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HIV/AIDS Bureau Division of State HIV/AIDS Programs (DSHAP)

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1 HIV/AIDS Bureau Division of State HIV/AIDS Programs (DSHAP)
Ryan White HIV/AIDS Program Part B Technical Assistance Webinar Building a Quality Management Program January 15, 2014

2 DSHAP Mission To provide leadership and support to States/Territories for developing and ensuring access to quality HIV prevention, health care and support services.

3 Agenda Opening Remarks/ Announcements Heather Hauck
Question and Answer Report on DSHAP’s 2013 Webinars Katherine Patterson, Magnus Azuine The Ryan White HIV/AIDS Program Moving Forward – Quality Initiatives Clinical Quality Management Susan Robilotto Georgia Quality Management Program Eva Williams Questions and Answer Closing Remarks

4 Heather Hauck Director Division of State HIV/AIDS Programs
Presenter Heather Hauck Director Division of State HIV/AIDS Programs

5 Announcements & Updates

6 Announcements FY14 RWHAP Part B Base/ADAP Earmark (X07) Awards
Important Deadlines: The due date for the next X07 ADAP Quarterly Report (AQR) Submission (for the 10/1/13-12/31/13 reporting period) is 1/31/2014. The AQR is being phased out. 4/30/14 will be the last AQR grantees will be required to submit. Unobligated Balances (UOB) Estimated Carryover: due January 31, 2014

7 2013 Ryan White RSR and ADR Submission Timelines
Date RSR ADR Grantees Providers Monday, December 2, 2013 RSR Grantee Report Start Date System opens for grantees to begin work on their RSR Grantee Report. Monday, January 6, 2014 RSR Provider Report Start Date System opens for providers to begin work on their RSR Provider Reports and upload their client-level data files. Monday, February 3, 2014 6:00 p.m. EST RSR Grantee Report due date All RSR Grantee Reports must be in “Certified” status. After this deadline, grantees must contact Data Support to certify or to make changes to their RSR Grantee Reports. Monday, March 3, 2014 2013 ADR Client XML Test Site Opens Monday, March 10, 2014 Target date for the submission of all RSR Provider Reports and client-level data. RSR Provider Reports should be in “Review” or “Submitted” status. Monday, March 24, 2014 Return for Changes deadline Last day for grantees to return RSR Provider Reports and client-level data to their providers for changes or corrections. Monday, March 31, 2014 6:00 p.m. ET All RSRs must be in “Submitted” status by 6:00 PM ET. Thursday, April 10, 2014 ADR Web System Opens for 2013 Data Collection Monday, June 9, 2014 2013 ADR is Due to HRSA

8 New SPNS FY 14 FOAs Released:
System-level Workforce Capacity Building for Integrating HIV Primary Care in Community Health Care Settings – Demonstration sites HRSA Deadline: March 10, 2014 System-level Workforce Capacity Building for Integrating HIV Primary Care in Community Healthcare Settings – Evaluation and Technical Assistance – HRSA HRSA/HAB will host a technical assistance (TA) webinar Wednesday, January 29, 2014 from 2:00 – 4:00pm EST (HRSA ) and Thursday, January 30, 2014 from 2:00 – 4:00pm EST (HRSA ) Register

9 Questions

10 A Review of DSHAP’s 2013 Webinars
I would now like to briefly review the TA webinars completed by the division for CY 2013. In November of CY 2012, we solicited feedback from Ryan White HIV/AIDS Program Part B Grantees on the division’s technical assistance webinars by asking grantees to complete the 2013 Technical Assistance Webinar Content Request which included a series of 10 questions. The results from the content request were presented in a webinar for Part B grantees on February 13, 2013 entitled “The 2013 Technical Assistance Webinars Feedback and Part B Program Updates”.

11 Respondents There were a total of 51 respondents who completed the content request; the majority were State HIV/AIDS RW Part B Program Coordinators

12 Number of Years in Position
Interesting to note that the majority of respondents (34%) had been in their position only one year or less

13 Topics of Interest Healthcare Reform in States 28%
2013 Reauthorization 24% National Monitoring Standards 18% Early Intervention Services and working with CDC/ ADAP Eligibility, Enrollment and recertification 6% National HIV AIDS Strategy/ HAB Performance Measures/Quality Management Plans/Insurance continuation through ADAP 4% Maintenance of Efforts/Pharmacy Benefits Management overview and how to work with PBMs 2% One of the key questions grantees were asked to rank a list of topics from most to least important based on their interests. Healthcare Reform, the 2013 Reauthorization of the Ryan White legislation and the National Monitoring Standards were the highest ranked topics. So how did we do as a division?

14 DSHAP 2013 Webinars January 30, 2013
ADAP and Federal PCIP Coordination February 13, 2013 2013 TA Webinars Feedback and Part B Program Updates March 26, 2013 Clarifications on Client Eligibility Assessment and Recertification Requirements April 30, 2013 Carryover Requests and Federal Financial Reports (FFR): Tracking and Reporting of Rebates June 11, 2013 National Monitoring Standards Update and Schedule of Charges June 26, 2013 FY 2013 Part B Supplemental Funding Opportunity Announcement (FOA) and the ADAP ERF FOA October 10, 2013 FY 2014 Ryan White HIV/AIDS Program Part B /ADAP Earmark Funding Opportunity Announcement October 31, 2014 ADAP ERF 2014 FOA In CY 2013 the following webinars were completed by the division meeting our goal of providing two technical webinars per quarter

15 NASTAD Cooperative Agreement
March 2013 ADAP Crisis Lessons Learned Financial Forecasting Part One May 2013 Financial Forecasting Part Two ADAP and Health Reform June 2013 ADAP and Insurance September 2013 ADAP Application and Coordination with ACA October 2013 Plan Assessment Through the 2013 cooperative agreement with HIV/AIDS Bureau, the National Alliance of State and Territorial AIDS Directors (NASTAD) provided seven additional technical assistance webinars covering the following topics

16 Other HAB Sponsored Webinars
August 14, 2013; “Preparing for 2014: Overview of Ryan White HIV/AIDS Part B Program policy updates and guidance” sponsored by HAB August 29, 2013; “Better Together: State Strategies for Medicaid-Ryan White HIV/AIDS Program Coordination” sponsored by National Academy of State Health Policy through its cooperative agreement with HRSA November 20, 2013; “The Ryan White Program and Understanding Modified Adjusted Gross Income (MAGI)” sponsored by the HIV/AIDS Bureau in partnership with the CMS. December 4, 2013; “The Ryan White HIV/AIDS Program in States Not Expanding Medicaid” sponsored by HIV/AIDS Bureau There were also four additional webinars provided to Ryan White HIV/AIDS Part B grantees sponsored by the Health Resources and Services Administration (HRSA), the HIV/AIDS Bureau in partnership with the Centers for Medicaid and Medicare Services (CMS) to prepare grantees for implementation of the Affordable Care Act and assisting clients with enrollment into the Marketplace. Aug 14, 2013 Policy update topics: Outreach, Enrollment and Benefits Counseling Clarifications Regarding Medicaid-Eligible Clients and Coverage of services by Ryan White HIV/AIDS Programs Clarifications on Ryan White Programs Client Eligibility Determinations and Recertification Requirements Federal Register Notice: Ryan White HIV/AIDS Program Core Medical Services Waiver application requirements

17 Grantee Topics Completed
Healthcare Reform in States 2013 Reauthorization National Monitoring Standards Early Intervention Services and working with CDC ADAP Eligibility, Enrollment and recertification National HIV AIDS Strategy Quality Management Plans Insurance continuation through ADAP HAB Performance Measures Pharmacy Benefits Management overview; how to work with PBMs Maintenance of Effort The division was able to address many (54%) of the grantee’s topics of interest through the quarterly technical assistance webinars or through webinars provided in partnership with the bureau or cooperative agreements with our partners.

18 Additional Topics Cap on charges & sliding fee scales
Role of case managers in outreach and enrollment in Marketplace Impact of ACA on Ryan White Ryan White Services Report Implementation of insurance continuation programs & ACA Quality Management Plans ADAP Data Report (ADR) The following additional topics recommended by grantees in the webinar content request were also addressed last year.

19 How Did We Do? The division met and exceeded it’s goal
54% of grantee topics addressed A total of 19 technical assistance webinars completed. An increase of 130%! The Division of State HIV/AIDS Programs met and exceeded its goal of providing two technical assistance webinars every quarter. The division facilitated a total of nineteen (19) technical assistance webinars in calendar year This is an increase of more than 130% compared to the 8 webinars (two per quarter) established as the target by the DSHAP management team

20 2014 Webinar Evaluation Option 1 Option 2 Kpatterson@hrsa.gov
FY2012 carryover funds will be applied to FY 2014.

21 Building a Quality Management Program
HAB Expectations Heather Hauck, MSW, LICSW Director Division of State HIV/ AIDS Programs

22 Objectives HAB expectations for a Quality Management Program
Components of a Quality Management Program Grantee Presentation

23 We know that we provide multiple layers of value within HAB and the RW program. Most obviously, we provide funds for service delivery- that basic public health function of assurance of services.

24 Zero New Infections The Ryan White Program funds comprehensive HIV care systems for low-income individuals and families to reduce new HIV infections, to improve health outcomes for PLWH, and to reduce HIV-related health disparities. HAB ensures the maximum effectiveness of the Ryan White Program by assessing the HIV care and service needs of PLWH, shaping HIV policy, assessing models of care and services required, providing target training of the health care workforce, providing leadership on national HIV/AIDS quality measures. HAB facilitates improvements in HIV care through a continuum of quality HIV care for low-income individuals and families to reduce new HIV infections, to improve health outcomes for PLWH from diagnosis to achieve optimal treatment, and to reduce HIV-related health disparities. HAB leadership and staff continually assess the HIV care and service needs of PLWH via grantee/provider monitoring and oversight, client feedback, implementation of special studies and collaborative activities within HHS OPDVIS and other federal agencies. HAB leadership and staff provide expertise regarding HIV policy and consideration for the medically underserved on Federal care and treatment guidelines. In conjunction with Ryan White grantees and providers, HAB assesses models of care and services required for care completion with insight from the implementation of Special Projects of National Significance. Targeted training of the health care workforce through curriculum development, mini-residency experience to promote the adoption of HIV/AIDS care as a chronic illness. Training, dissemination and replication of effective models of care inclusive of medical homes to Ryan White and other clinical providers HAB staff provides leadership on national HIV/AIDS quality measures by the development, alignment among HHS OPDIVS and other federal agencies and adoption of these measures Ryan White clinical providers.

25 Quality Empower stakeholders to deliver high quality HIV care and treatment across the nation. Establish and monitor key HIV quality measures/indicators to assure high-quality care that address all stages of the care continuum and adhere to DHHS standards. Collect, analyze, and utilize data on health outcomes of PLWHA to improve and advance the treatment of care.

26 Quality HAB advances evidence-based, cost effective HIV care and treatment through the provision of training and capacity development grants and cooperative agreements. HAB provides leadership on national HIV/AIDS quality measures, including the development, alignment among HHS OPDIVS and other federal agencies and adoption of these measures by Ryan White clinical providers. HAB promotes clinical quality improvement by HAB staff and grantees through capacity development, monitoring grant activities and implementing special projects and studies.

27 Components of a Quality Management Program
Susan Robilotto, D.O. Clinical Consultant Division of Metropolitan HIV/AIDS Programs Division of State HIV/AIDS Programs

28 Ryan White HIV/AIDS Treatment Extension Act
All Ryan White grantees are required to establish clinical quality management programs to: Develop strategies for ensuring that such services are consistent with the guidelines for improvement in the access to and quality of HIV services Improve Assess the extent to which HIV health services are consistent with the most recent Public Health Service guidelines for the treatment of HIV disease and related opportunistic infections; and Evaluate

29 Programmatic Expectations
Funding Opportunity Announcement provides minimum expectations for grantees. Established and implemented a clinical quality management plan; Established processes for ensuring that Primary Medical Care services are provided in accordance with the Department of Health and Human Services (DHHS) treatment guidelines and standards of care; and Incorporated quality-related expectations into Requests for Proposals (RFP) and contracts.

30 Components of a QM Program
Quality Infrastructure Quality Management Plan Performance Measures Quality Improvement Projects

31 Quality Infrastructure
Infrastructure enhances systematic implementation of improvement activities. Infrastructure The infrastructure is the base on which the QM program is built. A solid base insures that the rest of the program can be built and maintained.

32 Quality Infrastructure
Quality Management Committee Leadership Stakeholders Touch on 3 important parts of the infrastructure: the QM committee, leadership and stakeholders.

33 Quality Management Committee
Builds the HIV program’s capacity and capability for quality improvement Involves program leaders and other key staff to cement their personal commitment to quality In a large organization, links the HIV quality program with the organization’s overall quality program The quality management committee leads the HIV program’s quality improvement activities. Its job is to build the program’s capacity and capability for improvement. The committee should include leaders from different areas of your HIV program and their involvement in the committee’s work will help strengthen their personal commitment to quality as well. If your HIV program is part of a larger organization, you will want to coordinate your quality improvement work with that of your organization as a whole. The quality management committee helps to do this.

34 Who might be on the committee?
For a Teaching Hospital (HIV case load: 700) Chief of Infectious Diseases AIDS Center Administrator Director of Ambulatory Care Director of Quality Improvement Director of Nursing AIDS Center Nurse Practitioner Clinic Coordinator for Case Management Senior Staff Nurse Patient Representative Part D Provider For a Community Health Center (HIV caseload: 100) Medical Director HIV Nurse Case Manager For a Network (State jurisdiction) (HIV case load: 20,000) Ryan White Program Coordinator State AIDS Director Quality Manager/Contractor Medicaid CDC Prevention Part C or Part D contractor Subcontractors (Case Manager, housing, food bank, etc.) Here are examples of what a QM committee may look like. These include the examples of a teaching hospital and a health center to illustrate how a State with small numbers of cases may think about structuring a QM committee.

35 Leadership Clearly articulated mission and vision statement
Ongoing measurement of performance Ongoing assessment by leaders Active coaching by leaders Organizations with strong capabilities in data and measurement have clearly articulated mission and vision statements with ongoing measurement of performance that links to the mission and the vision. They have ongoing assessment by leaders of quantitative performance measures and a clear method for leaders to use to prioritize and select processes on which to focus and improve. It’s also imperative to have active coaching by leaders of performance improvement teams.

36 Stakeholders How will staff, providers, consumers and others be involved in the CQM program? Engage internal and external stakeholders Communicate information about quality improvement activities Provide opportunities for learning about quality A strong QM program involves stakeholders. Stakeholders have different perspectives on improving HIV programs and care. Clinicians focus on technical aspects of quality HIV care, whereas consumers focus is on experience of receiving care. Involvement of all stakeholders builds a strong system of care.

37 Quality Management Plan
A quality management plan is a written document that outlines the grantee-wide HIV quality program, including a clear indication of responsibilities and accountability, performance measurement strategies and goals, and elaboration of processes for ongoing evaluation and assessment of the program. Updated quality management plans are going to be requested from all Part B grantees in FY14 The quality management plan is the written document describing how the quality management program works, what gets done, who does it and how. These are all spelled out, in writing, in the quality management plan.

38 Quality Management Plan of a Quality Management Plan
Quality statement Quality infrastructure Performance measurement Annual quality goals Engagement of stakeholders Evaluation The quality management plan should contain the six elements listed here. Keep in mind that the QM Plan should be viewed as a living document that is evaluated and updated on a regular basis. It is not something that is “checked off the list.”

39 The 10 QM Plan Rules Do not reinvent the wheel, use established frameworks to get started ‘Steal Shamelessly, Share Senselessly’ Size does not matter 80% planning, 20% writing (old software programming rule) A few visionary annual goals are better than plenty of useful ones Sample plans are out there. Use the references at the end of this Tutorial to find them, and begin there. As with so many things in quality, make use of what others have done and be willing to share what you’ve accomplished, to help others. It doesn’t matter how long it is. Substance matters more. Think through what you want to do before you start to write. Don’t obsess over the writing, it’s the planning that matters. Use the plan-writing process to push your organization forward.

40 The 10 QM Plan Rules (cont.)
6. Be inclusive, even if it takes longer to get your final QM plan If you have not touched your plan in the last 6 months, bring it to the next quality committee meeting A perfect plan is never written Plans are only as good as their implementation Get started Involve the people who need to be involved. They will make the plan a living document, rather than something that’s just a hoop to be jumped through. Here’s a tip to make sure your plan stays real – if you’re not using it regularly, haul it out and talk about it. It should be a living guide. Don’t let the perfect be the enemy of the good. If it works for your organization, it’s fine. Plans are only as good as their implementation. To use a popular cliché, just do it! All the planning in the world is for not if you do not take action.

41 Performance Measures Importance of Performance Measures:
Separating what you think is happening from what is really happening Establishing a baseline and allowing for periodic monitoring Determining whether changes lead to improvements Comparing performance with others Linking performance data to quality improvement activities Measuring HIV performance data helps us in many ways. We can separate what we think is happening from what is really happening and then establish a baseline and allow for periodic monitoring. From here, we can determine whether changes lead to improvements or not. It is equally important to compare performance across sites, and finally, link performance data to quality improvement activities.

42 HAB Performance Measures
2007: Started developing and releasing measures under the guidance of Dr. Cheever Currently 46 measures spanning clinical care, oral health care, ADAP, case management, and systems Alignment and streamline measure across federal programs Core measures received National Quality Forum endorsement in February 2013 asures.html WHAT DO WE WANT TO ACHIEVE? Emphasize Priorities- across the HIV Care Continuum Alignment with Other Federal Stakeholders- Parsimony

43 Quality Improvement Projects
Imbalance Balance Many grantees are measuring data but are lacking the next part of the QM program, the quality improvement part. Performance measurement alone is not quality improvement. However, to do quality improvement, you need performance measurement.

44 Quality Improvement Projects
PDSA Cycle There are different methods for developing quality improvement projects. One of the most commonly used is the Plan-Do-Study-Act cycle. The PDSA cycle is an effective model for developing short term quality improvement initiatives. The NQC website has a tutorial on the PDSA cycle.

45 Quality Management Program
QM Program evaluation tool Developed to help project officers and consultants to better evaluate QM Programs during site visits Identify if a program is meeting legislative requirements Identify areas in which a program has established “best practices” Identify areas where a program needs to improve in order to provide a high quality system of care Updated QM plans are going to be requested from all Part B grantees within the next year.

46 Quality Management Program
Resources: National Quality Center (NQC) NQC Quality Academy HIV/AIDS Bureau (HAB) Performance Measures easures.html

47 Georgia Department of Public Health Quality Management Program
Ryan White Part B Quality Management Program HRSA TA Webinar Building a Quality Management Program January 15, 2014 3:00 – 4:00 PM

48 Acknowledgments Rosemary Donnelly, SEATEC Clinical Director
Pamela Phillips, RW Part B QM Coordinator Michael Coker, RW Part B HIV Nurse Consultant Rachel Powell, RW Part B QM Data Manager Marisol Cruz, RW Part B Care Manager William Lyons, HIV Office Director Kim Brown, HRSA Project Officer RW Part B QM Core Team and Subcommittees National Quality Center RW Part B-funded health district staff Representatives/Grantees of other Georgia RW Parts

49 RW Part B QM Team Structure
HIV Medical Advisor HIV Office Director RW Part B Care Manager QM Team Lead HIV Nurse Consultant Quality Management Coordinator HIV Nurse Consultant Part-Time Data Manager HIV Prevention Manager

50 Part B-Funded Health Districts
Rome Dalton Cobb-Douglas Clayton East Metro LaGrange Dublin Macon Augusta Columbus Valdosta Albany Brunswick/Savannah Waycross Athens **3-2 Fulton and 3-5 DeKalb are funded primarily by Part A

51 Origins of the QM Program
1990’s: Nurse consultant for HIV Prevention asked to assist with quality reviews for medical care HIV Medical Advisor hired 2000 2005: Title II Collaborative with HRSA/NQC 18 months of TA and support Developed written QM Plan Created statewide QM Committee Additional QM staff hired Improved buy-in from all stakeholders

52 Elements of Current Structure
Georgia RW Part B Program QM Plan Statewide QM Core Team and Subcommittees Expectations for funded health districts Data Collection, Reporting and Analysis

53 Georgia RW Part B QM Plan
Communication & Coordination QM Core Team & Subcommittees Continuous Quality Improvement (CQI) Projects Evaluation Data Collection Local QM Plans & Annex-GIA Capacity Building (Training and TA) Part B QM Plan

54 Georgia RW Part B QM Plan
Implemented April 1 – March 31, updated annually Process to evaluate and revise: Meetings with stakeholders Review quality data NQC Assessments Federal initiatives Approval by QM Core Team and HIV Office Director prior to implementation

55 Statewide RW Part B QM Core Team
Purpose: To provide oversight and facilitation of the GA RW Part B QM Plan Meetings are held quarterly, face-to-face preferred in a central location for the state Composed of multidisciplinary professionals and consumers Subcommittees: Case Management, ADAP/HICP Collaboration with other RW Parts

56 Funded Health District QM Expectations
Ensure compliance with DHHS-related guidelines Participate in statewide Part B QM Program Develop and implement local QM Program Written QM Plan and work plan updated annually Leader and team to oversee the Program QM Goals, objectives and strategies Communicate results to all levels of the organization, including consumers as appropriate

57 Quality Data Collection and Reporting
Collaborate with Epi/Surveillance Surveys, e.g. statewide Client Satisfaction Survey Clinical and Case Management Chart Review Reliable Limitations in how the data is collected Time and resource intensive CAREWare Uniform comparison based on data that is entered Includes all eligible clients Generally less reliable for some measures and districts

58 Overview of a CQI Project
Clinical chart reviews were conducted in 2006 Two areas of improvement were found: dental exam and cervical cancer screening Districts not at goal were asked to incorporate these measures into their local QM Plans Improvement projects occurred at both the state and local levels In 2009, clinical chart review showed modest improvement in both measures Currently, clinical chart review data is being analyzed for CY The data will be compared with 2006 and 2009 to determine trends and next steps

59 CQI Project Data

60 Recent Projects Statewide client satisfaction survey In+Care Campaign
Collaboration with Medicaid Case Management Acuity Scale and Self Management Model ADAP/HICP CAREWare electronic application process Providing quality-related trainings and technical assistance

61 Challenges/Opportunities for Improvement
Time frame for reporting data back to stakeholders Innovative ways to improve CAREWare data entry Case management training disparity Technical capacity

62 Building a Program: Where to Begin?
National Quality Center trainings and TA Peer learning Obtaining buy-in from senior leadership and stakeholders Using tools from NQC outlining what a quality program should look like Written QM Plan QM Committee Process for data collection and reporting

63 Keeping the Program Strong
National Quality Center Trainings and TA Buy-in is an ongoing process Demonstrating the value of quality work Listening to stakeholders Being visible in the community Always working to improve Maintaining continuity through a detailed QM Plan and documentation of meetings and activities

64 Contact Information Eva B. Williams, MSN, FNP, MPH, AACRN HIV Nurse Consultant – QM Team Lead Phone: (404) Michael (Mac) Coker, MSN, RN, ACRN HIV Nurse Consultant Phone: (404) Pamela Phillips, BSW, MHA Quality Management Coordinator Phone: (404)

65 Questions


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