Post on 25-Apr-2018
HIV/AIDS Ambulatory Outpatient/Medical Clinical Performance DataClinical Performance Data
2009/10 (Year 19)
Mary Orticke RN MPHMary Orticke, RN, MPHChief, Quality Management
Office of AIDS Programs and Policy
1
Outline• Review OAPP’s framework for monitoring HIV
services
• Review performance based contract monitoring (PBCM) model, key components and uses of ( ) , y pdata
• Learn about the performance of medicalLearn about the performance of medical outpatient clinics on selected clinical performance measures – lessons learned and next steps
2
ServiceMap SPA 1: Antelope Valley
SPA 2: San Fernando
SPA 3: San Gabriel
SPA 5: West
SPA 4: Metro
SPA 7: EastSPA 6: South
35
SPA 8: South Bay
Monitoring Function
Auditor Controller Department of Public Health
Board of Supervisors
Auditor ControllerContract Monitoring
Division
OAPP
Department of Public Health
Finance Planning ,Contract Admin
Care Svcs,Prevention Svcs
Medical Director,Research,
QM
Fiscal compliance
Contract management& monitoring (QA/QI)
Client level data mngmt& reporting, admin reviews
4community based organizations &
County agencies
Performance Based Contract Monitoring (PBCM) Key Components(PBCM) Key Components
• Rapid capture of review data
• Agency on-site preliminary reportingAgency on site preliminary reporting
• Final review published in 15 days or less• Previously 45-120+ daysPreviously 45 120 days
• Performance data and corrective actions tracking in a central database
• Identification of performance levels across agenciesPeak > or = 97% Competent 88% to 96%Conditional < or = 87%
• R i & h d li f f t i5
• Responsive scope & scheduling of future reviews Full (long) or focused (short) reviews
Scoring Performance
Site specific P f
Performance categories i t d t
g
2009/10 R i < 87% > 97%88% - 96%
Performance scores using aggregate data
82%
98%94%
COMPETENT
79% 91%95%
PEAKCONDITIONAL2009/10 Review % %% %
82%79%94%91%
95%98%
321 65 4 35 6 214Providers Providers
6
Benefits of PBCM• Streamline contract monitoring process across
divisions• Acknowledge areas of excellence & identify
areas for improvement• Accurately measure agency’s performance• Increase efficiency of monitoring• Focus on delivery of high quality services• Maintain high performing contractsMaintain high performing contracts
7
Uses of Data• Provide feedback to stakeholders
• Focus agencies on their improvement efforts• Focus agencies on their improvement efforts
• Focus technical assistance on areas needing gimprovement
• Share best practices
• Identify emerging trends in the system of care• Identify emerging trends in the system of care
8
Ambulatory Medical Outpatient Clinical Performance MeasuresClinical Performance Measures
• Labs – CD4, viral loadLabs CD4, viral load
• Medications – antiretroviral therapy (ART), prophylaxis
• S i t i ti i f ti & th• Screenings – opportunistic infections & other conditions, adherence
• V i ti h titi i i fl• Vaccination – hepatitis, pneumonia, influenza
• Counseling – HIV risk, hepatitis/alcool, tobacco ticessation
• Referrals – ophthalmology consults, dental care
9
About the Data• Obtained from program monitoring data for funded
HIV/AIDS medical outpatient clinics
• Reporting period – monitoring conducted during R Whit Y 19 12 th i t it iRyan White Year 19; 12 months prior to site review
• Sample – 35 clinics, 948 medical records
• HAB and HIVQUAL benchmark data included where available in each graphwhere available in each graph
10
About the Data
• Number of clinic sites & records may vary for some measuresmeasures
- gender specific measures- addition of the measure mid cycle in the monitoring periodperiod
• Mean and median scores calculated for each measure
• Cli i bli d d• Clinic names blinded
11
Overall Performance in Year 19Overall Performance in Year 19
Conditional
14%Clinics
(Tn)
PEAK 20
57%29%
PEAK> or = 97% 20
COMPETENT88% - 96% 1057%29%
PeakCompetent CONDITIONAL< or = 87% 5
12Ambulatory Outpatient Medical (AOM) clinics (Tn=35)Records reviewed (Tn=948)
Comparison by Performancep y(Yr 18 and 19)
25
202015
20
85
10
55
10
0
PEAK COMPETENT CONDITIONAL
AOM clinics , Yr 19 (Tn=35)
Review Compliance Summary (Year 18)
Review Compliance Summary (Year 19)
( )Records reviewed , Yr 19 (Tn=948)
AOM clinics< Yr 18 (Tn=34)Records reviewed, Yr 18 (Tn=1114)
13
P f f AOM Cli iPerformance of AOM Clinicson Selected Clinical Measures
14
Percentage of patients who had two or more CD4 T ll t f d t l tCD4 T-cell counts performed at least
3 months apart 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 99 10099100
81
8892
95 97 97100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 99 100
63
79
90
60
70
80
90
e (%
)
30
40
50
60
Com
plai
nce
0
10
20
AOM Clinics (Tn=35)
HAB Median, 2006
HIVQUAL 2006, Top 25%
TFC
MeanCharts Reviewed (Tn=948)
15
Percentage of patients who had two or more g pviral load tests performed at least 3 months apart
100
6976
89 90 92 94 94 96 97 97 97 98 98 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 10094
100
64
78
9094
70
80
90
e (%
)
3130
40
50
60
Com
plai
nce
31
0
10
20
C
AOM Clinics (Tn=33)
HAB Median, 2005
HIVQUAL 2005, Top 25%
MeanCharts Reviewed (Tn=880)
16
Percentage of patients with CD4 T-cell counts <350 ll / 3 AIDS d fi i diti hcells/mm3 or an AIDS-defining condition who were
prescribed ART100100
100100100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100
100100
70
80
90
100
e (%
)
30
40
50
60
Com
plai
nce
0
10
20
C
AOM Clinics (Tn=35)
HAB Median, 2006
HIVQUAL 2006, Top 25%
TFC
MeanCharts Reviewed (Tn=948)
17
Percentage of pregnant women prescribed antiretroviral th (ART) d i th d d thi d t i ttherapy (ART) during the second and third trimester
100 100 100 100 100 100 100 100 100 100100100
10091
60
70
80
90
ce (%
)
100
20
30
40
50
Com
plai
nc
0
10
20
AOM Clinics (Tn=9)TFC
MeanCharts Reviewed (Tn=306)
18
Percentage of patients with HIV-infection ART h h d li id lon ART who had a lipid panel
100100
6972 74
80 80 81 81 83 8690 91 91 92 92 95 96 97 97 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100
9297
100
859092
70
80
90
100
e (%
)
30
40
50
60
Com
plai
nce
0
10
20
C
AOM Clinics (Tn=33)
HIVQUAL 2006, Top 25%
HAB Median, 2006
TFC
MeanCharts Reviewed (Tn=880)
19
Percentage of patients with CD4 T-cell count < 200 g pcells/mm3 who were prescribed PCP prophylaxis
10010098
100
80
100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 98 1009498
60
70
80
90
ce (%
)
50
20
30
40
50
Com
plai
n
0
10
HIVQUAL 2006 Top 25%
AOM Clinics (Tn=35)
HIVQUAL 2006, Top 25%
HAB Median, 2006
TFC
MeanCharts Reviewed (Tn=948)
20
Percentage of patients with CD4 count < 50 cells/mm3 who i d MAC h l i ithi treceived MAC prophylaxis within measurement year
100100100
67 67
75
100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100
88
1009588
70
80
90
e (%
)
67 67
30
40
50
60
Com
plai
nce
00
10
20
C
AOM Clinics (Tn=24)
HIVQUAL 2005, Top 25%
HAB Median, 2005
TFC
MeanCharts Reviewed (Tn=681)
21
Mean
Percentage of patients who had at least one test f hili f d ithi th tfor syphilis performed within the measurement year
99100
92 9497 98 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 99 10096
80
90
70
80
90
e (%
)
30
40
50
60
Com
plai
nce
0
10
20
C
AOM Clinics (Tn=35)
HIVQUAL 2006, Top 25%
HAB Median, 2006
TFC
MeanCharts Reviewed (Tn=948)
22
Mean
Percentage of adult patients who had a test for h ithi th tgonorrhea within the measurement year
100
71
8591
94 95 95 97 98 98 98 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 98 1009098
70
80
90
100
e (%
)
30
40
50
60
Com
plai
nce
0
10
20
C
AOM Clinics (Tn=35)TFC
MeanCharts Reviewed (Tn=948)
23
Percentage of patients who had a test for Chlamydiaithi th twithin the measurement year
100
71
8591
94 95 95 96 97 98 98 98 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 98 1009098
70
80
90
100
e (%
)
30
40
50
60
Com
plai
nce
0
10
20
C
AOM Clinics (Tn=35)TFC
MeanCharts Reviewed (Tn=948)
24
Percentage of patients who have ever been tested for H titi B t t d h d t d H B t t iHepatitis B status and have documented Hep B status in
the medical record96
100
84 87 8993 95 95 96 97 97 97 97
100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 10096
1009096
70
80
90
e (%
)
43
30
40
50
60
Com
plai
nce
0
10
20
C
AOM Clinics (Tn=35)Mean
Charts Reviewed (Tn=948)
25
Percentage of patients for whom Hepatitis C screening was f d d t t d t d i h t t l tperformed and status documented in chart at least
once since the diagnosis of HIV-infection10097100
76
87 8791
95 95 96 97100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100
9510097
9095
70
80
90
100
e (%
)
43
63
30
40
50
60
Com
plai
nce
0
10
20
C
AOM Clinics (Tn=35)
HIVQUAL 2006, Top 25%
HAB Median, 2006
TFC
MeanCharts Reviewed (Tn=948)
26
Percentage of patients who received testing with results documented for latent tuberculosis infection (LTBI) in thedocumented for latent tuberculosis infection (LTBI) in the
measurement year with any approved test (tuberculin skin test [TST] or interferon gamma release assay [IGRA])
8 80
88 8892 94 94 95 96 96 96 97 97 100 100 100 100 100 100 100 100 100 100 100 100 100 100
86
96
7886
80
90
100
%)
3846
50
60 6167
7378 80
56
75
30
40
50
60
70
ompl
ainc
e (%
90
10
20
30
Co
AOM Clinics (Tn=35)
HAB Median, 2006
HIVQUAL 2006, Top 25%
TFCCh t R i d (T 948)
27Mean
Charts Reviewed (Tn=948)
Percentage of patients who ever received screening f T l dii d t d i h tfor Toxoplasma gondii as documented in chart
100 100 100 100 100 100 100 100 100 100 100 100 100 100 100100
64
7680
86 8691 91 92 92 93 94 95 96 96
100 100 100 100 100 100 100 100 100 100 100 100 100 100 100
86
969086
60
70
80
90
e (%
)
42
63 64
30
40
50
60
Com
plai
nce
013
0
10
20
AOM Clinics (Tn=33)TFC
MeanCharts Reviewed (Tn=880)
28
Percentage of female patients who had PAP lt d t dPAP screen results documented
90100
80 81 83 86 86 86 87 88 8892 94 96
100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100
88
9689
71
90
88
60
70
80
90
ce (%
)
50 5055
60 60
20
30
40
50
Com
plai
nc
0
10
AOM Clinics (Tn=35)
HIVQUAL 2006, Top 25%
HAB Median, 2006
TFC
MeanCharts Reviewed (Tn=948)
29
Percentage of patients who have received complete d i i (t d ) i t H titi Adosing regimen (two doses) against Hepatitis A
100 100 100 100 100 100 100 100100
7580 80 82 83 86 86 88 89 90 91 92 92 93 95
100 100 100 100 100 100 100 100
73
86
90
73
60
70
80
90
e (%
)
27 2933 33
40
50
57
30
40
50
60
Com
plai
nc
013
17
27
0
10
20
AOM Clinics (Tn=33)TFC
MeanCharts Reviewed (Tn=880)
30
Percentage of patients who completed the vaccination i f H titi B d d t ti i h tseries for Hepatitis B and documentation in chart
98 100 100 100 100 100 100 100 100 100 100 100 100 100100
64 6773
78 79 7983 84 85 88 89
92 93 94 94 95 98
84
939084
60
70
80
90
e (%
)
3843
48
58
30
40
50
60
Com
plai
nc
00
10
20
AOM Clinics (Tn=35)TFC
MeanCharts Reviewed (Tn=948)
31
Percentage of patients who have ever received a l i tipneumococcal vaccination
93100
6770
7378 79 81 82 84
88 88 89 89 90 91 92 93 94 95 95 95 95 96 96100 100 100 100 100
82
89
939082
70
80
90
e (%
)
5054
59
67
30
40
50
60
Com
plai
nce
1521
0
10
20
AOM Clinics (Tn=33)
HIVQUAL 2005, Top 25%
TFC
MeanCharts Reviewed (Tn=880)
32
( )
Number of patients who received influenza vaccination ithi th t i dwithin the measurement period
100
66
7578
81 8387 88 89
94 95100 100
90
70
80
90
100
e (%
)
2936 36 36
4247 47 48 50 50
54 55 56 57 59
66
56 5456
30
40
50
60
Com
plai
nce
10 12
25 26 26 2629
0
10
20
C
AOM Clinics (Tn=33)
TFC
MeanCharts Reviewed (Tn=880)
33
Percentage of patients who have had ag pmental health assessment
100
7680
8692 94 94 94
98 98 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 10096
1009096
70
80
90
e (%
)
4535
30
40
50
60
Com
plai
nce
20
10
20
C
AOM Clinics (Tn=33)
HIVQUAL 2005, Top 25%
HAB Median, 2005
MeanCharts Reviewed (Tn=880)
34
Percentage of patients on ART who were assessed for adherence (and counseled if suboptimal adherence)adherence (and counseled if suboptimal adherence)
two or more times in the measurement year
99100
89 89
97100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 99 100
9295
70
80
90
e (%
)
56
30
40
50
60
Com
plai
nce
0
10
20
C
AOM Clinics (Tn=33)
HIVQUAL 2006, Top 25%
HAB Median, 2006
MeanCharts Reviewed (Tn=880)
35
Percentage of patients with HIV infection who received HIV risk counseling within
the measurement year
9498 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 98 10095
98
90
100
70
83
94
60
70
80
90
nce
(%)
20
30
40
50
Com
plai
n
0
10
20
AOM Clinics (Tn=33)TFC
MeanCharts Reviewed (Tn=880)
36
Percentage of patients who have been assessed for substance use (alcohol and illicit substances) in thesubstance use (alcohol and illicit substances) in the
measurement year10094
100
72 73
81 83 83
94 94 96 98 98 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 10094
1009390
94
70
80
90
e (%
)
42
30
40
50
60
Com
plai
nce
0
10
20
C
AOM Clinics (Tn=33)
HIVQUAL 2005, Top 25%
HAB Median, 2005
TFC
MeanCharts Reviewed (Tn=880)
37
Percentage of patients with HIV and Hepatitis B (HBV) or H titi C (HCV) i f ti h i d l h lHepatitis C (HCV) infection who received alcohol
counseling within the measurement year
75 7580
8691
95 95 95100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100
92
1009092
70
80
90
100
%)
40
50
60
ompl
ainc
e (%
0
33
0
10
20
30Co
AOM Clinics (Tn=33)TFC
MCh t R i d (T 880)
38
MeanCharts Reviewed (Tn=880)
Percentage of patients who received tobacco cessation counseling within the measurement yearcounseling within the measurement year
98100
67
7480
8892
95100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100
77
10098
88
90
7770
80
90
100
e (%
)
33
43 4550 50
6367
30
40
50
60
Com
plai
nce
1217 17
20
0
10
20
C
AOM Clinics (Tn=33)
HIVQUAL 2005, Top 25%
HAB Median, 2005
MeanCharts Reviewed (Tn=880)
39
Percentage of patients with CD4 count < 50 cells/mm3
ith d t d hth l l f l ithi thwith documented ophthalmology referral within the measurement year
100
67 67
8083
92
100 100 100 100 100 100 100 100 100 100 100
75
100
100100
90
7570
80
90
100
e (%
)
40
50
67 67
30
40
50
60
Com
plai
nce
0 0 00
10
20
AOM Clinics (Tn=21)
HIVQUAL 2005, Top 25%
HIVQUAL 2005 (Median)
TFCCharts Reviewed (Tn=551)
40Mean
Charts Reviewed (Tn 551)
Percentage of patients who received a referral to a dentist at least once during the measurement year
100
59 60 61 62 62 64 65
77 7881 83
92
100 100 100
56
90
60
70
80
90
nce
(%)
1724
31 3134 34
4043 46 47 50 50 50
5459 60
52 50
56
39
52
20
30
40
50
Com
plai
n
0 0 2 717
0
10
HIVQUAL 2006, Top 25%
AOM Clinics (Tn=33)HAB Median, 2006
MeanCharts Reviewed (Tn=880)
41
What did we do well?What did we do well?
What can we improve?42
Comparison by Performance Scorep y
92 92 94 94 95 96 96 98 98 98 98 99 99 99 100100
Conditional Competent Peak
5256
73 75 7782 84 86 86 88 88 91 92 92 94 94 95
60
80
e (Y
ear 1
9)
52
0
20
40
% C
ompl
ianc
e
0%
Clinical/Performance Measures
43
We did extremely well in …
• HAART• STD screening – chlamydia, gonorrhea• Counseling – adherence HIV riskCounseling adherence, HIV risk• CD4 monitoring• PCP prophylaxis
44
We also did well in …• Hepatitis screening – Hep B & C• Assessments – mental health, substanceAssessments mental health, substance
use• Screening – cervical cancerScreening cervical cancer• Labs – lipids • Counseling – alcohol useCounseling alcohol use• ARV for pregnant women• Prophylaxis - MACProphylaxis MAC
45
We can improve on….• Screening – toxoplasmosis, ophthalmology,
tuberculosistuberculosis• Vaccination – Hep A & B, flu, pneumonia• Counseling – tobacco cessation• Referrals for dental careReferrals for dental care
46
Low Performing Clinics
• Transient population• Unaware of performance/no baselineUnaware of performance/no baseline• Frequency of process – not always done,
easily missed• Nature of process – ex. TSTs for TB screening• Performance and system issues within the
clinic leadership staffing resourcesclinic – leadership, staffing, resources• Geographic disparities in access to certain
servicesservices • Transportation
47
Next Steps• Implement rapid capture system using tablet PCs
in the field
• Develop central database for performance data d ti ti tand corrective action management
48
Questions?
49
Acknowledgements
Lusine Aloyan, PHNSuthep Chantorn PHNSuthep Chantorn, PHNCarlos Vega-Matos, MPAJane Maynard, PHN, MSy , ,David PieriboneJennifer Sayles, MD, MPHJ S dJames SaavedraVirgilio Zabala
50
For More Information
Mary Orticke, RN, MPHChief Quality ManagementChief, Quality Management
Office of AIDS Programs and Policy600 South Commonwealth Ave., 10th Floor
L A l C lif i 90005 4001Los Angeles, California 90005-4001Phone: 213-351-8083
Fax: 213-738-6566E-mail: morticke@ph.lacounty.gov
This presentation will be available atwww.ph.lacounty.gov/aids
51