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Incorporating HIV/AIDS Bureau Measures into Your Quality Portfolio Tracy Matthews Chief Clinical Advisor Department of Health and Human Services Health Resources and Services Administration HIV/AIDS Bureau Lori DeLorenzo Quality Consultant, HIV/AIDS Bureau Organizational Ideas Part D Quality Conference August 29-30-2011 1 Learning Objectives • Discuss the HAB quality expectations for Part D grantees • Review the HAB performance measures and explore how they are defined • Explore how to apply and utilize the measures to meet your regional/local needs • Share examples of how HAB measures have been applied locally 2 Why Measure the Quality of HIV Care? • Communicates priorities • Identify areas for improvement • Track the effectiveness of different quality improvement strategies • Provide information to others about the quality of care and services they receive 3 Why Measure the Quality of HIV Care? • Builds a community of providers focusing on the same aspects of care • Provides a way to compare performance across programs and over time • The National HIV/AIDS Strategy sets clear goals for improvement in HIV care • Quality management is a legislative requirement of the Ryan White HIV/AIDS Treatment Extension Act of 2009 4 Ryan White HIV/AIDS Treatment Extension Act All RWTMA grantees are required to establish clinical quality management programs to: – Assess the extent to which HIV health services are consistent with the most recent Public Health Service guidelines for the treatment of HIV disease and related opportunistic infections; and – Develop strategies for ensuring that such services are consistent with the guidelines for improvement in the access to and quality of HIV services 5 HAB Expectations for Quality Management A Quality Management Program should consist of a systematic process with identified leadership, accountability and dedicated resources and uses data and measureable outcomes to determine progress toward relevant, evidence-based benchmarks. – Infrastructure – Performance Measurement – Quality Improvement 6 The HAB Performance Measures • Each group of measures represents different aspects of care and treatment • Combined, the measures offer an agency the opportunity to examine system level performance 7 Creating a Balanced Set of Measures Clinical Systems Level Quality AIDS Drug Assistance Program Management Pediatric Program Oral Health Medical Case Management 8 The Clinical Performance Measures Address Three Aspects of Care Laboratory Screening Counseling, mental health and substance use assessment Medical and Dental Care and Treatment Clinical Care 9 Medical Care and Treatment Includes: • • • • • • • • • • ARV therapy for pregnant women Hepatitis B vaccination Influenza vaccination Medical visits Oral exam PCP prophylaxis ARV therapy Pneumococcal vaccination Viral load monitoring Viral load suppression 10 Laboratory Screening Measures Look at Appropriate Screening for: • • • • • • • Cervical cancer Chlamydia & gonorrhea Hepatitis B Hepatitis C Lipids Syphilis Tuberculosis 11 Counseling, Mental Health and Substance Use Assessment Include: • • • • HIV transmission risk screening Hepatitis/HIV alcohol counseling Mental health screen Substance use screen 12 Medical Case Management • Care Plans • Medical Visits 13 Oral Health • • • • • Dental and Medical History Dental Treatment Plan Oral Health Education Periodontal Screening or Examination Phase I Treatment Plan Completion Note: These measures are used by dental providers who are providing the actual services 14 System Level Measures • Waiting Time for Initial Access to Outpatient / Ambulatory Medical Care • HIV Test Results for PLWHA • Disease Status at Time of Entry Into Care • Quality Management Program • System-Level Performance 15 Pediatric Performance Measures: Overview • Age of eligible population varies by measure – Refer to detail sheet for exact age range – Utilize table of PMs for quick reference • Addresses clinical, social and system issues Pediatric Measures • Adherence Assessment and Counseling • ARV Therapy • CD4 Value • Developmental Surveillance • Diagnostic Testing to Exclude HIV Infection in Exposed Infants • Health Care Transition Planning for HIV-infected Youth • HIV Drug Resistance Testing Before Initiation of Therapy • • • • • • • • Lipid Screening Medical Visit MMR Vaccination Neonatal Zidovudine Prophylaxis PCP Prophylaxis for HIVExposed Infants PCP Prophylaxis for HIVInfected Children Planning for Disclosure of HIV Status to Child TB Screening 17 Elements of HAB PMs • Performance Measure • Numerator and Denominator Definitions • Patient Exclusions • Data Element • Data Sources • National Goals, Targets & Benchmarks • US Public Health Service Guidelines • References/notes • Examples (Systems-level) 18 Eligibility, Numerator and Denominator: Each is Different • Who is eligible to be evaluated? (Who constitutes the overall population?) • What part of this population should have received the care being measured? (Who should be counted in the denominator?) • What part of those who should have received the care did receive the care? (Who should be counted in the numerator?) 19 Pediatric HIV Drug Resistance Testing Eligibility Denominator Numerator Percentage of pediatric patients with HIV infection who had an HIV drug resistance test performed before initiation of ARV therapy if therapy started during the measurement year Number of HIV-infected pediatric patients who: • were prescribed ARV therapy during the measurement year for the first time; and • had a medical visit with a provider with prescribing privileges at least once in the measurement year Number of HIV-infected pediatric patients who had an HIV drug resistance test performed at any time before initiation of ARV therapy 20 Eligible Patients Pediatric HIV Drug Resistance Testing Performance Measure Percentage of pediatric patients with HIV infection who had an HIV drug resistance test performed before initiation of ARV therapy if therapy started during the measurement year Denominator Number of HIV-infected pediatric patients who: • were prescribed ARV therapy during the measurement year for the first time; and • had a medical visit with a provider with prescribing privileges at least once in the measurement year Numerator Number of HIV-infected pediatric patients who had an HIV drug resistance test performed at any time before initiation of ARV therapy 21 How to Calculate the Performance Rate on the Pediatric HIV Drug Resistance Testing Eligible Patients: Percentage of pediatric patients with HIV infection who had an HIV drug resistance test performed before initiation of 100 ARV therapy if therapy started during the measurement year Number of HIV-infected pediatric patients who had Numerator: an HIV drug resistance test performed at any time 90 before initiation of ARV therapy = 90% Number of HIV-infected pediatric patients who: Denominator: • were prescribed ARV therapy during the measurement year for the first time; and • had a medical visit with a provider with prescribing privileges at least once in the measurement year 100 22 Selecting and Prioritizing Measures 23 HAB Does Not Require Grantees to Use These Measures But it strongly urges you to use the measures to: • Track and trend performance over time • Identify areas for improvement • Integrate them into your written quality management plans • Modify the measures to meet the needs of your patients and community 24 Role of HAB Performance Measures: A la Carte Dining Selecting & Prioritizing Measures • Consider the following: – Epidemic • Primary modes of transmission • Change in trends • Subpopulations affected – Population served • Race/ethnicity • Gender • Age • Risk factors • Culture 26 Selecting & Prioritizing Measures (cont.) • Services provided • Sophistication & maturity of quality program • Influencing factors – Priority areas of funding agencies – Other measures being monitored by other RW programs in the region • Presents an opportunities to coordinate or compliment activities and compare results 27 Balanced Measures • 1 or 2 measures are not sufficient • Consider the purpose of the measures – Primary focus of your program will impact the set of measures selected • Family centered care network vs. primary care clinic • State or region-focus vs. stand alone clinic • Support services program vs. clinical program 28 TB Screens HAB Measure: Percentage of clients with HIV infection who received testing with results documented for latent tuberculosis infection (LTBI) since HIV diagnosis…….2010 = 99% NJ RWPD Measure: Percentage of clients with HIV infection who received testing with results documented for latent tuberculosis infection (LTBI) within the measurement year…….2010 = 81% Annual screening “read” rates rise in children and adolescents over 6 years from low 40th percentile to low 80th percentile: Linkage with schools which allow school nurses to read the plant and fax/call results to RW clinic. No need for a return visit. Annual screening “read” rates in women also rise to 80th percentile partly due to use of the more expensive QuantiFERON screen when applicable and affordable….3 strikes and you’re out – QuantiFERON is in! CD4 Monitoring HAB Measure: Percentage of clients with HIV infection who had 2 or more CD4 T-cell counts performed in the measurement year at least 3 months apart. Denominator includes patients with ONE medical visit. NJ RWPD Network • averaged a steady 76% over the past 2 years…..quite mediocre, certainly not stellar! Is this a measure that the Network should focus on for improvement? • Nicely ask Careware to rerun the HAB measure using TWO medical visits in the denominator. Results rise to 88% • Is this still a measure worthy of focused improvement efforts? To improve CD4 screens, should we focus first on improving visit rates? Looking at root cause helps drive QI activity. Examples from the Field • Agency name • Identify the HAB measures used for your Part D program – Identify any modifications that have been made to the measure to better reflect your population • If you’ve run the data in various ways to look at subpopulations, what did you look at and how was it used? • Discuss how the measures have been used to make improvements to the Part D care delivery system – Include info about how the measures have been used across your network sites 31 What Are You Using? • What measures are being used? • Are gaps noted in the type of measures used or element of care? • If set up as a network, how are measures used for satellite sites? • What changes will you make? 32 Contact Information Tracy Matthews Chief Clinical Advisor HIV/AIDS Bureau 301-443-7804 [email protected] Marlene Matosky Quality Specialist HIV/AIDS Bureau 301-443-0798 [email protected] Lori DeLorenzo Quality Consultant HIV/AIDS Bureau Organizational Ideas [email protected] 33 Contact Information National Quality Center (NQC) 212-417-4730 NationalQualityCenter.org [email protected] HIVQUAL-US 212-417-4620 HIVQUAL.org [email protected] How do you rate the overall effectiveness of this workshop? 20% 20% 20% 20% 20% 1. 2. 3. 4. 5. Very effective Effective Somewhat effective Ineffective Very ineffective How effective was this workshop in providing you practical solutions and strategies for your program? 20% 20% 20% 20% 20% 1. 2. 3. 4. 5. Very effective Effective Somewhat effective Ineffective Very ineffective This workshop have the right blend of lecture and group discussion? 20% 20% 20% 20% 20% 1. 2. 3. 4. 5. Strongly agree Agree Somewhat agree Disagree Strongly disagree NQC offer additional webinars on this topic in the future? 20% 20% 20% 20% 20% 1. 2. 3. 4. 5. Strongly agree Agree Somewhat agree Disagree Strongly disagree