Ryan White Title I – St. Louis EMA Grantee: City of St. Louis, Department of Health

Funded by HRSAHIV/AIDS Bureau

Ryan White Title I – St. Louis EMARyan White Title I – St. Louis EMAGrantee: City of St. Louis,Grantee: City of St. Louis,

Department of HealthDepartment of Health

National Quality Center (NQC)2

About the St. Louis EMA

• Urban & rural; St. Louis city, & 6 MO counties; 5 IL counties

• Popl: 2.6 million; 76% Caucasian, 18% African American (AA)

• HIV popl: 5,174 persons; 80% from urban core; AA represent 77.4% of HIV+ women; 8% are IDU

• AIDS incidence: 60.5% AA; 82.5% male; 60.5% MSM

• CM clients: ~ 2,513 clients

• Title I primary care clients: ~500 clients

• 61.2% of Title I service budget funds health care in ’06 (medical, dental, drugs, & healthcare continuation)


Priorities of Clinical Quality Management

Initially 1. Initiating, & maintaining positive relations with Title I

primary care providers (PC MDs)

Now1. Seeking ways to improve clinical behavior of PC MDs,

2. Decreasing communication gap between case managers & PC MDs about clients

3. Decreasing communication gap between Title I fiscal subcontractor & PC MDs about services available


Challenges in Setting Up Clinical QI Program

1. No baseline clinical data prior to 2003

2. No previous relationship between Grants Administration (GA) & PC MDs

3. Fiscal subcontractor is funded by Title I to contract with PC MDs for clinical services

4. Thus, GA can not directly implement some key clinical improvements, which slows pace of improvement

5. Most PC MD sites are private offices


Challenges in Clinical Data Collection & Use

Data Collection1. Reviewing charts is like reviewing the cleanliness of MD’s home

2. Charts are often quite disorganized

3. Level of documentation is often poor & difficult to interpret

Use of Data1. How to report poor results to proud, under-funded PC MDs?

2. For many PC MDs, cost of providing HIV primary care > benefit

3. Thus, there is low to no incentive to change behavior

4. For clients, relationship with PC MD is very important

5. Grant emphasizes importance of keeping clients engaged in care

6. How to prevent PC MDs from “opting out” of HIV care?


Approach to Setting Up Clinical QI Program

1. Called other EMAs: Asked for advice & chart review instruments

2. Decided to use an established instrument: HIVQUAL

3. Didn’t hesitate to contact HIVQUAL for help

4. Asked PC MDs for their feedback on instrument & methodology

5. Adopted “here to help” vs. “auditor” attitude in communicating & working with PC MDs


Approach to Clinical Data Collection & Use

1. Developed second instrument to collect data from PC sites regarding their strengths & needs

2. Provided instruments in letter notifying about chart reviews

3. Focused on care received vs. quality of documentation

4. Provided PC sites with their results & results for all charts reviewed

5. Solicited PC MD questions, concerns about results

6. Adopted non-defensive attitude: “Negative feedback is better than no feedback”


Example of Results Sent to Providers


Client-level graph:Effects of HARRT started June 20


Clinical Quality Improvement Projects

1. Conducted desk-side audit using clinical service dB

2. Collected contact info (i.e. emails) to notify PC MDs of local & on-line HIV-related training and CMEs

3. Coordinated HIV training for PC MDs and their clinical staff via state & regional AETCs

4. Solicited input from PC MDs about quality improvement

5. Implemented policy requiring PC MDs are “HIV Specialists” based on NY AIDS Institute HIV specialist criteria or obtaining AAHIVM credentials


Lessons Learned

Data collection1. Define specific terms for each variable measured

2. Don’t take behavior of PC MD and their staff personally

3. If possible, provide results to PC MDs & staff ASAP

Use of Data1. Put yourself in the PC MDs shoes

2. Just providing poor results will NOT motivate improvement

3. Review charts at all PC sites, including those with <5 clients

4. Provide de-identified results from all sites to all PC MDs

Documents

Ryan White Title I – St. Louis EMA Grantee: City of St. Louis, Department of Health