Indianapolis Transitional Grant Area (TGA)

Indianapolis Transitional Grant Area (TGA)

Quality Management Plan

Ryan White Part A

2015-16

Ryan White Part A Quality Management Program-Background

The Indianapolis Transitional Grant Area (TGA) is a ten county geographic area that has been disproportionately affected by HIV/AIDS. The Ryan White HIV/AIDS Treatment Modernization Act of 2006 requires that all Ryan White grantees establish and maintain a quality management program to ensure access to primary HIV care that is consistent with the most recent Public Health Service guidelines; to assure that receipt of such services result in an improvement of health outcomes and quality of life; and to encourage and promote substantive consumer involvement in maintaining the quality management process.

Quality Management Program Mission

The mission of the Indianapolis quality management program is to improve quality of care and access to medical and supportive services for people living with HIV/AIDS in the TGA. This will be accomplished through the development of a comprehensive quality management plan that uses performance measures and epidemiological data to systematically improve the delivery of medical and support services and access and adherence to medical care.

Dedication

This quality management plan is dedicated to all of the Indianapolis Transitional Grant Area residents who are infected and affected by HIV/AIDS and to those persons who we have lost to this epidemic. It is our goal that through the implementation of the quality management plan that every person living with HIV/AIDS in the Indianapolis and surrounding areas will have access to the best standards of HIV care and that as a result, will be able to enjoy a healthy, happy and long life.

Quality Management Goals

v  Early HIV disease detection

v  Ensure access to and retention in HIV care

v  Improve data-management systems

v  Assure the provision of quality core medical and supportive services

v  Maintain a comprehensive quality management program and plan

.Quality Management Infrastructure

The Clinical Quality Management Committee (CQM), a core component of the Ryan White Part A QM program, is responsible for identifying quality improvement needs, setting quality improvement (QI) goals, and developing and implementing strategies for improving access to HIV care through continuous QI activities. The CQM Committee previously consisted of three core components: administrative, medical advisory, and consumer. As part of the 2013/2014 annual evaluation of the CQM Program, all three components of the QM Committee voted to merge the three components into one team. The QM Committee is a cross Part, interdisciplinary committee that is under the direction of the Part A administration. Committee membership is composed of representatives from core and supportive service provider agencies and consumers who reside in the TGA. Combining the core components into one large committee has resulted in more efficient use of resources, has facilitated more effective communication about and dissemination of QM issues and concerns, and has led to greater participation in QM meetings. CQM program staff and QM Committee roles and responsibilities are described in the following section.

The medical advisors inform the Committee and Part A Grantee on TGA-wide medical goals and objectives that will be included in the TGA wide Quality Management Plan, Comprehensive Plan, and annual Part A Implementation Plan. The medical advisors provide additional guidance on identifying and prioritizing quality concerns, and establishing quality measures. Consumer Committee members work collaboratively with the Part A Grantee and other Committee members in identifying and implementing QI projects related to client satisfaction with service utilization and delivery. The CQM committee meets on an as needed to quarterly basis and meetings are held in concurrence with other Planning Council committee meetings. The Grantee provides quarterly updates of QI projects and clinical practice guidelines that impact standards of care in the TGA to the QM Committee. The QM Committee works collectively with the Needs Assessment, Systems of Care, and Consumer Access Planning Council on projects related to consumer engagement and satisfaction and works with the Priority Setting and Resource Allocation Committee to triage QI priorities.

Roles and Responsibilities

The Project Director: Michael Wallace provides direction and technical assistance to the Medical Advisory and Consumer Quality Management Committees, secures and approves funding for quality improvement (QI) initiatives, and serves as the QM representative for HRSA. In addition, the CQM Program, including QI activities and initiatives, and QI education and technical assistance is supported by three grantee personnel.

CQM Program Manager: Dana Hines, MSN, RN, serves as the quality program manager for Ryan White Part A Program. The QM Program manager develops and manages the QM Plan, facilitates the QM Committee, coordinates quality improvement efforts, ensures continuous quality improvement of Part A program services, and monitors subcontractor’s core and supportive service performance measures and adherence to the Part A standards of care. The CQM program manager also coordinates the Local Pharmacy Assistance Program Advisory Board and assists the Part A Program Director in writing the Part A grant, Progress Report and Implementation Plan.

Project and Training Coordinator: Coya Campbell, BS, is experienced in STD surveillance, case management, and disease intervention. He works in collaboration with the CQM Program in identifying QI training needs, conducting site visits and chart audits, providing training and technical assistance to subcontractors, and in monitoring adherence to the local TGA and National Monitoring Standards of Care.

CAREWare Data Manager: Jill Carr is the CAREWare data manager for the RWSP. She supports CAREWare for providers and staff and manages data collection and reporting on an ongoing basis. She specifically supports data management needs for the Part A Program. She specifically manages data requests for HIV/AIDS Bureau (HAB) performance measures reports, the Part A Progress Report and Implementation Plan, the RSR, and manages ongoing data requests and technical assistance requests from Ryan White Service Providers.

RWSP Epidemiologist: Tammie Nelson is responsible for completing the Epidemiological Profile, developing data collection tools, overseeing data collection, implementing the local evaluation plan, and working with the Project Director and QM staff to compile data regarding accomplishments, progress, and barriers.

Lead Medical Advisor: Dr. Bree Weaver serves as lead clinical advisor for the Part A CQM program. She provides medical leadership in quality assessment and improvement activities, and assists in the incorporation of HIV/AIDS treatment guidelines into TGA specific guidelines and/or protocols. Dr. Weaver also participates in quarterly chart reviews/audits of outpatient/ambulatory relatedHAB measures, makes recommendations for improving performance in low scoring areas, and maintains subject matter expertise inHAB Core Performance Measures. Finally, she serves as quality champion to provide clinical leadership in physician relationship building for Ryan White quality improvement initiatives and assists in the development and implementation of provider education programs related to clinical quality improvement activities for the TGA.

Consumer QM Committee Chair: Mr. Brian Fisher serves as the consumer chair for the QM Committee. Mr. Fisher identifies as a person who has been living with HIV/AIDS for more than two decades and is also a member of the Planning Council.

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Quality Improvement and Capacity Building

Table 1: Summary of QI Capacity Building and Quality Improvement Projects 2008-2016

2016 / Inactive Clients Review
Retrospective review of all 2014 inactive RWSP clients continues and will be completed by June 2016. Refer to pp. 15-16 for additional information and results.
Training and Capacity Building
Developing a case management training manual for Part A sub-awardees to ensure quality and continuity of case management in the TGA.
2015 / Ryan White Program Recertification
Survey to examine reasons why clients were not recertifying for the RWSP
Inactive Client List
Started retrospective review of all RWSP clients that became inactive in 2014
2014 / Local Pharmacy Assistance Program
Established local pharmacy assistance advisory program (LPAP) board, policies and procedures governing LPAP services, and developed a Ryan White Parts A & C formulary.
2014 / Client Concern Survey
The Client Concern Survey was a consumer and sub-contractor driven initiative that aimed to identify the most pressing concerns of consumers in the TGA. The survey consisted of one open ended question, “Do you have any major concerns right now? Or what is your biggest concern?” Four case management agencies participated in the survey and data were collected over a six week period of time. Survey results were shared with the Planning Council and the consumer chair of the CQM committee organized and prioritized the client concerns according to its modifiability, feasibility of being improved through a QI project, and likelihood of impacting client access to care. The top concerns in order: 1) Assistance with cost of insurance premiums, 2) assistance paying medical and drug copays, 3) housing assistance, 4) increased need for food and utility assistance due to changing insurance programs, 5) need for more psychosocial referrals and programs to manage stress of daily life, 6) quicker access to mental health programs, 7) life skills and employment programs, 8) more comprehensive and reliable transportation
2014 / Job Placement Assistance was one of the key concerns expressed by clients in the Client Concern Survey. To address these concerns the Grantee in conjunction with several care coordination agencies, plans to coordinate a series of workshops that addresses job placement, applying for and finding jobs with a criminal history, answering tough questions about criminal convictions on applications, and strategies for finding employers who hire felons. This CQM committee will collaborate with the consumer access committee of the Planning Council on this project that is set to launch in November 2014.
2014 / Targeted Psychosocial Case Notes Guide: As part of our ongoing review and monitoring of the National Standards of Care, the CQM Program and the Project Training Coordinator began a targeted review of psychosocial case notes. The purpose of this review was to assess the quality of the services being provided and to monitor adherence to the service definition of psychosocial services. Findings from this review suggested a need for more guidance on writing case notes, documenting outcomes of the service, screening for the need of referrals, and making referrals when appropriate. To facilitate this improvement, a standardized template was developed for use in CAREWare. The Grantee developed the template and obtained feedback from the psychosocial service providers before initiating the go live. The template addresses the following: 1) What problem or concern is the client seeing you for today?, 2) What actions or steps did you take to help the client resolve their problem or concern?, 3) How did the client respond to the actions or steps that you provided in helping them resolve their concerns?, 4) Was a referral made as a result of today’s visit?, 5) If a referral was made, to where?, 6) Is this the client’s initial psychosocial visit?, 7) Is this a repeat psychosocial or substance abuse visit?,8) If this is a repeat visit, describe how the problems or concerns that the client expressed at their last visit were resolved?
2012-2013 / QM Program Manager provided technical assistance and capacity building for all sub-grantees in the development of their agency-specific QM plans.
2011-2012 / First 90-Day Labs QI Project
Formed clinical advisory group to streamline first 90 day labs. This interdisciplinary group consisted of physicians, pharmacists, consumers and grantee administrative staff. Together this group outlined the initial laboratory tests that newly diagnosed and newly enrolled patients should receive while covered only under the Ryan White services program. This group also identified labs that could be delayed until transition to ICHIA, Medicaid or Medicare. In FY 2010/11 47% of Outpatient/ambulatory dollars were spent on labs. After implementing the First-90 Day Protocol in FY 2013/14 the amount spent decreased to 31.1%
2011-2012 / Medical Transportation Survey The goals of the medical transportation survey were to evaluate client satisfaction with medical transportation (MT), identify gaps in the MT service, and obtain client input on ways to improve MT services. Surveys were mailed to clients according to those who agreed to receive Ryan White-related mail. Results were compiled and changes were made to medical transportation policies as a result. Specifically the Grantee disseminated information to all clients through care sites about the following regarding MT: Eligibility requirements, Where/how to access, MT providers, and types of transportation available. Grantee also helped with plans to provide individual MT assistance to assist clients who are too weak to take the bus in attending their medical and other HIV-related appointments.
2010-2011 / Floating/Traveling Medical Case Management
A QI evaluation of medical case management service utilization conducted during FY 2010-11 revealed that clients who received medical care from HIV specialists outside of Eskenazi (formerly Wishard) or LifeCare were not able to access MCM elsewhere because of liability and institutional constraints. In order to ensure equitable access to MCM for all Ryan White eligible clients living in the Indianapolis TGA, RWSP developed a floating MCM position that would be responsible for traveling to primary care sites and providing MCM to clients who were not Wishard or LifeCare patients. Since this role was launched on March 1, 2012, 77 new clients (meaning those who did not receive care at Eskenazi or LifeCare) have received this service. During FY 2012-13, this number increased to 154 and in FY 2014-14 the number of clients served through this mechanism was 596. This QI project has expanded access to MCM and has changed service delivery in that MCM is now a mobile service that can be delivered to any client regardless of where they receive medical care.
Medical versus Non-Medical Case Management
Completed acuity assessments at all funded agencies to help distinguish non-medical case management activities from medical case management activities. Also completed an 18 month capacity building project for case management redesign. Concept analysis and agency-level acuity assessments were used to guide the service redesign of non-medical and medical case management services. Result of this project was presented at APHA in Denver, CO.
2009-2010 / Standards of Care
The Systems of Care Committee of the Planning Council has completed standards of care for the following service categories: local pharmacy assistance; medical transportation; mental health; oral health; outpatient ambulatory; psychosocial support; and substance abuse. As of August 2010 the following standards are pending: medical and non-medical case management, early intervention services, childcare, emergency financial assistance, housing and outreach.
2009-2010 / Using the PDSA Model to Improve Cervical Cancer Screening
In June 2009 the Part A QM program in collaboration with LifeCare Infectious Disease Clinic implemented a PDSA model to test a series of strategies suggested by patients and staff to improve cervical cancer screening rates. Strategies included placing educational brochures in the exam rooms, lobby, and nurse practitioner led education. Screening rates improved from 4-15%.
Outcome: Screening rates remain low. This ongoing challenge is partly due to missing data/underreporting and partly due to lack of screening capacity within the HIV clinical care site. Results presented at the American Public Health Association (APHA) Conference in Philadelphia, PA.
2008-2009 / New TGA Capacity Building
Completed an 18 month capacity building for new TGA’s sponsored by the National Quality Center.
October 2008
Began collecting HAB performance measures data
November 6, 2008
The Ryan White Part A Planning Council in full session on November 6, 2008 approved, in principle, the establishment of a Quality Management Committee and designated it as a Standing Committee of the Council.
Perinatal HIV Exposures
Formed informal perinatal work group to evaluate the rate of perinatal transmission in the TGA. This work group eventually secured funding to formally implement the Fetal Infant Mortality Review (FIMR)/HIV project in Marion County. FIMR is an enhanced perinatal transmission prevention program that uses formal case reviews and community action to investigate cases of exposure and to prevent future perinatal transmissions. Outcome: This project lead to the One Test Two Lives Campaign and practice changes for HIV testing during pregnancy.
Standards of Care
Established local standards of care for core medical and support services.

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