Quality of Care Programs

HIV Quality of Care Program

Program Description

The AIDS Institute is committed to promoting, monitoring, and supporting the quality of HIV clinical services for people with HIV in New York State. The Office of the Medical Director coordinates quality improvement activities including the development of clinical performance measures derived from practice guidelines, on-site quality of care reviews, promotion of quality improvement activities, peer learning opportunities for HIV providers, and consultations to support on-site quality improvement efforts. The ultimate objective for each HIV program in New York State remains the development of a sustainable independent quality management program that reflects the capacity to dynamically analyze and continuously improve HIV treatment, care, and supportive services.

The Office of the Medical Director coordinates the participation of several groups of stakeholders to accomplish these tasks including: (1) an internal quality of care workgroup based at the AIDS Institute; (2) the AIDS Institute's Medical Care Criteria Committee, responsible for clinical guidelines development; (3) the HIV Quality of Care Clinical Advisory Committee, comprised of expert HIV providers who advise on the development, implementation, and refinement of the quality program; (4) the Quality Committee for HIV Medicaid Managed Care Special Needs Plans (HIV SNPs); (5) the New York City Part A Quality Management Program Advisory Committee; and (6) the AIDS Institute's Consumer HIV Quality Committee, a group of 20 persons living with HIV who represent diverse communities affected by the HIV epidemic in New York State. The interaction of providers and consumers with the AIDS Institute through these various groups allows New York State to remain responsive to the needs of the communities that it serves, while responding to changes in clinical and scientific knowledge.

Statewide quality of care program standards have been developed that apply to all HIV health care facilities, regardless of their caseload, location or service delivery model. These standards ensure that the best clinical care is provided to patients throughout New York State by improving systems of care delivery and by stimulating quality monitoring. In addition to medical chart reviews, organizational assessment tools have been created to determine the extent to which these program standards have been implemented. Annual assessments of providers’ quality management programs are conducted by AIDS Institute staff and consultants. Data from these assessments are used to guide technical assistance and consultation to further enhance providers’ quality management programs and to develop future strategies to advance the statewide Quality of Care Program.

All HIV programs throughout New York State were expected to self-report their quality of care performance data. In 2006, 163 HIV programs submitted their performance data based on a review of 5995 medical records. These results are being validated by an external review agency. With the assistance of the HIVQUAL software, performance data results are instantly available to HIV programs, allowing them to immediately utilize their data findings to prioritize upcoming quality activities. Data findings were presented to various provider stakeholders and consumer representatives. The Quality of Care Program expects that nearly 200 HIV programs in New York State will participate in the upcoming 2007 data submission.

Facility-based results of the quality of care reviews are presented as aggregate data so that providers can evaluate overall performance rather than focus on individual cases. Results for specific regions in New York State are provided as well, in a format that permits comparative evaluation and reference to performance standards while maintaining patient confidentiality. The results are used to target providers for assistance and consultation, rather than to penalize. The 2006 New York State Performance Data Report with regional report of performance data has been issued for key quality indicators, and whenever possible, with longitudinal data.

Quality of care consultants provide professional assistance to build quality management programs in HIV clinical facilities throughout New York State. They work with clinicians and administrative staff to set priorities for improvement initiatives and develop plans for quality improvement and ongoing internal quality monitoring. Consultants provide education in quality improvement tools and techniques, assist with the interpretation of data, and promote creative thinking by facility personnel to improve performance.

The Quality of Care Program has established several HIV Quality of Care Learning Networks using a methodology adapted from the Institute for Healthcare Improvement Breakthrough Series model. The New York model combines ongoing on-site consultation with structured one-day or half-day group meetings that focus on quality management, also using existing performance measurement strategies. The goals of these networks are to improve the quality of HIV services, strengthen provider infrastructure and increase competency in performance measurement. Learning Networks currently underway include the following supportive program services: harm reduction services, food and nutrition, treatment adherence support, mental health, and case management. Ambulatory care groups currently engaged in these collaborative activities include 17 New York public hospital clinics, 14 co-located primary care programs in drug treatment clinics, 12 Designated AIDS Center hospitals that serve large HIV populations, 20 Part C funded Community Health Centers, a group of 15 upstate hospitals and community health centers, 8 Adult Day Treatment facilities, and 21 Adolescent Providers across the State. These Learning Networks provide a forum for peer learning which enables teams to exchange ideas through the network’s activities.

The HIV Quality of Care Program continues to include people living with HIV/AIDS (PLWHA) in planning, implementing, and evaluating quality of care program activities. The HIV Quality of Care Consumer Advisory Committee has been focusing its attention on the following areas: involvement of consumers in quality activities, concerns of the deaf and hard of hearing community, and input in upcoming activities by the AIDS Institute. In 2007, a Youth Committee was formed to solicit feedback from HIV-infected adolescents and to routinely present concerns of the Youth Committee to AIDS Institute committees. Consumer Advisory Committee members continue to review upcoming adult and pediatric clinical guidelines developed by the HIV Clinical Guidelines Program.

Recent areas of emphasis have included patient retention, management of patients on antiretroviral therapy, and improving clinical information systems. Refinement of measurement strategies to enhance clinical outcomes based on available viral load and CD4 data has also become a major priority for the program as well as the capacity of all HIV programs in New York State to self-report their annual HIV performance data.

Contact:

Clemens Steinböck, M.B.A.
Director, Quality Improvement Initiatives
Office of the Medical Director
(212) 417-4730
cms18@health.state.ny.us

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AIDS Intervention Management System (AIMS)

Program Description

The AIDS Intervention Management System (AIMS) was created in 1986 to collect, organize, and evaluate data associated with the care of HIV-infected patients. AIMS is responsible for utilization reviews for HIV-related inpatient stays and Medicaid-funded ambulatory care; quality of care reviews at Designated AIDS Centers (42 statewide) and ambulatory care facilities; and analysis and reporting of data gathered through all review activities and special studies.

The goals of the AIMS program, currently administered through a contract with Island Peer Review Organization include:

  • creation of a review process that ensures services are necessary, appropriate, and meet professionally-recognized standards of care;
  • development and management of data systems that support review activities and permit program evaluation and policy development; and
  • identification of service needs and development of mechanisms to address shortcomings or inefficiencies.

During FY 2007, AIMS conducted approximately 46,035 reviews were conducted, including 27,693 quality-of-care reviews, 15,334 utilization reviews, up to 1,481 maternal-pediatric HIV prevention and care program reviews, and 3,008 Special Needs Plans program reviews. All quality-of-care reviews were conducted at ambulatory care sites. Reviews included the piloting or implementation of over 16 different quality-of-care algorithms at acute and ambulatory care facilities. Reviews were conducted at acute care providers other than Designated AIDS Centers in an effort to assure that all New Yorkers with HIV receive clinically appropriate services regardless of site. Utilization reviews resulted in approximately $2.6 million in Medicaid reimbursement denials.

Contact:

Dawn Lajeunesse
AIMS Program Administrator
Bureau of HIV Program Review & Systems Development
Division of Medicaid Policy & Programs
(518) 486-1383
dal07@health.state.ny.us

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HIV Clinical Guidelines Program

Program Description

The AIDS Institute's Office of the Medical Director directly oversees the development, dissemination and implementation of state-of-the-art clinical practice guidelines. These guidelines address the medical management of adults, adolescents and children with HIV infection; primary and secondary prevention in medical settings; as well as mental health and substance use treatment.

Guidelines Development: AIDS Institute clinical guidelines are developed by distinguished committees of clinicians and other experts with extensive experience providing care to people with HIV infection. Committees are charged with developing standards of care for patients in their areas of specialty. Committees meet regularly to assess current recommendations and to write and update guidelines in accordance with newly emerging clinical and research developments. External peer and consumer review of all new and revised guidelines ensures that opinion from outside the committees is incorporated.

Current committees include:

  • Medical Care Criteria Committee (Adult);
  • Committee for the Care of Children and Adolescents with HIV Infection;
  • Dental Standards of Care Committee;
  • Mental Health Committee;
  • Women's Health Committee;
  • Substance Use Committee;
  • Physician's Prevention Advisory Committee; and the
  • Pharmacy Committee.

New and updated HIV Clinical Guidelines are posted directly on the Program's HIV Clinical Resource website located at www.hivguidelines.org. All current guidelines as well as quality of care materials, including best practices booklets and slide presentations on clinical education topics, are available and may be downloaded from this site.

Guidelines Dissemination: Guidelines are disseminated to clinicians, support service providers and consumers through email notifications, targeted mailings and numerous AIDS Institute-sponsored educational programs. Distribution methods include the HIV Clinical Resource website, the Clinical Education Initiative, the AIDS Education and Training Centers (AETC), the HIV/AIDS Materials Initiative as well as at quality program activities. Over 80 current guidelines are posted on the website in both pdf and pda format, making them available to users throughout New York State and worldwide

Guidelines Implementation: Guideline recommendations are best implemented when they are actively disseminated through a coordinated plan to reach their appropriate target audiences, including clinicians, supportive services providers and consumers. Although one version of the guidelines may be appropriate for all of the groups that need the information, more often, specific versions of the guidelines are needed and are prepared for different audiences. For example, the AIDS Institute has produced a manual for consumers which explains antiretroviral therapy guidelines in non-clinical terms. A similar booklet was developed based on the mental health guidelines which is designed for the needs of case managers and other non-clinical staff. Guidelines implementation materials and strategies remain a program priority.

The HIV Clinical Guidelines Program works with other programs in the AIDS Institute to promote adoption of guidelines. Clinicians, for example, are targeted through the Clinical Education Initiative (CEI) and the AIDS Education and Training Centers (AETC). The CEI provides tailored educational programming on site for health care providers on important topics in HIV care, including those addressed by the HIV Clinical Guidelines Program, and has added a technology center that may be accessed through the HIV Clinical Resource website. The AETC provides conferences, grand rounds and other programs that cover AIDS Institute guidelines topics.

HIV Education and Training Programs target supportive service programs and provide training on important HIV topics to non-physician health and human services providers. Training sessions are conducted in-person across the State as well as through video conferencing and audioconferencing.

The HIV Clinical Guidelines Program also works with the HIV Quality of Care Program to coordinate and promote implementation of HIV guidelines in New York State. By developing quality indicators based on the guidelines, the AIDS Institute has created a mechanism for measuring performance that allows providers and consumers to know to what extent specific guidelines have been implemented.

Finally, best practices booklets are developed through the HIV Clinical Guidelines Program. These contain practical solutions to common problems related to access, delivery or coordination of care. These booklets contribute to the overall effort to ensure that HIV guidelines are implemented and that patients receive the highest quality of HIV care possible.

Contact:

Tracy Hatton, MPH
HIV Clinical Guidelines Program
Office of the Medical Director
(212) 417-4617
teh04@health.state.ny.us

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Part A HIV Quality Management Program

Program Description

The Ryan White Part A HIV Quality Management Program measures health and supportive services, provides quality improvement facilitation, and builds capacity in facilities receiving Part A funding in the New York Eligible Metropolitan Areas, which includes New York City and Tri-county (Westchester, Rockland and Putnam counties). The Quality Management Program has built upon the existing infrastructure for quality management in New York State and integrates performance measurement of supportive service indicators—for example, case management—into the existing system of quality improvement activities developed for clinical providers. As a result, a comprehensive portfolio of clinical and non-clinical indicators has been developed, allowing performance reviews of all types of providers in order to measure and improve the quality of HIV services that are offered.

Performance indicators measuring the quality of support services have been developed for many Part A service categories, including ambulatory care, case management, food and nutrition, harm reduction, home care, treatment adherence, and mental health. These services cover more than 250 contracts among over 100 providers. Performance measurement reviews, conducted by professional peer review agencies, occur annually. The resulting performance review data are presented in aggregate as well as individual reports so that agencies are able to evaluate the systems of care at their institutions. These reviews provide both an assessment of the effectiveness of program services and stimulate quality improvement efforts.

In addition, the Part A Quality Management Program has established HIV Quality Learning Networks as vehicles through which providers are guided in the quality improvement process. These learning networks bring together provider participants from similar service categories to receive quality improvement guidance using the peer-learning model. Participants are able to exchange ideas through learning network activities. The networks, led by quality improvement experts allow providers to focus on improving the quality of their services and on sustaining improvements in their organizations. Organizational assessments are conducted by Part A quality management staff with each service provider to evaluate their quality program and identify areas for development or refinement. There are currently six learning networks of Part A providers: Mental Health, Case Management, Treatment Adherence Support, Food and Nutrition, Harm Reduction and Medical Case Management in Tri-county.

Contact:

Tracy Hatton, MPH
HIV Quality of Care Program Director Office of the Medical Director
(212) 417-4617
teh04@health.state.ny.us

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HIVQUAL

Program Description

HIVQUAL seeks to improve the quality of care delivered to persons with HIV in ambulatory care programs in New York State, in Ryan White Part C and Part D funded programs across the country and in President Emergency Plan for AIDS Relief (PEPFAR) focus countries through HIVQUAL International. The HIVQUAL US Program is a partnership between the New York State Department of Health AIDS Institute and Health Resources and Services Administration (HRSA), HIV/AIDS Bureau, Division of Community Based Programs, which has the primary goal of building capacity and capability for quality improvement among grantees of the Ryan White Treatment Modernization Act of 2006. Internationally, the Program offers consultation for capacity development for countries supported by PEPFAR, who wish to establish a national quality management program and in their HIV ambulatory clinics. Built upon the principles of quality improvement and models developed through New York’s HIV Quality of Care Program, this Program guides HIV providers to build and sustain quality management programs.

Key principles of the model include using aggregate data to measure performance, measuring core HIV clinical indicators based on clinical practice guidelines, and providing quality improvement (QI) consultations. Specific strategies include:

  • building internal organizational systems to sustain an HIV-specific quality management program;
  • facilitating quality improvement initiatives using multidisciplinary teams;
  • providing education about QI tools and methodologies;
  • encouraging peer learning opportunities; and
  • promoting support and commitment throughout the organization for quality.

At no cost to agencies, the program offers the HIVQUAL software, designed to capture data and generate reports to measure clinical performance, based on clinical practice guidelines. To respond to changes in clinical practice, the software is continually revised to ensure its consistency with current standards of care.

Through regional workshops and on-site consultation, providers and staff are offered education and training in organizational development to support quality improvement activities. This approach is designed to assist HIV programs to assess their HIV service delivery system, strengthen their HIV quality program, identify areas for improvement, develop and conduct quality improvement programs, and monitor and sustain beneficial changes over time.

In New York State, any health care provider accessing the enhanced HIV Medicaid reimbursement system should participate in the HIVQUAL program. Participation of all HIV providers is strongly encouraged, but not required by the New York State Department of Health.

Contact:

Joan Manuel Monserrate, MPH
Deputy Director, HIVQUAL
(212) 417-4620
jmm30@health.state.ny.us

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National Quality Center (NQC)

Program Description

In the last two decades, care for individuals with HIV/AIDS in the United States has advanced at a phenomenal pace. However, gaps in care still exist across the country and many providers face barriers when trying to deliver high quality care through the Ryan White HIV/AIDS Program, access and capacity for clinical services have been created to provide life-prolonging treatment and care for people living with HIV throughout the United States. As people with HIV are living longer, the increasing complexity of clinical care and the changing dynamics of those living with HIV challenge providers to deliver appropriate care to meet nationally recognized standards.

The 2003 Institute of Medicine report, Measuring What Matters, which focused on the allocation, planning, and assessment of the Ryan White HIV/AIDS Program, highlighted the need to continue measuring and improving the quality of care provided by Ryan White funded grantees. The 2006 reauthorization of the Ryan White Program emphasized the importance of quality of care activities and directs all grantees to develop and implement quality management programs to assure appropriate treatment for the patients they serve. Significant progress has been made addressing challenges and barriers to implementation of guidelines for HIV care. However, shortcomings and gaps in the provision of quality care remain.

The New York State Department of Health AIDS Institute was selected to develop and implement the National Quality Center (NQC) to serve as the primary national resource for quality improvement and quality management in HIV care. Since its inception in 2004, the National Quality Center (NQC) has provided leadership and support in quality improvement for Ryan White Program-funded grantees nationwide. Funded by the HIV/AIDS Bureau of the Health Resources and Services Administration (HRSA), NQC was founded to meet the demonstrated needs of Ryan White HIV/AIDS Program grantees for technical assistance with quality improvement. The aim of this national initiative is to build among grantees the capacity to improve the quality of HIV/AIDS care and services across the United States.

NQC provides technical assistance on quality improvement to Ryan White grantees of all Parts across the country. The NQC partners with the Institute for Healthcare Improvement, the Academy of Educational Development, and consultants with expertise in HIV/AIDS quality management to provide state-of-the-art technical assistance and consultative services.

Information related to quality improvement is disseminated through a variety of vehicles. The newly launched NQC website at NationalQualityCenter.org, which currently hosts over 180 materials, posts comprehensive and up-to-date HIV quality improvement resources for HIV providers and consumers. The NQC website fosters a range of peer learning opportunities by allowing providers to post and share success stories, tools, and other resources recommended for use. The NQC listserv provides the opportunity to effectively broadcast quality improvement-related messages and creates a forum to exchange ideas among grantees. NQC exhibits nationally at conferences with strong participation of HIV providers to distribute quality improvement resources.

Training and educational fora are provided on a wide array of quality-related topics through national technical assistance calls, regional quality improvement workshops, the Quality Academy - an online quality improvement course program, and the Training-of-Trainers Program. Topics for educational training activities are prioritized based on needs assessments with grantees and HRSA staff and include: quality management 101 and HRSA quality expectations; developing quality management infrastructure; introduction to performance measurement and using data for quality improvement; engaging staff and consumers in quality improvement activities; and cross-Part collaboration for quality management.

The NQC Training-of-Trainers Program directly assists Ryan White Program grantees build capacity for quality improvement. NQC implemented this national Training-of-Trainers Program to expand the pool of trainers across all Parts and to provide networking opportunities for participants with other HIV providers from across the country. As of August 2008, nearly 300 trainers have been trained through the Training-of-Trainers program; these trainers have completed 350 training sessions for others.

Intensive, individualized on-site and off-site consultation is offered to Ryan White Program-funded grantees, specifically designed to meet the quality management expectations of the Ryan White Program. NQC contracts with a pool of quality improvement experts with extensive experience in various aspects of HIV care and quality improvement.

The National Quality Center, with support from HRSA, has led several national collaboratives to build capacity for quality improvement. These learning collaboratives include face-to-face learning sessions in which grantees share progress in their improvement projects and action periods, and teams test and implement changes to improve HIV care and report on established indicators. Participating teams receive support throughout the duration of the collaborative through scheduled conference calls, listserv, a dedicated website, and consultations by expert faculty members.

Annual Steering Committee meetings, with representatives of Ryan White grantees and HRSA, ensure that NQC efforts are responsive to grantee needs. In addition, a national Consumer Advisory Committee convenes twice a year to provide consumer input into NQC activities.

Contact:

Clemens M. Steinböck, MBA
Project Director, National Quality Center (NQC)
Office of the Medical Director
(212) 417.4730
cms18@health.state.ny.us

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HIVQUAL-International (HQ-I)

Program Description

HIVQUAL-International (HQ-I) is a model for building capacity for quality management (QM) within the national health sector of countries around the globe supported by President’s Emergency Plan for AIDS Relief and UNICEF. The model is designed to improve and strengthen HIV health care services at both the national and clinic level. Capacity for QM is built in parallel with a nation’s Ministry of Health and local HIV ambulatory care clinics.

HIVQUAL-International was launched in Thailand in 2003 in partnering both the Thailand – US Cambodia, GAP-Thailand, HRSA and the Thai Ministry of Public Health. In addition to Thailand, the program has been implemented in Uganda, Mozambique, Namibia, Nigeria and Haiti. Pediatric programs have been implemented in Uganda and Guyana. Additionally, HQ-I is in the process of engaging Botswana, Rwanda, and Kenya, and anticipates that these countries will allocate funding for HQ-I activities.

When targeting a particular country and devising an international application, HQ-I adjusts its model for quality management together with staff from the country’s Ministry of Health and with U.S. Government partners. HQ-I has adapted the three basic components of QM - performance measurement, quality improvement, and quality program infrastructure - into unique national models that can be integrated and sustained with existing national QM activities to meet the goals of a country’s national AIDS program. Continued implementation of this approach through coaching and mentoring, peer learning through regional groups, and involving consumers in QM work contributes to the strength of health systems and promotes sustainable QM systems.

The need for HQ-I stems from the continued expansion of antiretroviral therapy (ART) delivery in countries supported by PEPFAR. The expansion of ART has successfully provided wide scale access to HIV treatment and reductions in HIV-related morbidity and mortality. This success is sustained, in part, through the systematic assessment of quality of services to assure that care is appropriate and adheres to national standards. Attention to quality of care is essential to identify whether resources are being used appropriately, whether those most vulnerable are receiving care, and to prevent harm through stimulating measurement that reflects adherence to national guidelines. Focusing on quality of care means focusing on implementation of guidelines at the local level and in specific organizational contexts of unique, low-resource healthcare settings. The initial emphasis of HQ-I has been to improve care of adults with HIV. Additional focus on pediatrics, prevention of mother-to-child transmission, and home-based care is planned. Implementation of these activities necessarily involves close coordination with the U.S. Government teams in each country and, with their support, other U.S. Government partners delivering successful HIV care, treatment and QM activities. Involvement of the Ministries of Health, integration of QM into national AIDS programs, and coordination with national quality monitoring programs is key to sustaining these activities.

Contact:

Richard E. Birchard, MS
Administrator
HIVQUAL-International Program
Office of the Medical Director
(212) 417-4749
reb08@health.state.ny.us