Maintaining and Improving a System of Care 1

1. Maintaining and Improving a System of Care 1 Slides for Module 7

2. Maintaining and Improving a System of Care 2 • Concept of a System of Care • Maintaining and Improving a System of Care through Service Standard, CQM and Coordination of Services • Assessment of the Efficiency of the Administrative Mechanism • How the PC/PB Helps Improve the System of Care

3. Concept of a System of Care • Defining and Understanding the System of Care • Shared Responsibility for the System of Care

4. Training Objectives: Concept of a System of Care Following this portion of the training, participants will be able to: • Define and describe a “comprehensive system of HIV care” • Describe the shared responsibility of the PC/PB and recipients in establishing, maintaining, and improving the local system of care

5. Centrality of the System of Care • RWHAP exists to support a system of comprehensive, appropriate core medical and support services for people living with HIV that have limited financial resources • In its early years, RWHAP helped to establish a continuum or system of HIV care • Current focus is on maintaining, assessing, and improving the system of care to reflect changes in the epidemic, prevention, treatment, and the broader health care system―and integrating prevention and care • PC/PB and recipient share responsibility for improving the system of care

6. Legislative Language Part A funds must support: • “core medical services that are needed in the eligible area for individuals with HIV/AIDS” including services related to “co-occurring conditions” ― [§2604(c)(1)] • Support services “that are needed for individuals with HIV/AIDS to achieve their medical outcomes”― [§2604(d)(1)]

7. HRSA/HAB Expectations for a Comprehensive System of Care • System of care is not limited to services paid for through RWHAP funds • The annual Part A application asks for a “description of the comprehensive system of care in the entire EMA/TGA, including the available core medical and support services funded by RWHAP Part A and by other sources, where services are located, and how clients access those services, including services for disproportionately impacted subpopulation(s) supported by MAI funds” [FY 2019 Notice of Funding Opportunity, p 11]

8. HRSA/HAB Expectations (cont.) RWHAP “requires services to be provided in a coordinated, cost-effective manner” and be “coordinated with all other public funding for HIV/AIDS” in order to: • Ensure that RWHAP is the “payor of last resort” • “Maximize the number and accessibility of services available” • “Reduce any duplication” − Part A Manual, pp 15-16

9. HRSA/HAB Expectations (cont.) The system of care should: • “address the service needs of newly affected and underserved populations – including disproportionately impacted communities of color and emerging populations” • “be consistent with HSRA’s goals of increasing access to services and decreasing HIV/AIDS health disparities…” • “be designed to address the needs of PLWH across all life stages” from being unaware of their “HIV status, through HIV counseling and testing, early intervention and linkage to care, to retention in care and treatment adherence”− Part A Manual, pp 15-16

10. Desired Characteristics of a Comprehensive System of Care • Availability of both core medical and support services • Accessible services– in terms of location, public transportation, and service hours • Appropriate services for diverse PLWH populations based on such characteristics as race/ethnicity, sexual orientation, gender/gender identity, age, and risk factor – provider staff speak needed languages and are culturally competent, with appropriate training and skills • Effective services that meet performance standards and contribute to viral suppression and other positive medical outcomes

11. Shared Responsibility for the System of Care The PC/PB: • Assesses service needs and gaps, which requires reviewing the existing system of care – including RWHAP-funded and other core medical and support services • Establishes service priorities and allocates Part A and Part A Minority AIDS Initiative (MAI) funds to specific service categories • Provides guidance and models for meeting service needs overall and for particular PLWH subpopulations, through use of tools like directives and service standards

12. Shared Responsibility for the System of Care (cont.) The Recipient: • Contracts with providers to deliver services • Specifies service requirements in RFPs and subrecipient agreements • Monitors subrecipients to ensure service quality • Manages a CQM program with subrecipients that: • Measures performance and medical outcomes • Implements quality improvement efforts • Coordinates with other RWHAP Parts and other public and private funders and services

13. Quick Scenario A: Describing the Local System of Care Suppose you meet a person with HIV who receives HIV care through RWHAP in another city but is thinking of moving to your EMA/TGA. That person asks you to “tell me about the system of HIV care, and how I can get access to both medical and support services.” • What would you say if the question came from: • A young MSM of color? • A transgender woman? • A long-time HIV survivor aged 60+? • How prepared are you to answer this question?

14. Service Standards, CQM and Coordination of Services • Development and Use of Service Standards • Role of Clinical Quality Management • Coordination of Services/Relationships with Other Programs

15. Training Objectives: Maintaining and Improving a System of Care Following this portion of the training, participants will be able to: Service Standards • Define “service standards” • Identify ways service standards are used by consumers, subrecipients, PC/PBs, recipients and Quality Managers • Describe a process for developing service standards

16. Training Objectives: Maintaining, and Improving a System of Care (cont.) Clinical Quality Management • Explain the concept of Clinical Quality Management (CQM) and the legislative requirement of the RWHAP to implement a CQM program • Identify and describe the three main components of a CQM Program • Describe at least 3 ways PC/PBs use CQM data Coordination of Services: • Explain HRSA/HAB expectations for PC/PB involvement in the coordination of services and relationships with other programs

17. Development and Use of Service Standards • Understanding Service Standards • Use of Service Standards • Development and Updating of Service Standards

18. What are Service Standards? • Written guidelines that outline for subrecipients the elements and expectations for implementing a service category in the EMA or TGA • Designed to: • Ensure that all subrecipients provide the same basic service components • Establish a minimal level of service or care • A jurisdiction’s service standards include: • Universal service standards that apply to all service categories • Separate standards for each funded service category

19. HRSA/HAB Expectations for Service Standards • Responsibility not addressed directly in the legislation • HRSA/HAB Guidance says that: • Recipient is “responsible for the development, distribution, and use of service standards” • For Part A programs, “developing service standards is a shared responsibility, typically led by the Planning Council” Service Standards: Guidance for Ryan White HIV/AIDS Program Grantees/Planning Bodies

20. Service Standards: A Tool for Many Users • Consumers: Any consumer should be able to read service standards and know what to expect “when accessing or receiving RWHAP funded services” • Subrecipients/Service Providers: “Service standards define the core components of a service category to be included in the model of service delivery” • PC/PBs: Service standards help PC/PBs understand what activities are being provided by subrecipients – and can help them identify possible changes/improvements Service Standards: Guidance for Ryan White HIV/AIDS Program Grantees/Planning Bodies

21. Service Standards: A Tool for Many Users (cont.) • Recipient: Service standards are used in Requests for Proposals, subrecipient contracts, and monitoring (including site visits and chart reviews) “to ensure that services are provided to clients in a consistent manner across service providers” • Quality Managers: “Service standards are the foundation for the clinical quality management program, and provide the framework and service provision from which processes and outcomes are measured” Service Standards: Guidance for Ryan White HIV/AIDS Program Grantees/Planning Bodies

22. Understanding Service Standards (cont.) 1 • Medical care standards must be consistent with HHS/Public Health Service (PHS) “care and treatment guidelines and other clinical and professional standards” • Non-clinical/support services may use “evidence-based best practices, National Monitoring Standards, and/or guidelines developed by state or local government” Service Standards: Guidance for Ryan White HIV/AIDS Program Grantees/Planning Bodies

23. Understanding Service Standards (cont.) 2 • Term used was previously “standards of care,” but that language has been used outside RWHAP to mean medical care and treatment – and RWHAP service standards cover both medical and support services • National service standards are not feasible due to: • Differences in state and local requirements • The need to tailor services to meet the needs of the jurisdictions

24. Understanding Service Standards (cont.) 3 • Service standards should be readily available to providers, consumers, and the public – on the recipient and/or PC/PB website • Service standards should describe the services so that anyone who reads them can understand: • What the service is • What a client can expect when receiving the service

25. HRSA-Recommended Topics to Address in Service Standards • Service Category Definition • Intake and Eligibility • Key Service Components and Activities • Personnel Qualifications (including licensure) • Assessment and Service Plan* • Transition and Discharge • Case Closure Protocol • Client Rights and Responsibilities • Grievance Process • Cultural and Linguistic Competency • Privacy and Confidentiality (including securing records) • Recertification Requirements* *Where Applicable

26. HRSA/HAB Guidance: Performance and Health Outcome Measures • Jurisdictions should NOT include performance measures or health outcomes in their service standards • Use of these measures is a recipient responsibility: • Recipients include performance standards in their RFPs • Potential subrecipients indicate in the application their ability to meet the performance standards • Selected subrecipients have performance measures in their contracts • Recipient monitoring addresses whether these measures, which are based on the service standards, are being met • Recipient monitoring for compliance is an administrative function

27. Developing Service Standards • Assign responsibility – usually to a PC/PB committee such as Care Strategy or System of Care • Determine priorities for development of service standards • Include all service categories that are currently funded or have been allocated funds for the next program year • Agree on the order of development based on clear criteria such as a service category’s allocation level or local priority • Set a timeline that fits into your annual calendar • Review and agree on an outline to be used for all service category-specific service standards

28. Developing Service Standards (cont.) 1 • Develop Universal Standards that apply to all service categories: • Include programmatic and fiscal requirements in the RWHAP Part A National Monitoring Standards • Address such topics as: • Access to Services • Agency Policies & Procedures • Client Rights & Responsibilities • Cultural & Linguistic Competence • Grievance Process • Personnel, Training, Licensing & Supervision • Intake and Eligibility • Transition and Discharge • Privacy & Confidentiality • Program Safety

29. Developing Service Standards (cont.) 2 • Establish a process for drafting service standards that: • Includes a review of federal guidelines, standards from other jurisdictions, and relevant state and local requirements • Includes ongoing recipient representation/participation • Provides for systematic technical input from providers, consumers, and other experts, including RWHAP-funded and other service providers • Manages potential conflict of interest by ensuring that subrecipients do not dominate in numbers or influence • Uses a combination of meetings and written input and reviews

30. Developing Service Standards (cont.) • Develop service standards using the agreed-upon process • Reference Universal Standards but do not repeat their content in service category-specific standards • Present draft standards for review by the PC/PB and recipient • Make needed revisions,then allow for external review by providers, consumers, and other experts • Consider and integrate external input to draft standards • Finalize service standards by vote of the PC/PB

31. Reviewing and Updating Service Standards: Use of Outcome Data • Review of outcomes is essential to measure the impact of RWHAP services • The PC/PB should consider the following • Are some outcome measures, as shared with the PC/PB, unacceptably low – for example, failure to reach adherence goals or low levels of viral suppression? • Does aggregate monitoring data from the recipient indicate that subrecipients are fully compliant with service standards? • If the answer to both questions is yes, then perhaps service standards may be outdated and need to be reviewed and refined

32. Reviewing and Updating Service Standards • Review and update standards as needed to incorporate: • The need for changes to improve outcomes • Legislative or HRSA/HAB administrative changes in service category definitions and descriptions • Changes in guidelines for HIV care and treatment • New or revised state or local requirements (e.g., licensing or certification changes) • Review all standards at least every 3 years, on a pre-determined cycle • Obtain technical input and public review from the same types of sources as in original development

33. Quick Scenario B: Updating Service Standards You are the PC/PB Care Strategy Committee. It has been 4 years since your service standards were updated. A comprehensive site visit from HRSA/HAB is scheduled in about 5 months and you want to move quickly on standards review and updates. The committee Co-Chair, who runs a large subrecipient, suggests the committee focus on the 4 service categories with the most funding, work with PC/PB and recipient staff to make essential updates based on HRSA/HAB guidance, and then ask the subrecipients providing those services to provide input for committee review and action. • Is this a good idea? Why or why not? • What might the committee do instead?

34. Clinical Quality Management: A Recipient Responsibility • Understanding CQM • Recipient Role • PC/PB Use of CQM Data

35. Legislative Language: CQM “REQUIREMENT- The chief elected official of an eligible area that receives a grant under [Part A] shall provide for the establishment of a clinical quality management program to assess the extent to which HIV health services provided to patients under the grant are consistent with the most recent Public Health Service guidelines for the treatment of HIV/AIDS and related opportunistic infection, and as applicable, to develop strategies for ensuring that such services are consistent with the guidelines for improvement in the access to and quality of HIV health services” ―§2604(h)(5)(A)

36. Funding for CQM • Legislation allows for activities associated with CQM to be supported with up to the lesser of: • 5 percent of the grant amount • $3 million • CQM activities are not considered administrative expenses • CQM funds must not be used to cover administrative costs

37. Clinical Quality Management Involves the coordination of activities aimed at improving: • Patient care • Health outcomes • Patient satisfaction

38. HRSA/HAB Expectations • CQM is a recipient responsibility • Part A PC/PB usually has primary responsibility for development of service standards, which are used in CQM but are a separate administrative activity • PC/PB should review CQM data for use in decision making such as: • Development or refinement of service standards • Priority setting and resource allocation • Development of directives

39. HRSA/HAB Expectations (cont.) 1 • Requirements described in Policy Clarification Notice (PCN) 15-02 • Recipient works directly with subrecipients to implement, monitor, and provide needed data on the CQM program • Recipients under RWHAP Parts A, B, C, and D all establish CQM programs • Coordination across all RWHAP-funded recipients and subrecipients is encouraged, to: • Reduce data burden • Align performance measurement • Maximize the impact of improved health outcomes

40. CQM Components • Infrastructure – provides capacity to plan, implement, and evaluate CQM program activities • Performance Measurement – the process of collecting, analyzing, and reporting data regarding patient care, health outcomes, and patient satisfaction • Quality Improvement – the development and implementation of quality improvement activities to make changes to the program in response to the data from performance measurement

41. CQM Component: Infrastructure • Includes leadership, dedicated staffing and resources, stakeholder involvement, a CQM Plan, and evaluation of the CQM program • Requires a CQM committee established by the recipient that develops the program and related activities • CQM Committee is not a PC/PB committee • Recipient may choose to include some PC/PB representatives as members • Includes involvement of consumers • Consumers often serve on the CQM Committee, but need not be PC/PB members • Can be trained to serve as quality advocates in their communities and participate in quality improvement activities

42. CQM Component: Performance Measurement • Selection of a portfolio of measures that best assess the services the recipient is funding – and reflect local HIV epidemiology and identified needs of PLWH – to include: • At least 2 performance measures for every funded service category where ≥50% of the recipient’s eligible clients receive at least 1 unit of service • At least 1 performance measure for every service category where greater than15% and less than 50% of the recipient’s eligible clients receive at least 1 unit of service • No measure need be identified for a service category where ≤15% of eligible clients receive at least 1 unit of service • An identified process to regularly collect, analyze, and report performance measure data at least quarterly

43. CQM Component: Quality Improvement Quality Improvement activities are: • Aimed at improving patient care, health outcomes, and patient satisfaction • Implemented using a defined approach or methodology • Carried out in an organized, systematic fashion – so the recipient can understand whether the changes or improvements had a positive impact or further changes are needed • Documented in writing

44. PC/PB Use of CQM Data • PC/PB should receive CQM data such as: • Performance and outcomes data overall and by service category • Aggregated data on service access, patient care, health outcomes, and consumer satisfaction • Information on the extent to which support services contribute to positive medical outcomes • Results of quality improvement projects • PC/PB uses CQM data for decision making about: • Allocation • Service models • Directives to improve services in particular geographic areas or for particular PLWH subpopulations

45. Quick Scenario C: Using CQM Data Your PC/PB is very concerned about low rates of retention and viral suppression among male Latino RWHAP clients, as reported in HIV care continuum data. You recently held 2 focus groups and a key informant session, which identified language issues, insufficient evening or weekend service hours, and limited awareness of the importance of early and continued antiretroviral therapy. The recipient’s Quality Manager tells the committee that this is also a priority concern of the CQM program. • How might the PC/PB benefit from the work of the CQM program in addressing this problem?

46. Coordination of Services/ Relationships with Other Programs • HRSA/HAB Expectations • PC/PB Strategies for Service Coordination

47. HRSA/HAB Expectations for Service Coordination • HRSA/HAB “expects to see collaboration, partnering and coordination between multiple sources of treatment, care and HIV testing, and HIV prevention service providers” • “In a mature continuum of care, collaboration between HIV testing sites, non-Ryan White Program providers, all Ryan White Program Parts (A, B, C, D, and F), Medicaid, and Veterans Administration should be established and maintained in the planning and implementation of services” ―Part A Manual, p 16

48. HRSA/HAB Expectations (cont.) B Recipients “are required to participate in an established HIV community-based continuum of care if such continuum exists within the area and maintain appropriate referral relationships with entities considered key points of access to the healthcare system” ―Part A Manual, p 15

49. PC/PB Role in Coordination of Services • PC/PB is a logical place for coordination of services/discussion of relationships among programs because of its composition--including representatives of: • Other RWHAP Parts • Other federal HIV programs – e.g., prevention, Housing Opportunities for Persons with AIDS (HOPWA) • Providers of a wide range of core medical and support services • Diverse consumers • Integrated/comprehensive plan includes an inventory of services and funding

50. PC/PB Role in Coordination of Services (cont.) 1 • PC/PB should keep informed about full range of HIV-related services, regardless of funding source • Committee responsible for system of care might discuss services funded through other Parts and provide a summary to the full PC/PB • PC/PB reviews data on other funding streams annually before doing resource allocation • PC/PB may hold roundtables with service providers to discuss issues, challenges, and opportunities to improve collaboration • Discussions must include management of Conflict of Interest for subrecipients