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Taking Your Quality Management Infrastructure to the Next Level: Clinic-based and Network-based Part D Programs Kathleen Clanon, MD Julia Schlueter, MPH
Funded by HRSA HIV/AIDS Bureau
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What Are the Special Characteristics of Part Ds that We Want to Measure and Improve?
• • • • • • • • Focus on women, children, youth and families Family-centered approach Multi-service, medical home model Network design is common Case managed coordinated care Cultural competence Consumer involvement Others?
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Improvement Activities Are Supported by a Quality Infrastructure National Quality Center (NQC)
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Real Life Challenges
• • • Julia Schlueter, MPH QM manager for Parts C and D Washington University in St. Louis Network AND University Clinic based designs…..
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Part D Quality Infrastructure Challenges: Network- and Clinic-Based Designs
Networks: Multiple agencies come together in one Part D program Multiservice Network: case management, mental health, substance abuse, primary care done by different agencies Patients get services at multiple agencies in the network Federation Network: multiple one-stop-shops come together. Clients usually get all services at only one site Clinic-based design: funding and services all concentrated in one agency, usually a university or public hospital National Quality Center (NQC)
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Network- and Clinic-Based Designs
• • Networks: Multiple agencies come together in one Part D program Multiservice Network: case management, mental health, substance abuse, primary care done by different agencies. Patients get services at multiple agencies in the network Federation Network: multiple one-stop-shops come together. Clients usually get all services at only one site Clinic-based design: funding and services all concentrated in one agency, usually a university or public hospital National Quality Center (NQC)
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Two Flavors: Distinct Challenges for Quality
• • • • •
Networks
Accountability Small investment in each agency, so trouble getting access to staff Trust in sharing data Getting buy-in for unified priorities Support services culture vs clinical culture • • • •
Clinic-Centered
Hospital/university hierarchy Competing quality priorities – all clinical or even non-HIV HIPAA paranoia re: collaborating community agencies Institutional rivalries National Quality Center (NQC)
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Exercise: Assessing Your Infrastructure
• • • Take 5 minutes to fill out the Diagnostic Assessment questionnaire based on the last 3 months in your program For 10 minutes, share with someone you don’t know what your infrastructure strengths and weaknesses are Use the action planning form to take notes: what area do you want to get ideas for in the next 20 minutes?
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What Do We Need Providers to Do?
Getting Beyond Our Agency • • • • • • • Demonstrate they are doing QI work, in compliance with Ryan White legislation Partner in data collection Participate in quality trainings Adopt joint service standards Coordinate in choosing indicators and improvement priorities Participate in joint improvement projects Be part of the quality committee…….
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Benefits of Multiagency QI
• • • • • Multidisciplinary thinking Joint prioritization of improvement work maximizes impact Share work of data collection, data analysis and data sharing Peer learning opps and mutual accountability Can improve systems of care beyond one agency; retention in care, late entry into care..
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Barriers to Participation
• • • • The Big Four: Time Turf Trust Turnover • • • Others: Data system incompatibility Data Denial Quality baggage / history of failed attempts National Quality Center (NQC)
Who Are Our Providers?
• • • • • Case management & supportive services agencies CBO/ASO’s Public Health departments Clinical providers Community Health Centers Hospital/University-based Public Health department clinics Professional services (Oral Health, Mental Health, Substance Abuse, etc.) Mental health providers
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Engaging Providers: What Works in Networks?
Contract language
can/should be very specific about their QI responsibilities (make quality part of job descriptions, new employee training) • Can use
monitoring visits
to look at/discuss actual examples/results of their QI work • Engage providers in developing data collection strategies that are
realistic and non-threatening
• Show them the data you are getting.
Regular data reporting
keeps providers interested & involved
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Engaging Providers: What Works in Networks?
Take on an
improvement in your own internal processes
and show your subcontractors you are walking the walk. •
Get your boss to brag
about your QI work at high level management & provider meetings; builds your “street cred” with the subcontractors.
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Reward transparency
; show participants that they will not be punished for being open about what needs to be fixed.
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Sharing Stories Across the Network…
Email “Attaboys”
Our QI Performing Stars!
This month’s Highlights…LifeLong and Tri-City LifeLong Medical Care – Lab test frequency skyrockets!
After reviewing their Q1 Performance Measurement data, LifeLong noticed that getting people into the lab for CD4 ct. test had been difficult. With a combined team effort, they identified 33 patients who hadn’t had blood work done in 2009. They contacted each patient with a hand written letter and lab requisition and included information about their last labs and appointments. Within a
3 week time period, 21 of the patients
done!
had blood work Before this improvement project 57% of LifeLong’s population did not have a CD4 test performed twice yearly. With their effort, 84% of the population now has their CD4 test complete! That is a
27% increase in 3 weeks
! They have also decided to incorporate the task into the M.A position and will be reviewing the database for similar patients every 6 months. Fantastic effort LifeLong keep up the good work!
Tri-City Health Center – A Women’s Health Campaign Soars!
Focusing on Women’s Health was the concept for improvement after the April QI meeting for TCHC…. For the 26 women in care they provided incentives of $20 Wal-Mart gift certificates for those who came in for a Pap test. With this effort the QI team was able to get 19 of their women’s Pap tests complete! This is
73% of their women
!
Contact Itta [email protected]
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Engaging Providers: What Works in Networks?
For those who also get other Ryan White • • • Program $ (Part B, C, D, AETC, SPNS): Offer to
organize multi-Part alignment meetings
minutes, follow-up calls.
; space, Refer to
application language
; all Parts now need to describe QI results in their apps. Work they do with you can go into the app!
Get HRSA persuasion.
Project Officers
to coordinate and help with
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What do we as Part D do for providers?
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Collect & report case management data from sites Collect & report clinical data from sites Develop/support client level clinical data system Collect data & report on care quality & outcomes Develop/support client level case management data system Provide staff support for data collection & reporting Collect patient satisfaction data from sites Provide software/hardware Develop: • clinical systems & collect & report data * • case mgmt systems & collect & report data ** * Chi Square = 7.64; Prob > ChiSquare .006 at 1, 37 df ** Chi Square = 6.15; Prob > ChiSquare .013 at 1, 37 df
N
31 28 28 28 26 27 24 22 25/29 25/32
% N
82 74 74 74 68 69 63 58 84 78
No (%) Sites
237 (88) 210 (78) 223 (83) 220 (81) 201 (74) 200 (74) 194 (72) 197 (73) From Abramowitz and Greene 2005, Survey of Title IV ED.s
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Engaging Providers: What Works in Clinic Based Models?
Provide support staff
to carry on the momentum at meetings; minutes-takers and assist with follow-up reminders.
Get the
residents and students
involved in projects.
Coordinate with and
tap into the hospital/clinic non-HIV QI
structure.
Reduce productivity targets
/case loads for those participating in QI pilot work.
Report at every meeting
and in newsletters on progress of quality improvement work.
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Resources
• www.nationalqualitycenter.org
Quality Academy tutorials are great to “prescribe” before meetings for all participants to increase their knowledge.
• Measuring Clinical Performance: A Guide for HIV Health Care Providers. A publication of the AIDS Education Training Centers and the New York State Department of Health, AIDS Institute, 2006. The guide can be downloaded at: http://nationalqualitycenter.org/index.cfm/6127/13908
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Resources National Quality Center (NQC)
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Family-Centered Care Resources
• www.familycenteredcare.org
Has resources for hospitals and clinics. Clinical orientation, lots of tools… • Abramowitz S, Greene D. Ryan White CARE Act Title IV programs: a preliminary characterization of benefits and costs.
AIDS Public Policy J
. 2005 Fall-Winter;20(3-4):108-25.PMID: 17624034 [PubMed - indexed for MEDLINE]Related Articles (table, slides 15 and 16.) National Quality Center (NQC)
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Contact Information
National Quality Center (NQC)
212-417-4730 NationalQualityCenter.org
HIVQUAL-US
212-417-4620 HIVQUAL.org
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