1. Moving Beyond Widgets : Measuring for Outcomes in Social Services The AIDS Foundation of Chicago Experience David Munar and Keri Rainsberger Michael Reese Health Trust Health Care Issues Roundtable February 24, 2012

2.  The mission of the AIDS Foundation of Chicago is to lead the fight against HIV/AIDS and improve the lives of people affected by the epidemic.  Founded in 1985 by community activists and physicians, the AIDS Foundation of Chicago (AFC) is a local and national leader in the fight against HIV/AIDS. We collaborate with community organizations to develop and improve HIV/AIDS services; fund and coordinate prevention, care, and advocacy projects; and champion effective, compassionate HIV/AIDS policy. AIDS Foundation of Chicago

3.  ClientTrack – AFC’s Client-Level Database  Client-level information on case management and supportive services  Used by the Northeastern Illinois HIV/AIDS Case Management Cooperative and the AIDS Foundation of Chicago housing programs  Homeless Management Information Systems (HMIS)  Client-level information on homeless persons and their service needs  Required by the US Department of Housing and Urban Development (HUD) and implemented by local continuum  AFC participates in the City of Chicago continuum database (ServicePoint). There are also separate HMIS implementations in most of the suburban counties and a few of the larger suburbs Social Service Databases

4.  Implemented and operated by the Chicago Department of Family and Support Services (DFSS) with support from many others  All HUD-funded programs are required to participate; other homeless service providers are encouraged to participate  The City of Chicago’s federal homeless funding is tied partially to the success of HMIS  AFC participates as an Interface agency by automatically uploading data on a regular basis. AFC also logs in directly to verify data was imported correctly City of Chicago HMIS

5. ClientTrack: Multiple Partners and Users ClientTrack 26 grants 258 users 37 agencies 13 programs

6. ClientTrack: Multiple Partners and Users ClientTrack 26 grants 258 users 37 agencies 13 programs Case Management for HIV+ Pregnant Women (PACPI) Case Management for people leaving correctional facilities Case Management for those needing rehabilitative services (DRS) CM for those needing assistance maintaining medical care (RW Medical) CM providing assistance with social service needs (RW Supportive) CM and Housing for chronically ill homeless persons (SHP) SAMSHA mental health and substance use services Long term housing assistance Short term/emergency financial assistance Part B non-CM services Housing outreach services Peer-based services Housing advocacy

7. ClientTrack: Multiple Partners and Users ClientTrack 258 users 37 agencies 13 programs 26 grants State Grants - Corrections - PACPI - DRS - Supportive Services (IDHS) - 100,000 Homes Campaign (DFSS) Federal Grants - Safe Start I (HUD) - Samaritan Supportive Housing Program (HUD) - Chronic Homeless Initiative (HUD) - Chicago Housing for Health Partnership (HOPWA- SPNS) - Renaissance Care Network (HOPWA-SPNS) - Re-entry for Housing and Health Partnership (HOPWA-SPNS) - Medicaid Supportive Housing (HUD) - Healthy Connections (SAMHSA) - Access to Wellness (SAMHSA) Private Grants - Homelessness Prevention Funds (Emergency Fund) State Pass Through of Federal Grants - Part B Cook - Part B Collar - IDPH HOPWA City Pass Through of Federal Grants - Part A Medical CM - Part A Supportive CM - Part A Emergency Assistance - Part A Transportation - Part A Early Intervention Services - Part A Housing Assistance - HOPWA Formula (CDPH Pass through) - Housing, Health, and Independent Living (HOPWA- SPNS, CDPH)

8. ClientTrack: Capturing Service Encounter and Outcomes Data

9. ClientTrack Services and Referrals Medical Indicators Assessments Case managers and clients set goals they would like to work on in the next six months. They then identify the tasks needed to reach those goals and a time frame by when they hope to accomplish the tasks. Service Plans

10. ClientTrack: Capturing Service Encounter and Outcomes Data ClientTrack Medical Indicators Assessments Services and Referrals Case managers record detailed case notes, and a record of all the face-to-face visits and phone calls made with or on behalf of the client. Case managers also check off the topics they have discussed with clients, as well as any referrals they made. The outcome of referrals is also documented.

11. Services and Referrals Service Plans ClientTrack: Capturing Service Encounter and Outcomes Data ClientTrack Assessments Medical Indicators Medical indicators are collected both from client report and directly from a client’s Primary Care Provider. Examples include: -HIV/AIDS Status and Diagnosis dates -Lab results -Vaccinations -Opportunistic Infections -Co-occurring conditions -General health status -Mental health and substance use screening

12. Tracking Client Care 11/28 Initial referral Newly diagnosed Assigned to agency same day 11/29 Call setting initial intake 12/7 Intake Set goals to obtain medical care and ADAP CM calls clinic on client’s behalf to schedule first appointment 12/16 CM receives medical form verifying appointment and medical information 2/2 Follow-up call from CM Client reports taking HIV medications Example This is a real example from one of our clients flowing through care. For most of our clients this flow is more complex with multiple issues being addressed.

13. Tracking Care at a System Level System level uses of data Understand how case management is being implemented Able to measure how system is comparing to standards of care Estimate impacts of policy or procedure changes Estimate eligible population for new services Easier and more in-depth reporting Data from July-December 2011

14.  Service data is entered and reported to multiple databases  Integration includes both the physical sharing of the data but also policies governing the sharing  ClientTrack as a “data warehouse” Moving Toward Data Integration

15.  Opportunities abound for additional data coordination  Shared definitions and standards important  Client confidentiality in an era of increased data sharing AFC’s Visions for Future Development: Data coordination Client Track Surveillance Medicaid EMR HMIS ADAP

16.  Assessing for outcomes  Clients assessed every 6 months  Researcher analyzing questions to see what outcomes we might be able to pull from this data  Analyzing processes  Where do clients hit snags in receiving needed services  Is data being entered correctly  Challenges of working with administrative data  Geared to users not researchers  Multiple sources of entry  Retrospective  In the “wild” rather than a laboratory AFC’s Visions for Future Development: Greater data analysis capabilities

17.  Automated chart audits  Implemented first stage this round  Allows review of 100% of charts virtually  Will be made available to agencies to do their own interim reviews  Quality Management Reports  Medical Case Management standards established  Reports for users at multiple levels (case managers, agency supervisors, AFC program coordinators) AFC’s Visions for Future Development: Robust quality improvement process

18. Quality Improvement Example  Medical Case Manager Standards  Developed from best practices, consultation with key informants  Based on a one year period, most standards require two instances within the year  Case Management Face-to-Face Visits (CM V)  Medical Visits (Med V)  Case Management Assessments (CM AS)  Care Plan Development and Update (CARE P)  Care Plan Has Medical Goal (MED G)  Adherence Counseling Provided (ADHER)  Communication between Primary Care Provider and Case Manager (PCP C)

19. Case Manager Tools : To Do List Quality Improvement Example Case Manager Tools : Indicators Check List

20. Example  Agency Indicator Review

21.  System Indicator Review (used by agencies and AFC) Quality Improvement Example

22. AFC Program Coordinator indicator review Quality Improvement Example

23.  The “Rich Silo” effect  Non-cooperation and gamesmanship between data sources creates detailed data that is still not shared  Quality data requires culture change  Requires a whole process outlook  Balancing privacy and confidentiality with increasing capabilities  Consider the need to know and usefulness before collecting data  Ensuring client consents and education keep up with sharing capacity  Standardization  Data can require a significant amount of recoding to be shared across databases  Ensuring programs are being integrated in a consistent way across providers  Deduplication Challenges and lessons learned

24.  Over 6000 clients who shared their data with us  258 users who enter and check data  The AFC Research Evaluation and Data Services, Care, and Housing Teams Acknowledgements

25. Medical Indicators Services and Referrals Service Plans ClientTrack: Capturing Service Encounter and Outcomes Data ClientTrack Assessments Clients complete an assessment every six months. Assessment topics include: -Basic demographics -General health status -Mental health and substance use screening -Access and barriers to care -Medical and supportive needs