clinical quality management plan...clinical quality management plan 5 | p a g e clinical quality...

State of California, Department of Public Health, Office of AIDS

Clinical Quality Management Plan

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Clinical Quality Management Plan April 2017 – March 2020

Ryan White Part B Program (HIV Care Program, AIDS Drug Assistance Program)

Released July, 2018



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Table of Contents Introduction ...................................................................................................................... 3

Quality Statement ............................................................................................................ 4

Vision ........................................................................................................................... 4

Mission ......................................................................................................................... 4

Purpose ........................................................................................................................ 4

Key Terms .................................................................................................................... 4

Clinical Quality Management Infrastructure ..................................................................... 5

Leadership and Accountability ...................................................................................... 5

CQM Committee ........................................................................................................... 6

Staff .............................................................................................................................. 7

CQM Plan ..................................................................................................................... 7

Stakeholder Involvement .............................................................................................. 7

Capacity Building .......................................................................................................... 9

Evaluation of CQM Program......................................................................................... 9

CQM Resources ........................................................................................................... 9

CQM Goals .................................................................................................................... 10

Goals and Objectives ................................................................................................. 10

Table 1: Office of AIDS (Recipient) Goals and Objectives ......................................... 11

Table 2: HIV Care Program Contractors’ Goals and Objectives ................................. 14

Performance Measurement ........................................................................................... 16

Data Sources .............................................................................................................. 16

Medical Monitoring Project ......................................................................................... 17

Performance Measures .............................................................................................. 18

Data Communication .................................................................................................. 26

Quality Improvement (QI) .............................................................................................. 26

Figure 1: Process for Determining RW Part B Quality Improvement Projects ............ 27

Methodology ............................................................................................................... 28

Monitoring of HCP Subrecipients Quality Improvement (QI) Projects ........................ 28

Current Quality Improvement Projects ....................................................................... 29

Process to Update CQM Plan .................................................................................... 29

Feedback.................................................................................................................... 29

Attachment A ................................................................................................................. 30



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Introduction

The U.S. Department of Health and Human Services (HHS), Health Resources and

Services Administration (HRSA), HIV/AIDS Bureau (HAB) administers the Ryan White

(RW) HIV/AIDS Program. The RW legislation created a number of programs, called

Parts, to meet needs for different communities and populations affected by HIV. Part B

of the RW HIV/AIDS Treatment Extension Act of 2009 (Public Law 111-87) provides

grants to U.S. states and territories to improve the quality, availability, and organization

of HIV health care and support services. In California, the RW Part B HIV care grant

includes funds for HIV Care Program (base), the AIDS Drug Assistance Program

(ADAP), Emerging Communities, and the Minority AIDS Initiative (MAI). In addition, the

grant includes RW Part B supplemental funds (base and ADAP) and ADAP shortfall

relief.

Title XXVI of the Public Health Service Act (Section 2618(b)(3)(E)) requires that each

State that receives a grant under RW establish a clinical quality management (CQM)

program to assess the extent to which HIV health services provided to patients under

the grant are consistent with the most recent Public Health Service guidelines

(otherwise known as the HHS guidelines) for the treatment of HIV disease and related

opportunistic infections. As needed, the CQM program shall develop strategies for

ensuring that such services are consistent with the guidelines in order to ensure the

access to and quality of HIV services.

As a RW Part B recipient, the State of California Department of Public Health (CDPH)

Office of AIDS (OA) ensures the availability of high-quality preventive, early intervention,

and care services that are appropriate, accessible, and cost effective for people living

with HIV.

The California RW Part B CQM Program is outlined in this CQM Plan. This plan is a

living document designed to be modified and updated as part of OA’s continuous quality

improvement process. The CQM Plan is effective April, 2017 through March, 2020 and

will be reviewed and revised in 2020.

If you have any questions or feedback concerning this plan, please contact RW Part B

CQM staff at (916) 445- 6047, or by email at [email protected].

mailto:[email protected]



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Quality Statement

Vision

All people living with HIV in California receive high-quality care and are virally

suppressed.

Mission

The mission of the RW Part B CQM Program is to support both optimum health

outcomes for Californians living with HIV and prevent new infections through effective

treatment of seropositive persons. This is accomplished by ensuring the availability of a

safety net of quality core medical and support services for all people living with HIV.

Purpose

HAB has defined ’quality‘ as the degree to which a health or social service meets or

exceeds established professional standards and user expectations.

The purpose of the RW Part B CQM Program is to systematically plan for, measure,

evaluate, and improve the quality of RW funded care and services delivered to people

living with HIV in California.

Key Terms

CQM Program

A CQM program is the coordination of activities aimed at improving patient care, health

outcomes, and patient satisfaction. The components of a CQM program are:

1. Infrastructure

2. Performance measurement

3. Quality improvement

CQM Plan

A CQM plan describes all aspects of the CQM program including infrastructure,

priorities, performance measures, quality improvement activities, action plan, and

evaluation of the CQM program.



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Clinical Quality Management Infrastructure

Leadership and Accountability

Chief of the Office of AIDS, Center for Infectious Diseases

As designated in California Health and Safety Code Section 131019, the CDPH OA has

lead responsibility for coordinating state programs, services, and activities relating to

HIV. The Chief of OA is responsible for directing the state’s HIV surveillance,

prevention, care, and treatment services for individuals living with HIV. The Chief serves

as a CQM Committee member and provides clinical and public health guidance to the

CQM Program.

Division Medical Officer, Office of AIDS

As the primary subject matter expert on medical and clinical activities in OA, the

Division Medical Officer leads multiple activities related to clinical quality improvement.

These include, but are not limited to, updating the ADAP medication formulary,

convening the Medical Advisory Committee, leading development of clinical guidelines,

providing guidance to RW Part B CQM activities, and leading CQM activities for OA that

fall outside of the RW Part B programs. This Division Medical Officer serves as the

CQM Committee Chair, shares responsibility for implementing Ryan White CQM

activities, and has accountability for non-Ryan White Part B CQM activities.

Chief of the HIV Care Branch

As the Principal Investigator for OA’s RW Part B funding, the HIV Care Branch Chief

provides strategic direction and management to the HIV Care Program (HCP) and the

Minority AIDS Initiative (MAI). OA HCP contracts with local health jurisdictions (LHJ)

and community-based organizations (CBO) to provide health care and support services

for these programs. The HIV Care Branch Chief also oversees the AIDS Medi-Cal

Waiver Program and the Housing Opportunities for Persons with AIDS (HOPWA)

Program. This Chief serves as a CQM Committee member and has accountability for

the RW Part B HCP, including CQM activities.

Chief of the ADAP Branch

The chief of ADAP coordinates, directs, and oversees the work within the ADAP Branch

which is responsible for providing life-saving medications and access to health

insurance to eligible persons living with HIV infection in California. The ADAP Branch

Chief oversees eligibility and enrollment activities, development of overall program

policy and fiscal forecasting, and client and contractor support activities. The ADAP

Branch Chief serves as a CQM Committee member and has accountability for the Part

B ADAP, including CQM activities.



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CQM Committee

The purpose of the CQM committee is to provide input, oversight, and facilitation of

California’s RW Part B CQM Plan. Each member serves an important role in ensuring

accountability, identifying gaps in care, fostering collaboration, sharing of knowledge,

and implementing quality improvement projects.

The CQM Committee includes members from various program areas within OA as

follows:

Chief of the Office of AIDS

Chief of HIV Care Branch

Chief of ADAP Branch

Division Medical Officer, Chair for the CQM Committee

Chief of Surveillance and Prevention Evaluation and Reporting Branch (SPER Branch)

Chief of ADAP and Care Evaluation and Informatics Branch (ACEI Branch)

Chief of Care Evaluation and Monitoring Section, ACEI Branch

Chief of ADAP Fiscal Forecasting, Evaluation, and Monitoring Section, ACEI Branch

Chief of the Surveillance Section, SPER Branch

Chief of HIV Prevention Branch

Chief of Care Program Section, HIV Care Branch

Chief of AIDS Medi-Cal Waiver Program section, HIV Care Branch

CQM Nurse, HIV Care Branch

Quality Management Nurse, Medi-Cal Waiver Program Section, HIV Care Branch

HIV Care Program staff, Care Program Section, HIV Care Branch

ADAP staff, Health Program Specialist I, ADAP Branch

Chief of Care Housing Unit, HIV Care Branch

Integrated Plan Implementation Specialist

Care Evaluation and Monitoring Section staff, ADAP and Care Evaluation and Informatics Branch

ADAP Fiscal Forecasting, Evaluation, and Monitoring Section staff, ADAP and Care Evaluation and Informatics Branch

CQM membership will be evaluated every three years or more frequently as needed

and changes made accordingly.

The CQM Committee meets on a monthly basis with workgroups meeting as needed. Every three months, the CQM Committee meeting will review CQM performance data to monitor progress toward meeting goals. The committee will assess the need to meet less frequently if it is meeting its goals.



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Staff

OA’s CQM program consists of the Division Medical Officer, one full time CQM nurse, a

Research Scientist, and other OA staff supporting the CQM activities in various

capacities, including program implementation, data collection and analysis, and grant

management.

Clinical Quality Management Nurse (1.0 FTE)

The CQM nurse reports to the HIV Care Branch Chief and is responsible for

coordinating the RW Part B CQM program, and other duties and responsibilities as

presented throughout this CQM Plan. The CQM nurse reviews all sub recipients’

progress reports and budget justifications and responds to any concerns about CQM

activities. The CQM nurse is also the RW Part B liaison to external quality management

work groups.

Division Medical Officer (0. 5 FTE)

The Division Medical Officer reports to the Chief of OA and is responsible for providing

clinical and programmatic consultation to OA and external stakeholders for CQM and

other activities, coordinating HIV-related CQM activities outside of RW Part B, including

engaging with Medi-Cal and private health care providers, and supporting RW Part B

CQM activities. The Division Medical Officer also has responsibilities unrelated to CQM.

CQM Plan

The CQM Plan is the document guiding the RW Part B CQM activities. CQM activities

that are outside the scope of RW Part B are addressed in other OA planning

documents. OA will revise the CQM Plan at least every three years. OA will distribute

the CQM Plan to HCP contractors and place it on the OA website.

CQM Committee Work Plan

The CQM Committee Work Plan delineates CQM program activities implemented to

achieve established CQM goals and objectives. Each activity has a corresponding

timeline and responsible parties. The CQM Committee will discuss progress on the

activities during the monthly CQM committee meetings.

The CQM Committee Work Plan is an internal document used by the CQM committee,

and is reviewed annually and revised as needed.

Stakeholder Involvement

Coordination within CDPH

Internal stakeholders within the OA have the opportunity to provide feedback on CQM

activities in order to ensure coordinated efforts across work groups. Additionally, the

CQM nurse and Division Medical Officer meet regularly with other CDPH programs,



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such as the Sexually Transmitted Disease Control Branch and Office of Health Equity,

to inform them of ongoing CQM activities and seek opportunities for collaboration.

Coordination with Other RW Programs in California

The RW Program Part B CQM Program will focus on collaboration of quality

management activities across all RW Parts in California which includes eight Part A, 41

Part C, and nine Part D recipients. This collaboration will be supported by having the

CQM nurse and Division Medical Officer communicate and share Part B CQM activities

with the Regional Quality Groups. Whenever feasible, the RW Part B CQM program will

support other California RW parts’ CQM activities.

Consumer Involvement

OA values consumer input in planning implementation, evaluation, and quality

improvement of HIV policies, programs and services. The CQM program will solicit

consumer input via the Part A planning councils or bodies, the California Planning

Group (CPG), satisfaction surveys, and feedback elicited through the OA website.

California Planning Group

The CPG is OA’s statewide planning and advisory group for HIV care and prevention

activities. The CPG is currently composed of 28 members, with 10 nominated members

who were nominated by each of the 10 RW Part A Planning Councils and HIV Planning

Groups in California, and 18 at-large members. The CPG members reflect the diversity

of the HIV epidemic in California based on HIV status, age, gender identity,

race/ethnicity, sexual orientation, and geographic/metropolitan statistical area

distribution (e.g., urban and rural residence), and represent those involved in HIV

prevention, care, and treatment services/programs. The CPG membership includes 13

persons who have self-identified as living with HIV, and 7 persons that receive RW

and/or ADAP services. CPG members have provided input on the development of this

plan and will continue to provide input on the CQM Plan prior its implementation.

ADAP Client Satisfaction Survey

ADAP periodically conducts client satisfaction surveys to evaluate program services and

collect feedback. Feedback from these surveys is available for planning quality

improvement activities. The CQM program is considering expanding the surveys to

include specific questions to inform CQM activities.

The CQM program will continue to explore other ways to involve consumers in CQM

activities.

RW Part B HIV Care Program Subrecipients’ Involvement

The 42 HCP contractors are generally LHJs and CBOs contracted to provide the range

of allowable core medical and supportive services.



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After consulting with HRSA’s CQM consultants, the RW Part B CQM committee elected

to require HCP subrecipients to implement CQM activities as directed by the state’s

CQM Plan. As such, HCP subrecipients are no longer be required to submit individual

CQM plans for Part B activities. However, HCP subrecipients must maintain adequate

staffing and infrastructure to implement CQM activities outlined inTable 2: HIV Care

Program Contractors’ Goals.

Capacity Building

The CQM nurse will coordinate webinars and training opportunities around quality

management for OA CQM staff, CQM committee members, and RW Program Part B

subrecipients.

HCP subrecipients’ CQM technical assistance/training needs will be assessed through

requests in HCP subrecipients' applications, monitoring of HCP subrecipients’ semi-

annual reports, data monitoring, and through training evaluations and/or needs

assessments.

The Center for Quality Improvement and Innovation (CQII), formerly known as the

National Quality Center (NQC), and Institute of Healthcare Improvement training

materials and resources will be utilized where appropriate.

Evaluation of CQM Program

The CQM Committee will evaluate the CQM program using the NQC’s Organizational

Assessment for Ryan White HIV/AIDS Program Part B Grantees at least annually.

The CQM Plan is assessed using the NQC’s Checklist for the Review of an HIV-Specific

Quality Management Plan, assessment tool.

CQM Resources

Financial Resources

The RW HIV/AIDS Program legislation (Section 2618 of the PHS Act) allows Part B

recipients to allocate part of the grant award to support the clinical quality management

program.

Guidance/Technical Assistance Resources

The following resources are available to the CQM program:

HRSA CQM Consultants

HRSA Ryan White HIV/AIDS Program CQII

Guidance Documents listed below:

o PCN 15-02 Clinical Quality Management Policy Clarification Notice and Frequently Asked Questions

https://careacttarget.org/cqii

http://www.ihi.org/Pages/default.aspx

http://nationalqualitycenter.org/resources/organizational-assessment/

http://nationalqualitycenter.org/resources/organizational-assessment/

http://nationalqualitycenter.org/files/quality-management-plan-review-checklist/

http://nationalqualitycenter.org/files/quality-management-plan-review-checklist/

http://hab.hrsa.gov/manageyourgrant/clinicalqualitymanagementpcn.pdf

http://hab.hrsa.gov/manageyourgrant/clinicalqualitymanagementpcn.pdf

http://hab.hrsa.gov/manageyourgrant/clinicalqualitymanagementfaq.pdf



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o HIV/AIDS Bureau Performance Measures o Department of Health and Human Services HIV/AIDS Medical

Practice Guidelines

o HIV/AIDS Bureau Part B Monitoring Standards (Part B specific, Universal Monitoring Standards, and Frequently Asked Questions)

o HIV/AIDS Bureau Part B Manual o HIV/AIDS Bureau ADAP Manual o National HIV/AIDS Strategy

o Laying a Foundation for Getting to Zero: California’s Integrated HIV Surveillance, Prevention, and Care Plan

CQM Goals

Goals and Objectives

The CQM goals and objectives listed in Tables 1 and 2 are based on the following:

Findings and recommendations in the HRSA HIV/AIDS Bureau Comprehensive

Site Visit Report, March 8 through 10, 2016.

Findings from the NQC’s Organizational Assessment for Ryan White HIV/AIDS

Program Part B Grantees. The CQM committee and the NQC coach completed

this assessment in December 2016.

Strategies and activities from Laying a Foundation for Getting to Zero:

California’s Integrated HIV Surveillance, Prevention, and Care Plan for 2017-

2021.

http://hab.hrsa.gov/deliverhivaidscare/habperformmeasures.html

https://aidsinfo.nih.gov/guidelines

https://aidsinfo.nih.gov/guidelines

http://hab.hrsa.gov/manageyourgrant/granteebasics.html



https://hab.hrsa.gov/sites/default/files/hab/About/RyanWhite/habpartbmanual2013.pdf

http://hab.hrsa.gov/manageyourgrant/adapmanual.pdf

https://www.hiv.gov/federal-response/national-hiv-aids-strategy/nhas-update

https://www.cdph.ca.gov/Programs/CID/DOA/CDPH%20Document%20Library/IP_2016_Final.pdf






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Table 1: Office of AIDS (Recipient) Goals and Objectives

The activity period for implementing each objective is noted with an “X”. “FY” is the RW grant fiscal year, April 1 – March

30.

Goals and Objectives

FY 2017 – 2018

FY 2018 – 2019

FY 2019 – 2020

Goal 1 – Build a CQM program infrastructure to support a systematic process with identified leadership, quality planning and accountability, and dedicated resources

1.1 By March 2019, determine the infrastructure, including resources and staffing, needed to successfully meet CQM program expectations.

X

1.2 Hold monthly CQM committee meetings. X X X

1.3 By June 2017, identify and document in the CQM Plan, specific CQM program activities that the HCP subrecipients will undertake every fiscal year and communicate these requirements to HCP subrecipients.

X

1.4 By December 2017, codify CQM requirements and activities in HCP subrecipients’ agreements (e.g., contracts).

X

1.5 Provide at least one training opportunity annually to build the capacity of subrecipients to undertake CQM activities.

X X X

1.6 Monitor each subrecipient's engagement in the CQM Plan’s performance measurement data and quality improvement projects at least semi-annually.

X X X

1.7 By December 2018, develop a process for consultation with non-consumer stakeholders on Part B CQM activities.

X

1.8 By June 2018, develop a process for consumer consultation on Part B CQM activities.

X X

1.9 Provide at least one CQM training opportunity annually for CQM committee members and staff.

X X X

1.10 By July 2018, determine the role of ADAP subrecipients in CQM activities and communicate this to ADAP subrecipients.

X



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Goal 2 – Use performance data to identify opportunities for improvement; develop and implement measures to evaluate the success of change initiatives; set funding priorities and allocations; align initiatives; monitor program status; and ensure that accurate, timely data and information are available to subrecipients

2.1 By June 2017, identify at least two performance measures for each RW Part B funded services.

X

2.2 By July 2017, inform HCP subrecipients of the RW Part B performance measures and collection requirements.

X

2.3 CQM committee will meet quarterly to review and analyze CQM performance measures.

X X X

2.4 By December 2017, determine process for and implement a mechanism to communicate CQM performance data to HCP subrecipients.

X

2.5 By June 2018, establish on-going import of HIV lab data from the California HIV Surveillance System to ARIES so that RW providers have access to complete, accurate, and timely viral load and CD4 data.

X

2.6 By July 2018, implement a method to measure the percentage of ADAP clients that fail to pick up the ARV prescriptions.

X

2.7 By December 2018, determine whether client satisfaction surveys can be used to inform CQM activities.

X

2.8 By July 2018, determine a meaningful measure and data collection activities for monitoring inappropriate antiretroviral regimen components among ADAP clients.

X X

2.9 By August 2018, determine a meaningful measure and data collection activities for housing stability and/or homelessness.

X

Goal 3 – Apply robust process improvement methodology to achieve program goals and maintain high levels of performance over long periods of time

3.1 Identify a quality improvement methodology by June 2017. X

3.2 Identify and implement a quality improvement project for at least one funded service category at any given time.

X X X

3.3 Document the quality improvement activities that are underway at any given time. X X X



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Goal 4 – Evaluate the extent to which the CQM program is meeting the identified program goals related to quality improvement planning, priorities, and implementation

4.1 By June 2017, determine a process to evaluate the CQM program’s infrastructure, activities, processes and systems.

X

4.2 Study and act on findings of CQM program evaluation at least annually to ensure the CQM Plan continues to respond to identified goals and activities.

X X X

Goal 5 – Provide the framework from which processes and outcomes are measured by developing standards of care for every funded service category for all regions of the state

5.1 By March 2019, develop standards of care of at least the 10 most highly utilized/funded categories in the state.

X X

5.2 By April 2020, determine a peer review process for the developed standards of care.

X



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Table 2: HIV Care Program Contractors’ Goals and Objectives

The activity period for implementing each objective is noted with an “X”. FY” is the RW grant fiscal year, April 1 – March

30.

Goal 6- Participate in clinical quality management activities as contractually required

Goals and Objectives FY 2017 - 2018

FY 2018 - 2019

FY 2019 - 2020

6.1 Maintain adequate infrastructure and staff to conduct CQM activities at any given time.

X X X

6.2 Every fiscal year, implement and monitor performance measures as determined by the RW Part B CQM program (See the following sections of the CQM Plan for further details: Statewide HCP’s Performance Measures and HCP’s Performance Measures per Service Category).

X X X

6.3 Collect RW HIV AIDS Program Services Report (RSR) data for use in performance measurement of RW Part B CQM program and report data to OA within 14 days of service provision. At a minimum, subrecipients funded for Outpatient/Ambulatory Health Services and Medical Case Management Services must enter these CQM data elements into ARIES: Current Living Situation, Date First HIV+, CD4 Test Date, T Cell Count, Viral Load Date, Viral Load Value, STI/Hepatitis screening (gonorrhea, chlamydia, and syphilis), ART (Type, start and end date, ART drugs).

X X X

6.4 Review performance data at least quarterly to identify clients that need additional support in staying in medical care or maintaining viral suppression.

X X X

6.5 Before the beginning of each fiscal year, or with any budget revision, HCP subrecipients requesting to budget for CQM activities will submit to the OA a quality improvement proposal. The proposal must describe infrastructure, performance measures, and proposed activities, and the plan to report outcomes on approved activities (See Attachment A in the CQM Plan).

X X X

6.6 Every fiscal year, participate in relevant capacity building and quality improvement activities as directed by RW Part B CQM program.

X X X

6.7 In coordination with the RW Part B CQM program, conduct quality improvement projects at the contractor/subcontractor level.

X X X



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Goal 6- Participate in clinical quality management activities as contractually required

6.8 Implement the RW Part B standards of care for funded service category standards (once developed by OA).

X



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Performance Measurement

Data Sources

AIDS Regional Information and Evaluation System (ARIES)

All California RW Part B providers either manually enter or import their data into ARIES,

a web-based, centralized HIV client management and service tracking system.

Providers funded by other RW Parts, HOPWA, and the AIDS Medi-Cal Waiver Program

in California also use ARIES. ARIES provides a comprehensive data infrastructure for

program reporting and monitoring. With client consent, ARIES data is used for

coordination of client services among medical and support providers. Reports generated

from ARIES are used to guide program planning, improve service delivery, evaluate

provider/contractor performance, and comply with HRSA/HAB reporting requirements

on HAB Performance Measures and the RW Services Report (RSR). OA currently uses

ARIES to measure and report on CQM and contract compliance indicators.

In 2013, HAB revised its performance measure portfolio for clinical accuracy and

relevance, consistency with national guidelines, alignment with other federal agencies,

and feasibility for implementation in electronic health record systems. Currently, OA has

programmed 22 of the 46 revised measures into ARIES. Detailed information can be

found in the ARIES HAB QM calculation document.

The ARIES HAB QM Report interface allows HCP subrecipients and service providers

to customize their QM reports. For example, users are able to run the performance

measures for their entire agency caseload or restrict measures to focus on a particular

key population or service category. This capability allows providers to have data

informing them where to target their CQM activities. Instructions regarding running the

QM report are in the December 2015 ARIES Advisor Newsletter.

California HIV Surveillance System data

The OA Surveillance Section maintains a confidential, central registry of demographic

and clinical information on all reported California HIV cases. In order to leverage

surveillance laboratory data that are already reported to OA, OA continues to explore

the legal and technical requirements for importing surveillance data into ARIES. This

would allow all providers to more easily identify clients that need additional support in

staying in medical care or maintaining viral load suppression.

AIDS Drug Assistance Program

ADAP maintains the ADAP Enrollment System (AES) as a centralized repository for

client and program data. AES data is used to assess the following ADAP performance

measures: Application Determination, Viral Load Monitoring, and Viral Load

Suppression.

https://www.cdph.ca.gov/programs/aids/Documents/QMCalulations.pdf

http://www.cdph.ca.gov/programs/aids/Documents/ARIESAdvisorNewsletter2015-12.pdf



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ADAP contracts with a Pharmacy Benefits Manager (PBM) to coordinate with

pharmacies to dispense ADAP formulary medications to eligible clients. The PBM uses

a proprietary system for all ADAP-related data collection and reporting. ADAP is

collaborating with the PBM to develop a process for monitoring inappropriate

antiretroviral regimen components among ADAP clients.

The PBM is required to provide a report on clients that fail to pick up prescribed

antiretroviral drugs. This report, which OA and the PBM are still developing, will support

CQM activities related to retention in care and achieving viral load suppression.

ADAP Client Satisfaction Survey OA previously administered a voluntary and anonymous ADAP Client Satisfaction

Survey via field ADAP enrollment workers. The Client Satisfaction Survey has been on

hold during the transition period from ADAP’s previous Enrollments Benefit

Management contractor. ADAP is currently exploring ways to improve the survey

methodology and to establish a more systematic way to administer the survey. One of

the CQM committee goals is to expand the ADAP Client Satisfaction Survey in order to

get consumer input on CQM related activities.

Chart Reviews

Client chart reviews may be conducted as needed to inform CQM activities.

Medical Monitoring Project

The Medical Monitoring Project (MMP) is a surveillance project designed to produce

detailed clinical and behavioral information about a representative sample of people

living and diagnosed with HIV in the United States. The HHS Centers for Disease

Control and Prevention (CDC), in collaboration with state and local health departments,

conducts MMP nationwide including in California. Data is collected through in-person

interviews of people living with HIV followed by detailed medical records abstractions.

MMP data can be used to identify clinical quality or access concerns statewide. One of

the CQM committee goals is to leverage MMP patient interviews and chart reviews to

inform CQM related activities.



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Performance Measures

The CQM Committee will meet quarterly to review and analyze data on chosen HCP and ADAP performance measures.

The indicators and goals were chosen to align with the HRSA HIV/AIDS Bureau (HAB) performance measures, the

National HIV Strategy goals, and California’s Integrated Plan for 2017-2021.

Table 1: ADAP Performance Measures

Indicator Definition Data Source

RW Part B Baseline (04/2015 –03/2016)

2020 Target

Viral Load Monitoring

Percentage of ADAP clients served in the measurement year who have a viral load test in that year

AES and CHSS

79.5% 95%

Viral Load Suppression

Percentage of ADAP clients served in the measurement year with at least on viral load test who have a viral load <200 copies/ml in that year1

AES and CHSS

88.7% 90%

Application Determination

Percentage of ADAP clients with a complete2 initial or renewal ADAP application in the measurement year whose application passes secondary review within 91 days of the initial application

AES TBD3 85%

Formulary Percentage of new ARV classes that are included in the ADAP formulary within 30 days of the date of inclusion in the PHS Guidelines for the Use of Antiretroviral agents in HIV-1 infected Adults and Adolescents during the measurement year

ADAP staff

100% 100%

AES: ADAP Enrollment System

CHSS: California HIV Surveillance System 1 Viral load suppression data will be stratified by age, race, gender, and enrollment status to identify disparities in priority groups defined by California’s integrated plan and HRSA + NQC end-disparities campaign. Viral load suppression shall be determined based on the client’s most recent data available during the year of interest. 2 A complete ADAP application is defined as an application submitted by a local ADAP enrollment worker without a temporary

access period or eligibility extension request. 3 TBD: To be determined. Baseline data is unavailable since the new ADAP application process was implemented in FY 2017-

2018.

http://enddisparitiesexchange.org/



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Table 4: HIV Care Program Performance Measures

Indicator Definition Data Source

RW Part B Baseline (04/2015 – 03/2016)

2020 Target

Linkage to HIV Medical Care

Percentage of newly diagnosed clients in the measurement year who have a HIV medical care visit within 1 month of HIV diagnosis

ARIES TBD1 85%

Prescribed ART

Percentage of all clients served during the measurement year who are prescribed antiretroviral therapy (ART) for the treatment of HIV infection in that year

ARIES 81.8% 90%

Viral Load Suppression 1 and 2

1: Percentage of all clients served during the measurement year who have a viral load <200 copies/ml in that year

ARIES 76.8% 80%

2: Percentage of clients served during the measurement year with at least on viral load test who have a viral load <200 copies/ml in that year

ARIES 86.4% 90%

Chlamydia Screening

Percentage of all clients served during the measurement year who had a test for chlamydia in that year

ARIES 46.9% 75%

Gonorrhea Screening

Percentage of all clients served during the measurement year who had a test for gonorrhea in that year

ARIES 45.9% 75%

Syphilis Screening

Percentage of all clients served during the measurement year who had a test for syphilis in that year

ARIES 60.2% 75%

Housing Status

Percentage of all clients served with a known housing status during the measurement year who were stably housed in that year

ARIES 75.1% 85%

All indicators will be stratified by age, race, gender, and exposure category to identify disparities in priority groups defined by California’s integrated plan and HRSA + NQC end-disparities campaign. Viral suppression is defined as a HIV viral load test that is <200 copies/ml. Indicators will be determined based on the client’s most recent data available during the year of interest. ARIES: AIDS Regional Information and Evaluation System

http://enddisparitiesexchange.org/



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Table 5: HIV Care Program Performance Measures by Service Category

The CQM committee has identified the following indicators as appropriate measures for each of the HCP service categories. The indicators are defined the same as the general program indicator, but are restricted to clients who have received the identified service.

Service Category Indicator (for clients served in the specified service category)

Baseline (04/2015 – 03/2016)

2020 Target

Outpatient/Ambulatory Health Services (formerly Outpatient/Ambulatory Medical Care)

Prescribed ART 95% 90%

Viral Load Suppression1

86.5% 80%


88.4% 90%

Chlamydia Screening 51.9% 75%

Gonorrhea Screening

46.2% 75%

Syphilis Screening

59.9% 75%

Early Intervention Services

Linkage to HIV Medical Care

TBD1 85%

Prescribed ART

85% 90%


69.2% 80%


72.7% 90%

Health Insurance Premium and Cost Sharing Assistance for Low-Income individuals

Prescribed ART

TBD2 90%


84.3% 80%


93.3% 90%



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Baseline (04/2015 – 03/2016)

2020 Target

Home Health Care Prescribed ART

TBD3 90%


TBD3 80%


TBD3 90%

Home and Community-Based Health Services

Prescribed ART

TBD2 90%


62.9% 80%


93.6% 90%

Hospice Services The performance measures for this service category will be established once the standards of care for RW Part B are developed

TBD4

Mental Health Services

Prescribed ART

90% 90%


80.7% 80%


87.9% 90%

Medical Nutrition Therapy

Prescribed ART

96% 90%


84.5% 80%


87.2% 90%



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Baseline (04/2015 – 03/2016)

2020 Target

Medical Case Management, including Treatment Adherence Services

Prescribed ART

87% 90%


80.5% 80%


84.9% 90%

Oral Health Care Prescribed ART

86% 90%


81.8% 80%


89.3% 90%

Substance Abuse Outpatient Care

Prescribed ART

97% 90%


65.5% 80%


67.9% 90%

Non-Medical Case Management Services

Prescribed ART

77% 90%


77.7% 80%


86.2% 90%

Emergency Financial Assistance

Prescribed ART

61% 90%


57.7% 80%


84.4% 90%



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Baseline (04/2015 – 03/2016)

2020 Target

Food Bank/Home Delivered Meals

Prescribed ART

77% 90%


74% 80%


84.2% 90%

Health Education/Risk Reduction

Prescribed ART

74% 90%


79.7% 80%


83.6% 90%

Housing Services Prescribed ART

68% 90%


68.4% 80%


83.9% 90%

Housing Status

59.2% 70%

Legal Services Prescribed ART

80% 90%


78.4% 80%


86.4% 90%



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Baseline (04/2015 – 03/2016)

2020 Target

Linguistic Services

Prescribed ART

TBD2 90%


94.7% 80%


94.7% 90%

Medical Transportation

Prescribed ART

TBD2 90%


73.7%

80%


82.4% 90%

Outreach Services Linkage to HIV Medical Care

TBD1 85%

Prescribed ART

77% 90%


70.7% 80%


77.9% 90%

Psychosocial Support Services

Prescribed ART

TBD2 90%


86.7% 80%


97.5% 90%



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Baseline (04/2015 – 03/2016)

2020 Target

Referral for Health Care and Support Services

Prescribed ART

TBD2 90%


81.7% 80%


91.1% 90%

Substance Abuse Services (residential)

Prescribed ART

TBD2 90%


TBD2 80%


TBD2 90%

TBD: To be determined. Reason is coded as follows: 1 OA is still determining this baseline. 2 There are high levels of missing data for these indicators, so baseline measures are not yet available. OA is working on improving data quality. 3 This service category was not used during the baseline measurement period. 4 Performance measures will be determined once standards of care are developed.



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Data Communication

HCP utilizes standardized HIV Care Program Provider Reports generated from ARIES data to highlight HCP subrecipients’ programmatic and CQM data. OA generates and distributes these profiles annually to assist HCP subrecipients with identifying and resolving data issues and areas for program improvement. HCP advisors review these reports with HCP subrecipients at the annual monitoring site visits.

External communications with stakeholders will occur through presentations and

updates to the CPG, monthly OA updates bulletin, and updates to the regional planning

councils and regional quality improvement groups and networks.

Quality Improvement (QI)

The CQM program seeks to use performance indicators results to identify and

implement needed QI projects aimed at improving patient care, health outcomes, and

patient satisfaction. The CQM committee will select and prioritize RW Part B activities

for QI projects for at least one funded service category at any given time. The process

for determining QI projects is outlined in Figure 1: Process for Determining RW Part B

Quality Improvement Projects.



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Figure 1: Process for Determining RW Part B Quality Improvement Projects



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Methodology

The CQM program will implement and document QI activities using the Model for

Improvement methodology developed by Associates in Process Improvement and

endorsed by the Institute for Healthcare Improvement. This methodology was chosen

because it allows for implementation of change while building knowledge sequentially

with multiple Plan-Do-Study-Act (PDSA) cycles for each idea.

Figure 2: The PDSA Cycle for Learning and Improvement

Monitoring of HCP Subrecipients Quality Improvement (QI) Projects

Once the CQM committee prioritizes activities for QI projects, CQM staff will

communicate these decisions to HCP subrecipients. HCP subrecipients that do not

meet established benchmarks will be expected to participate in focused technical

assistance webinars and then implement at least one QI project to improve the

performance measure for the prioritized activity.

The CQM committee will meet quarterly to review HCP subrecipients’ data and progress

in improving the performance measures. For HCP subrecipients who are not able to

improve after the focused technical assistance webinars and implementation of the QI

project, the CQM staff will follow up and provide individualized technical assistance.

HCP subrecipients will have an opportunity to provide detailed descriptions of their QI

projects in the semiannual progress reports. HCP and CQM staff will follow up and

provide feedback and technical assistance as needed.

http://www.apiweb.org/

http://www.ihi.org/Pages/default.aspx



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If an HCP subrecipient is unable to report required data, implement a QI project, or

meet established benchmarks despite individualized technical assistance, HCP advisors

will conduct an in-person follow up during the annual monitoring site visits. HCP

subrecipients will be required to develop a corrective action plan if they are unable to

meet the CQM standards. HCP advisors will follow up on the implementation of the

HCP subrecipients’ corrective action plan as needed.

Current Quality Improvement Projects

1. Increasing extragenital gonorrhea and chlamydia screening for men who have

sex with men who are living with HIV.

2. Increasing viral load suppression among youth ages 18-24 years old.

Process to Update CQM Plan

The CQM nurse will create a draft revision, if necessary, of the CQM Plan by

September 1, 2019. This draft will be circulated among the CQM committee, CPG

members, HCP contractors, and any other identified stakeholder for input. The final

revision will be approved and released by April 1, 2020.

Feedback

Any questions or feedback concerning this plan, should be communicated to OA RW

Part B CQM staff at (916) 445- 6047, or by email at [email protected].

mailto:[email protected]



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Attachment A

RYAN WHITE PART B CLINICAL QUALITY MANAGEMENT PROGRAM (CQM)

QUALITY IMPROVEMENT PROPOSAL TEMPLATE

All Ryan White Part B HIV Care Program (HCP) contractors requesting to fund a CQM improvement project(s) must complete this template for each project, and report measurable outcomes of the project(s) at the end of the grant year. A. What you are trying to accomplish

1. Project: Provide a brief description of your proposed project. Include:

a. What problem you are trying to address b. Summary of current relevant data c. What you expect to accomplish

2. Measures: Does your proposed project address at least one of the HCP performance measures (See Ryan White Part B Program (HIV Care Program, AIDS Drug Assistance Program) CQM Plan)? If you choose to work on an improvement project using other measures, please explain why.

3. Change: Describe the change you will make resulting in an improvement.

B. How you will know when a change is an improvement

What indicators will you use to measure your progress? Copy/paste the following table for additional measures.

Indicator/Measure Name

Numerator

Denominator

Data Source

Baseline (most recent results)

Target/Goal

C. How you will implement the quality improvement project

1. Infrastructure/staffing: Who will be involved in this improvement project? 2. Describe your implementation methodology 3. Identify key dates for planning and implementing this improvement project.

Include: a. Project start date b. How often you will measure performance on the indicator (s) listed in B

above to see if your improvement activities are effective 4. Resources: Describe how the CQM budget amount requested will be utilized. 5. CQM champion: Provide contact information for the CQM lead in your agency.