 6.

Measuring depression levels in HIV-infected patients as part of routine clinical care using the nine-item Patient Health Questionnaire (PHQ-9). Crane PK, Gibbons LE, Willig JH, Mugavero MJ, Lawrence ST, Schumacher JE, Saag MS, Kitahata MM, Crane HM. AIDS Care. 2010 Jul;22(7):874-85.

Cost ramifications of increased reporting of detectable plasma HIV-1 RNA levels by the Roche COBAS AmpliPrep/COBAS TaqMan HIV-1 version 1.0 viral load test. Willig JH, Nevin CR, Raper JL, Saag MS, Mugavero MJ, Willig AL, Burkhardt JH, Schumacher JE, Johnson VA. J Acquir Immune Defic Syndr. 2010 Aug 1;54(4):442-4.

New syphilis cases and concurrent STI screening in a southeastern U.S. HIV clinic: a call to action. Baffi CW, Aban I, Willig JH, Agrawal M, Mugavero MJ, Bachmann LH. AIDS Patient Care STDS. 2010 Jan;24(1):23-9.

Racial disparities in HIV virologic failure: do missed visits matter? Mugavero MJ, Lin HY, Allison JJ, Giordano TP, Willig JH, Raper JL, Wray NP, Cole SR, Schumacher JE, Davies S, Saag MS. J Acquir Immune Defic Syndr. 2009 Jan 1;50(1):100-8.

Missed visits and mortality among patients establishing initial outpatient HIV treatment. Mugavero MJ, Lin HY, Willig JH, Westfall AO, Ulett KB, Routman JS, Abroms S, Raper JL, Saag MS, Allison JJ. Clin Infect Dis. 2009 Jan 15;48(2):248-56.

The therapeutic implications of timely linkage and early retention in HIV care. Ulett KB, Willig JH, Lin HY, Routman JS, Abroms S, Allison J, Chatham A, Raper JL, Saag MS, Mugavero MJ. AIDS Patient Care STDS. 2009 Jan;23(1):41-9.

Clinical inertia in the management of low-density lipoprotein abnormalities in an HIV clinic. Willig JH, Jackson DA, Westfall AO, Allison J, Chang PW, Raper J, Saag MS, Mugavero MJ. Clin Infect Dis. 2008 Apr 15;46(8):1315-8.

Failure to establish HIV care: characterizing the "no show" phenomenon. Mugavero MJ, Lin HY, Allison JJ, Willig JH, Chang PW, Marler M, Raper JL, Schumacher JE, Pisu M, Saag MS. Clin Infect Dis. 2007 Jul 1;45(1):127-30.

Nucleoside reverse-transcriptase inhibitor dosing errors in an outpatient HIV clinic in the electronic medical record era. Willig JH, Westfall AO, Allison J, Van Wagoner N, Chang PW, Raper J, Saag MS, Mugavero MJ. Clin Infect Dis. 2007 Sep 1;45(5):658-61.

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