provided; Participate in QI processes such as Case Management Task Force; Participate in IPG and CAREAssist Advisory Group, QM Task Force; Meet Standards of Service; Implement their own QI programs. trainings; Technical assistance; Summary report on the Local CM Chart Review distributed; Reports at IPG and CAREAssist Advisory Group; Reports & survey results posted on web site. IPG Members Provide input and advise; Participate in discussions about data and information; Make recommendations; Review written reports. Written & verbal reports at IPG meetings; Reports & survey results posted on web site. Oregon HIV Services QM Task Force Provide input; Shared knowledge and education about QM methodology & issues; Networking and collaboration toward standardization statewide. Reports at meetings. Reports & survey results posted on each program’s web sites. HIV Care & Treatment staff Provide data. Provide analysis of data. Provide suggestions on improvement. Implement improvement activities. Review program reports. Assist in writing grant applications – the QM components. Staff meetings. Reports. Participation at IPG, CAREAssist Advisory Group and the QM Task Force. Program Design & Evaluation Services Provide evaluation skills. Evaluate program components. Develop reports on findings. Report to IPG, CAREAssist Advisory Group & QM Task Force. Staff meetings. Reports. Participation at IPG, CAREAssist Advisory Group and the QM Task Force.
8. Special evaluation projects Data Reported Time Line Source Oregon Medical Monitoring Project (Needs data, treatment outcomes data, risk assessment data) Annual Update provided since 2008 Program Design & Evaluation Services (PDES) Medical Care Coordination Pilot “2010 HIV Case Management QM Survey: Results from the Baseline Assessment of the Pilot Service Region” Completed August 2009 Program Design & Evaluation Services (PDES) Medical Care Coordination Pilot “2010 HIV Case Management QM Survey: Results from the Follow-up Assessment of the Pilot Service Region” Completed September 2010 HIV Case Management: A Case Study of a Regional Collaboration (evaluation of best practice of MD and Medical Case Management quarterly case conferencing) Completed June 2010 2009 CAREAssist Client Survey: A Report on Clients’ Health and Well-Being and their Experiences with the Program. Completed January 2010 Time to Quit: CAREAssist Clients’ Smoking Cessation Experiences Completed July 2009 An Evaluation of Access and Care Delivery Barriers for Latino PLWH/A in the Part B Region of Oregon Completed April 2009 Oregon Medical Practices that Provide HIV Care: 2008 Snapshot Completed April 2008 There are two models of medical case management offered in Oregon Balance of State. The County-Led Medical Case Management model (33% of clients in case management in the Balance of State) is the traditional public health nurse model of case management and was offered in Clatsop, Crook, Deschutes, Hood River, Jackson, Jefferson, Linn, Polk and Tillamook counties
Proportion of clients who have health insurance increases over time. Change in the number of clients with reported “primary source of insurance” and health insurance. Number and percent of clients with “no primary source of insurance” and no health insurance in record and the number and percent of HIV-positive clients with record of “primary source of insurance” and health insurance. Source: CARE Ware & CM Chart Review. Reported by case managers. County Led CM: Quality of life of Ryan White Program clients is improved or maintained over time. Increased percentage of aggregate clients in Acuity Levels #1 and 2, over a twelve month period of time Case manager reported acuity level results for individual clients every twelve months. Sources: County Led CM CARE Ware. Reported by case managers in County Led CM. County Led CM: Number of clients adhering to HIV medications regime increases over time. Increased percentage of aggregate clients who are assessed in the Adherence Life Stage at Acuity Level #1 and #2, over a twelve month period of time. Case manager reported Adherence acuity level results for individual clients every twelve months. Source: County Led CM CARE Ware. Reported by case managers in County Led CM. Number of clients receiving HIV-related treatment that adheres to PHS standards increases over time. Increased percentage of aggregate clients who have current (within past 12 months) labs in their case management files. Increased percentage of aggregate clients who have a CD4 or VL test result reported in the database within the past 12 months. Increased percentage of clients in CAREAssist who report having a CD4 or VL within the past 6 months on their re-certification Current labs appear in the client file. Case manager reported CD4 and VL for individual clients every twelve months. Client reported CD4 and VL test dates on CAREAssist application every 6 months. Source: CM Chart Review. CAREWare. Reported by case managers. CAREAssist database.
application. Increased percentage of statewide aggregate clients in HARS with a CD4 or VL test in the first 6 months of the reporting period and the second 6 months of the reporting period. CD4 and VL tests reported to surveillance by laboratories. eHARS database. Number of clients receiving HIV-related treatment that adheres to PHS standards increases over time. Increased percentage of statewide aggregate clients in HARS with a CD4 test in the first 6 months of the reporting period and the second 6 months of the reporting period or a VL test in the first 6 months of the reporting period and the second 6 months of the reporting period. CD4 and VL tests reported to surveillance office by laboratories. Source: eHARS database. Persons with HIV are identified early in their disease progression and are able to access services earlier with better health outcomes. Decreased number of individuals newly reported with HIV infection who also have an AIDS diagnosis. Number of individuals newly reported with HIV infection who also have an AIDS diagnosis vs. total number of individuals who were reported. Source: eHARS database. Persons with HIV are accessing HIV treatment to slow the progression of HIV to AIDS. Decreased number of individuals who progress from HIV to AIDS within a 12 month period. Number of individuals newly reported with HIV (not AIDS) who progress to an AIDS diagnosis within 12 months of HIV diagnosis vs. total number of individuals newly reported with HIV. Source: eHARS database. Persons with HIV are successfully accessing HIV treatment. Decreased number of individuals with HIV who die within 12 months of their diagnosis. Number of individuals who die within 12 months of their HIV diagnosis vs. total number of individuals Source: eHARS database.
Outcomes Indicators Data Source(s) 2009 2010 2011 2012 Quality of life of CARE Act clients is improved or maintained over time. Acuity Assessment Level Clients with Acuity updated at least annually CAREWare Acuity 1 Acuity 2 Acuity 3 Acuity 4 29% 53% 15% 4% 76% 26% 57% 16% 1% 79% County-Led CM 23% 63% 13% 1% 84% County-Led CM 20% 67% 13% 0% 81% Disease progression among case managed clients is slowed or prevented over time. CD4 of 200 or above Viral load of 10,000 or below eHARS (CAREWare) 78% 78% 81% (87/%) 80% (90%) 81% (87%) 82% (92%) (Combined) 83% (88%) 84% (93%) (Combined) Proportion of clients accessing primary health care services increases over time. Clients with primary care provider reported CAREWare 93% 95% Combined 98% Combined 98% Proportion of clients who have primary medical treatment payer increases over time. Clients reporting a primary medical treatment payer CAREWare 90% 93% Combined 96% Combined 95% Outcomes Indicators Data Source(s) 2009 2010 2011 2012
Number of clients adhering to HIV medications regime increases over time. Adherence Stage 1 Adherence Stage 2 Adherence Stage 3 Adherence Stage 4 Adherence assessment reported CAREWare CAREWare 69% 15% 13% 2% 88% 69% 17% 10% 4% 89% County-Led CM 73% 14% 9% 5% 94% County-Led CM 73% 11% 9% 7% 97% Primary care services meet HIV-related treatment standards. Reported CD4 or VL within the last 12 months. CAREWare 83% 84% Combined 95% Combined 86% Clients are finding out their HIV status early in their disease progression. AIDS status of newly reported HIV diagnosis (% who also have AIDS). eHARS 39% 36% 30% 47% Clients are getting into CAREAssist (and treatment) early in their disease progression. AIDS status of newly enrolled CAREAssist clients. (% who have AIDS). eHARS 53% 47% 53% 56% MCC Regional: Clients remain in medical case management. Total number of active clients "lost to follow-up" over 12 months period. CAREWare (MCC Regional) N/A N/A 1.3% 1.3%
new clients will have an RN Assessment & RN Acuity. Assessment & Acuity and documentation completed. (MCC Regional) Chart Review 100% 100% MCC Regional: All new clients will have a CC Screening & CC Acuity. Clients receiving CC Screening & Acuity and documentation completed. CAREWare (MCC Regional) Chart Review N/A N/A 95% 100% 79% 100% MCC Regional: All CC Acuity 1 or 2 clients will have an Intake/Update service entry within the past 12 months. CC Acuity 1 or 2 clients receiving an annual Update have a service entry completed. Chart Review N/A N/A 89% 76% MCC Regional: All CC Acuity 1 or 2 clients will have a CC and RN Triage service entry within the past 12 months. CC Acuity 1 or 2 clients receiving a CC and RN Triage will have a service entry completed. Chart Review N/A N/A 100% 78% MCC Regional: All CC Acuity 3 and 4 clients will have a CC Screening and Acuity service entry within the past 12 months. CC Acuity 3 and 4 clients will receive an annual CC Screening and have an updated Acuity service entry completed. CAREWare (MCC Regional) Chart Review N/A N/A 92% 100% 69% 83% MCC Regional: All CC CC Acuity 3 clients
Acuity 3 clients will have a CC contact within the past 30 days. receive a CC contact every 30 days with service entry completed. CAREWare (MCC Regional) N/A N/A 91% 88% MCC Regional: All CC Acuity 4 clients will have a CC contact within the past 14 days. CC Acuity 4 clients receive a CC contact every 14 days with service entry completed. CAREWare (MCC Regional) N/A N/A 100% 100% County Led: All clients in HIV Medical Case Management will have a current Care Plan in their file. Clients receiving HIV Medical Case Management have an updated Care Plan documented either on the Care Plan form or using the CAREWare template. CAREWare (County Led) 87% 88% 90% 97% MCC Regional: All RN Acuity 3 and 4 clients will have a current Nursing Care Plan. RN Acuity 3 and 4 clients will have an updated (based on acuity level) Nursing Care Plan using CAREWare template. Chart Review N/A N/A 100% 100% MCC Regional: All RN Acuity 3 and 4 clients will have received an RN intervention in RN Acuity 3 and 4 clients will have an received an RN intervention and the CAREWare (MCC Regional) Chart Review N/A N/A 92% 100% 91% 100%