Programación Básica con NQC Patricio A. Castillo 03/05/2008.
Sherry Martin, NQC Coach, Claudia Medina, NQC Fellow, Julia Schlueter, NQC Fellow
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Transcript of Sherry Martin, NQC Coach, Claudia Medina, NQC Fellow, Julia Schlueter, NQC Fellow
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Quality Institute #2Session 2: Guidance to Creating a Culture for Quality: How to Work with your Subcontractors on Quality ManagementSherry Martin, NQC Coach, Claudia Medina, NQC Fellow, Julia Schlueter, NQC FellowThursday, November 29, 2012 8 am to 9:30 amDelaware ARWA-0248
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NQC and Quality Workshops at 2012 AGM
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NQC at 2012 AGM
• Networking Opportunities - Interact with your peers… Tue, Nov 27 12pm: HIVQUAL
Regional Group– Thurgood Marshall Ballroom West
Wed, Nov 28 12pm: in+care Campaign - Thurgood Marshall Ballroom South
• NQC Exhibit Booth - Stop by our booth…
• NQC Office Hours - Meet one of our NQC coaches...
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Session Agenda
• Key success factors to achieve high performance results
• Successful strategies used to engage subcontractors- Part A, B, C and D agencies
• Group exercise – identification of measures on which to focus improvement initiatives; challenges and potential solutions
• Key learning points – group reports
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Learning Objectives
• Describe the importance of aligning subcontractor agency quality management plans and improvement initiatives with those of the grantee and/or the National AIDS Strategy
• Identify the critical few opportunities for improvement for subcontractors based upon results of measures and national information and goals
• Describe methods used successfully to ensure accurate, consistent and timely data on key measures and subcontractor engagement in the quality program
• Implement improvement initiatives across the network to encourage a unified sustained approach
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Key Success Factors to Achieve High Performing Results
• Alignment of goals, measures, improvement initiatives to achieve mission and national strategy goals
• Accurate and consistent data collection methods and definitions
• Contractual agreements that define quality program expectations
• Strong guidance and tools – service plans, education forums, one-on-one data assistance
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The Mission/Purpose StatementThe Focus of the Quality Program
• Describes the core function of the network and delineates the scope of services
• May describe the vision for the future• Directs and prioritizes network goals and
action plans• Aligns the organization with subunits• Drives all strategic decisions
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Mission Statement Examples
• Our mission is to develop and maintain a state-wide quality program that improves patient health outcomes for individuals living with HIV. The vision is to become trend-setters in quality health care initiatives.
• The (network name) Network’s mission is to: provide comprehensive family-centered health care and support services for women, youth, children and families infected with or affected by HIV in (State/Region/City).
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Alignment – Key Success Factor
All stakeholders should understand and agree to the tenets of the Mission, Vision and/or Purpose Statements
– Rethink and articulate the mission/vision/purpose occasionally with all stakeholders
– Align with current national treatment information, including the National AIDS Strategy
– Communicate in multiple ways, frequently– Align with reward, recognition and
accountability programs
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Alignment – Key Success Factor Quality Infrastructure, Plans and
Contracts• Agency Quality Committee includes leaders
from each subcontractor agency• Agency Quality Plan (Purpose) is endorsed by
all agencies and reviewed annually• Subcontractor Quality Plans include
relationship with the agency, common goals and methods
• Contracts with subcontractors describe quality program expectations
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Alignment – Key Success FactorAccurate and Consistent Data
• Measure definitions must be consistently applied at all sites; this requires validation
• Sampling methods must be consistent• Source data must be accurate• Data collection must be frequent
enough to provide usable information• Results should be arrayed against time
(run or control charts) for analysis
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Alignment – Key Success FactorIdentification of Measures to Improve
• Identify measures to improve performance on the basis of results and current national and local information, including the National AIDS Strategy
• Prioritize the selection on the basis of those that will progress the network to their mission
• Include all subcontractor representatives in the selection
• Define data collection logistics together – data sources, sampling methods, definitions, frequency of reporting and formatting
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Alignment – Key Success FactorImprovement Initiative Direction and
Guidance• All subcontractors identify an agency
measure on which to focus improvement work based upon their results
• Subcontractors use quality methods to identify opportunities to improve the network measure and to conduct an improvement project
• Network provides help with data collection and submission and quality improvement methods
• Progress on measures are reviewed regularly• Improvement strategies are shared formally
and regularly• “Home runs” are celebrated
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Measures to Evaluate Mission/Purpose Progress
Our mission is to develop and maintain a network-wide quality program that improves patient health outcomes for those individuals living with HIV. The vision is to become trend-setters in quality health care initiatives and family centered care. What are possible measures that might be selected to achieve this vision?
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Potential Measures for Improvement Focus
• Patient outcome (and surrogate) measures– Mortality– Viral Load Suppression – ( National AIDS
Strategy)
• Process measures– Retention- in- Care; Medical Visits – ( National
AIDS Strategy)– New patients
• Results are in the “trendsetter class”– Best practice clinics
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Measures to Evaluate Mission/Purpose Progress
The (network name) Network’s mission is to: provide comprehensive family-centered health care and support services for women, youth, children and families infected with or affected by HIV in (State/Region/City).
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Potential Measures to Evaluate Mission
• Patient HIV outcome measures segregated by women, youth, children
• Primary care measures – diabetic, asthma, cardiac
• Family engagement measures identified through various listening posts Surveys Focus groups
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Idaho HIV Care ProgramsA low incident state’s
experience with quality management programs.
BeBe ThompsonRW Part B/ADAP Coordinator
Idaho Dept. of Health and Welfare
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The ChallengeHIV/AIDS Treatment Cascade.
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A LITTLE BACKGROUND
Idaho HIV Care:• Low incidence state (1,254 PLWH/A, 12/31/2010)• Ryan White Part B and Part C’s only• Staff and funding limited• All state, clinic and contractor staff have many roles• RWPB funds HIV monitoring labs and medical case
management • Part C’s provide nearly all clinical and primary care for
Idaho’s HIV positive
Challenge:• How do we align our quality management activities to
the National HIV/AIDSStrategy?• Statewide measures encompassing all clinics and
contractors
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Part B and Part C Interactions
• Different data collection and measure exclusions
• HIV Qual versus HAB Performance Measures• Choose one and stick to it for statewide
measuresFocus on the strategy’s three primary goals:1.Reducing the number of people who become
infected with HIV2.Increasing access to care and improving
health outcomes for people living with HIV3.Reducing HIV-related health disparities
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NQC Consultant and Idaho QM Committee
• Move away from categorizing in clinical and non-clinical measures
• Look instead at what the measure is really telling you in terms of the NHAS primary goals
• Does the measure tell you anything about access to care?
• The quality of the care received?• Retention in care?• Are your client’s eligible for your programs?
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Quality of Care
• Percent of clients who had two or more CD4 T-cell counts in the measurement year, one in the first half and one in the second half.
• Percent of clients who had two or more Viral Load counts in the measurement year, one in the first half and one in the second half.
• Percentage of active clients with a CD4 count below 200cells/mm who were prescribed prophylaxis during the measurement year
• Percentage of clients who have a documented SAMISS completion in CAREWare during measurement year.
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Retention in Care
• Percent of clients who had two or more medical visits in an HIV care setting during the measurement year.
• Percent of clients who are newly enrolled with a medical provider with prescribing privileges who had a medical visit in each of the 4 month periods in the measurement year.
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Monitored Viral Load Suppression• Track and monitor viral loads of HIV positives
for the following:1. State of Idaho broken out by
• Race• Ethnicity• Gender• Risk factor
2. Health Districts(7)• Race• Ethnicity• Gender• Risk factor
• Question from committee was how to handle outliers?
• Follow-up required- ARV’s prescribed, reduced VL?
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Program Eligibility Measures
• Proportion of clients recertified for eligibility every six months
• Percentage of clients accessing services with eligibility documented in CW (HIV status, Income, Insurance Status)
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RWPB ContractsProvider contracts:
5.Provide HIV Medical Case Management services in accordance with the rules, regulations, policies, and procedures as written in the Idaho Ryan White Part B HIV Medical Case Management Policies and Procedures Manual. This manual can be found on the Family Planning, STD and HIV Programs website www.safesex.idaho.gov under HIV Care and Treatment.
6.Ensure staff providing direct services to clients attend monthly conference calls with the RWPB Program staff and attend all mandatory trainings as deemed necessary by the Program.
a. Annual HIV Medical Case Management training in Boise as determined appropriate by the program.Contracts include performance metrics specific to contract management and monitoring.
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RWPB Policy and Procedure Manual
Manual includes:•All RWPB and some RWPC polices and eligibility•Current copy of MCM forms also at www.safesex.idaho.gov•Statewide Quality Management Plan which includes performance measures and QI projects•CAREWare Data Entry Manual with data element definitions, print screens, and step by step instructions.
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Contractors Quality Management
• Each provider has their own policy and procedure manual.
• Reviewed and approved to be in compliance with the RWPB Policies and Procedures
• Require each contractor to work on Quality Improvement within each agency
• Contractors will be required to report on QI projects
• Work in progress……
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CONTRACTS
Julia Schlueter, MPH, NQC Fellow Quality Manager
Washington University School of MedicineSt. Louis, MO
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FIRST STEP– IDENTIFY WHERE YOU ARE
1. Grantee – Mission/Vision = Quality Management Plan (Checklist)
2. Identify Subcontractors – Share Grantee’s Quality Management Plan
3. Include Quality Management Component within the contracts (see example)
4. Identify how subcontractors are collecting data.5. Work on unifying data collection methodology.
6. As a Network identify indicators that are relevant to all the subcontractors (1-3)
7. Identify indicators that are relevant to each subcontractor Clinical Indicators Non- clinical indicators should be always link to or aim
to assure disease management
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CONTRACT STEPS CONTINUED8. Clarify annual quality goals and establish
benchmarks - Network - Provider
9. Identify and communicate how and when meetings and reports are going to take place.
10. Identify individuals responsible for reporting at each provider site.
11. Providers should share their quality projects with the network- Annual storyboard success celebration
12. Offer TA to subcontractors to identify goals, objective, improvement projects.
13. Involve consumers in the process.
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CONTRACT SAMPLE 1V. MISCELLANEOUS1. Changes2. Grant Related Income 3. Reporting
Example 1: XXXX agrees to provide client-level data on any and all patients served with these funds. These data will be used to satisfy federally-mandated reporting requirements and progress reports and include but are not limited to: patient demographics, HIV/AIDS status, financial eligibility, type and number of services provided, and biological or other health outcome indicators that support the grantee’s (insert grantee name) Clinical Quality Management program. XXXX will provide HIV/AIDS treatment and/or services in accordance with the U.S. Public Health Service and the HRSA HIV/AIDS Bureau guidelines. Data will be entered directly into the grantee’s CAREWare data system (monthly) or shall be provided (at the end of each quarter) via a provider data export (PDE) file that is compatible with the grantee’s CAREWare system. Complete data requirements are specified in Appendix C.
4. Civil Rights and Equal Employment Opportunity
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CONTRACT SAMPLE 2I. General PrinciplesII. Description of Support
a. Mission of grantee and previous performance of clients served. Include projection for next year.b. Key Activities by funded position
i. Include QI responsibilities by position. Ex: clinical quality management activities for the Part C/D
Network including site-based quality team meetings (at least 8 meetings/year) and updating the Part C/D Quality Manager regularly on XXXX’s quality management activities.
III. Responsibilities and Specific Outcomes Expected of XXXX
IV. Grantee responsibilities – include monitoring of service delivery and data, clinical monitoring in coordination with Part A, fiscal monitoring
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CONTRACT SAMPLE 2
III.Example of Responsibilities and Specific Outcomes Expected of XXXX• Program representative(s) attend scheduled Part C/D Provider Meetings (quarterly)
and other meetings as requested to support coordination of quality services across the Network;
• Develop and maintain annual clinical quality management goals that align with the Part C/D Network goals
• Implement a Clinical Quality Management program that evaluates how the XXXX clinic works and make changes where necessary, document all agenda, activities and minutes; Conduct at least 8 quality team meetings each year Execute at least 4 PDSA cycles for the selected quality indicator each year At minimum, select a new quality project to work on each year At minimum, quarterly review indicator data
• Track data necessary for HRSA data reporting and contribute this information to the centralized database (e.g., XXX) in a timely manner, including at minimum data necessary to compile the following reports: Quarterly Part C/D Progress Report (see Attachment B for Part D Work Plan) Annual Ryan White Services Report (RSR) (
http://www.careacttarget.org/topics/rsr.asp) Monthly Progress Updates with HRSA Part C/D Project Officer
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Case Study—Working With Sub-Grantees on Quality Management
Alberta Lin FerrariBaltimore-Towson Part A
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Baltimore-Towson’s Part A Program
• Scope: Baltimore city plus 6 counties, 9,753 PLWH/A served Over 20 categories, 37 sub-grantees and 140 service contracts.
• Some sub-grantees serve thousands of Ryan White clients and have dedicated QI staff, Others serve hundreds and have staff who multi-
task.• Services provided to PLWH/A of all
ages/genders—clients are 62% male, median age 47, 84% African-American.
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Sub-Grantee Contracts
• CQM requirements: Sub-grantees must Have a quality management plan in place Cooperate with CQM reviewers Respond to any areas needing improvement
• CQM expectations: Sub-grantees also Participate in Technical Assistance Identify QI projects Report back on their progress
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Perspective
• Clear distinction between CQM and Contract Management reviews. CQM reviews’ objective is improving quality Contract management review’s objective is
ensuring compliance with contracts.
• Initial skepticism of QI reviews (and occasional resistance)
• With time and care sub-grantees have developed collaborative relationships with a shared mission of improving quality.
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CQM Reviews1. Chart reviews of multiple service categories on a rotating 4-year schedule, although primary medical care services are reviewed every year. QI staff:•Perform chart reviews of services provided the prior FY. Chart review tools measure performance against local standards of care, PHS standards, HAB quality indicators,•Provide immediate impressions (de-briefing), •Analyze EMA-wide data,•In the spring, host TA sessions (details to follow),•In summer, provide sub-grantees with reports comparing their performance with that of their peers, identifying strengths and areas for improvement.
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CQM Reviews (continued)
2. Agency Assessment Has changed over time. Initially looked at
licensures, compliance with Public Health Standards
Past three years have focused on assessments of sub-grantees QI structures, processes and outcomes.• Short self-assessment for two years• This year, Organizational Quality Assessment
Tool developed by HIVQUAL-US and The NY Department of Health’s AIDS Institute
3. Consumer satisfaction interviews focused on the categories under review.
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Technical Assistance Sessions
• Series of 2-3 sessions for Core Services• Separate sessions for Supportive Services• QI training provided
Tools from the National Quality Center such as the PDSA cycle, fishbone analysis, writing a quality management plan.
Special topics such as results from special projects, techniques for effective communication with clients, becoming a patient-centered medical home.
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Technical Assistance Sessions (continued)
• EMA-wide results of the review are presented
• Participants select EMA-wide areas for improvement—indicators that all sub-grantees will work on improving
• Participants brainstorm and select QI projects appropriate for their agency
• At the second TA, sub-grantees provide structured reports on their projects and learn from one another
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Payoff to Sub-Grantees
• De-briefings provide immediate feedback on reviewers’ impressions of areas for improvement
• TA sessions provide both QI training and opportunity for sub-grantees to share experiences with QI challenges and projects
• QI tools are modeled for adoption at sub-grantee agencies
• Additional TA is provided to individual sub-grantees at their request, and “QI 101” is provided occasionally for new staff
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Clinical Outcome Improvements2009 2011
Clients with two or more medical visits during the year
87% 93%
Clients with two or more CD4 tests 78% 88%
AIDS-defined clients prescribed highly active antiretroviral therapy (HAART)
89% 95%
Undetectable Viral Load 42%(2007) 51%
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Process Improvements
• Reduction in missing data• Improvements in eligibility verification• Increased proportion of clients having
other insurance—use of Ryan White as payer of last resort
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CASE STUDY
Claudia Medina, MD, MHA, MPHAssistant Director / Quality Management
FACES – Children’s Hospital , LA
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Participant Exercise
• Each group will be given an example of a HIV Agency: mission/purpose, goals, subcontractor agencies and results of measures from each of the agencies
• Groups identify a: 1) facilitator, 2) scribe, 3)reporter • Identify, based on all the information:
– Appropriate measure(s) to improve the Agency performance– Potential focus of improvement for each of the
subcontractors– Challenges to making this work– Solutions to mitigate the challenges
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HELPING YOUR SUBCONTRACTORS TO FIND THEIR BASE LINE
1. Subcontractor has someone responsible for data collection?
2. Subcontractor has a clear process in place to collect data?
3. Subcontractors understand the Performance Measurement?
4. Subcontractors have a clear definition of the indicator they are tracking? Denominator/Numerator
5. Subcontractors understand how to do a fish bowl, flowchart process, PDSA. etc.?
6. Subcontractors are aware of Grantee goals? 7. Subcontractors need TA?
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Non-Clinical Indicators / Clinical Indicators = One Overall Quality
Management Plan1. Main purpose off all Ryan White Parts is to assure HIV disease
management through different services. 2. How do you know if patients are having their disease manage? 3. Start small, start SMART
a. Specific b. Measurablec. Attainabled. Realistice. Timely
4. Make your non-clinical / clinical. Make them count!
There is only ONE target! QUALITY OF CARE
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CASE STUDY
• BEFORE YOU START KNOW YOUR GRANTEE MISION AND VISION
• WHAT IS YOUR GRANTEE GOAL• MAP YOUR SUBCONTRACTORS• UNDERSTAND THEIR SERVICES,
POLICIES AND PROCEDURES• CREATE SERVICE/DATA DICTIONARY• SUPPORT THEM
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Measures to Evaluate Mission/Purpose Progress
Our mission is to develop and maintain a network-wide quality program that improves patient health outcomes for those individuals living with HIV. The vision is to become trend-setters in quality health care initiatives and family centered care.
What are possible measures that might be selected to achieve this vision?
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Goals of the Quality Management Program
• To promote and build quality into the program’s organizational structure and process.
• To conduct strategic planning that includes the grantee and its sub-recipients and stakeholders
• To provided effective monitoring and evaluation of client outcome indicators and service delivery to ensure that services meet accepted performance standards.
• To ensure that services provided are positively perceived by clients, the provider network, and the community.
• To ensured prompt identification and analysis of opportunities for improvement with implementation of actions and follow-up.
• To coordinate quality management activities.• To maintain compliance with local, state, and federal regulatory requirements
and accreditation standards, and specifically, to assure that the program is responsive and consistent with the Ryan White Treatment Modernization Act.
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CASE STUDYNetwork EXAMPLE with 10 providers
divided as follow:
Site Type of ProviderFunding
Sources for that Provider
Service Category fund by Grantee
Primary CareMedical Case Management
Non-Medical Case
Management
Mental Health
Other Support Service
A CHC Part A,C,DYouth &
Adult
B UNIVERSITY. Part B,C,DYouth &
AdultC CBO Part A, D X X X X
D HOSPITAL Part D Pediatric Only
E CHC Part A,C,DYouth &
Adult
F UNIVERSITY Part A,C,DYouth and
AdultG CBO Part A, D X X X X
H HOSPITAL Part B X
I UNIVERSITY Part D,C,AYouth &
Adult
J UNIVERSITY Part DYouth &
Adult
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Complete Region Data for Performance Measurements
Data as of July 31, 2011
A B C D F G H* I J K
AVERAGE PART D
NetworkGoal
TOP 25%
IHI GOAL
CD4 58% 56% 35% 21% 82% 16% 51% 28% 50% 45% 44% 75% 79% 90%
VL 55% 60% 34% 18% 82% 16% 51% 8% 46% 55% 42% 75% N/A N/A
MV 72% 76% 34% 35% 47% 41% 74% 40% 64% 86% 57% 80% N/A N/A
HAART IN AIDS 89% 86% 37% 64% 89% 0% 72% 22% 93% 100% 65% 90% 100% 90%
PCP 51% 67% N/A 0% 0% 9% N/A 0% 93% 0% 22% 75% 100% 95%
ARV PREG 43% 100% 100% 0% 0% 100% 100% 49% 95% N/A N/A
Neonatal AZT 45% 29% 0% 94% 42% 95% N/A N/A
PCR exposed 35% 24% 0% 69% 32% 95% N/A N/A
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Where to Start?
Appropriate measure(s) to improve the Network performance
Potential focus of improvement for each of the subcontractors
Challenges to making this work Solutions to mitigate the challenges
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Ryan White Part D Network In Louisiana
Performance Measure Jul-11
Part D Jul-12 GOAL
CD4 44% 62% 75%Viral Load 42% 61% 75%MV 64% 72% 80%HAART IN AIDS 65% 78% 90%PCP Prophylaxis 22% 50% 75%AR
V Pregnancy 49% 96% 95%Neonatal AZT 42% 79% 95%PCR Exposed 32% 57% 95%
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