Workshop: Early Successes of a Title II National Collaborative to Build Capacity for Quality Improve

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Workshop Early Successes of a Title II
National Collaborative to Build Capacity for
Quality Improvement

• Panel of Presenters.
• Barbara Boshard, RN, BSN, MS, of Missouri
• Susan DiCocco, RN, of Ohio
• Randy Jones, BSW, of Alabama
• Moderated by Barbara Boushon

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Learning Objectives of the Workshop

• Describe the HAB Title II Collaborative, its
  goals and early successes.
• Meet participating teams to share their
  experiences and lessons learned from this Title
  II Collaborative.
• Be able to access measures, tools, best practices
  and other resources from the Title II
  Collaborative.

3
Background on the Title II Collaborative
Demonstration Project

• This Collaborative is supported by cooperative
  agreements from the Health Resources and Services
  Administration (HRSA), HIV/AIDS Bureau (HAB) to
  the National Quality Center (NQC) and the
  Institute for Healthcare Improvement (IHI).

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Background

• New legislative requirements of the 2000 RWCA
  Reauthorization direct grantees to develop,
  implement and monitor quality management (QM)
  programs to ensure that
• Service providers adhere to established HIV
  clinical practices
• QM strategies include support services that help
  people receive appropriate HIV health care
• Demographic, clinical, and health care
  utilization information is used to monitor trends
  in the spectrum of HIV-related illnesses and the
  local epidemic.

5
Background

• The RWCA focus on quality reflects two national
  trends
• Improvement
• Accountability

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Timeline

• Vanguard Meeting November 2004
• Expert Meeting January 2005
• Faculty Meeting May 2005
• Learning Session I June 2005
• Learning Session II November 2005
• Half-day Virtual Session May 2006
• Half-Day Virtual Session September 2006
• Learning Session III November 2006
• Synthesis Meeting Winter of 2007

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Improvement Opportunities (Domains of
Improvement)

• Alignment Across Jurisdictions and Services,
  including ADAP, to support a common vision of
  service delivery and quality of services
• Integration of Data and Information Systems to
  facilitate information sharing and performance
  measurement to support delivery of quality health
  services
• Improving Access to Care and Retention of
  HIV/AIDS Clients and
• Optimization and Management of Resources within
  the currently constrained environment including
  recruitment and retention of personnel.

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Expectations and Goals of the Collaborative

• By the end of the Collaborative, Title II
  Grantees will have
• Tested and implemented changes in at least two of
  the domains of improvement
• Developed or refined an effective quality
  management plan and program for the State or
  Jurisdiction in accordance with the Ryan White
  CARE Act legislation, and initiated
  implementation of processes to ensure and
  demonstrate quality of care and services
• Developed plans to support ongoing and
  collaborative quality improvement efforts,
  through integrating and using the tools made
  available during the Collaborative to spread
  quality management to their contractors/constituen
  ts.

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Participants

• Alabama
• District of Columbia
• Florida
• Georgia
• Michigan
• Missouri
• Ohio
• Oregon

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Ryan White CARE Act Title II

• Title II CARE Act Funding 1,203,362,569
• Alabama 11,705,778
• DC 16, 875,124
• Florida 108,800,440
• Georgia 35,412,808
• Michigan 14,902,329
• Missouri 10,231,106
• Ohio 15,732,171
• Oregon 5,719,559
• SUBTOTAL 219,379,315 18.2 of RWII
  Funds

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The Potential Impact

• 86,408 PLWA reported in the 8 states
• At least 43,000 PLHIV estimated
• TOTAL POTENTIAL IMPACT
• IMPROVING THE QUALITY OF CARE FOR 129,000
  PLHIV/AIDS --
• gt10 of PLHIV/AIDS in United States

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Faculty

• Chair Person Bruce Agins, MD, MPH
• Lead Faculty
• Gloria Maki
• Dwayne Haught, MSN, RN
• Faculty
• Kathleen Clanon, MD
• Lanny Cross
• Lisa Hirschhorn, MD, MPH
• Deborah Isenberg, MPH
• Julia Hidalgo, ScD, MSW, MPH

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Staff

• National Quality Center (NQC)
• Clemens Steinbock, MBA, Director of the NQC
• JoAnn Perou, MA, Project Manager
• Barbara Boushon, RN, BSN, Project Director
• Ginna Crowe, RN, MS, Project Improvement Advisor
• HIV/AIDS Bureau (HAB)
• Magda Barini-Garcia, MD, MPH, Chief Medical
  Officer, DSP and HAB Quality Lead
• Lori DeLorenzo, MSN, RN, QI Consultant
• Kerry Hill, MSW, Project Officer DSS
• Karen Ingvoldstad, Project Officer DSS

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Measures
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Process Measures
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Outcome Measures
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QMP Assessment Tool

• A.1 Title II quality management plan
• A.2 Selection of performance and outcome measures
  
• A.3 Work plan for the implementation of QM plan
• B.1 Title II organizational structure
• B.2 Quality management committee in place
• B.3 Involvement of Title II stakeholders
• B.4 Evaluation processes in place
• C.1 Collection of performance data
• C.2 Internal QI project(s)
• C.3 QI training and TA to Title II providers

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Quality Management Plan Assessment
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Collaborative Goal
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Collaborative Goal
Collaborative Goal
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Aim

• ..the overarching purpose of the Collaborative
  is to improve the quality of care for people
  living with HIV in the state or jurisdiction.
• HAB definition of quality Quality is the degree
  to which a health or social service meets of
  exceeds established professional standards and
  user expectations

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Team Presentations

• Please hold questions until the Question and
  Answer section to follow the three presentations

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Expectations and Goals

• By the end of the Collaborative, Title II
  Grantees will have
• Tested and implemented changes in at least two of
  the domains of improvement
• Developed or refined an effective quality
  management plan and program for the state or
  jurisdiction in accordance with the Ryan White
  CARE Act legislation, and initiated
  implementation of processes to ensure and
  demonstrate quality of care and services
• Developed plans to support ongoing and
  collaborative quality improvement efforts,
  through integrating and using the tools made
  available during the Collaborative to spread
  Quality Management to their contractors/constituen
  ts

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Enhanced Referral Tracking System (ERTS)
Sharon Jordan, B.S., M.P.H.,
Director Planning and Development Branch Randy
Jones, B.S.W., Manager Technical Assistance and
Data Quality Planning and Development
Branch Division of HIV/AIDS Prevention and
Control Alabama Department of Public Health
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What is ERTS?
A systematic way of identifying and documenting
linkage to care of initial post-test positive
clients and through further tracking attempt to
locate and connect those not in care to AIDS
Service Organization services
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What Did we Know About Client Referrals
Prior to ERTS?

• Health Department referral process varied greatly
  by region
• Limited or no data on post-test referral
  activity

• No system to track initial referrals

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Highlights
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Highlights

• Public Health Area 5 has 82 of the area's
  clients in care
• Public Health Area 6 has 74 of the area's
  clients in care
• Public Health Area 7 has 68 of the areas
  clients in care
• Public Health Area 8 has 58 of the areas
  clients in care
• Public Health Area 9 has 82 of the areas
  clients in care
• Public Health Area 10 has 71 of the area's
  clients in care
• Public Health Area 11 has 65 of the area's
  clients in care
• Public Health Areas 4 7 had less to no activity
  of tracking as a result of no HIV Coordinator
  working in these areas
• 66 of Alabama's newly diagnosed cases are
  receiving HIV Care throughout the state

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Enhanced Referral Tracking System Clients by
PHA Period 01/05 to 12/05
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Enhanced Referral Tracking System Cases by
Gender in PHA 01/05 to 12/05
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Enhanced Referral tracking System Clients by
Race PHA 01/05 to 12/05
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Enhanced Referral Tracking System Code Usage by
PHA 2005
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Enhanced Referral Tracking System Clients by PHA
2005
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Benefits of the Enhanced Referral Tracking System
(ERTS)

• HIV Coordinator Staff help fill gap to link
  clients to care.
• Client disposition coding improves tracking.
• Identifies clients not in care and links to
  services.
• Strengthens working relationships between the HIV
  Division, STD Division, AIDS Service
  Organizations, Consumers and other agencies.
• Provides baseline and benchmark data to improve
  performance measures regionally and statewide.

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Thanks

• 
  Program Development/Implementation Committee
• Bridget Byrd, Brenda
  Cummings, Sharon Jordan, Randy Jones,
• Marilyn Knight,
  Delia Reynolds, and Lani Thompson
• Division of HIV/A IDS
  Prevention and Control
• 
  HIV Program Coordinator Staff
• Anthony Merriweather,
  M.P.H., Director Surveillance Branch
• Division of
  STD Prevention and Control
• Marvin Fleming ( former CDC assignee)
  and John Keltner (CDC assignee)
• Area Disease
  Intervention Specialist Staff
• 
  Pilot Participants
• Montgomery AIDS Outreach,
  West Alabama AIDS Outreach
• Maude
  Whately Health Services
• Public Health Areas
  3 and 10 HIV and STD staff

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Expectations and Goals

• By the end of the Collaborative, Title II
  Grantees will have
• Tested and implemented changes in at least two of
  the domains of improvement
• Developed or refined an effective quality
  management plan and program for the state or
  jurisdiction in accordance with the Ryan White
  CARE Act legislation, and initiated
  implementation of processes to ensure and
  demonstrate quality of care and services
• Developed plans to support ongoing and
  collaborative quality improvement efforts,
  through integrating and using the tools made
  available during the Collaborative to spread
  Quality Management to their contractors/constituen
  ts

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Ohios Title II Quality Management Plan

• From Paperweight to Useful Tool

..and a few of our other favorite things!
Susan DiCocco, RN Title II Quality Management
Administrator Ohio Department of
Health susan.dicocco_at_odh.ohio.gov
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QM Plan

• HRSAs Quality Management Nine-Step Process
  manual used as a guide
• The plan seemed lengthy but
• breaking it down into
• sections helped

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QM Plan (continued)

• The body of the plan seemed wordy so developing a
  work plan helped to break it down into smaller
  activities
• Important to continually
• update the plan

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QM Workplan

• Allows the tracking of QM activities and monitors
  their progress
• Not only data measures but also process measures
  such as grant monitoring
• Currently in MS Word format
• Goal is to update it quarterly

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EXAMPLE
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Lessons Learned..

• Dont start from scratchuse a template or sample
  plan
• Assign the development of the plan to a specific
  person
• Use a format for the work-plan that facilitates
  frequent updates by all staff (such as MS Access)

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Next Steps

• Workplan has been useful but a little cumbersome
  to update in current format
• Next step is to move it to MS Access to allow
  for
• unlimited queries on any of the
• columns
• Staff can update their own
• activities as they complete
• them

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and the last of our favorite things
The Buckeyes
Northern Illinois This Saturday 9/2/2006
Michigan 82 days 11/18/2006

• Susan DiCocco, RN
• Title II Quality Management Administrator
• Ohio Department of Health
• susan.dicocco_at_odh.ohio.gov

Go Bucks!
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Expectations and Goals

• By the end of the Collaborative, Title II
  Grantees will have
• Tested and implemented changes in at least two of
  the domains of improvement
• Developed or refined an effective quality
  management plan and program for the state or
  jurisdiction in accordance with the Ryan White
  CARE Act legislation, and initiated
  implementation of processes to ensure and
  demonstrate quality of care and services
• Developed plans to support ongoing and
  collaborative quality improvement efforts,
  through integrating and using the tools made
  available during the Collaborative to spread
  Quality Management to their contractors/constituen
  ts

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Linking a Quality Management Plan Across the Wide
Missouri

• Ryan White All Grantees Meeting
• Washington, DC
• Presented by
• Barbara Boshard, RN, BSN, MS
• August 2006

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Imagine If

• Imagine that the Federal Government mandated that
  all Ryan White grantees had to play in the same
  sand box!
• What are you doing now?
• What changes do you need to make?

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Objectives

• To share the process that Missouri uses to
  collaborate across titles
• To share Missouris Quality Management Plan (QMP)
• To maximize resources
• To improve outcomes
• To identify opportunities by which your state can
  collaborate with existing and new titles and
  partners

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Creating Opportunity

• Missouri adopted a formalized quality management
  plan across several titles

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Missouris Collaborative Vision

• 100 Access
• 0 Disparity
• Clients needs more important than grantees needs
• Priority services primary care and medications

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How did this happen?

• Historical framework of using the Collaboration
  Continuum
• Communication
• Cooperation
• Coordination
• Integration
• Collaboration

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Steps Along Continuum Leading to QMP

• 1996 SCSN Process
• 1997 HIV/AIDS Statewide Advisory Committee
  formed
• 1998 All grantees quarterly meetings
• 2000 Formation of MACMIP
• 2002 Grantees ranked priority data needs
• 2002 HIV-Qual for Titles III, IV
• 2003 Added GPRA/PART data priorities

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More StepsLeading to QMP

• 2003 Title I in KC participated in Title I EMA
  QI Collaborative
• 2005 Scope of work with 3 collaboratively
  determined outcomes
• 2005 Title II participation in Title II QI
  Collaborative
• 2005 Title I in St. Louis received QI TA
• 2006 NQC QI 101 for all contractors

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Missouris QMP

• Ten Grantees majority are partners
• Pending Commitments from most other Grantees
• Additional Partners
• Central ASO (RAIN)
• Data Manager and Benefits Administrator (HSI)

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Components of QMP

• Vision
• Purpose
• Aims/Goals
• Definitions
• Structure
• Improvement Plan
• Outcomes

• Capacity Building
• Communicating Results
• Acknowledging Results
• Signature Page
• Annual Review

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Challenges

• Time
• Increased Morbidity/Decreased Mortality
• Decreasing Dollars
• Data System Capacity
• Staff Turnover
• Legislative Changes
• Grantees who choose not to play in the sandbox

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How do I Apply this to My State?

• P Plan
• D Do
• S Study
• A Act

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P Plan

• What do I want to accomplish?
• Who cares and what do they care about?
• What can we do better?
• What prevents us from doing better?
• What are our underlying problems?
• What changes can we make?

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D Do it

• Get together
• Talk
• Plan

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S Study

• How did we do?
• Did it work?
• If it didnt work what can we do now?

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A Act

• If it worked, how can we do it every time?
• Lets celebrate!

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Lessons Learned

• Power of collaboration
• Power of small steps to create significant
  change.
• Success can come out of failure
• Importance of data for success

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Using QI for Success Examples

• Access to Care for Missouri PLWH
• Increase of completed annual eligibility reviews
  for ADAP from 80 when this project started to
  94
• Increase annual eligibility review for all
  clients in CM from 70 to 80

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Comments or Questions?!

• Presented by
• Barbara Boshard, RN, BSN, MS
• Coordinator of Quality Improvement
• University of Missouri School of Medicine
• Department of Internal Medicine
• One Hospital Drive
• MA425B Health Science Center
• Columbia, MO 65212
• (T) 573-884-0770
• boshardb_at_health.missouri.edu

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Questions and Discussion

• Panel

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Websites for Quality Improvement
NationalQualityCenter.org

• HIV measures
• Change ideas
• Best Practices
• Tools/Resources
• Literature
• FAQ

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Tools from the Title II Collaborative

• Located at NationalQualityCenter.org
• Title II Quality Organizational Assessment and
  Introduction
• QM Plan checklist, QM Plan presentations, QM Plan
  examples from States
• Indicator definitions
• Presentations Retention, Managing Resistance to
  Change
• Morecheck it out!

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Thank You

• National Quality Center (NQC) 888-NQC-QI-TA
• NationalQualityCenter.org
• NQCTA_at_health.state.ny.us