Systems Linkages and Access to Care for

Populations at High Risk for HIV Infection in New York State

June 12, 2012

HRSA HIV/AIDS Bureau Special Projects of National Significance

Bruce Agins, MD,MPHGregory Young, MD FACEPAndrew Doniger, MD,MPHGale Burstein, MD, MPH

Monica Sweeney, MD, MPHKatherine Godesky, MPH, MSW

Welcome and Updates

LINKAGE, RETENTION, AND QUALITY IMPROVEMENT

Bruce Agins, MD, MPH

Meeting Outcomes

1. Increase their understanding of the NY Links statewide linkage to care initiative, the role of evaluation, and Western NY’s important role.

2. Identify existing collaborative relationships and new opportunities for linking patients to care.

3. Address issues related to data collection during pilot test phase and understand tasks for collecting data on agency-specific performance measures and for data submission on August 1, 2012.

4. Share successful efforts with testing and linking patients to care and patient retention strategies through peer exchange.

Morning AgendaNetworking Breakfast and Registration 9:30-10:00

Sign-In and Networking BreakfastList expectations.

Welcome and Updates 10:00-10:30

Bruce Agins, MD,MPHGregory Young, MD FACEPAndrew Doniger, MD,MPHGale Burstein, MD, MPHMonica Sweeney, MD, MPHKatherine Godesky, MPH, MSW

Linkage, Retention, and Quality Improvement 10:30-11:00 Bruce Agins, MD, MPH

Introductions & Response to Expectations 11:00-11:15 Nanette Brey Magnani, EdD

What is SPNS? What is the WNYS Collaborative? 11:15-11:30 Clemens Steinbock, MBA

Small Group Work: Building a System to Link and Retain Patients

11:30-12:30 Nanette Brey Magnani,EdDTable Facilitators

Afternoon AgendaEpidemiology Data and its Relevance to WNYS 1:15-1:30 Dan Gordon, PhDSmall Group Work: Measures, Collection, Submission 1:30-2:45 Clemens Steinbock, MBARole of Evaluation in NY Links 2:45-3:00 Diane Addison, MPH

Break 3:00-3:15

Panel Presentation : Improving Care 3:15-3:45

Facilitator: Steve Sawicki, MHSAAIDS Care: Lizz Ortoloni-Walls, Sr. Director of Patient and Client ServicesECMC: Ellen O’Brien, Program Manager

Wrap Up: Summation-Consumer Sub-Committee-Next Steps-Evaluation

3:45-4:00Steve Sawicki, MHSAJulian Brown, Consumer Representative

GROUP INTRODUCTIONS AND REVIEW OF GROUP’S EXPECTATIONS

Nanette Brey Magnani

WHAT IS SPNS?WHAT IS THE WNYS COLLABORATIVE?

Clemens Steinbock, MBA

SPNS Overview

What are ‘SPNS’?

• Special Projects of National Significance– Part of the Ryan White HIV/AIDS Program and

administered by the HRSA HIV/AIDS Bureau– Aims to support the development of innovative models of

HIV care that respond to emerging needs of Ryan White clients

– Topics for SPNS funding prioritized by HRSA– Strong evaluation/research component to assess the

effectiveness of models, and then focus on the dissemination and replication of successes at a national level

SPNS Initiative – Systems, Linkages andAccess to Care

• Development of innovative and sustainable systemic models of linkage to improve access to and retention in quality HIV care

• Alignment of different components of the public health system, such as surveillance, counseling/testing, emergency rooms, mental health/substance use clinics, correctional health-care facilities (traditional and non-traditional providers)

• Alignment with National HIV/AIDS Strategy Goals:– Reduce number of people who become infected w/HIV– Increasing access to care and optimizing health outcomes – Reducing HIV related health disparities

Non-Engager Sporadic User Fully Engaged

Engagement in Care Continuum

[1] Health Resources and Services Administration, HAB. August 2006. Outreach: Engaging People in HIV Care Summary of a HRSA/HAB 2005 Consultation on Linking PLWH Into Care. [2] Eldred L, Malitz F. Introduction [to the supplemental issue on the HRSA SPNS Outreach Initiative]. AIDS Patient Care STDS 2007; 21(Suppl 1):S1–S2.

SPNS Initiative – Systems, Linkages andAccess to Care

• 4-year funding cycle awarded to high incidence states• Adapted approach of the Collaborative Model

developed by the Institute for Healthcare Improvement (IHI)

• Development of grantee-specific evaluation strategies to identify and document successful models

• Comprehensive multi-state evaluation led by a national evaluation center (UCSF – Janet Myers)

SPNS Initiative – Systems, Linkages andAccess to Care

• Overall goals for this initiative, consistent with National HIV/AIDS Strategy, are to: – increase the number of individuals who know their

serostatus– increase the number of newly diagnosed linked to HIV care

within three months of diagnosis– increase the number of individuals who are virally

suppressed– increase the number of people living with HIV retained

continuously in quality HIV care

SPNS Initiative – Systems, Linkages, andAccess to Care

• Timetable– RFA Announcement: March 2, 2011– Grant Application: April 4, 2011– Initiation of SPNS Grant: September 1, 2011; October, 2011; and WNY,

June, 2012– End of SPNS Grant: August 31, 2015

• SPNS Awardees: – New York – Louisiana– Massachusetts– North Carolina– Pennsylvania– Virginia – Wisconsin

NYS Links Overview

Together, WE – identify innovative solutions for improving linkage to and retention in HIV care to support the delivery of routine, timely, and effective care for PLWHA in New York State; and

– bridge systemic gaps between HIV related services to achieve better outcomes for PLWHA through improving systems for monitoring, recording, and accessing information about HIV care in NYS.

NY Links Mission

Years 1 & 2 Collaborative Waves• Wave I: Upper Manhattan Regional Group and Western NYS• Wave II: 2 Collaboratives in NYC• Wave III: 2 Upstate Collaboratives

Years 3 & 4 Statewide Dissemination• Identification of Successful Linkage/Retention Interventions• Statewide Conference(s) to Promote Successful Interventions• Webinars, Conference Calls, etc.• Posting on AIDS Institute and other QI Websites

Timeline

Year 2 Year 3 Year 4

Collaborative Waves Statewide Dissemination

Data and Systems Integration

Year 1

SPNS Evaluation

Purpose: • to identify and address key issues and to effectively utilize already available data

sets (epi/surveillance, Medicaid, AIRS, etc.) to improve linkage/retention• to make these data sets accessible to frontline providers for quality

improvement efforts

Major Participants: • Denis Nash (lead) & Dr. Bruce Agins• Dennis Tsui (Medicaid)• Dr. Colin Shephard (NYCDOHMH Epi & Surveillance)• Mary Irvine (NYCDOHMH E-Share)• John Fuller (NYSDOH AIRS)• Dr. Lou Smith & Dan Gordon (NYSDOH Epi & Surveillance) • Eli Camhi (Metroplus) • Tom Moore (Healthix)

Data Subcommittee

• Blue-Clinical Program Participating in the Upper Manhattan Regional Group• Yellow-Supportive Service Program Participating in Upper Manhattan

Regional Group

Upper Manhattan Regional Group

• Engagement of all medical and non-medical providers in the Upper Manhattan geographic area to improve linkage to and retention in HIV care (31 sites)

• Current Progress:– 3rd Learning Session: April 10th , 2012 – 1st Collection of Collaborative Measures:

April 2nd, 2012– 2 QI Workshops modified for linkage and

retention have been held• Next Steps:

– Test and evaluate provider-driven interventions

– Provide data measures technical assistance

Western New York State• Engagement of all HIV medical and non-medical

providers in the Western NY geographic area (Rochester and Buffalo) to improve linkage to and retention in HIV care

• Current Progress:– Support and involvement of Erie and Monroe County DOH– List of participating providers developed– Planning Group developed

• Next Steps:– 1st Collaborative Meeting: June 12– Continue to conduct initial introductory Site Visits

WNY Collaborative Teams by Zip Codes

As of April 26, 3012• Red-Clinical Programs Participating in the

WNYS Regional Collaborative

WNY Collaborative Model and Dates

June 12F2F

SMALL GROUP WORK:BUILDING A SYSTEM TO LINK AND RETAIN PATIENTS

Nanette Brey Magnani

Building a System to Link and RetainOverview: To visually create a system and its sub systems that depict organizational relationships that link patients to care within each region of Western NY – Buffalo area and Rochester area.

The diagrams will illustrate:• the strength of organizational relationships (none to strong). • linking and retaining patients in care

Uses: Over time,• identify strengths, weaknesses, and opportunities for

improvement (system, sub-systems)• peer exchange• identifying needs for TA and content and methodology for

regional workshops

Part 130 minutes

1. Each agency writes its name on a circle. If there are several departments within an agency, the department(s) can write its name on each of the designated color circle.

2. Each agency goes up to the flip chart and tapes its circle(s) on the flip chart paper.

3. Draw a blue arrow connecting your agency to those agencies that you have a linkage and retention relationship with, ie, protocols in place, frequent referrals and follow up. An arrow in one direction means the communication is essentially in one direction. An arrow that goes in both directions means there is communication and feedback re patients referred, linked and documented.

4. Draw a green line to those agencies that you have a more informal relationship with and less frequent referrals.

5. If you work with an agency that is not here, add its name to a circle and tape it to the diagram.

6. Write down questions, circumstances that fall outside of these directions.

Part 220 minutes

1. For those agencies (departments) that you have a blue line, write down your strategies or what you do to refer and link patients to care.

2. For agencies (departments) that provide primary care, write in your circle or next to it, what strategies you use to retain patients in care.

Part 310 min

Large group exchange:1. Share your experience and observations in creating

the diagram. Were there new insights? To what degree was there agreement?

2. What are some of your system’s strengths? sub-systems strengths?

3. Are there opportunities to strengthen your system? Sub-system?

4. What can you observe about your strategies for linking or retaining patients?

WORKING LUNCHINTRODUCTION TO RESPONSE TEAM

Clemens Steinbock

Collaborative Response Team

A Collaborative Response Team is a self-organizing, peer-driven group made up of 5-10 nominated leaders with complementary skill sets and roles from among each NYS Collaborative membership.

Purpose:– Streamline communication across teams– Strengthen leadership capacity in the Collaborative– Support & direct Collaborative activities– Increase sustainability beyond the Collaborative

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Response Team Members Wanted!

Expectations:– Conduct regular team meetings– Share information routinely with collaborative body– Participate in Collaborative planning efforts– Report back on collaborative progress to constituents– Support collaborative members in QI competency

Membership:– Cross-agency & cross-provider category– Reflects various functional skill needs of the Collaborative– Composition and core roles flexible based on needs of the

Collaborative– Membership determined by Collaborative participants

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Afternoon AgendaEpidemiology Data and its Relevance to WNYS 1:15-1:30 Dan Gordon, PhDSmall Group Work: Measures, Collection, Submission 1:30-2:45 Clemens SteinbockRole of Evaluation in NY Links 2:45-3:00 Diane Addison, MPH

Break 3:00-3:15

Panel Presentation : Improving Care 3:15-3:45Facilitator: Steve Sawicki, MHSAAIDS Care: Lizz Ortoloni-WallsECMC: Ellen O’Brien

Wrap Up: Summation-Consumer Sub-Committee-Next Steps-Evaluation

3:45-4:00Steve Sawicki,Julian Brown, Consumer Representative

EPIDEMIOLOGY DATA AND ITS RELEVANCE TO WNYS

Dan Gordon, PHD

SMALL GROUP WORK:MEASURES, COLLECTION, SUBMISSION

Clemens Steinbock

Review: Performance Measures

Measure Agency Type

Linkage All Programs that Conduct HIV Testing

Retention HIV Clinical CareNew Patient

Retention Clinical Engagement Supportive Services &

General Medical Assistance*

New Client Clinical Engagement

Brief Overview of NYS Links Measures

Small Group Instructions: 20 minutes

1. Take out information on performance measures in your packets.

2. Select a group facilitator.3. Beginning with the first measure, have a volunteer from

your group explain the first Linkage to Care measure for agencies that do HIV Testing.

4. Repeat with volunteers for 2a and then 2b; then 3a and then 3b.

5. There is a resource person at each table to answer questions and provide additional explanation if needed.

6. Small Group Report Out•List questions/concerns on a flip chart

paper that could not be addressed in your group.

7. Large Group Exchange• Report out from each group.• Questions for large group discussion.

Review:Data Collection

Data CollectionTo the extent possible, integrate data collection into current approach - e.g. modify intake and referral forms to include questions then enter

• onto a tracking form• into an EMR, e.g., AIDS Care and Evergreen use

EMD• Excel spreadsheet – e.g. for Supportive

Services (in your packet)• AIRS

Small Group Instructions: 20 minutes.

1. Take out information on pre-work and data elements in your packets. This is the same or similar information that was reviewed during pre-work webinars and during some site visits.

2. Select a group facilitator.3. Review each measure and take notes on flip chart paper.

Tool 1: HIV Testing – Understood, able to collect data; identify issues, concerns, questions.Tool 2a. Primary Care Global Retention – repeat….Tool 2b. Primary Care New Patient Retention – repeat…Tool 3a. Clinical Engagement – repeat...Tool 3b. New Client Clinical Engagement – repeat…

4. Resource people are with your group to assist.

Small Group Report Out: 5 minutes

1. Ask for a different volunteer to share results of group’s discussion.

2. Large group discussion on issues needing resolution.

Data Submission

Our Logo . . .

Performance Measurement Reporting Expectations

• Self reporting of NY Links measures every 2 months

• Submission of performance measurement data to NY Links online data basis (www.newyorklinks.org/database)

• Sharing of improvement activities

Website at newyorklinks.org

Data Submission

• Access to NY Links Database: NewYorkLinks.org/database/• Online application allows agencies to self-report their performance data• Immediate access

– to individual scores trended over time– to benchmarking reports– to reports based on common search criteria

Data Entry

Data Entry• Enter Numerator and Denominator

• Enter how measure was collected

• Describe patient pool• Specify data limitations

Data Reporting

Action Plan

Small Group Instructions: 15 minutes

1. Take out a copy of the SPNS Action Plan2. Table Facilitator reviews action plan and

examples.3. Identify at least 3 tasks as part of your agency’s

next steps. Fill in who is responsible and when the task needs to be completed by.

4. Table Facilitator checks in if the tasks are doable by August 1st.

5. Quick report back to the large group.

ROLE OF EVALUATION IN NY LINKSDiane Addison, MPH

PANEL PRESENTATION: IMPROVING CARE

WRAP UP: SUMMATIONSteve Sawicki

Introduction to Consumer Subcommittee

Next Steps

• CONTINUED SITE VISITS– SIGN UP AT THE REGISTRATION DESK

• AUGUST 1ST DATA SUBMISSION• UPCOMING ACTIVITIES (DATES TBD)

– QI 101 WORKSHOP– SEPTEMBER WNYS COLLABORATIVE MEETING

Collaborative Organizational Assessment

Cross Service CollaborationAre cross-service communication strategies in place to solicit feedback from all HIV service areas and to promote QI activities across the organization?Score 0 Score 1 Score 2 Score 3 Score 4 Score 5

Score 0 No communication strategies are in place to solicit feedback across services and to promote QI activities across the organization.

Score 1 Key-stakeholders are only informed about cross-service activities on an as-needed basis.

Score 2Score 3 Communication strategies are in place to routinely inform staff/key

stakeholders about quality improvement activities across the agency; regular updates are sent out to key-stakeholders; staff of all services are included; internal and external key-stakeholders are asked to provide feedback about upcoming cross-services QI activities

Score 4Score 5 All services across the HIV program are regularly informed about

cross-service quality activities; an individual or a team is assigned to regularly communicate with key stakeholders; a written communication plan is in place and updated routinely; quality improvement successes are routinely shared with all key stakeholders; multiple communication channels (email, mail, internet, etc.) are identified to communicate across the agency and with external stakeholders; quality improvement successes are openly shared for peer learning.

Are cross-service communication strategies in place to solicit feedback

from all HIV service areas and to promote QI activities across the

organization?1. Score 02. Score 13. Score 24. Score 35. Score 46. Score 5

Collaborative Performance MeasurementAre appropriate performance and outcome measures selected, and methods outlined to collect and analyze performance across all services?

Score 0 Score 1 Score 2 Score 3 Score 4 Score 5

Score 0 No appropriate performance or outcome measures are selected to collect and analyze performance data across all HIV services; methods to collect and analyze the data are not outlined.

Score 1 Only those indicators are selected that are minimally required by external parties; no process took place to annually review and update cross-service indicators and its definitions; methods to collect data are not described.

Score 2Score 3 Selection of indicators is based on input across all services; indicators include

appropriate clinical or system measures to measure performance across all services; indicators reflect accepted standards of care; indicator information is shared with key stakeholders across the HIV program; processes are outlined to measure and analyze statewide performance data.

Score 4Score 5 Portfolio includes clinical and system indicators with written indicator

descriptions; measures are annually reviewed, prioritized and aligned with local, statewide and national quality goals; all indicators are operationally defined, and augmented with specific targets or target ranges, including desired health outcome; agency-wide data collection plans are clearly outlined and strategies to analyze data are detailed and routinely updated; stratification by race/ethnicity is included in the analyses to detect health care disparities.

Are appropriate performance and outcome measures selected, and

methods outlined to collect and analyze performance across all services?1. Score 02. Score 13. Score 24. Score 35. Score 46. Score 5

Collaborative Quality Improvement Activities Are joint quality improvement project(s) conducted with the engagement of all services within the organization?Score 0 Score 1 Score 2 Score 3 Score 4 Score 5

Score 0 Quality improvement projects are not conducted across services to improve key systems and/or quality of care issues.

Score 1 Quality improvement activities focus on individual services; projects across services are used for inspection; selection of quality activities is only done across a few services.

Score 2Score 3 Several services have input in the selection of program-wide quality

projects; quality improvement activities focus across services; at least one quality project across services was conducted in the last 12 months; quality improvement activities are tracked.

Score 4Score 5 Structured process of selection and prioritization of quality projects is in

place; all services are involved in the program-wide quality improvement project; findings are routinely shared with all services and are presented to the quality infrastructure inclusive of all services; the goals for projects are routinely reviewed to ensure relevancy.

Are joint quality improvement project(s) conducted with the

engagement of all services within the organization?

1. Score 02. Score 13. Score 24. Score 35. Score 46. Score 5

Meeting Evaluation

Highlights & Aha! Moments

• What have been some of your personal highlights or Aha! Moments from today’s meeting?

• Use the next 2 minutes to reflect on today

How do you rate your overall experience with today’s meeting?

3%

8%

17%

47%

25%Chart Title

1. Very Good2. Good3. Okay4. So, So 5. Not Very Good

The meeting presenters were knowledgeable and answered

questions effectively.

3%

0%

9%

41%

47%Chart Title

1. Strongly Agree2. Agree3. Neutral4. Disagree5. Strongly Disagree

Today’s meeting kept me interested

and engaged.

3%

12%

15%

52%

18%Chart Title

1. Strongly Agree2. Agree3. Neutral4. Disagree5. Strongly Disagree

Today’s meeting had the right balance of lecture and group work.

6%

22%

13%

47%

13%Chart Title

1. Strongly Agree2. Agree3. Neutral4. Disagree5. Strongly Disagree

The strategies gained from today’s meeting will improve my

collaborative efforts.

3%

3%

35%

45%

13%Chart Title

1. Strongly Agree2. Agree3. Neutral4. Disagree5. Strongly Disagree

What is your confidence level in moving forward with this process?

7%

3%

53%

23%

13%Chart Title

1. Extremely Confident2. Very Confident3. Kinda Confident4. Not Really Confident5. Scared!

Additional Comments about Today

• What worked well today for you?

• What should we do differently tomorrow?

THANK YOU FOR YOUR PARTICIPATION

Contact Information

Steve Sawicki, SPNS Lead,svs03@health.state.ny.us

Nanette Brey Magnani, EdD, breymagnan@aol.com

Annelise Herskowitz, Program Assistant axh18@health.state.ny.us , 212.417.4731

Clemens Steinbock, Director of Quality Initiatives,cms18@health.state.ny.us

Generic information, info@newyorklinks.org