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Developing indicators for Part D family and
youth centered programs
NQC Part D TA Call
September 27, 2010
Learning Objectives
• Review applicable HAB measures for Part D
grantees
• Discuss screening versus indicators
• Engage call participants in discussion of what
indicators are important to them
• Learn what indicators your Part D peers have
developed for family and youth programs
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What Makes a Good QI Indicator?
• Relevance
• Does the indicator affect a lot of people or programs?
• Does the indicator have a great impact on the programs or
clients in your network or program?
• Measurability
• Can the indicator realistically and efficiently be measured
given finite resources?
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What Makes a Good QI Indicator? (cont.)
• Accuracy
• Is the indicator based on accepted guidelines or developed
through formal group-decision making methods?
• Improvability
• Can the performance rate associated with the indicator
realistically be improved given the limitations of your
services and population?
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HAB Measures
HAB HIV/AIDS Core Clinical Performance Measures
• Group 1 measures provide an excellent start and can serve
as a foundation on which to build, especially if a clinical
program has no performance measures.
• Group 2 measures are important measures for a robust
clinical management program and should be seriously
considered.
• Group 3 measures represent areas of care that are
considered "best practice," but may lack written clinical
guidelines or rely on data that are difficult to collect.
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HAB Measures
• Medical Case Management Performance Measures
are for clients of all ages and focus on:
• Care plans
• Medical visits
• Oral health measures for all clients providing direct
oral health services
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HAB Measures
Coming soon:
• HAB Pediatric Measures
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HAB Group 1 Indicators
• ARV Therapy For Pregnant Women: % of
pregnant women
with HIV infection who are prescribed antiretroviral therapy
• CD4 T-Cell Count: % of
clients who had 2 or more CD4 counts at
least 3 months apart
• HAART: % of clients with AIDS who are prescribed HAART
• Medical Visits: % of clients who had two or more medical visits in an
HIV care setting
• PCP Prophylaxis: % of
were prescribed PCP prophylaxis
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clients with CD4 count <200 cells/mm3 who
NQC Indicators
Obstetrics/Gynecological Care
•
•
Cervical Pap Test
Preconception Care and Counseling
ANTENATAL CARE
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•
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•
•
HIV RNA Measurement at 34-36 Weeks’ Gestation
Prescription of Antiretroviral Prophylaxis during Pregnancy
Avoidance of Certain Antiretroviral Regimens during Pregnancy
Counseling Pregnant Woman with HIV Infection to Avoid Breastfeeding
Cesarean Section Offered if HIV RNA >1,000 copies/mL
INTRAPARTUM CARE
• Intrapartum Zidovudine Delivery : Administration of Intrapartum
• Regimen for Pregnant Women who Have Never Received Antiretroviral Therapy
POSTPARTUM CARE
• Maternal Postpartum Follow-Up Linkage to HIV Primary Care Provider after Delivery
NEONATAL and infant care
• HIV Testing in Infants
• Neonatal Care and Prophylaxis
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Screenings v. Indicators
Screening
• A test to determine if an individual has a disease
(mental or physical)
• Positive result should lead to diagnostic procedures
• Ex: Cervical cancer screening, TB screening,
hypertension
• A proactive approach to disease identification
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Screenings v. Indicators
Indicators
• Measures disease state or progression
• Typically yield one data point per incidence of
measurement
• Can be measured and trended over time
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Screenings v. Indicators
Example of a
screening tool
•Michigan uses the
results to help create
a Family Self Sufficiency Plan
•Automated and easy
to use
Goetschy, J, Clark, D July 31, 2006. Michigan Family Automated Screening Tool (FAST) & Family Self-Sufficiency Plan (FSSP).
http://www.state-itc.org/TANF_NTHS_2006/documents/S3b%
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Screenings v. Indicators
Example
A clinic is located in an area with a high prevalence of
drug use, HIV infection and individuals with mental
health issues
What would these environmental factors indicate for
the youth and adolescent population?
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High
severity
The Four Quadrant Framework for
Co-Occurring Disorders
Less severe
mental disorder/
more severe
substance
abuse disorder
Less severe
mental disorder/
less severe substance
abuse disorder
Low
severity
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More severe
mental disorder/
more severe substance
abuse disorder
More severe
mental disorder/
less severe
substance
abuse disorder
A four-quadrant
conceptual framework to
guide systems integration
and resource allocation
in treating individuals
with co-occurring
disorders
(NASMHPD,NASADA
D, 1998; NY State; Ries,
1993; SAMHSA Report
to Congress, 2002)
High
severity
What Indicators Are Important to You
What are the special characteristics of Part Ds that we
want to measure and improve?
•
•
•
•
•
•
•
Focus on women, children, youth and families
Family-centered approach
Multi-service, medical home model
Network design is common
Case managed coordinated care
Cultural competence and consumer involvement
What else?
Standard, chart review-type measures don’t capture these special aspects very
well……
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What Indicators Are Important to You
How can these Part D-specific characteristics be
measured?
•Take off-the-shelf, client-level measures and give them a Part
D spin:
• Clinical (HAB and NQC/HIVQUAL) measures
• Case management and care coordination measures
and consider
•Creating measures at a network level to:
• Measure the family-centeredness of the program
• Measure aspects of network functioning
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What Indicators Are Important to You
Family Centered Care Core Concepts
•
•
•
•
Respect and dignity. Health care practitioners listen to and honor patient and
family perspectives and choices. Patient and family knowledge, values, beliefs and
cultural backgrounds are incorporated into the planning and delivery of care.
Information Sharing. Health care practitioners communicate and share
complete and unbiased information with patients and families in ways that are
affirming and useful. Patients and families receive timely, complete, and accurate
information in order to effectively participate in care and decision-making.
Participation. Patients and families are encouraged and supported in
participating in care and decision-making at the level they choose.
Collaboration. Patients and families are also included on an institution-wide
basis. Health care leaders collaborate with patients and families in policy and
program development, implementation, and evaluation; in health care facility
design; and in professional education, as well as in the delivery of care.
Institute for Patient – And Family – Centered Care; http://www.ipfcc.org/faq.html
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What Indicators Are Important to You
• How do we measure if care is truly family centered?
• The term family has been redefined over the years;
are we sensitive to that as practitioners?
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What Indicators Are Important to You
Family-Centered Care Self-Assessment Tool (Oct. 2008). Family Voices, Albuquerque, NM. http://www.familyvoices.org/pub/projects/fcca_FamilyTool.pdf
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What Indicators Are Important to You
Performance Measurement Strategies: Clinical Only
Pros:
• Pre-defined measures
• Benchmarking available
• HAB requires some clinical measurement
Cons:
• Clinical measures capture clinical aspects of care
• Don’t capture core mission and full scope of Part D
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What Indicators Are Important to You
Network Level - Measure aspects of network
functioning
Issues:
• Harder to measure and not much off-the-shelf
• Level of analysis providers/network, not client-level
• Communication and care coordination issues
increase dramatically
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Elements of Family Centered Care
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•
•
•
•
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Promote cultural sensitivity
Facilitate client feedback
Help clients become informed consumers
Support family involvement in care
Support and facilitate consumer advisory board
Family Centered Care: Aspects of 6 Elements1
Cultural Sensitivity in Planning
Involve consumers in planning
Provide bi-cultural materials
Provide staff diversity training
Use Consumer Feedback in Planning
Use consumer feedaback surveys
Hire clients as staff
Sponsor CABs
Hold focus groups
Network-sponsored Family Activities
Support groups
Recreation programs
Newsletters
No. T4
Networks
% T4
Networks
No.
Funded
Sites
%
Funded
Sites
35
34
30
90
87
77
246
239
220
91
89
82
35
31
29
28
90
79
74
72
246
228
194
207
91
85
72
77
38
27
22
97
69
56
264
183
149
98
68
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Ryan White CARE Act Title IV programs: a preliminary characterization of benefits and costs. Abramowitz S, Greene D.AIDS Public Policy J. 2005 Fall-Winter;20(34):108-25.PMID: 17624034 [PubMed - indexed for MEDLINE]Related Articles
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Fostering Family Centered Care (Continued)
Help Clients become Informed Consumers
Support client attendence at workshops
Consumer staff provide peer support
Provide consumer workshops
Develop/make available materials
Network Support for CAB
Food
Consumer Conferences
Transportation
Child Care
CAB Activities
Identifies program needs
Discusses network programs
Participates in advocacy
Sponsors client activities
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No. T4
Networks
% T4
Networks
No.
Funded
Sites
%
Funded
Sites
38
33
31
31
97
85
79
79
267
241
234
198
99
90
87
74
31
31
29
24
79
79
74
62
234
225
221
198
87
87
82
74
33
29
25
19
85
74
64
49
224
214
186
146
83
80
69
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Measures of Network Functioning
• Coordination of care across provider sites
• Coordination of leadership across sites through management team
• Coordination of providers and linkages among them
• Services integration – one stop shopping and co-located services
• Uniform policies and procedures for:
• Network Management - Planning, budgeting, administration
• Service Delivery – protocols of care, care coordination, CQI
• Adopting and succeeding with a single improvement project
across the network (for instance, pap tests or patient
retention)
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Care Coordination Measures: One Example
Assuming a need for referral has been identified:
• Was referral made
• Was referral received/acknowledged by recipient site
• Did client received service/client referred elsewhere, etc.
Assuming a support need has been identified:
• Date the need was identified
• Date the need was addressed (housing received; etc.)
• Was it communicated back through the network
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Learn from Your Peers
Non-clinical intervention to improve medical
outcomes
Example:
A program site found that no AZT was available for newborns
in the first 48 hours after discharge on the weekends which is a
critical time to prevent perinatal transmission
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Learn from Your Peers
Improvement idea:
Improve the process to get medications regardless of a
weekend discharge.
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Learn from Your Peers
Started Small
• Made a plan to identify hospitals that delivered HIV+
mothers in the last 3 years
• Discussed ideas with stakeholders
• Raised awareness to local pharmacy
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Learn from Your Peers
What were the benefits?
• Pharmacy became partner
• Hospitals or mother could contact pharmacy partner
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Learn from Your Peers
Example from Public Health Solutions
Indicator
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Measure
Domestic violence assessment (or “violence assessment”)
adolescents (13 yo – 24 yo); women 24 yo +
Referrals tracking and documentation (service received if referral was made)
adolescent HIV+ clients 13 yo – 24 yo
Mental health—annual assessment[3]
adolescent HIV+ clients 13 yo – 24 yo
Adherence counseling provided for clients on HAART
adolescent HIV+ clients 13 yo – 24 yo
Nutrition services (annual referral, annual assessment)
adolescent HIV+ clients 13 yo – 24 yo
Documentation of support services in charts and medical records
adolescent HIV+ clients 13 yo – 24 yo
Case Management assessment and service plan up-to-date
adolescent HIV+ clients 13 yo – 24 yo
Disclosure discussed with caregiver and/or pediatric-adolescent patient (annual)
(“disclosure assessment”) [4]
adolescent HIV+ clients 13 yo – 24 yo
Learn from Your Peers
• Who else ?
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Resources
• More detailed information about the HIVQUAL measures can be
accessed at: http://www.hivguidelines.org
• Measuring Clinical Performance: A Guide for HIV Health Care
Providers. A publication of the AIDS Education Training Centers and
the New York State Department of Health, AIDS Institute, 2006. The
guide can be downloaded at:
http://nationalqualitycenter.org/index.cfm/6127/13908
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Family-Centered Care Resources
• Abramowitz S, Greene D. Ryan White CARE Act Title IV programs: a preliminary
characterization of benefits and costs. AIDS Public Policy J. 2005 Fall-Winter;20(3-4):10825.PMID: 17624034 [PubMed - indexed for MEDLINE]Related Articles (table, slides 15 and
16.)
• Circle of Care Principles of Family Centered Care
www.circleofcarephilly.org/
• Family-Centered Care Self-Assessment Tool (Oct. 2008). Family Voices, Albuquerque, NM.
http://www.familyvoices.org/pub/projects/fcca_FamilyTool.pdf
• Trivette,M., Dunst, K., Boyd,K., Hamby, D. ‘Family-Oriented Program Models, Helpgiving
Practices and Parental Control Appraisals’. Exceptional Children, Vol. 62, 1995
• www.familycenteredcare.org
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