ryan white title i – st. louis ema grantee: city of st. louis, department of health
DESCRIPTION
Ryan White Title I – St. Louis EMA Grantee: City of St. Louis, Department of Health. 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; - PowerPoint PPT PresentationTRANSCRIPT
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)
National Quality Center (NQC)3
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
National Quality Center (NQC)4
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
National Quality Center (NQC)5
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?
National Quality Center (NQC)6
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
National Quality Center (NQC)7
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”
National Quality Center (NQC)8
Example of Results Sent to Providers
National Quality Center (NQC)9
Client-level graph:Effects of HARRT started June 20
National Quality Center (NQC)10
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
National Quality Center (NQC)11
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