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Chicago Department of Public Health -- Ryan White Part A Quality Management Program Early Intervention Services (EIS)

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Chicago Eligible Metropolitan Area (EMA) Number of client charts reviewed: 222

The dashboards below are visual displays of quality indicators set by Ryan White standards and performance measures. The purpose of the dashboard is to provide consolidated data so the information can be monitored at a glance. While not on a single page, the information below highlights the indicators in the following manner:

Red: <60 Orange:

60-69 Yellow: 70-79

Lite Green: 80-89

Green: 90-100

Gray: Not judged a performance measure

Unacceptable Poor Fair Good Excellent

There are twenty EIS agencies funded by the Chicago Department of Public Health’s (CDPH) Ryan White Part-A program.

Fifteen of the agencies were newly funded for EIS for 2015. The data presented in the tables below were abstracted

during the quality management reviews of the EIS agencies. Four (4) of the 20 EIS agencies were previously funded prior

to March 1, 2015 and are indicated with an asterisk. The measurement review periods were March 1, 2014 – February

28, 2015 for agencies funded before March 1, 2015 (previously funded) and March 1, 2015 – August 31, 2015 for

agencies funded beginning March 1, 2015 (newly funded).

While patient eligibility varied according to some of the performance indicators, the four main components for early

intervention services (EIS) includes: (1) HIV Testing and Counseling, (2) Health Education & Literacy Training, (3) Linkage

to Care and (4) referrals. The clinical quality management site reviews were conducted from September through

October 2015.

The Chicago EMA aggregate rate for the required four major components for EIS was 65%. However, it is important to

note that the fifteen newly EIS funded agencies were only funded for less than a year at the time of the site review.

Therefore, the site review served as a technical assistance visit, rather than the normal site review visit. Performance

rates varied between prior and newly funded agencies and within individual agencies. For example, as noted in table A,

depending on the performance measure the rate varied from 0 – 100% regardless of the length of time the agency had

been funded.

Demographics

As shown in the figures below, of the 222 charts reviewed, most were Black males of non-Hispanic ethnicity.

(The mean age was 36 years old)

Chicago Department of Public Health -- Ryan White Part A Quality Management Program Early Intervention Services

N/A = Not Applicable of 17

Major Areas Reviewed:

EIS Services EMA Mean

HIV Testing & Counseling 83%

Health Education & Literacy Training 51%

Linkage/Retention to Care 69%

Referral Services 57%

Total 65%

Total Aggregate Score for the required EIS components (majored areas reviewed) = 65%

A: Documentation of signed consent forms by the client that he/she received a copy of

Total EMA Aggregate Rate = 84%

Client rights and responsibilities

Consent for treatment

Release of information

Confidentiality policy

Grievance procedures

A (n=4) 100% 100% 100% 100% 100%

C (n=15) 100% 100% 100% 100% 100%

D (n=10) 100% 100% 56% 100% 100%

E (n=14) 0% 100% 100% 100% 64%

F (n=15) 33% 100% 100% 80% 33%

G (n=3) 67% 67% 67% 67% 67%

H (n=11) 55% 91% 80% 91% 73%

I (n=14) 100% 100% 14% 100% 93%

J (n=14)* 100% 100% 100% 100% 100%

K (n=14)* 79% 0% 57% 100% 100%

L (n=15) 87% 93% 93% 100% 93%

N (n=4) 0% 100% 75% 75% 0%

M (n=10) 100% 100% 100% 90% 100%

O (n=13) 77% 85% 69% 77% 85%

P (n=15)* 80% 100% 100% 93% 67%

Q (n=11) 100% 100% 100% 100% 100%

R (n=10)* 100% 90% 67% 90% 100%

T (n=9) 44% 100% 89% 67% 0%

U (n=13) 100% 100% 100% 100% 100%

V (n=8) 100% 100% 100% 100% 100%

EMA Mean 76% 91% 83% 92% 79%

*= funded prior to 3/1/15



B: Documentation of HIV testing Total EMA Aggregate Rate= 83%

Confirmed HIV status

Documentation that the meaning of a positive HIV test was explained to the patient

Referral for medical case management discussed and provided

Referral for appointment with medical provider discussed and provided

A (n=4) 100% 100% 75% 100%

C (n=15) 100% 67% 40% 93%

D (n=10) 100% 50% 10% 90%

E (n=14) 79% 79% 21% 100%

F (n=15) 93% 93% 60% 100%

G (n=3) 100% 67% 67% 100%

H (n=11) 82% 64% 30% 100%

I (n=14) 100% 79% 29% 93%

J (n=14)* 100% 100% 100% 100%

K (n=14)* 100% 93% 50% 86%

L (n=15) 100% 87% 93% 93%

N (n=4) 100% 80% 100% 100%

M (n=10) 50% 0% 0% 50%

O (n=13) 100% 77% 77% 77%

P (n=15)* 93% 80% 80% 87%

Q (n=11) 91% 100% 100% 100%

R (n=10)* 100% 90% 90% 100%

T (n=9) 100% 100% 89% 100%

U (n=13) 100% 100% 100% 92%

V (n=8) 100% 100% 88% 100%

EMA Mean 94% 80% 65% 93%




C: Documentation of Initial Intake

Total EMA Aggregate Rate= 51%

Date of first EIS services visit at this agency:

Documentation of a Completed initial intake assessment during first contact with the client

A (n=4) 0% 0%

C (n=15) 13% 13%

D (n=10) 10% 0%

E (n=14) 7% 7%

F (n=15) 100% 80%

G (n=3) 33% 33%

H (n=11) 45% 45%

I (n=14) 0% 14%

J (n=14)* 100% 100%

K (n=14)* 93% 92%

L (n=15) 100% 100%

N (n=4) 40% 30%

M (n=10) 100% 75%

O (n=13) 100% 85%

P (n=15)* 27% 20%

Q (n=11) 100% 91%

R (n=10)* 100% 90%

T (n=9) 44% 44%

U (n=13) 8% 8%

V (n=8) 38% 38%

EMA Mean 53% 48%




D: Documentation of Service Plan Signed by the…


Client Medical

case manager

Medical social

worker

EIS specialist

LTC specialist

Other

Provider [physician or

nurse practitioner

clinical nurse specialist]

Complete service plan

A (n=4) 0% 0% 0% 0% 0% 0% 0% 0%

C (n=15) 47% 56% NA NA NA NA 91% 100%

D (n=10) 10% NA NA NA NA NA 10% 10%

E (n=14) 36% NA NA NA NA NA 64% 93%

F (n=15) 0% 33% 25% 31% 18% NA 36% 40%

G (n=3) 0% 0 0 0 0 0 0 0%

H (n=11) 9% 20% 30% 13% NA NA 36% 36%

I (n=14) 14% 50% 57% NA NA NA 100% 86%

J (n=14)* 50% 73% NA NA NA NA 100% 100%

K (n=14)* 29% 23% 31% Not Asked Not Asked 54% N/A 36%

L (n=15) 40% 50% 44% 100% N/A N/A 100% 87%

N (n=4) 0% 70% NA NA NA NA 80% 90%

M (n=10) 0% 0% 0% 0% 0% 0% 0% 0%

O (n=13) 31% 38% 8% 9% NA NA 10% 23%

P (n=15)* 0% 73% 56% 50% 17% 17% 69% 73%

Q (n=11) 55% 100% N/A 89% 100% N/A 100% 100%

R (n=10)* 0% NA NA Not Asked Not Asked 20% N/A 60%

T (n=9) 56% 71% NA 33% NA 67% 71% 78%

U (n=13) 0% 92% NA NA NA NA 100% 92%

V (n=8) 100% 83% NA 60% NA NA 100% 100%

EMA Mean 24% 52% 28% 39% 27% 23% 63% 60%

*= funded prior to 3/1/15; Z=the aggregate rate is based on the service plan signed (by the client and at least one staff type) and completed plan.

Due to revisions in the data collection forms, certain items were ‘Not Asked’ for the two Pilot certain agencies.



E1: Documentation of Health Education and Literacy Training (E1, E2)


Risk reduction education on:

Adherence counseling about HIV medications and treatment

Labs and their meaning

Hep B Hep C STD/STI TB

Condom use/sexual risk management

IDU/drug or alcohol use

A (n=4) 100% 100% 0% 0% 25% 0% 50% 75%

C (n=15) 100% 73% 67% 67% 80% 67% 100% 93%

D (n=10) 80% 60% 33% 0% 67% 33% 80% 78%

E (n=14) 100% 86% 38% 38% 54% 46% 77% 57%

F (n=15) 100% 93% 67% 67% 80% 67% 87% 80%

G (n=3) 67% 33% 33% 33% 33% 33% 0% 0%

H (n=11) 91% 73% 9% 18% 45% 10% 73% 67%

I (n=14) 100% 86% 14% 0% 7% 21% 29% 29%

J (n=14)* 100% 93% 36% 36% 43% 36% 71% 50%

K (n=14)* 100% 93% 93% 79% 71% 71% 79% 71%

L (n=15) 100% 100% 53% 60% 87% 33% 93% 77%

N (n=4) 100% 90% 30% 30% 50% 20% 60% 40%

M (n=10) 25% 25% 0% 0% 0% 0% 0% 0%

O (n=13) 38% 62% 31% 23% 23% 15% 15% 23%

P (n=15)* 93% 80% 33% 33% 57% 29% 73% 57%

Q (n=11) 100% 91% 18% 45% 82% 9% 91% 64%

R (n=10)* 100% 80% 30% 30% 70% 60% 40% 43%

T (n=9) 100% 88% 38% 38% 75% 38% 63% 75%

U (n=13) 92% 100% 50% 50% 75% 46% 77% 69%

V (n=8) 100% 88% 50% 75% 75% 50% 100% 88%

EMA Mean 89% 80% 36% 36% 55% 34% 63% 57%




E2: Documentation of Health Education and Literacy Training

HIV Rx

side effects

Nutrition Oral

health/ hygiene

Exercise

Tobacco cessation

[only if tobacco

use]

Importance of early

initiation of treatment

Alternative therapy

Legal issues

How to cope with living

with HIV

Disclosure

A (n=4) 100% 50% 50% 50% 50% 25% 0% 0% 25% 25%

C (n=15) 67% 40% 27% 27% 87% 80% 27% 33% 80% 40%

D (n=10) 60% 20% 10% 0% 38% 30% 0% 0% 10% 0%

E (n=14) 100% 50% 21% 21% 80% 71% 7% 14% 71% 23%

F (n=15) 80% 62% 8% 25% 56% 58% 8% 15% 87% 87%

G (n=3) 33% 67% 0% 0% 33% 0% 0% 0% 0% 0%

H (n=11) 73% 27% 45% 9% 0% 30% 0% 13% 20% 18%

I (n=14) 64% 79% 14% 7% 21% 57% 7% 8% 43% 33%

J (n=14)* 100% 93% 79% 57% 77% 71% 50% 64% 93% 100%

K (n=14)* 93% 100% 86% 79% Not Asked

86% 21% 14% 50% 57%

L (n=15) 93% 92% 18% 30% 62% 60% 0% 50% 73% 100%

N (n=4) 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

M (n=10) 80% 60% 70% 10% 63% 70% 0% 0% 80% 60%

O (n=13) 54% 62% 46% 62% 38% 50% 46% 40% 54% 62%

P (n=15)* 73% 80% 47% 20% 60% 60% 0% 40% 53% 60%

Q (n=11) 100% 55% 55% 0% 45% 64% 0% 18% 82% 82%

R (n=10)* 100% 30% 10% 10% Not Asked

60% 0% 0% 40% 22%

T (n=9) 75% 63% 75% 13% 43% 63% 13% 50% 63% 63%

U (n=13) 77% 92% 69% 38% 54% 85% 23% 92% 92% 85%

V (n=8) 100% 75% 75% 25% 63% 88% 0% 38% 100% 100%

EMA Mean 76% 60% 40% 23% 48% 57% 11% 26% 57% 52%

*= funded prior to 3/1/15 Due to revisions in the data collection forms, certain items were ‘Not Asked’ for the two pilot agencies.



*=

funded prior to 3/1/15;

F1: Documentation of Referrals(F1, F2) Total EMA Aggregate Rate = 57%

Referral plan completed within 5 business days of initial intake

Client received 1st clinical visit with a clinical provider within 3 months after a confirmed HIV test result

Medical case management services

Substance abuse treatment

Mental health

A (n=4) 75% 100% 100% NA 67%

C (n=15) 53% 80% 36% 73% 50%

D (n=10) 0% 67% 0% NA 10%

E (n=14) 14% 79% 0% 7% 7%

F (n=15) 40% 93% 57% 22% 56%

G (n=3) 0% 67% 33% NA 33%

H (n=11) 27% 60% 18% 14% 55%

I (n=14) 29% 86% 36% NA 33%

J (n=14)* 71% 100% 100% 17% 33%

K (n=14)* 71% 92% 50% 57% 78%

L (n=15) 80% 80% 80% 31% 60%

N (n=4) 50% 100% 25% 25% 25%

M (n=10) 100% 100% 100% 29% 25%

O (n=13) 17% 27% 25% 17% 17%

P (n=15)* 79% 73% 80% 0% 21%

Q (n=11) 82% 100% 80% NA 50%

R (n=10)* 90% 100% 86% 40% 57%

T (n=9) 78% 89% 100% 11% 25%

U (n=13) 92% 100% 100% 18% 30%

V (n=8) 88% 100% 100% 67% 71%

EMA Mean 57% 85% 60% 33% 40%



F2: Documentation of Referrals

Medical care Specialty care Dental care Partner notification

Referrals monitored

Other supportive services

A (n=4) 75% 33% 75% 33% 75% 0%

C (n=15) 80% 50% 8% 23% 73% 43%

D (n=10) 20% 0% 0% 0 20% 10%

E (n=14) 64% 29% 14% 0% 21% 21%

F (n=15) 92% 40% 13% 14% 82% 86%

G (n=3) 67% 0% 33% 0% 0% 33%

H (n=11) 55% 13% 44% 0% 27% 29%

I (n=14) 100% 50% 17% 17% 42% 42%

J (n=14)* 100% 36% 56% 30% 92% 67%

K (n=14)* 79% Not Asked Not Asked 14% 21% 10%

L (n=15) 93% 50% 18% 54% 93% 63%

N (n=4) 0% 0% 0% 0% 0% 0%

M (n=10) 90% 20% 75% 0% 60% 0%

O (n=13) 25% 17% 8% 8% 8% 17%

P (n=15)* 53% 33% 36% 0% 50% 23%

Q (n=11) 82% 33% 13% 0% 88% 57%

R (n=10)* 78% Not Asked Not Asked 14% 50% 50%

T (n=9) 89% 67% 0% 33% 86% 33%

U (n=13) 67% 33% 58% 17% 92% 17%

V (n=8) 100% 57% 38% 29% 100% 88%

EMA Mean 70% 33% 28% 22% 54% 34%

*= funded prior to 3/1/15; Y=aggregate rate includes medical, dental and specialty care plus referrals monitored. Due to revisions in the data collection forms, certain items were ‘Not Asked’ for the two pilot agencies.



G: Documentation of Medical Assessment/Evaluation Total EMA Aggregate Rate = 96%

Medical assessment/evaluation completed &

signed by a credentialed medical provider Completed medical assessment/evaluation

A (n=4) 100% 100%

C (n=15) 100% 100%

D (n=10) 100% 100%

E (n=14) 100% 100%

F (n=15) 100% 100%

G (n=3) 100% 100%

H (n=11) 100% 100%

I (n=14) 100% 100%

J (n=14)* 100% 100%

K (n=14)* 86% 86%

L (n=15) 100% 100%

N (n=4) 100% 100%

M (n=10) 50% 50%

O (n=13) 100% 100%

P (n=15)* 93% 93%

Q (n=11) 100% 100%

R (n=10)* 100% 100%

T (n=9) 89% 89%

U (n=13) 100% 100%

V (n=8) 100% 100%

EMA Mean 96% 96%




H1: Documentation of Completed Current Risk Assessment (H1, H2, H2) Total EMA Aggregate Rate = 63%

Completion of risk assessment during the review period

Current HIV risk factors:

MSM Heterosexual IDU Unprotected

sex

Victim of sexual assault

Victim of domestic violence

A (n=4) 50% 100% 100% 100% 50% 0 0

C (n=15) 93% 50% 50% 55% 64% 8% 8%

D (n=10) 20% 63% 30% 40% 67% 0 0

E (n=14) 57% 21% 29% 21% 50% 0 0

F (n=15) 67% 57% 33% 33% 50% 0 0

G (n=3) 67% 33% 0% 0% 0% 0 0

H (n=11) 73% 78% 80% 33% 89% 0 0

I (n=14) 36% 67% 40% 40% 75% 43% 43%

J (n=14)* 93% 100% 80% 25% 71% 15% 15%

K (n=14)* 86% 64% 45% 20% 82% 33% 50%

L (n=15) 100% 100% 88% 75% 73% 0 0

N (n=4) 90% 83% 29% 33% 33% 0 0

M (n=10) 50% 25% 0% 0% 0% 0 0

O (n=13) 54% 77% 29% 22% 67% 14% 0

P (n=15)* 87% 50% 82% 0% 56% NA 8%

Q (n=11) 91% 90% 50% 63% 82% 9% 0

R (n=10)* 70% 80% 33% 40% 70% 0 0

T (n=9) 88% 60% 60% 0% 50% 38% 25%

U (n=13) 77% 64% 42% 0% 75% 0 0

V (n=8) 100% 100% 50% 43% 75% 0 0

EMA Mean 72% 68% 48% 32% 59% 23% 7%

*= funded prior to 3/1/15; c=aggregate rate includes completion of risk assessment, MSM, heterosexual and unprotected sex.



H2: Documentation of Current Risk Assessment

Ever tested for STD/STIs

Ever diagnosed

with an STD/STI?

If yes, specify which one [counts not rates]

Syphilis Chlamydia Gonorrhea If treated, was the partner(s)

tested?

A (n=4) 100% 50% 2 - 1 -

C (n=15) 100% 50% 7 4 4 0

D (n=10) 100% 67% 8 5 4 0

E (n=14) 86% 29% 1 - - -

F (n=15) 80% 27% 4 - - -

G (n=3) 100% 67% 2 - - -

H (n=11) 91% 70% 4 1 1 -

I (n=14) 29% 17% 2 1 1 -

J (n=14)* 100% 14% 1 - 1 -

K (n=14)* 77% 20% 1 - - -

L (n=15) 93% 50% 4 2 - -

N (n=4) 0% 0% 0 0 0 0

M (n=10) 90% 20% 1 1 - -

O (n=13) 45% 36% 3 4 4 1

P (n=15)* 87% 33% 1 3 - -

Q (n=11) 100% 64% 5 0 - -

R (n=10)* 80% 86% 5 4 5 -

T (n=9) 88% 38% 1 0 - -

U (n=13) 100% 17% 2 3 2 -

V (n=8) 100% 7% 1 1 1 -

EMA Mean 82% 38% 3% 2% 2% 1%

*= funded prior to 3/1/15;



H3: Documentation of Current Risk Assessment:

Hep B? If yes, treated?

Hep C? If yes, treated?

TB? If yes, treated?

Substance use - any of the following: [counts not rates]

IDU Crack/ cocaine

Marijuana Methamphetamines

Alcohol Tobacco use

A (n=4) 100% 100% 100% 100% 75% 100% 1 3 3 - 3 4

C (n=15) 100% 80% 93% 40% 93% 75% 6 8 5 4 8 11

D (n=10) 100% 75% 70% 0% 80% 0% 7 6 7 7 9 9

E (n=14) 93% 05% 93% 40% 79% 43% 3 5 7 2 9 10

F (n=15) 67% 50% 87% 83% 67% 0% - - 4 - 7 6

G (n=3) 100% 100% 67% N/A 67% 50% - - 1 - 2 2

H (n=11) 91% 0% 91% 0% 73% 33% 1 1 1 - 3 4

I (n=14) 64% 0% 43% N/A 50% 0% 2 2 3 2 4 5

J (n=14)* 100% N/A 100% N/A 86% 0% - - 3 - 6 7

K (n=14)* 86% 20% 86% 86% 57% N/A 1 - 2 - 4 -

L (n=15) 93% 14% 93% 33% 87% 0% - 2 7 2 6 9

N (n=4) 100% 40% 80% 17% 50% 0% 2 1 1 1 4 7

M (n=10) 0% 0% 0% 0% 0% 0% - - - - - -

O (n=13) 36% 36% 36% 36% 9% 0% - 4 2 2 7 7

P (n=15)* 93% 50% 93% 38% 80% 57% - 5 4 - 11 11

Q (n=11) 82% 14% 82% 14% 73% 0% 4 1 2 - 6 5

R (n=10)* 78% 60% 70% 70% 60% 25% 1 2 2 - 5 -

T (n=9) 100% N/A 100% N/A 100% 100% - - 4 - 6 4

U (n=13) 92% 60% 92% 60% 92% 40% - 3 3 1 10 11

V (n=8) 100% 25% 100% 0% 100% 25% 3 4 6 3 6 5

EMA Mean 84% 43% 79% 39% 69% 29% 3% 3% 4% 3% 6% 7%

*= funded prior to 3/1/15; e= Total Aggregate Rate for Documentation of Risk Assessment (H1, H2, H2) = 63%



I: Documentation of Linkage/ Retention in Care Total EMA Aggregate Rate = 69%

Client received 1st clinical visit with a clinical

provider within 3 months after

a confirmed HIV test result

2 medical appointments

within the review period - 90 days apart.

Reasons the patient did not

have at least two medical

visits

Follow-up telephone calls,

letters &/or home visit) for missed appointments

Client successfully

retained 3 months

Client successfully

retained 6 months

A (n=4) 100% 100% 100% 100% 100% NA

C (n=15) 80% 93% 71% 60% 73% NA

D (n=10) 67% 30% 20% 86% 57% NA

E (n=14) 79% 64% 70% 92% 63% NA

F (n=15) 93% 73% 100% 89% 89% NA

G (n=3) 67% 33% 0% 0% 0% NA

H (n=11) 60% 36% 63% 63% 14% NA

I (n=14) 86% 57% 44% 43% 56% NA

J (n=14)* 100% 93% 91% 100% 93% 62%

K (n=14)* 92% 50% 27% 46% 46% 46%

L (n=15) 80% 73% 100% 100% 82% NA

N (n=4) 100% 70% 100% 100% 83% NA

M (n=10) 100% 0% 0% 0% 0% NA

O (n=13) 27% 17% 0% 0% 0% NA

P (n=15)* 73% 67% 70% 92% 79% 64%

Q (n=11) 100% 82% 100% 100% 100% 67%

R (n=10)* 100% 80% 67% 71% 71% 71%

T (n=9) 89% 78% 100% 100% 83% NA

U (n=13) 100% 92% 100% 100% 100% NA

V (n=8) 100% 100% 67% 100% 100% NA

EMA Mean

85% 64% 65% 72% 64% 61%

*= funded prior to 3/1/15;



The low rate of case closures may be due to the large number of newly funded agencies shown in table J. Most (80%) of the agencies had been funded/in operation for less than 12 months and the clients would not be eligible for case closure.

J: Documentation of Case Closure Total EMA Aggregate Rate = 30%

Case closure

Reason for case closure: [counts not rates]

Met milestone

Deceased

Incarcerated/sentenced to prison exceeding 90 day

Relocated out of service area

Assisted living/nursing home

Discontinued services

Lost to follow-up

No Reason

A (n=4) NA NA NA NA NA NA NA NA NA

C (n=15) NA NA NA NA NA NA NA NA NA

D (n=10) NA NA NA NA NA NA NA NA NA

E (n=14) NA NA NA NA NA NA NA NA NA

F (n=15) NA NA NA NA NA NA NA NA NA

G (n=3) NA NA NA NA NA NA NA NA NA

H (n=11) NA NA NA NA NA NA NA NA NA

I (n=14) NA NA NA NA NA NA NA NA NA

J (n=14)* 69% 4 0 0 0 0 0 0 0

K (n=14)* 0% 0 0 0 0 0 0 0 0

L (n=15) NA NA NA NA NA NA NA NA NA

N (n=4) NA NA NA NA NA NA NA NA NA

M (n=10) NA NA NA NA NA NA NA NA NA

O (n=13) NA NA NA NA NA NA NA NA NA

P (n=15)* 0% 0 0 0 0 0 0 0 0

Q (n=11) NA NA NA NA NA NA NA NA NA

R (n=10)* 50% 3 1 0 0 0 0 0 0

T (n=9) NA NA NA NA NA NA NA NA NA

U (n=13) NA NA NA NA NA NA NA NA NA

V (n=8) NA NA NA NA NA NA NA NA NA

EMA Mean 30% 3.00 1.00 1.00 1.00 1.00




FINAL SCORE FOR EIS SITE VISIT

I. Total Aggregate EMA Score for the major four EIS components = 65%

EIS Services EMA Mean

HIV Testing & Counseling 83%

Health Education & Literacy Training 51%

Linkage/Retention to Care 69%

Referral Services 57%

Total 65%

II. Total EMA Aggregate Score for all areas reviewed = 65%

Total EIS Services Reviewed EMA Mean

1. Evidence that the client signed and received a copy of all consent forms 84%

2. Documentation of HIV Testing/Counseling 83%

3. Documentation of Initial Intake 51%

4. Documentation of Service Plan 61%

5. Documentation of Health Education &Literacy Training 51%

6. Documentation of Referrals 57%

7. Documentation of Medical Assessment/Evaluation 96%

8. Documentation of Completed Risk Assessment 63%

9. Documentation of Linkage/Retention in Care 69%

10. Documentation of Case Closure 30%

Total 65%

Minimum Passing Score = 80% Total EMA Score = 65%

III. Strengths: a) 84% = Documentation of consent forms signed by the client b) 83% = Documentation of HIV Testing/Counseling. c) 96% = Documentation of Medical Assessment/Evaluation d) 94% = Confirmed HIV status e) 93% = Referral for appointment with medical provider discussed and referral provided f) 89% = Adherence counseling about HIV medications and treatment. g) 96% = Medical Assessment/Evaluation completed and signed by a licensed medical provider. h) 96% = completed Medical Assessment/Evaluation



IV. Areas of Quality Improvement (areas 70% & below)

1. Documentation of initial intake a) 53% = Documented the date of the first EIS visit at the agency. b) 48% = Completion of initial intake assessment during first contact with the client.

2. Documentation of Service Plan a) 24% = of service plans were signed by the client b) 39% = of service plans were signed by the provider c) 60% = complete service plan

3. Documentation of Health Education % Literacy Training a) 51% = documentation of complete Health education and literacy provided to the clients

4. Documentation Referrals a) 57% = Referral plan was completed within 5 business days of the initial intake. b) 70% = Documentation that the client was referred for medical care. c) 23% = was referred for dental care d) 54% = evidence that the referrals were monitored.

5. Documentation of Complete Risk Assessment a) 72% = Complete Risk Assessment.

6. Documentation of Linkage/Retention in Care a) 64% = Two medical appointment s within the review period 90 days apart. b) 65% = reasons the client did not have at least two medical visits. c) 72% = follow-up telephones calls, letters and/or home visit for missed appointment. d) 64% = Client successfully retained in care for 3 month

*All items below 80% are areas for quality improvement.

V. Quality improvement plan for agencies with a total score of 60 and below:

All Delegate Agencies will receive 1-2 mandatory EIS trainings (TBA).

Agencies with a total score of 60 and below will require individual technical assistance.

EIS will be one of the service categories selected for the annual site review for 2017

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