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Hartford, CT TGA 2018-2021 QM Plan Revised 4/2016; 1/17; 9/17, 7/18, 4/19

Hartford Transitional Grant Area (TGA)

Quality Management Plan

2018-2021

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Table of Contents

I. Overview………….…………………………………………..………………….………………………………………2 MissionCore ValuesPurpose

II. Quality Improvement Directions ………………………………………..…………………………......……3 National HIV/AIDS Strategies for the United StatesCT Cross Parts CollaborativeConnecticut HIV/AIDS Planning Consortium Hartford TGA

III. Evaluation, Assessment, Results (Core Services)........................................................10TGA Results HRSA/HAB Measures EIIHAH

IV. Quality Management Goals and Projects for 2018-2021……………………………….....……12HAB Measures Statewide/TGA Percentages and Goals (FY 16/17)Evaluation, Assessment, Results (Non-Core Services)

V. Overview of the Quality Management Program Accountability Structure ……………..13TGA Leadership TeamQuality Management CommitteeQuality Accountability DiagramStakeholder Engagement in Quality Management

VI. Building TGA Capacity ……………………….………………………………………………….……………….15

Appendix A…………………………………………………………………………..……………………….……….16Performance Indicators

Appendix B………………………………………………………………...…….……………………………………17Local Performance Measures for Supportive and Core Services 2017-2018

Appendix C……………………………………………………………………………..………………………………25QM Work Plan


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I. Overview The Greater Hartford Transitional Grant Area (TGA) supports HIV/AIDS services in three counties: Hartford, Middlesex, and Tolland. Approximately 1,206,836 persons live in the three counties with 3,479 HIV infected individuals noted as of Dec 2017. Of the people living with HIV/AIDS there is 3,046 within Hartford County, 303 within Middlesex County and 130 within Tolland County as of 2017. Of these individuals infected with HIV/AIDS, 40% are Hispanic, 29% Caucasian, 30% African American and 2% other races. The route of transmission of the disease include: injective drug users (IDU) accounting for 31%; Men who have sex with men (MSM) 28%; Heterosexual 25%; 12% other/unknown, 2% MSM/IDU and 2% Perinatal. 67% male and 33% female makes up the HIV/AIDS population within the TGA. An estimated 339,128 persons are living below the poverty level in Connecticut, this equates to about 10.2% of the population. With more that 67.7% of persons living with HIV/AIDS living below the federal poverty level according to CAREWare data in 2017.

A. MissionThe mission of the Hartford TGA’s QM program is to continually improve the quality of services for persons living with HIV/AIDS/HCV. The goals of the program include:

o Insure that services are delivered in accordance with Department of Health and Human Services’ HIV/AIDS/HCV treatment guidelines and the TGA’s standard of care

o Build and support the development of the quality management capacity at the sub-recipient level based on need

o Collect and report performance measurement data to identify improvement areas and to trend data for benchmarking within the TGA and Statewide.

o Promote quality improvement and quality management accountability to participate in Getting to Zero (G2Z) activities and initiatives at sub-recipient agencies

o Refine as necessary standards of care and monitor program adherence to determine where technical assistance or other action is required

o Expand quality management culture across the TGA

B. Core Values The Hartford TGA is committed to the following core values:

1. Decrease the number of new infections by 25%, from 291 in 2018 to 218 in 2021 2. Increase the percentage of persons with diagnosed HIV infection who are virally

suppressed to at least 80%.3. Increase the percentage of persons with diagnosed HIV infection who are retained in

HIV medical care to at least 90%.

C. Purpose The purpose of the Hartford TGA Quality Management, (QM) Program is to continuously promote improvement in processes of care – clinical and non-clinical throughout the TGA to achieve desired client-level health outcomes. The Quality Management Program is defined by quantifiable Standards of Care that are reported in CAREWare, a software program provided and supported by HRSA/HAB to Ryan White providers.


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II. Quality Improvements DirectionsFor 2018-2021, the City of Hartford TGA has aligned its quality management and improvement goals with national, state, and city initiatives. These initiatives are: the National HIV/AIDS Strategy Updated to 2020, Connecticut HIV/AIDS Planning Consortium (CHPC), Getting to Zero Commission, and Hartford specific improvement needs based on performance measurement and epidemiology data.

A. National HIV/AIDS Strategy, (NHAS) for the United States The Ryan White Part A Quality Management program is dedicated to working with local, state, and federal entities to better serve those living with HIV/AIDS as well as reduce the numbers of those infected. The NHAS are the following:

1. Decrease the number of new infections by 25%, from 291 in 2018 to 218 in 2021 2. Increase the percentage of persons with diagnosed HIV infection who are virally

suppressed to at least 85 percent.3. Increase the percentage of persons with diagnosed HIV infection who are retained in

HIV medical care to at least 90 percent.

TABLE 1: 2019 Core BenchmarksCore Measures TGA Statewide 2021

2017 2018Core 1: Viral load suppression 81% 83% 90%

Core 2: Prescription of antiretroviral therapy

92% 92% 97%

Core 3:HIV medical visit frequency

68% 67% 90%

Core 4: Gap in HIV medical visits 15% 17% 13%These Core Measures have been adopted as HRSA Performance Measures as illustrated in Table 5 and 5b below

TABLE 1b: HCV 2016 Core Benchmarks Measures TGA National 2020

2016 2017HCV01 Linkage to Care for HCV Treatment TBDHCV02 Retained in Care for HCV Treatment TBDHCV03 HCV Patients that have achieved SRV TBD

To align with the NHAS the Hartford TGA informed the HIV care continuum of the importance of retention in care and viral load suppression. In doing so, the End+ Disparity project was initiated:

This initiative promotes that application of quality improvement interventions with the ultimate goal of increasing viral load suppression rates for targeted disproportionate HIV


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subpopulations. The aim is to reduce disparities among people living with HIV. The vulnerable populations that are the focus of this project include:

MSM of color Black Heterosexual Females Black Heterosexual Males Transgender Individuals Youth (ages 13-24)

TABLE 2: End+ Disparities performance measures aggregated report VP THOCC St.

FrancisCHS Rockvill

e (EHCN)Hartford Hospital

UCONN CCMC TGA Total

BHF 100% 94.29% 86.11% 100% 75.86% 86.36% 50% 88.67%BHM 100% 82.86% 82.76% 100% 78.26% 80% 100% 82.47%MSMC 100% 88.37% 93.75% 100% 81.40% 75% 80% 89.34%TRAN 100% 0% 50% 100% 66.67% 100% 0 66.67%YOU 0 75% 75% 0 100% 100% 75.86% 78.05%

4/29/2019 Performance measure report for vulnerable populations of target

Key Table 2: VP – Vulnerable Populations, BHF – Black Heterosexual Female, BHM – Black Heterosexual Males, MSMC – Men who have Sex with Men of Color, TRAN - Transgender, YOU – Youth, THOCC – Hospital of Central Connecticut, St. Francis/Burgdorf, CHS – Community Health Services, Hartford Hospital/Brownstone, UCONN – University of Connecticut Health Center, CCMC – Connecticut Children Medical Center, TGA – Hartford Transitional Grant Area.

The Hartford TGA believes in the no missed opportunities philosophy, therefore all service categories aid clients obtain the above. Table 3 Quality Management Continuum of Care below illustrates in detail.

TABLE 3: Quality Management Continuum of Care HIV Care ContinuumPerformance Measures

Goal Outcome Service Category

Linked to Care Increase in the percent of persons with an HIV+ diagnosis with at least one medical visit within 3 months of diagnosis.

Linkage to HIV Medical CareNumerator: Number of persons diagnosed with HIV in the calendar year who attend routine HIV

Outpatient Ambulatory CareEarly Intervention ServicesMedical Case Management


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medical care within 3 months of diagnosis in the calendar yearDenominator: Number of persons diagnosed with HIV in calendar year

Mental Health Substance Abuse Medical Transportation

Retention in Care

Increase in the percent of HIV clients with a medical visit at least two or more times three months apart.

Retention in HIV Medical CareNumerator: Number of HIV patients receiving Part A Outpatient/ Ambulatory Medical Care in calendar year with 2 or more medical visits three months apartDenominator: Number of HIV/AIDS patients receiving Part A Outpatient/ Ambulatory Medical Care in calendar year

Outpatient Ambulatory CareEarly Intervention ServicesMedical Case ManagementMedical Transportation Mental HealthSubstance Abuse

Prescribed ART Increase the number of AIDS clients prescribed ART.

Antiretroviral Therapy (ART) Among Persons in HIV Medical CareNumerator: Number of patients with AIDS receiving Part A Outpatient/ Ambulatory Medical Care in calendar year on ARTDenominator: Number of patients with AIDS receiving Part A Outpatient/ Ambulatory Medical Care in calendar year

Outpatient Ambulatory CareMedical Case ManagementMental HealthSubstance AbuseHousing ServicesMedical Transportation

Virally suppressed

Increase in the number of patients with viral loads <200 copies/mL .

Viral Load Suppression Among Persons in HIV Medical Care Numerator: Number of persons with HIV/AIDS whose viral load is < 200 copies

Outpatient Ambulatory CareMedical Case Management Medication Adherence Mental Health


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Denominator: Number of persons with HIV/AIDS who are prescribed ART in calendar year

Substance AbuseHousing Services

0

500

1000

1500

2000

2500

3000

3500

40003479

TGA Continuum of CareRyan White Medical Providers

2018

Num

ber

1009 1074988

20% Not in Care (695 clients)

98%

904

Data is run on Calendar year- Pulled on 6/4/2019Data Source-Bar #1- “Diagnosed” Data from DPHBar #2- “Total Clients” CAREWare CY 2018 Financial ReportBar #3- “One visit” HAB01 Performance Measure Denominator Bar #4- “Two visit” HAB01 Performance Measure NumeratorBar #5- CORE01 Performance Measure


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B. CT Cross Parts Collaborative/CQMThe Ryan White Part A Quality Management program has been an active participant of the CT Cross Parts Initiative since its inception in 2008. The CT Cross Parts Collaborative identifies low performing measures based on results of a statewide quality of care report using the HRSA/HAB measures. Each Part is responsible for initiating a quality improvement project to increase the measures. In 2016, the CT Cross Parts Collaborative integrated with Connecticut HIV/AIDS Planning Consortium (CHPC).

C. Connecticut HIV/AIDS Planning Consortium (CHPC) Connecticut HIV/AIDS Planning Consortium (CHPC) is a collaborative effort which includes active participation by Connecticut’s two Ryan White Part A Programs (the Greater Hartford TGA and the New Haven/Fairfield EMA), funded statewide care and prevention service providers, PLWH, representatives from Ryan White Parts C, D and F (Connecticut AIDS Education and Training Center) and other state department agencies (Department of Correction, Department of Social Services, and Department of Mental Health and Addiction Services). The integrated planning body’s main mission is to conduct primary statewide planning and to facilitate information sharing across local, regional and statewide programs involved in HIV/AIDS care and prevention


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service delivery. The Systems Analyst, the Quality Management Nurse, and Program Manager attend the eight monthly meetings, per year. In an attempt to improve service delivery across the state, both CHPC and the Hartford TGA share the following performance measures:

HIV positivity Viral load suppression Linkage to care Retention in care Partner Services PrEP

In the table below the indicators are defined with baseline percentages and the 2021 goals.

TABLE 4: CHPC and Hartford TGA Shared IndicatorsIndicators Definition Bench line/ Goals1. HIV Positivity Numerator: Number of newly

diagnosed (dx) in the 12-month calendar year

Denominator: Population of Connecticut (per 100,000 people)

Base line: State 277; TGA 142021 Goal: State 218; TGA 18

2. Viral Load Suppression

Numerator: Number of persons with an HIV diagnosis with a viral load <200 copies/mL at last test in the 12-month calendar year

Denominator Number of persons with an HIV diagnosis and who had at least one HIV medical care visit in the past 12-month calendar year

Base line: State 85%; TGA 83%2021 Goal: State 90%; TGA 85%

3. Linkage to Care Numerator: Number of persons who attended a routine HIV medical care visit within 3 months of HIV diagnosis

Denominator: Number of persons newly diagnosed with HIV in 12-month calendar year

Baseline: State 93%;TGA 81%2021 Goal: State 95%; TGA 81%

4. Retention in Care Numerator: Number of patients in the denominator who had at

Baseline: State 68%; TGA 71%2021 Goal: State 70%; TGA 90%


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least one HIV medical visit in each 6 month period of the 24 month measurement period with a minimum of 60 days between first medical visit in the prior 6 month period and the last medical visit in the subsequent 6 month period

Denominator : Number of patients with a diagnosis of HIV with at least one HIV medical visit in the first 6 months of the 24‐month measurement period

5. Partner Service Numerator :Number of newly diagnosed interviewed (i.e., linked) by Partner Services.

Denominator Total number of newly diagnosed referred to Partner Services.

Baseline: State & TGA 94;2021 Goal: State & TGA 95;

These indicators are monitored quarterly by the TGA and CHPC semi-annually.

D. City: Hartford TGAThe City of Hartford will also align its quality management program with its Early Identification of Individual with HIV/AIDS/HCV (EIIHAH) Plan. The TGA’s EIIHA Plan incorporates:

1. The TGA was awarded a co-infected HCV HIV grant, as a result incorporated HCV results in the EIIHAH plan

2. The objectives are to Identify individuals with HIV/HCV and target: Gay, Bisexual, Men Who Have Sex with Men (MSM), Transgender Men and Women, Individuals Over 50, and Black and Hispanic Heterosexual Individuals with focus on Black women.

3. The objectives are to Inform persons of their HIV/HCV positive diagnosis, Refer persons who test positive to services, and Link them with medical care and medical case management.

4. The Planned Outcomes of the EIIHAH Plan are the identification of HIV/HCV positive individuals in each of the target groups. These individuals will be linked to HIV/HCV primary care, medical case management, and their retention in medical care will be carefully monitored. Efforts must be made to connect persons testing positive with Disease Intervention Services/Partner Services and other HIV/HCV prevention services.


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Additionally, the TGA has expanded its own HIV/HCV QM program across service categories and is committed to:

1. Monitoring the HRSA/HAB measures on an ongoing basis.2. Monitoring the revised local measures on an ongoing basis. 3. Assisting providers with quality improvement activities to improve low

performance measures.

III. Evaluation, Assessment, Results (Core Services)The results in the following sections comprise of data that reflect the outpatient ambulatory care services in the Hartford TGA. Table 5, identifies the 16 active HAB measures, Table 5b identifies 13 retired HAB measures. Table 5 displays the trends within the TGA over the previous 5 years. In Table 5, the measures are color coded according to performance: green – excellent, yellow – very good, grey – fair, and red – poor. In the fall of 2013 HRSA/HAB retired several of these measures leaving it to the digression of the TGA/EMAs to create their own performance measures portfolio. The Hartford TGA chose to retire measures based on HRSA’s new list of measures as well as the results of the previous years. The measures will remain accessible in CAREWare, therefore providers are able to continue data collection.

A. TGA ResultsThe tables below represent the TGA’s aggregate data set for the 16 active and retired HAB measures over a seven-year period.

TABLE 5: HRSA HAB Measures 2014-2018* As of February 14, 2019HAB PERFORMANCE MEASURES 2014 2015 2016 2017 2018

HAB02 % with >=2 CD4 Count 82% 72% 67% 64% 64%HAB03 CD4 <200 with PCP Prophylaxis 79% 69% 72% 73% 72%

HAB07 Cervical Cancer Screening 43% 33% 59% 68% 69%

HAB08 Hepatitis B Vaccination 60% 61% 58% 55% 56%

HAB09 Hepatitis C Screening 87% 91% 89% 90% 91%HAB10 HIV Risk Counseling 75% 80% 84% 84% 89%HAB12 Oral Exam 33% 36% 32% 26% 30%HAB13 Syphilis Screening 77% 79% 77% 73% 72%HAB 14 TB Screening 83% 90% 94% 93% 93%HAB 17 Hepatitis B Screening 75% 77% 78% 67% 68%HAB 21 Mental Health Screening 65% 85% 82% 84% 77%HAB 23 Substance Abuse 74% 84% 76% 80% 75%CORE01 Viral Load Suppression 82% 82% 82% 81% 83%CORE02 Prescription of HIV antiretroviral Therapy 93% 93% 96% 92% 92%

CORE03 Medical Visit Frequency 73% 71% 65% 68% 67%CORE04 Gaps in Medical Visits 12.5% 12% 13% 15% 17%


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TABLE 5b: Retired Measures 2010-2019Retired HAB Performance MeasuresHAB06 Adherence Assessment (Retired) HAB 18 Hepatitis/HIV Alcohol Counseling (Retired)HAB04 AIDS Client on HAART(Retired) HAB 19 Influenza Vaccination(Retired)HAB05 Percentage of Pregnant Women on ART (Retired)

HAB 20 MAC Prophylaxis (Retired)

HAB01 Two Primary Care Visits (Retired) HAB 22 Pneumonia Vaccination (Retired)HAB11 Lipid Screening (Retired) HAB 24 Tobacco Cessation Counseling (Retired)HAB 15 Chlamydia Screening (Retired) HAB 25 Toxoplasma Screening (Retired)HAB 16 Gonorrhea Screening (Retired)

*Some Measures have been retired* Green – excellent; Yellow- very good; Grey- fair; Red- poor. CORE04 is a reverse measure, where all sites should be at 7% or 8% as a benchmark. HAB measures from each category of measures are further explained at: -http://hab.hrsa.gov/deliverhivaidscare/habperformmeasures.html

Data Analysis: Quality strengths and improvementsAs mentioned above HRSA/HAB revised their performance measure portfolio and as a TGA 12 performance, measures and 4 core measures will be continuously monitored by the Grantees office. Currently, as a TGA we have excelled (90% - 100%) in four measures, six measures fell in the very good range (70%-89%), five scored fair (50%-69%) while the remaining one measure fell below 50% range (49% and below). To address those measures that are performing fair/poor the TGA has set goals for 2018-2021 to improve these measures.

Data Analysis: Introduction The core measures were previously known as the In+Care Campaign measures. The Campaign was a quality improvement initiative focusing on improving lives and the health of our communities by retaining patients in HIV care and preventing them from failing out of care. The measures were introduced to TGA in the spring of 2014, the benchmarks are as of 2018-2021. The QM team will continue to monitor the data as a TGA and statewide. See Table 5 for listing of CORE measures.

B. Early Identification of Individuals with HIV/AIDS/HCV (EIIHAH) The objectives of the EIIHAH Plan are to:

1. Identify individuals with HIV/HCV and target Gay, Bisexual, Men who have Sex with Men (MSM), Transgender Men and Women, Individuals over 50, and Black and Hispanic Heterosexual Individuals with focus on Black Women

2. Inform persons of their HIV/HCV positive diagnosis3. Link them with medical care and medical case management


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TABLE 6: 2018 EIIHA Table – Sub Populations, extracted from CAREWare for calendar year 2018

Performance Measure

Gay Man

Man who has sex with

men

Bisexual Man

Black Heterosexual

Man

Hispanic Heterosexual

Man

Individuals over 50

1.Identify 51 67 51 159 183 254

2.Inform (Newly Diagnosed)*

3.Refer (Newly Diagnosed)

4.Link (Newly Diagnosed)

5.Re-engaged into Care

*In 2018 1 individual identified as positive, however no risk factor information was available.

The TGA’s new EIIHAH populations includes: Gay, Bisexual, Men Who Have Sex with Men (MSM), Transgender Men and Women, Individuals Over 50, and Black and Hispanic Heterosexual Individuals with focus on Black women.

IV. Quality Management Goals and Projects for 2018-2021Table 7 illustrates QI Projects that were identified using CAREWare data and were common projects identified among providers (and surveys, statewide initiatives). Quality reports are reviewed to sustain gains >90% on performance measures semi-annually. QI projects for End+ Disparities, Viral Load Suppression, Cervical Cancer Screening and Oral Health Screening are continuing projects as they are a challenge for the TGA and therefore remain as a quality improvement goal for 2018-2021. EIIHAH baseline data is reviewed to determine additional QI projects.

TABLE 7: HAB Measures Statewide/TGA Percentages and Goals (FY 16/17)****Please note – the State has not made a decision on what measures they will be focusing on for 2018-2021. The table below illustrated Statewide Measures and Goals up to FY 16/17.

HAB Measures TGA Baseline

2012 Goals

2013 Goals

2014 Goals

2015 Goals

2016 Goals

2017 Goals

Cervical Cancer (7) 43% 49% 50% 50% 50%Hepatitis B

vaccination (8)61% 60% 70% 70% 70%

Oral screening (12) 36% 25% 50% 50% 50%Influenza vaccine (19) 44% 60% N/A N/A N/A N/A N/AMAC prophylaxis(20) 58% 60% N/A N/A N/A N/A N/A


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Current On-Going TGA QM InitiativesPart of expanding the TGA’s quality management plan will be to:

Revise the Medical Case Management Standard of Care to align with and incorporate the newly developed Medical Case Management Forms

Offer training for Hepatitis C (HCV) for case managers, early intervention staff, and psychosocial support peers for sustainability purposes

Align Housing status selections in CAREWare with those available in the HOPWA HMIS (CaseWorthy) in an effort to improve system and service coordination through the HIV and Housing Data Integration Grant (DIG).

Promote and foster collaboration between non-core providers, housing opportunity for People Living with HIV/AIDS providers and core providers on collaborative PDSAs

Strengthen consumer involvement in quality management initiatives across the TGA

V. Overview of the Quality Management Program Accountability Structure

A. TGA Leadership Team: Ryan White Quality Management Nurse—an experienced registered nurse who has

received training from the National Quality Center on quality management and quality improvement. Conducts program evaluation, organizational assessment, and capacity building. He/She will serve as the quality improvement manager for Ryan White Part A Program service providers and works in close collaboration with funded agencies to build and increase capacity for quality improvement activities. Additional functions of the QM Nurse include: conducting onsite performance reviews, identifying practice areas in need of improvement, and guiding quality improvement teams using theoretically based models such as clinical quality improvement, PDSA, and the chronic care model. The QM nurse provides support to Ryan White Project Manager in setting quality improvement goals and developing clinical and non-clinical performance measures.

Ryan White Project Manager – has the ultimate responsibility for leadership of the process; is the liaison with the HRSA project officer; issues provider contracts to deliver HIV AIDS services in alignment with approved Standard of Care.

Ryan White Systems Analyst – (1) Collect, analyze and disseminate HIV/AIDS data to shareholders (2) Collect and analyze program data to advise Grantee and/or agency level quality projects (3) Provide Technical assistance for all Part A sub-recipient Quality Management Teams (4) Provide on-going capacity building trainings and technical assistance for providers on CAREWare utilization

Health Department Epidemiologist – assists the systems analyst to: (1) interpret the data; (2) provide user friendly data sets to the QM Committee; (3) assist with training providers to interpret data and (4) provide data on HIV incidence and prevalence (5) collaborate on a local and statewide level where necessary in order to build capacity for the QMC


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B. Quality Management Committee

The Ryan White Hartford TGA QM Committee meets 4 times per year (once per quarter) to review and discuss the Hartford TGA QM Plan, current PDSAs, performance measures, quality indicators, performance evaluation, and other topics as indicated. The QM Committee is facilitated by the TGA QM Nurse.

Quality Management Committee Members – TGA Leadership Team, Ryan White Part C and D program managers, Ryan White Part B Quality Manager, a consumer, a Data Support specialist from an urban infectious disease clinic, and an LPN from an infectious disease clinic serve on the QM committee, HOPWA Housing Provider, Medical Case Management Clinical Nurse Manager

C. Quality Accountability Diagram

Diagram Key: CHPC – Connecticut HIV/AIDS Planning Consortium; HIPSCA – Health Insurance Premium Cost Sharing Assistance, EIS – Early Intervention Services; ACT – AIDS CT, CHC – Community Health Center, CHS – Community Health Services, COHC – Charter Oak Health Center, CRT – Community Renewal Team, Inc., CCSG – Connecticut Children’s Specialty Group (formerly CT Children’s Medical Center [CCMC]), HH – Hartford Hospital (Brownstone), HGLHC – Hartford Gay & Lesbian Health Collective Inc., HRA – Human Resources Agency of New Britain/Wellness Resource Center, LCS – Latino Community Services, Rockville – Prospect Rockville Hospital, Mercy – Mercy Housing & Shelter Corporation, St. Francis – Saint Francis Hospital (Burgdorf Clinic), THOCC – The Hospital of Central Connecticut, UCONN – University of Connecticut Health Center

D. Quality Management Site Leaders QM site leaders are responsible for the oversight of quality management activities for their respective primary medical or supportive service agencies. Agency managers or their


Reports to:City of Hartford

CHPCPlanning Council/Continuum of

Care

Hartford TGA QM Team

Core

Oral Health

COHCHH

HGLHC

Substance Abuse/ Mental Health

COHCCHCCRTHH

HIPSCA

ACT

Outpatient Ambulatory

CHSCCSG

HHRockville

St. FrancisTHOCCUCONN

Medical Case Management

ACTCOHCCHS

CCSGHH

UCONN

EIS

CRTLCS

Non Core

Food

ACTCHC

HGLHCHRA

Housing

ACTMercy

Transportation

ACTCHCLCS

Psychosocial Support

ACTHRALCS

Emergency Financial

Assistance

ACT

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designees typically serve as the site leader and key contact for quality management related activities. The QM Manager will identify who these individuals are.

E. Stakeholder Engagement in Quality Management External stakeholders were selected based on their commitment to improving and ensuring accessing to quality care for all patients living with HIV/AIDS/HCV in the Hartford TGA and on their willingness to participate in ongoing quality improvement initiatives. Stakeholders were strategically selected based on their ability to assist the Ryan White grantee in fulfilling the core and supportive service categories outlined by the Human Resource and Services Administration (HRSA). Internal and external stakeholders are outlined in the table below.

TABLE 8: Stakeholder MatrixInternal External Ryan White Program Staff Ryan White Project Manager Ryan White Part A Quality Program Manager Ryan White Part C Program Director Ryan Part D Program Director Ryan White Infectious Disease Nurse

Epidemiologist Minority AIDS Initiative (MAI) Data

Coordinator QA & TA manager Ryan White Planning Council member

(Continuum of Care committee) Ryan White Consumer Positive Empowerment Committee Member

CT State Public Department of Health Program Director HIV/AIDS Surveillance

National Quality Center

Part A (NH) Part B (State) Part Cs Part D

VI. Building TGA Capacity In 2018-2021, the Hartford TGA will continue to build QM capacity through the activities described below:

1. Establish QM activities in non-core services2. Promote internal CAREWare and data training within sub-recipients 3. Continue to train Planning Council members on QM 4. Performance measure and reporting 5. QI Projects (team based) – sub-recipient agencies6. QM plans should be updated regularly at sub-recipient level7. Sub-recipients are to conduct PDSAs for local measures that are not at goal8. Define team roles and responsibilities9. Continue team meetings10. Review and revise of the QM Plan on a regular basis (see workplan)


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11. Attend at least 1 QM meeting for every sub-recipient each fiscal yearAppendix A

Performance Indicators

The following performance indicators are used statewide to monitor the quality of care received by those living with HIV/AIDS in the Hartford TGA. These indicators are provided by HRSA/HAB:

1. ≥ 2 CD4 counts in the measurement year 2. CD4 < 200 with PCP prophylaxis3. Cervical cancer screening4. Hepatitis B vaccination5. Hepatitis C screening6. HIV Risk Counseling7. Oral Exam8. Syphilis screening 9. Tuberculosis screening 10. Hepatitis B screening11. Mental health screening 12. Substance abuse assessment13. Viral load suppression (CORE)14. Prescribed antiretroviral therapy (CORE)15. Medical visit frequency (CORE)16. Gap in medical visit (CORE)

The following performance indicators are used to monitor the quality of care received by those living with Hepatitis C (HCV) in the Hartford TGA.

1. HCV01 Linkage to Care2. HCV02 Retention in Care3. HCV03 Sustained Virologic Response


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Appendix BHartford TGA Local Performance Measures for Supportive and Core Services 2017-2018

Source of information retrieved from Source: Ryan White Service Utilization database.

Performance Measures TGA Wide

ACT01.01.2017

-12.31.2017

ACT01.01.2018

-12.31.2018

Service: Emergency Financial Assistance

71% 47% 71%

1. 92% of EFA HIV persons with a diagnosis who had at least one HIV medical care visit in each 6-month period of the 24-month measurement period, with a minimum of 60 days between the first medical visit in the prior 6-month period and the last medical visit in the subsequent 6-month period2. 80% of HIV-infected emergency financial assistance service clients that access emergency financial assistance services 89% 95% 89%

Service: Food Bank/Home-Delivered Meals

64% 80% 75%

1. 92% of food services persons with an HIV diagnosis who had at least one HIV medical care visit in each 6-month period of the 24-month measurement period, with a minimum of 60 days between the first medical visit in the prior 6-month period and the last medical visit in the subsequent 6-month period2. 80% of HIV-infected food/meals clients that access food/meals services (documented referral) 93% 96% 85%

Service: Health Insurance Premium & Cost Sharing Assistance

73% 44% 73%

1. 92% of HIPSCA persons with an HIV diagnosis who had at least one HIV medical care visit in each 6-month period of the 24-month measurement period, with a minimum of 60 days between the first medical visit in the prior 6-month period and the last medical visit in the subsequent 6-month period2. 80% of HIV-infected Health Insurance Premium & Cost Sharing Assistance clients that access Health Insurance Premium & Cost Sharing Assistance services

91% 97% 91%

Service: Housing Services

68% 44% 70%

1. 94% housing service persons with an HIV diagnosis who had at least one HIV medical care visit in each 6-month period of the 24-month measurement period, with a minimum of 60 days between the first medical visit in the prior 6-month period and the last medical visit in the subsequent 6-month period 2. 85% of housing persons with an HIV diagnosis who were homeless, non-permanently or temporarily housed in the 12-‐month measurement period who received housing services (Documented Housing referral for MAI)

81% 96% 84%

Service: Medical Transportation 70% 58% 71%1. 94 % of medical transportation services persons with an HIV diagnosis who had at least one HIV medical care visit in each 6-


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month period of the 24-month measurement period, with a minimum of 60 days between the first medical visit in the prior 6-month period and the last medical visit in the subsequent 6-month period measurement year2. 85% of medical transportation persons who attended a routine HIV medical care visit within 3 months of HIV diagnosis 78% 82% 84%

Service: Medical Case Management

76% 54% 62%

1. 94% of medical case management clients with an HIV diagnosis who had at least one HIV medical care visit in each 6-month period of the 24-month measurement period, with a minimum of 60 days between the first medical visit in the prior 6-month period and the last medical visit in the subsequent 6-month period.2. 90% of HIV-infected medical case managed (including treatment adherence) clients with a viral load <200 copies/ml at last test in the 12-month measurement period.

83% 44% 82%

Service: Psychosocial Support

58% 35% 54%

1. 94% of psychosocial support persons with an HIV diagnosis who had at least one HIV medical care visit in each 6-month period of the 24-month measurement period, with a minimum of 60 days between the first medical visit in the prior 6-month period and the last medical visit in the subsequent 6-month period2. 85% of psychosocial persons who attended a routine HIV medical care visit within 3 months of HIV diagnosis. 66% N/A 66%

Data is as of March 2019 extracted from CAREWare 3/22/19


CCSG01.01.2017

-12.31.2017

CCSG01.01.2018

-12.31.2018


76% 69% 100%


83% 62% 74%



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CHC01.01.2017

-12.31.2017

CHC01.01.2018

-12.31.2018


64% No data 38%

1. 92% of food services persons with an HIV diagnosis who had at least one HIV medical care visit in each 6-month period of the 24-month measurement period, with a minimum of 60 days between the first medical visit in the prior 6-month period and the last medical visit in the subsequent 6-month period2. 80% of HIV-infected food/meals clients that access food/meals services (documented referral) 93% 100% 93%

Service: Medical Transportation

70% No client met these criteria 23%

1. 94 % of medical transportation services persons with an HIV diagnosis who had at least one HIV medical care visit in each 6-month period of the 24-month measurement period, with a minimum of 60 days between the first medical visit in the prior 6-month period and the last medical visit in the subsequent 6-month period measurement year2. 85% of medical transportation persons who attended a routine HIV medical care visit within 3 months of HIV diagnosis 78% No data 23%

Services: Mental Health Services

75% No data 33%

1. 94% of mental health persons with an HIV diagnosis who had at least one HIV medical care visit in each 6-month period of the 24-month measurement period, with a minimum of 60 days between the first medical visit in the prior 6-month period and the last medical visit in the subsequent 6-month period2. 85% of HIV Positive clients newly enrolled in Mental Health Services that received a completed screening 100% 100% 100%



CHS01.01.2017

-12.31.2017

CHS01.01.2018

-12.31.2018


76% 72% 93%


83% 74% 86%



20


COHC01.01.2017

-12.31.2017

COHC01.01.2018

-12.31.2018


76% No clients met these criteria 50%


83% 41% 78%


75% No clients met these criteria 47%

1. 94% of mental health persons with an HIV diagnosis who had at least one HIV medical care visit in each 6-month period of the 24-month measurement period, with a minimum of 60 days between the first medical visit in the prior 6-month period and the last medical visit in the subsequent 6-month period2. 85% of HIV Positive clients newly enrolled in Mental Health Services that received a completed screening 100% 50% 100%

Services: Oral Health Services

34% No clients met these criteria <1%

1. 85% of HIV-infected clients who receive oral health care services will have an oral health treatment plan updated at least once in the measurement year (documented initial and updated plan in records)



CRT01.01.2017

-12.31.2017

CRT01.01.2018

-12.31.2018

Services: Early Intervention Services0.0013% <1% 0%1. 5% of clients who had an early intervention service that had a

positive HIV test in the 12 month measurement period‐2. 85% of clients receiving Early Intervention service with an HIV+ diagnosis will have a referral to HIV primary medical care within the measurement year

0.009% 100% 0%


75% 73% 76%

1. 94% of mental health persons with an HIV diagnosis who had at least one HIV medical care visit in each 6-month period of the 24-month measurement period, with a minimum of 60 days between the first medical visit in the prior 6-month period and the last medical visit in the subsequent 6-month period2. 85% of HIV Positive clients newly enrolled in Mental Health 100% 100% 100%


21

Services that received a completed screeningService: Substance Abuse

93% No clients met these criteria 98%1. 92% of substance abuse persons with an HIV diagnosis who

are prescribed ART in the 12 month measurement period‐2. 90% of substance abuse persons with an HIV diagnosis with a viral load <200 copies/mL at last test in the 12-month measurement period

94% 90% 95%



HH01.01.2017

-12.31.2017

HH01.01.2018

-12.31.2018


76% 84% 87%

1. 94% of medical case management clients with an HIV diagnosis who had at least one HIV medical care visit in each 6-month period of the 24-month measurement period, with a minimum of 60 days between the first medical visit in the prior 6-month period and the last medical visit in the subsequent 6-month period.

2. 90% of HIV-infected medical case managed (including treatment adherence) clients with a viral load <200 copies/ml at last test in the 12-month measurement period.

83% 79% 85%

Service: Mental Health Services

75% N/A 97%

1. 94% of mental health persons with an HIV diagnosis who had at least one HIV medical care visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between the first medical visit in the prior 6 month period and the last medical visit in the subsequent 6 month period2. 85% of HIV Positive clients newly enrolled in Mental Health Services that received a completed screening 100% N/A 100%

Service: Oral Health

34% N/A 0%1. 85% of HIV-infected clients who receive oral health care services will have an oral health treatment plan updated at least once in the measurement year (documented initial and updated plan in records)Service: Substance Abuse Services

93% N/A 71%1. 92% of substance abuse persons with an HIV diagnosis who are prescribed ART in the 12 month measurement period‐2. 90% of substance abuse persons with an HIV diagnosis with a viral load <200 copies/mL at last test in the 12-month measurement period

94% N/A 93%

Data is as of March 2019 extracted from CAREWare 3/22/19Performance Measures TGA Wide HGLHC HGLHC


22

01.01.2017-

12.31.2017

01.01.2018-

12.31.2018Service: Food Bank/Home-Delivered Meals

94% 60% 66%

1. 92% of food services persons with an HIV diagnosis who had at least one HIV medical care visit in each 6-month period of the 24-month measurement period, with a minimum of 60 days between the first medical visit in the prior 6-month period and the last medical visit in the subsequent 6-month period2. 80 % of HIV-infected food/meals clients that access food/meals services (documented referral) 93% 53% 50%

Service: Oral Health Care

34% 59% 49%1. 85 % of HIV-infected clients who receive oral health care services will have an oral health treatment plan updated at least once in the measurement year (documented initial and updated plan in records)



HRA01.01.2017

-12.31.2017

HRA01.01.2018

-12.31.2018


64% 19% 45%

1. 92% of food services persons with an HIV diagnosis who had at least one HIV medical care visit in each 6-month period of the 24-month measurement period, with a minimum of 60 days between the first medical visit in the prior 6-month period and the last medical visit in the subsequent 6-month period2. 80 % of HIV-infected food/meals clients that access food/meals services (documented referral) 93% 96% 100%


58% 86% 47%

1. 94% of psychosocial support persons with an HIV diagnosis who had at least one HIV medical care visit in each 6-month period of the 24-month measurement period, with a minimum of 60 days between the first medical visit in the prior 6-month period and the last medical visit in the subsequent 6-month period2. 85% of psychosocial persons who attended a routine HIV medical care visit within 3 months of HIV diagnosis. 66% N/A None

documentedData is as of March 2019 extracted from CAREWare 3/22/19


23



MERCY01.01.2017

-12.31.2017

MERCY01.01.2018

-12.31.2018

Service: Housing Services

68% No data 70%

1. 94% housing service persons with an HIV diagnosis who had at least one HIV medical care visit in each 6-month period of the 24-month measurement period, with a minimum of 60 days between the first medical visit in the prior 6-month period and the last medical visit in the subsequent 6-month period 2. 85% of housing persons with an HIV diagnosis who were 81% 100%



LCS01.01.2017

-12.31.2017

LCS01.01.2018

-12.31.2018

Services: Early Intervention Services0.0013% <1% <1%1. 5% of clients who had an Early Intervention service that had a

positive HIV test in the 12 month measurement period‐2. 85% of clients receiving Early Intervention service with an HIV+ diagnosis who are out of care will have a referral to HIV primary medical care within the measurement year.

100% 100% 100%

3. 85% of clients receiving Early Intervention service with an HIV+ diagnosis will have a referral to HIV primary medical care within the measurement year

0.009% 100% 100%

Service: Medical Transportation

70% 58% 76%

1. 94 % of medical transportation services persons with an HIV diagnosis who had at least one HIV medical care visit in each 6-month period of the 24-month measurement period, with a minimum of 60 days between the first medical visit in the prior 6-month period and the last medical visit in the subsequent 6-month period measurement year2. 85% of medical transportation persons who attended a routine HIV medical care visit within 3 months of HIV diagnosis 78% 82% 82%


58% 60% 80%

1. 94% of psychosocial support persons with an HIV diagnosis who had at least one HIV medical care visit in each 6-month period of the 24-month measurement period, with a minimum of 60 days between the first medical visit in the prior 6-month period and the last medical visit in the subsequent 6-month period2. 84% of psychosocial persons who attended a routine HIV medical care visit within 3 months of HIV diagnosis. 66% No clients met

these criteriaNo clients met these criteria

24

homeless, non-permanently or temporarily housed in the 12-month measurement period who received housing services (Documented Housing referral)

25%



THOCC01.01.2017

-12.31.2017

THOCC01.01.2018

-12.31.2018


76% N/A 99%


83% N/A 91%



UCONN01.01.2017

-12.31.2017

UCONN01.01.2018

-12.31.2018


92% 55% 92%1. 92% of medical case management to include treatment adherence persons with an HIV diagnosis who are prescribed ART in the 12 month measurement period‐2. 90% of HIV-infected medical case managed (including treatment adherence) clients with a viral load <200 copies/mL at last test in the 12-month measurement period

83% 30% 74%



0

Appendix CQM Work Plan

Activity Objectives Responsible Staff Time Frame

QM Committee Meetings

Hold quarterly meetings and any additional meetings as needed QM Nurse, Program Manager, QM

Committee Members

May, July, September,

JanuaryAsk for input for agenda, create and distribute to membersRecord meeting for minutes, review, edit and distribute to members

Data Collection & Performance

Measurement

Performance Measures reviewed on a monthly basis, data assessed monthly

QM Nurse, Program Manager, Systems

AnalystOn-going monthly

PDSAs reviewed on a quarterly basis at minimum QM Nurse June, September, December, March

Work with providers to develop improvement plans and QI projects as needed QM Nurse, Program

Manager As neededPDSA technical assistance, webinars, and trainings given as neededPair core and non-core sites with like PDSAs to facilitate collaboration

Guided by data, QM Committee members collaborate and brainstorm for QI projects, strategy tweaks and new interventions

QM Nurse, Program Manager, QM

Committee Members


January

Capacity Building

Attend NQC Webinars and Trainings (Quality Academy and Training on Coaching Basics or Training Quality Leaders)

QM Nurse, Program Manager, Systems

AnalystOn-Going

Attend and offer general QI trainings and resources held during QM committee meetings, lunch & learn webinars, or as needed. Examples include: TGA/State Wide Quality Summits, CT DPH trainings, NQC trainings, CHPC trainings, local clinical expert presentations, etc.

TGA Leadership, Sub-recipient QI staff, QI

experts

Minimum 2 per year

Offer targeted QI trainings and Technical Assistance for sub-recipients as identified by recipient QM Nurse As needed

Site Visits

Schedule site visits to be completed by end of January

QM Nurse, Program Manager

Annually, completed by end

of January

Sub-recipients to receive URN list at least 48 hours prior to visitSites to receive report within 30 daysSite to respond to corrective action/recommendations within 30 days of report receipt, follow up visits scheduled as neededQI training needs assessed. Follow up trainings/TA given as needed

Quality Improvement Review and update relevant documents – examples include Medical QM Nurse, Program May, July,


1

Projects

Case Management forms, Standards of Care, QI tools etc.

Manager, QM Committee Members

September, January

Guided by data, determine TGA-wide QI ProjectsReview QI project priorities for long-term progress, short term progress, continued relevance and make adjustments/modifications as neededReview QI projects for alignment with national directives such has NHAS 2020, HAB priorities etc.

Evaluation

Trend data on performance measure outcomes to assess progress annually

QM Nurse, Systems Analyst February/March

Conduct an annual Organization Assessment and use results to guide future direction and priorities QM Nurse February

QM Plan Updates

Have QM committee review sections of QM plan and identify areas that need adjustments

QM Nurse, Program Manager, QM

Committee Members


JanuaryQM Plan is presented to Planning Council for review QM Nurse July

Updates to QM Plan are completed as needed and annually by TGA QM Nurse, Program Manager

As needed, April/May


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