HIV/AIDS Ambulatory Outpatient/Medical Clinical ... · HIV/AIDS Ambulatory Outpatient/Medical Clinical Performance DataClinical Performance Data 2009/10 (Year 19) Mary Orticke, …

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



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


TFC


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


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)


HAB Median, 2006

TFC


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)


HAB Median, 2006

TFC


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)


HAB Median, 2005

TFC


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)


HAB Median, 2006

TFC


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



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



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)


HAB Median, 2006

TFC


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


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



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)


HAB Median, 2006

TFC


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



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



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)


TFC


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


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)


HAB Median, 2005


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)


HAB Median, 2006


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



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)


HAB Median, 2005

TFC


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


MCh t R i d (T 880)

38


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)


HAB Median, 2005


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 (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


AOM Clinics (Tn=33)HAB Median, 2006


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: [email protected]

This presentation will be available atwww.ph.lacounty.gov/aids

51

Documents

HIV/AIDS Ambulatory Outpatient/Medical Clinical ... · HIV/AIDS Ambulatory Outpatient/Medical Clinical Performance DataClinical Performance Data 2009/10 (Year 19) Mary Orticke, …