Panel of Presenters: Lena Lago, MPH, M&E Branch Manager, Care Bureau, HAHSTA/DC DOH

1. Impact of DC EMA Cross-Part Collaborative on DC/WV/VA AIDS Drugs Assistance Programs Panel of Presenters: Lena Lago, MPH, M&E Branch Manager, Care Bureau, HAHSTA/DC DOH Damber K. Gurung, Ph.D., M&E Specialist, Care Bureau, HAHSTA/DC DOH Jay Adams, MA, Ryan White Part B Program, WV DOH Anne Rhodes, MS, Services Analyst, HIV Care Services, Virginia DOH

2. Organization of Panel Presentation • Overview of DC EMA Cross-Part Collaborative • Impact of the Collaborative on DC ADAP Client Enrollment Process • Virginia Experience with DC EMA Cross part Collaborative • West Virginia Experience with DC EMA Cross part Collaborative

3. Overview: District of Columbia Eligible Metropolitan Area Cross-Part Collaborative Lena Lago

4. DC EMA Collaborative: Overview • Sponsored by HRSA and managed by the National Quality Center (NQC) • All-Parts (A, B, C, D, and F) Ryan White Program-funded grantees in the Washington, D.C. EMA, including • Maryland • Virginia and • West Virginia • Initiated March 2011 to continue to September 2012

5. DC EMA Collaborative: Activities and Timeline

6. IHI Breakthrough Series - Collaborative Model Source: National Quality Center application of The Breakthrough Series: Institute for Health Improvement (IHI) Collaborative Model for Achieving Breakthrough Improvement; 2003

7. DC EMA Collaborative: Purpose Statement The HRSA HIV/AIDS Bureau (HAB) sponsored the development of the D.C. Quality Management Cross-Part Collaborative: • To strengthen the regional capacity for collaboration across Ryan White Parts (Parts A, B, C, D and F), • For alignment of quality management goals to jointly meet the Ryan White HIV/AIDS Program legislative mandates, • For joint quality improvement activities to advance the quality of care for people living with HIV across constituencies within a region, and • To coordinate HIV services seamlessly across Parts.

8. DC EMA Collaborative: Performance Measures Adult/Adolescent Measures (6): • Viral Load Testing Frequency • Viral Load Suppression • Medical Visits • Syphilis Screening • PCP Prophylaxis • Oral Exam

9. DC EMA Collaborative: Performance Measures ADAP Measures (2): • ADAP Applications (Measure #14) - Percentage of ADAP applications approved or denied for new ADAP enrollment within 14 days (two weeks) of ADAP receiving a complete application in the measurement year • ADAP Eligibility Recertification (Measure #15) - Percentage of ADAP enrollees who are reviewed for continued ADAP eligibility two or more times in the measurement year

10. DC EMA Collaborative: EMA-Wide ADAP Data Rounds 1-6 Trends

11. DC EMA Collaborative: Accomplishments • Strengthened partnerships across Parts in the Washington, D.C. EMA as evidenced by established communication strategies for the purpose of collaboration for quality management; region-wide quality management priorities; and joint training opportunities. • A portfolio of performance measures in place for strategic planning and quality improvement processes and data are routinely collected based on standardized data collection methodologies. • A unified, regional Cross-Part quality management plan in place for the Washington, D.C. EMA area; supported by a work plan for implementation. • Joint quality improvement projects initiated and each grantee contributes to the success.

12. Impact of Cross-Part Collaborative on DC ADAP Client Enrollment Process Damber K. Gurung

13. DC ADAP: Client Enrollment • Client eligibility criteria: • DC Resident, 500% FPL, Asset Limit ($25,000), HIV+ • Clients must recertify every six months • Clients must fill prescriptions at participating pharmacies (#21): • Use one proprietary pharmacy database (Pharmacy Benefit Manager) • Formulary - 105 drugs including all antiretroviral drugs (n = 28 in 2010/2011)

14. DC ADAP Profile: Clients Enrolled (June, 2010–2012)

15. DC ADAP Profile: Clients Served (June, 2010 – 2012)

16. DC ADAP Client: Monthly Enrolled and Served (Trend: 2007 to 2012)

17. DC ADAP Client Enrollment Business Process To be inserted

18. ADAP (New) Applications (Measures #14): Process or Challenges DENOMINATOR: # Clients who have newly applied for ADAP assistance; • New client applications • Identifying New clients vs. Recertified clients; Unidentified clients • Missing data: dates, approval • Data error: approval dates earlier than Application received dates • Duplicate new applications • Applicants multiple ethnicities

19. ADAP (New) Applications (Measures #14): Process or Challenges (contd.) NUMERATOR: # New clients’ approved/denied within 2 weeks of ADAP receiving a complete application • Exclude applicants who were approved >14 days after (complete) application was received • Adjusting applicants’ multiple ethnicities

20. ADAP Recertification (Measures #15): Process or Challenges DENOMINATOR: ADAP Enrollees reviewed for continuous eligibility • Identify Recertifying clients • Include recertifying clients from “New client” category • Exclude clients who were termed within 180 days of the measuring period • Exclude applications with data error or data missing • Adjusting applicants’ multiple ethnicities

21. ADAP Recertification (Measures #15): Process or Challenges (Contd.) NUMERATOR: ADAP Enrollees reviewed 2 or more times (150 days part) for continued eligibility – Process or Challenge • Selection of clients - recertified 2 or more times • Selection of clients - recertified 2 or more times at least 150 days apart

22. The PDSA Cycle for Learning and Improvement The Source: National Quality Center (NQC), The Quality Academy Tutorial The PDSA Cycle

23. PDSA Cycle: PLAN (Plan a change) • OBJECTIVE: Continuous Quality Improvement (CQI) in client enrollment process • The plan was implemented by CHSS Bureau’s M&E team and involved ADAP log (access database) as well as all ADAP staff. • Planning started in October 2011; Plan included • System change: Changes in database parameters • Process improvement: Standardizing processes of data field identification and data entry; Training

24. PDSA Cycle: DO(Try it out on small scale) • Data manager & ADAP staff collaborated to identify action steps for projected system change and process improvement • Identification of parameters for change- data fields, date ranges

25. PDSA Cycle: DO(Action Items) • Reconfigure database making relevant fields required for approved clients • Communicate with program staff on client type (New or Recert) definition and classification • Reconfigure data system using validation rule to avoid errors • Development/implementation of standard data entry procedure • Brainstorm corrective measures with program staff

26. PDSA Cycle : STUDY (Observe the Results) • Measuring rate of completion: • Client type (new or recertification) identification • Approval date • Approval date together with approved by (Enrollment Specialist’s Name) • Comparison: Rate of completion were to be compared between before and after the changes

27. PDSA Cycle : STUDY QI Results

28. PDSA Cycle: ACT(Action Items) • Communicate with program staff on issues • Brainstorm corrective measures with program staff • Development/implementation of standard data entry procedure • Plan System Interventions • Plan Mini Projects for continuous Improvement

29. DC ADAP New Application (Measure # 14) Trend

30. DC ADAP Recertification (Measure # 15)Trend

31. DC ADAP Enrollment -Collaborative Measures Trend (2011-2012)

32. LESSONS LEARNED & Challenges • Measurements reveal inadequacies in data, systems and processes • Mini-projects can sustainably improve data quality impacting program outcome • Engaging stakeholders is crucial for sustained quality improvement • QI must continue regardless of changing environment

33. Virginia’s experience: DC EMA Cross-part Collaborative by Anne Rhodes

34. VA ADAP: Persons and Cost, 2010-2012 Source: VA-ADAP database, Division of Disease Prevention, Virginia Department of Health, August 2012

35. VA-ADAP: Eligibility Process 2010 • Contractor site conducted eligibility • Data sent monthly to VDH • Prescription data stored in a separate database housed at a university contractor • Data completeness/data matching issues

36. VA-ADAP Current Eligibility Process Clients and/or case worker submit ADAP applications to VDH. ADAP Operations Technicians (AOT) process client applications. A peer reviews application and supporting documents. AOT sends letter to client. ADAP Operation Specialist determines final disposition for client applications. AOT faxes statement to provider. ADAP Data Manager enters client information into ADAP database. AOT faxes statement to local health department. AOT faxes statement to Central Pharmacy.

37. VMARS: VA Medication Access Reporting System • Online report that provides updated eligibility information to local health departments and medical providers • Includes date of last fill for ADAP Rx (if available), along with application approval date • LHD Staff and medical site complete application and send to VDH ADAP for approval before being assigned logon for system

38. Database(s)

39. PDSA Cycle: PLAN • OBJECTIVE: Improve application and recertification process for ADAP to ensure all needed data were collected and potential payer sources were checked • The plan was implemented by VDH’s HIV Care Services unit • The plan included • System change: Move of ADAP eligibility processes in-house to VDH • Process improvement: Data matches, uniform recertification processes

40. PDSA Cycle: DO • Contract staff were hired at VDH to conduct re-certifications and to be trained in conducting eligibilities • ADAP application redesigned to include all ADR elements and to capture more insurance and other payer source information • Contract with eligibility company was phased out in June 2012

41. PDSA Cycle : STUDY • Measuring time of application completion: • Client type (new or recertification) • Application date • Approval date • Measuring percent of clients found to have other payer sources

42. VA-ADAP Indicators

43. PDSA Cycle: ACT Anticipated Outcomes • % of clients found to have other payer source will increase from 11% to 15% • Time from application to disposition will decrease from 7.6 days to 4 days • Data currently show average time to disposition of 5.4 days

44. QUESTIONS & ANSWERS? Contact: damber.gurung@dc.gov