Developing Quality Management Activities from the Ground Up

Elizabeth Graves Love, MPH

Houston EMA

Outline Houston EMA at a Glance The CPCDMS Outcomes Evaluation Clinical Chart Review Client Satisfaction Measurement Resources Conclusions and Questions

I. The Houston EMA at a Glance

The Houston EMA Six county area in southeast Texas,

covering 5,921 square miles

General population of 4,290,277

Estimated number of diagnosed PLWH/A is 20,045

Houston EMA

Adm inistrative AgencyH a rris C o u n ty H e a lth D e p artm e nt

H IV S erv ice s S e c tion(H IV S e rv ice s)

Ryan W hite P lanning Council(R W P C )

Grantee/CEOH a rris C o u n ty Ju d ge

The Houston EMA FY 2003 Title I allocation is $20,526,823

HIV Services administers 67 service contracts with 27 local providers

Over 7,000 PLWH/A access Title I services each year

II. The Centralized Patient Care Data Management System

The CPCDMS The CPCDMS is a real-time, de-identified,

client-level database application

The system was implemented in June 2000

To date over 10,500 clients have been registered in the CPCDMS

The CPCDMS Records are created, accessed and updated

by providers via DSL data linking using a unique 11-character client code No client-identifying information is collected

Client records are stored at HIV Services on a database server in SQL format

The CPCDMS Data collection occurs through one of three

processes Client registration Service encounter information Medical updates

Through these processes the data that is essential to QM activities is collected

The CPCDMS Users schedule reports using Crystal

Reports software Providers use reports to generate backup

billing documentation and manage programs

HIV Services uses reports to obtain unduplicated data across all providers, service categories and/or grant codes

The CPCDMS 31 local Ryan White-funded providers are

online and using the CPCDMS

This includes all providers funded by Titles I, II, III and IV in a 10-county area

III. Outcomes Evaluation

Background HRSA began emphasizing the importance

of evaluating CARE Act programs in the late 1990’s

The Houston EMA began discussing options in FY 1999

Roles and Responsibilities The RWPC requested that HIV Services

develop and implement a comprehensive, ongoing evaluation program

The RWPC determined that its role would be one of general process oversight

Getting Ready In early FY 2000 HIV Services hired an

FTE Project Coordinator to manage this and other quality-related initiatives

Job description required a graduate degree and documented evaluation experience

Getting Ready In summer 2000 HIV Services completed

necessary background work Reviewing HRSA materials and existing

evaluation models Setting project goals and timeline Surveying the level of awareness among

providers and RWPC members Conducting a resource inventory

Getting Ready Project Goals included:

Developing appropriate outcomes and indicators for each funded service

Involving all stakeholders Minimizing the pain of data collection for

providers and clients Providing accessible, useful data to the

RWPC and providers on a regular basis

Getting Ready In fall 2000, HIV Services conducted an

orientation meeting for providers, RWPC members and consumers

HIV Services then facilitated work groups to select outcomes and indicators for 27 Title I service categories

Selecting the Outcomes Each group worked through the United

Way’s logic model, which provides steps for choosing appropriate outcomes

For each selected outcome the group chose appropriate indicators and data collection methods

Selecting the Outcomes Example – Primary Medical Care

Outcome – Slowing/prevention of disease progression

Indicator – 75% of clients will improve or maintain CD4 counts and viral loads over time

Data Collection Method – CPCDMS

Selecting the Outcomes Example – Rehabilitation

Outcome – Improved ability to perform activities of daily living (ADL)

Indicator – Change over time in the percent of clients who report an improvement in the ability to perform ADL after completing rehabilitation therapy

Data Collection Method – Client survey

Selecting the Outcomes Example – Outreach

Outcome – Entrance into the system of care Indicator – By the end of the fiscal year, 50%

of clients will enter Ryan White primary care Data Collection Method - CPCDMS

Selecting the Outcomes Once the work groups reached consensus,

the RWPC reviewed and approved the outcome measures

The outcome measures are reviewed and revised each fiscal year

Background Work During the RWPC approval process, HIV

Services prepared the following: Data collection tools and analysis reports Policies and contract language describing

requirements for providers Training for providers

Data Collection Through registrations, service encounters and

medical updates, the CPCDMS collects the following data used in outcomes analysis: Demographics CD4 counts, viral loads and stage of illness Opportunistic infections and co-morbidities Health and support service utilization

Data Collection Through special screens created for certain

service categories, the CPCDMS collects the following data used in outcomes analysis: Provider assessment of client progress Health data not collected in primary care Number of hospitalizations and ER visits

Data Collection In general, the CPCDMS cannot provide

information about Quality of life Cost-effectiveness Knowledge, attitudes and practices

Client surveys collect this information

Data Collection Client Surveys

HIV Services developed and piloted the pre- and post-test surveys

Virtually all surveys are less than one page in length; most are four questions or less

No demographic information is collected

Data Collection Survey Administration

In FY 01 survey administration and data entry was manual

Since FY 02 survey administration and data entry has been automated through the CPCDMS

Provider Requirements Providers are contractually obligated to

participate in evaluation activities

Reimbursements may be withheld if a provider is not in compliance

Implementation Prior to the beginning of FY 2001,

providers received instructions and training on evaluation activities

Data collection began March 1, 2001

Data Analysis and Reporting Providers must submit outcomes data to

HIV Services each quarter

Data is stored in SQL format and analyzed using Crystal Reports

Each provider and the RWPC receives results on a quarterly basis

Using Outcomes Data Providers use outcomes data to report to

their boards, complete RFPs and for internal quality improvement

The RWPC uses outcomes data in all planning processes

Using Outcomes Data - Example Primary Care Outcome 1.1 – Slowing or

prevention of disease progression Indicator - 75% of clients will decrease or

maintain their viral load over time

In FY02 79% of Title I primary care clients decreased or maintained their viral load

The RWPC increased the allocation for primary care by 10% for FY04

Using Outcomes Data - Example Household Items Outcome 3.1 – Improved or

stabilized living conditions Indicator - Change in the percent of clients with

improved or stabilized living conditions due to receiving furniture or household items

FY01 and 02 data showed that this program had no impact on client living conditions

The RWPC did not fund this service for FY04

Successes From conception to implementation, project

development took just six months

The project has support and participation from all key stakeholders

The resulting data has enhanced RWPC decision-making as well as our Title I grant application

Challenges At first providers were wary about the

possibility of extra work

RWPC members require ongoing education about understanding and using outcomes

IV. Clinical Chart Review

Background In April 2001 HRSA issued its guidance on

quality management One goal is to ensure that medical services

are consistent with treatment guidelines

The EMA determined that clinical chart review could best accomplish this goal

Roles and Responsibilities Following HRSA guidance, HIV Services

assumed project oversight

The RWPC QA Committee maintains an advisory role

Getting Ready In FY 2001 HIV Services hired an FTE

Program Development Coordinator to oversee clinical chart review

Job description required a graduate degree along with documented experience in QA/utilization review

Getting Ready During winter 2001 HIV Services

completed all necessary background work Reviewing PHS Guidelines and HRSA’s

Primary Care Assessment Tool Reviewing tools and methodologies from

other EMAs Determining provider expectations

Scope of Work With this information HIV Service

determined the scope of the project Each health-related service would undergo an

annual review of client records A qualified contractor would perform the

chart reviews HIV Services would analyze and report

findings

Scope of Work Participating service

categories include: Primary Care Case Management Oral Health Care Vision Care Professional

Counseling

Substance Abuse Treatment

Rehabilitation Hospice Care Home Health Care Drug

Reimbursement

Contractor HIV Services contracted with a masters-

level RN to help develop the tools and to conduct the reviews

Reimbursement is on a per-chart basis

Tool Development For each service category a set of core

questions was developed Example – What percentage of primary care

clients receive the recommended number of CD4, viral load and CBC tests each year?

These questions drove tool development

Tool Development Primary care tool borrows heavily from

HRSA’s Primary Care Assessment Tool 30 data elements

Case management tool follows EMA standards of care for case management 15 data elements

Implementation Providers received instructions and training

on chart review activities Provider obligations Sample generation Review schedule Reporting

Provider Requirements Providers are contractually obligated to

participate in chart review activities

Providers must accommodate the review Provide a work space for the contractor Have charts pulled and ready for review

Sample Generation Desired sample characteristics

10% of the caseload for each service

Reflective of the population served

Randomly selected

Sample Generation To generate the sample, a CPCDMS report

randomly selects 10% of the clients seen during the time under review, mirroring the demographic make-up of all clients

HIV Services provides the sample to the provider immediately prior to the review so charts may be pulled

Implementation During FY02 charts for four Primary Care

sites and eight Case Management sites were reviewed 400 primary care charts 235 case management charts

Oral health and vision care have been added in FY03

Analysis and Reporting The contractor provides raw data to HIV

Services in MS Access format for analysis

HIV Services forwards preliminary results to each provider for their comment

Final results are disseminated to providers and the RWPC

Using the Data - Example Providers are using chart review data for

internal quality improvement Example – One clinic’s results showed that

very few TB+ clients received confirmatory chest x-rays, which were performed off-site

The clinic purchased the necessary equipment to perform chest x-rays on-site

Using the Data - Example The RWPC is using chart review data

during their decision-making processes Primary Care chart review data showed that

just 29% of clients on ART received adequate medication adherence education

The RWPC strengthened the Primary Care service definition for FY 2004, mandating med ed and specifying who may provide it

Using the Data - Example HIV Services is using chart review data to

strengthen contract language and documentation requirements Case Management chart review showed the

quality of client assessment tools varied among providers

HIV Services has developed a standardized assessment tool, required in FY 2004

Successes Most providers consider chart review to be

a free service, saving money and staff time

The RWPC quickly embraced the value of chart review data

After just one year, the data has resulted in significant changes in service delivery

Challenges Tool development for services other than

Primary Care has been challenging

Some providers were concerned that results might be used in a punitive manner

V. Client Satisfaction

Background Prior to FY 2002 HIV Services required

that all providers measure satisfaction

Methodologies and tools varied

HRSA’s QM guidance in April 2001 led to a reconsideration of client satisfaction

Background HIV Services decided to centralize the

measurement of client satisfaction to ensure consistent and reliable data

As with clinical chart review HIV Services assumed project oversight The RWPC QA and Affected Community

Committees provide input and feedback

Background During FY 2001 HIV Services conducted

all necessary background work Collecting and reviewing providers’ current

methodologies and tools Reviewing methodologies from other EMAs Developing methodology and timeline Developing survey instruments

Scope of Project Methodology employs a survey with

questions that address the service, the provider and the Title I system overall

On an annual basis a 10% convenience sampling is surveyed for each service

Survey Development HIV Services developed a core set of

questions as well as questions relevant to each service category Each service category has a unique survey

The surveys were piloted at agency sites

Survey Development Providers and RWPC members assisted

with survey development Many survey questions were borrowed from

providers’ previous survey tools RWPC Affected Community Committee

members provided consumer insight

Survey Administration Each provider must survey 10% of their

clients during a six-week period set by HIV Services

The same methodology used to generate outcomes surveys through the CPCDMS is used to generate client satisfaction surveys

Survey Administration HIV Services provides each agency with a

locked box in which clients deposit completed surveys

This ensures that providers never see completed surveys, thus encouraging clients to provide honest answers

Provider Requirements Providers are contractually obligated to

participate in client satisfaction activities

Providers with successful methods for measuring satisfaction already in place may be exempt from participation

Implementation In FY 2002 1,061 surveys were completed

The sample mirrored demographic characteristics of the entire Title I client population

In FY 2003 1,750 surveys were completed

Data Analysis and Reporting Survey forms are scanned at HIV Services and

the data is stored in a SQL database that is linked to other CPCDMS data

Crystal Reports is used to generate analysis reports

Each provider and the RWPC receives results each year

Using the Data - Example The RWPC uses the results when setting

service definitions Drug Reimbursement clients indicated they

were not receiving adequate information from pharmacy staff about side effects, drug interactions, diet and dosage

RWPC strengthened the service definition to mandate specific education requirements

Successes The standardized methodology provides

the EMA with data from the provider, service category and Title I perspectives

Centralizing satisfaction measurement benefits providers and the RWPC

Challenges Initially providers were concerned that

clients would feel “over-surveyed”

The RWPC Affected Community Committee helped alleviate these concerns, and in fact most clients have welcomed the opportunity to provide feedback

VI. Resources

Staff Resources HIV Services has 2.5 FTE assigned to

evaluation and QM activities

A masters-level RN contractor provides chart review services

An IT consultant helps build CPCDMS survey modules and analysis reports

Financial Resources Overall FY 2004 QM budget is $434,760,

2% of total allocation

Salary for two FTE $150,000 for chart review contractor $100,000 for CPCDMS consultant

VII. Conclusions

Conclusions Centralizing QM activities at the Grantee level

results in standardized methodologies, project continuity and consistent data

Buy-in from stakeholders is essential Automating processes whenever possible eases

the burden on all stakeholders Regular data reporting keeps stakeholders

interested and involved Borrowing methods and tools is a lifesaver

For more information…Elizabeth Graves Love, MPH

Harris County Public Health and Environmental Services Department

HIV Services Section

713-439-6041

elove@harriscountyhealth.com

www.harriscountyhealth.com/hivservices