Early Intervention Services (EIS) Learning Collaborative Series - - PowerPoint PPT Presentation

CDPH Ryan White Part A Early Intervention Services (EIS) Learning Collaborative Series Meeting #2

Tuesday, September 20, 2016

Agenda

• Welcome
• Learning Collaborative Structure & Requirements Recap
• EIS Service Category Refresher
• Quality Improvement Check-In: Where Your Agency Should Be
• Agency EIS Program Presentations
• Austin CBC
• Mount Sinai
• Root Cause Analysis as a QM/QI Tool
• Coaching Team Meeting & Discussion
• Close

Goals for Today’s Meeting

1) Gain a solid understanding of CDPH Learning Collaborative structure and purpose. 2) Obtain new ideas about EIS program best practices. 3) Understand root-cause analysis as a QM/QI tool. 4) Identify concrete next steps in the QIP process.

PHIMC Mission and Vision

Public Health Institute of Metropolitan Chicago (PHIMC) enhances the capacity of public health and health care systems in Illinois to promote health equity and expand access to services.

How We Work

PHIMC leads efforts to strengthen the public health infrastructure in Illinois through:

• Organizational Development
• System Transformation
• Fiscal Management
• Program Implementation

How does PHIMC fit into Ryan White Part A?

• Technical assistance provider partnering with CDPH to implement

Ryan White Quality Management (RW QM) across the Chicago EMA.

• Prior to March 2015, MATEC was lead on this project for 14 years.
• MATEC contracted primarily with Training Resources Network-
• Ms. Susan Thorner’s consulting agency.

The CDPH RWQM Program is….

A partnership between PHIMC and the Chicago Department of Public Health’s Quality Management (QM) Unit to provide training, technical assistance, and capacity building support to Ryan White Part A funded agencies in an effort to maintain sustainable internal QM infrastructure across the Chicago EMA.

How is RWQM Implemented?

• QM Site Visit Implementation
• Learning Collaboratives
• Webinars
• Support core MATEC Trainings
• Generating QM Newsletter/Online QM Resources
• Participation in Community Planning Efforts, i.e. CAHISC and the MAG
• Updating CDPH Standards of Care
• Audit Tool Creation & Data Collection
• Sub-recipient and CAHISC member surveys
• Conflict Resolution Training & Grievance Access

PHIMC and CDPH collaborate on the following items:

What is Quality Management (QM) vs. Quality Assurance (QA) or Quality Improvement (QI)?

• Quality Management: All functions to evaluate and

improve quality

i.e. QM committee + QM plan + QM site visits from funder, etc.

• Quality Assurance: Checking Boxes

i.e. Program Monitoring Site Visits

• Quality Improvement: Enhancing Services

i.e. Increasing percentage of AOMC clients receiving STI screening

What is a “Learning Collaborative”?

• Model developed by the Institute for Healthcare Improvement (IHI)

in 1994, later adopted by NQC & HRSA

• Since 2000, NY State Health Department has tested LC model with

RW Parts A-D

• In 2008, NQC published LC guide for RW providers nationwide
• Implementing quality improvement & identifying best practices
• Designed for clinical care

http://nationalqualitycenter.org/files/planning-and-implementing-a-successful-learning-collaborative-pdf/

What is a CDPH Ryan White Part A Learning Collaborative (LC)?

• One Ryan White core service category selected based on CDPH

Quality Management site visits from previous year.

• At least four LCs occur in given grant period (March 1st- Feb

28th).

• Agencies that received QM site visit in previous year are

required to attend.

• Open to all CDPH RW Part A funded agencies.

Who should attend an CDPH RW Part A LC?

• CDPH Ryan White Part A-funded agencies
• Designated members of RW quality improvement team OR

agency staff implementing the service category in question

• For 2016 EIS focused series, this may include:
• Member of RW QI team
• Program Managers
• EIS specialists
• LTC staff
• Anyone else instrumental in implementing EIS

What are the requirements for LC participants?

• Register and attend four Learning Collaboratives.
• Complete and present on one quality improvement project

for your agency by January 25, 2017.

• Work with and report to assigned coach as necessary.

Ultimately to improve quality of designated RW program(s) at your agency!

2016 Early Intervention Services (EIS) Learning Collaborative Series: Structure

• Four provider meetings
• Best Practices Presentations from EIS Providers
• Quality Improvement Tips, Tricks, Trends
• Built in time to meet with coaches & team

Acknowledging the challenges with utilizing EIS in an LC format

• Brand new service category
• Limited data
• Standards of care do not include measurable indicators
• Intervention contains non-clinical/social components

What We Know: The 4 Buckets of Early Intervention Services (EIS)

• HIV Counseling and Testing
• Linkage to Care
• Referrals
• Health Literacy

Applying the NHAS Indicators to EIS

NHAS Indicator 4: Increase percentage of newly diagnosed person linked to HIV medical care within one month of their diagnosis to at least 85%. NHAS Indicator 5: Increase the percentage of person with diagnosed HIV infection who are retained in HIV medical care to at least 90%. NHAS Indicator 6: Increase the percentage of persons with diagnosed HIV infection who are virally suppressed to at least 80%.

Steps to selecting an EIS Quality Improvement Project

Step 1: Select an NHAS indicator. Step 2: Select one of the buckets of EIS. Step 3: Identify small-scale projects. Step 4: Conduct PDSA.

Quality Improvement Projects: Where You Should Be

Step 1: Select an NHAS indicator. Step 2: Select one of the buckets of EIS. Step 3: Identify small-scale projects. Step 4: Conduct Plan, Do, Study, Act cycle(s), also known as PDSAs

Step 4: Conduct PDSA(s) PDSAs are a small part of a larger quality improvement project. How do they fit into the larger project?

Quality Improvement Projects: Where You Should Be

QIP vs. PDSA

Example QIP: Increase % of clients linked to care. Example PDSA: One peer navigator makes home visits for short period of time. Data is essential to illustrate where you are, where you want to go, and where you end up.

More questions about the Process?

Ask your coach and your team!

EIS Program Presentations

Austin CBC

• Cook County Health & Hospital Systems
• Community-Based Org

Mount Sinai Hospital

• Hospital System

Austin CBC Initiative Early Intervention Services (EIS) PROJECT SNAPSHOT September 2016

EIS Team: EIS Coordinator: Chamille Johnson, CHES EIS Specialist: Lasheena Miller (2) Medical Case Manager (s): Cerese Depardieu, Lajanice Page (2) Peer Navigator (s)

PROJECT FUNDED SCOPES

HIV Testing and Counseling Referral Services Linkage to care and/or Re-engagement to care Health Education and Literacy Training

SCOPES PROGRESS TO DATE

Activity Goal Unduplicated Clients Units of Service Counseling/Testing 400 265 269 Health Education/ Literacy 28 25 171 Referral Linkage to Care- Primary 12 14 14 Referral to Specialty Care 28 15 39

HIV Testing and Counseling

 Project Goals coincide with NHAS goals to increase the amount of individuals tested and aware of their HIV status.  HIV Testing and counseling conducted at

 CCHHS Austin Clinic onsite daily  Weekly at Austin Community Area Food pantry.  Testing conducted monthly at outreach activities and special community events  Mobile testing w/partner Community Based Organization Association House

 HIV testing and counseling sessions

 Client is provided with personalized risk assessment  SMART GOALS are discussed and client centered behavioral change set.  Client is provided with demonstration as needed

 Condoms  Clients who qualify for PrEP are referred onsite.

Linkage to care and/or Re-engagement to care

 EIS specialist enrolls Ryan White eligible clients who are newly diagnosed or have been out of HIV care for 6+ months:

• 1. EIS Linkage Coordinator will follow up with client regarding Confirmatory test

result by scheduling appointment once results become available via Cerner.

• 2. EIS Linkage Coordinator or EIS Specialist will schedule follow up appointment in

Cerner with an assigned clinician.

• 3. EIS Linkage Coordinator or EIS Specialist will refer client to Ryan White Medical

Case Management onsite for case management services, Program intake, and referrals to other supportive services.

• 4. Client sees EIS Specialist, Peer Navigator or Linkage coordinator for counseling,

and Health Education/Literacy Training. Client sees LCSW for Mental Health Screening.

• 5. Client receives EIS services until deemed ready for case closure by EIS staff.

Clients are referred for linkage through Outreach, Offsite/onsite HIV testing, Referrals from local CBO’s, CCHHS, and CDPH STI clinics.

1st Medical Appointment

EIS Peer Navigator greets patient, provides guidance on how to navigate clinical services, offers peer support, information on CAB, support groups and peer program. Prior to client arrival, CBC multidisciplinary team has pre- clinic case conference to discuss client, their needs, referrals and action plan. Client sees medical provider, EIS Specialist, Mental Health Provider, and Medical Case Management for Intake. Depending on clients needs, Substance abuse counselor, prevention specialist, PharmD, ALCC and benefits counselor are available onsite.

Referral Services

 EIS specialist makes specialty care referrals for clients based upon their needs:

 Referrals to internal and external specialty care providers.  All clients are screened by medical case management and receive medication adherence services.  INTERNAL: Clinical Therapist, Substance Abuse Counselor, Medical, DRS, Correction case management, Prevention for Positives Behavioral Intervention Mpowerment, AOMC Care, PrEP referrals, PharmD, Benefits  EXTERNAL: E.G., New age services Methadone clinic, Vital Bridges, CORE Center, Haymarket, CDPH DIS for partner services.

 EIS Specialist documents the date the referral was made, the referral follow up date, and the results of the referral on the clients individualized referral plan form.  All Referrals documented in clients chart and in clinical notes in electronic medical records by EIS specialist.

Health Education and Literacy Training

 Utilization of CRCS to identify SMART Goals and develop individual client centered service plans.  Health Education is documented using a Risk Assessment and Progress Notes.  Health Education/Literacy training is conducted by the EIS team during:

 AOMC visits  non clinical appointments (via phone and face to face appointments)  BREAKFAST CLUB during clinic 1st and 3rd Tuesday of each month  BASYC Peer Program Client Education Sessions

 Topics discussed during health education and literacy include:

 Adherence, Safer sex, STI’s, Nutrition, Substance abuse, Smoking, Labs Disclosure, Nutrition, Physical Activity, Oral health.

 Health education is documented in clients chart and in clinical notes in electronic medical records by EIS specialist.

Follow-up and Retention

 Clients are linked to AOMC services within 30 days of diagnosis or referral for re-engagement.  Unsuccessful linkage is documented on CDPH Case Reports and submitted for CDPH surveillance.  All clients linked are reminded of medical appointments at least two days before medical appointment. No shows are immediately rescheduled the next day.  EIS specialist follows up with lost to care client with phone calls or the clients identified best method of communication. Unsuccessful communication is followed up with a letter and case finding.

PROJECT SUCCESS

IMPLEMENTATION OF PEERS AS KEY STAFF  SUCCESSES

 Peer Navigators have been useful in identifying HIV testing sites, providing peer role modeling, support and health education.  Utilizing a CSU Master of Public Health Intern to assist in health education, HIV testing and outreach

 IMPLEMENTATION OF MEDICAL CASE MANAGEMENT

 Onsite MCM present for immediate enrollment into RW Case management  Continuous communication with EIS Team during case conferencing and electronic medical records documentation.  62% of eligible EIS Clients enrolled in MCM, other 38% enrolled in other forms of case management, ineligible or declined services.

PROJECT Successes

 Wraparound services available onsite for linkage and specialty care referrals  Onsite lab for confirmatory testing  Onsite PrEP services  Onsite Multidisciplinary team for internal referrals  More than 90% of enrolled EIS clients are adherent to ART  1% positivity rate due to targeted HIV testing in areas where high risk clients congregate on mobile testing unit.  Mutually beneficial partnerships with other local CBO’s.

PICTURES

PICTURES

PICTURES

Questions?

Patient Care/EIS/Prevention Manager: Chamille Johnson Chamille.Johnson@hektoen.org EIS Specialist: Lasheena Miller

• Lasheena. Miller@hektoen.org

Mount Sinai Hospital's HIV Ryan White Part A Early Intervention Services September 20th, 2016

Location Of Services

Mount Sinai Hospital Infectious Diseases Center

1st Floor 1414 S. Fairfield Chicago Il, 60608

92

Introduction

• Mount Sinai Hospital is located in the heart of Chicago’s Lawndale
• neighborhood. It serves a diverse population of clients, which is represented

in the three Infectious Disease outpatient clinics.

HIV Comprehensive Care Through the Entire Life Cycle

Providing HIV Services since 1998 Birth Through End of Life Medical Care

Adult Infectious Disease OB/Gyne and Perinatology Adolescent and Pediatrics Delivering age appropriate services to over 287 patients.

Ryan White Program Services

Ryan White services are provided to HIV infected individuals eligible and enrolled in the Ryan White Part A program as the payor of last resort. The same services are equally offered to all

• ther payor sources.

HIV Comprehensive Services

Core Services – HIV primary care inpatient and outpatient services – ADAP Services – Mental Health Services – Medical Case Management – Early Intervention Services

• Patient navigators to ensure linkage to care
• HIV testing, Outreach, and Prevention
• Clinical Research
• Outside collaboration with CDPH, ACHN, Rush, Stroger, Lurie

Children’s Hospital, and University of Chicago We have special programs for the Deaf & Hard of Hearing populations of all ages. Our staff is bilingual and bicultural

Early Intervention Program Services

Early Intervention Services (EIS):

HIV testing and targeted counseling, referrals services, linkage to care, health education and literacy training that enable client to navigate the HIV system of care Eligibility:

• HIV positive
• Newly diagnosed (Diagnosed with HIV </=18 months)
• Disengaged from care (missed 2 consecutive

appointments >/= 3 months apart)

Sinai’s HIV Patient population

29% of our clients utilize Ryan White Services

67 patients covered under Ryan White Ambulatory 20 patients covered under Ryan White Mental Health 67 patients covered under Ryan White Psycho Social 15 patients enrolled in the Ryan White Early Intervention Services

Early Intervention Clients Demographics

Total Clients enrolled: 15 Gender:

• 13 Male
• 1 Transgender M/F
• 1 Female

Race and Ethnicity:

• 12 African American
• 3 Hispanic/Latino

Risk Factors (client identified):

• 12 MSM
• 3 Heterosexual

Early Intervention Work Flow

• Receipt of Referral
• EIS worker Responds to referral within 24-48 hours
• Within 72 hours meets with client
• Intake assessment is conducted, consents are

signed, action plan and referrals are completed at intake, client is now enrolled in EIS services

• Follow up on referrals
• Attend first two medical appointments
• Case closure

Early Intervention Services

Early Intervention Specialist (EIS) work flow

Eligible patient is referred from the Emergency Department, Fast Track, Inpatient, Infectious Diseases center, and or and External Referral

Patient requests

• nly an

appointment (no additional service

• r referral)

Patient agrees to sign EIS paperwork. EIS specialist receives referral from Patient navigator, medical case manager, mental health worker medical provider and or an external source EIS Specialist gathers patient information, assesses client medical and social needs, completes all remaining paperwork, and secures Employment and Residence

• Verification. EIS specialist

completes Case Management Screener to determine if patient is eligible for CM. Patient is enrolled in medical case management at Mount Sinai Hospital

EIS specialist responds to referral and meets with client within 72 hours of receiving referrals

EIS specialist completes any required action plan and necessary referrals (on-going for 6 months) for all cases referred and opened for EIS services Data release, Referral Verification, and other forms completed as necessary. EIS Case Closure

EIS specialist notifies medical case managers of the referral and need to meet with client, if inpatient medical case manager will meet client on the unit before discharge

EIS specialist and medical case manager work closely together to address the needs of the client

Early Intervention Services Referral Process

PN has a face-to-face meeting with assigned patients (ensure they were notified of status prior to meeting). (1) Offer HIV 101 Education Patient requests only an appointment (no additional service

• r referral) or to be linked to care
• utside of Sinai.

Navigation is complete. If patient requests to be linked to care at Sinai: (1) Ensure CD4 and viral load are ordered (2) Set up appointment at Sinai (3) Offer Connect 2 Care (4) Notify EIS Specialist (Christopher) (5) Notify Medical Case Manager/s (6) Notify Mental Health Specialist (Jacque), and ID Physician (Doctors Glick, Mohapatra, and Russell). PN completes a CDPH Case Report Form for patients who are:

• Newly diagnosed with HIV
• Newly diagnosed with AIDS
• Living with HIV/AIDS who dies

OR

• When a CD4 and VL are drawn at Sinai on a

new/known patient who we recently become aware of. One time only. EIS Specialists (Christopher) has face-to- face meeting with patient and assesses whether patient qualifies for EIS (EIS Baseline), is eligible for Case Management (AFC Screener), needs for Mental Health Services and any other referrals to external services NO CASE MANAGEMENT NEEDED: EIS Specialist (Christopher) completes action plan(s) and necessary referrals (on-going for 6 months). EIS case is closed when all action plan items are met. CASE MANAGEMENT NEEDED: EIS specialist (Christopher) notifies Sinai MCM (Alberto/Nikiya) of patient’s eligibility for CM fills out Case management referral form and sends to MCM CM (Alberto/Nikiya ) verbally accepts referral, they will sign and return referral from to EIS Specialist (Christopher). Mental Health Referral EIS Specialist (Christopher) Completes referrals form for Mental Health Services and send to Mental Health Specialist (Jacqueline Franqui). All referrals internal or external will be included in the EIS patient action plan EIS Case Closure.

PN (Kim R.) identify patients who tested or self-report positive at Sinai at least 2 times a day (upon arrival, early afternoon) in your assigned location. Print

• ut Meditech #15, 16, 17,

23 reports. Update master list by 2:00 p.m. Mental Health Specialist confirms receipt of referral and signs referral from and gives back to EIS specialist (Christopher)

Program Success

• Excellent communication between providers and EIS worker
• Ability to schedule a client for their first HIV related

appointment within 2 weeks of their first face to face

• All clients successfully linked to care

(First appointment made and attended within 30 days of referral)

• More 75% of the clients linked were retained in care

( Attended 2 consecutive appointment =>3months apart)

• All Clients were referred and enrolled in medical case

management

• 73% of the clients were undetectable
• Between March to February 2016 there were over 294 unique

units of service

Challenges

• Intakes at times had to be delayed due to clients being

discharged from the hospital

• Multiple people working with one client
• Client forming a repoire with one case worker and not with the
• ther
• Boundaries
• Working with transient clients
• Inability to contact some clients due to change in address or

phone number not in service

• There are 2 EMR systems that do not communicate which

made data reporting difficult

Lessons Learned

• Realistic expectations as it relates to the date of Intake

assessment

• Communication to all staff regarding the eligibility for EIS

services to effectively and efficiently assist the client

• Set an expectation with the client as far as the services that

are offered by the EIS worker

• Case closures case by case
• Setting expectation with providers on the role of the EIS

worker

Questions?

Ana Fuentes, Clinical Quality Care Program Manager ana.fuentes@sinai.org

Break

Tuesday, September 20, 2016

Why is this happening?

Exploring causes of problems in our service delivery

PDSAs not working??

• Maybe we need to back up to find root causes for ideas of

useful trial ideas

Tools to dig into causes…

• Fishbone diagram, aka Cause and Effect diagram, aka

Ishikawa diagram

• 5 Why’s

Fishbone diagrams

Organizes and displays theories about causal factors of process problems:

• Allows constructive use of anecdotes from all team members
• Encourages a balanced view
• Demonstrates complexity of the problem

Process problems are caused by:

• Methods
• Materials
• Equipment
• Environment
• People

How does it work?

• Write down the effect (problem)
• Decide on major areas (M, M, E, E, P)
• Brainstorm possible causes within each
• Ask “Why?” 3 to 5 times

Ask “Why?”

• Indulge your inner 3-year old!
• Push to get to real cause
• Don’t go too far!
• Stop when you hear something that your team can work on…

Continue on the Fishbone diagram

• When ideas run low, ask for “just one more”
• Ask “Why?” for all the categories of cause till you get workable

ideas

• Check for logic, completeness and balance
• Did you find causes for every area they might exist?
• Did you dig down (at least 5 “why’s”) for each cause?

Try one at your seats…

• Pick a “problem” from your daily activities
• Brainstorm possible causes and place them in the various

major cause areas

• Now ask why…go on, keep going
• Did you find something you can try to make a change

quickly?

• PDSA it!

How did that go?

What were your problems? What causes did you find? What PDSAs could/will you try?

Possible Causes of Delayed Test Results

What PDSAs might you try from the example fishbone diagram?

• People
• Environment
• Materials
• Methods
• Equipment

Fishbone Diagram Resources

• https://www.youtube.com/watch?v=BW4qvULMJjs

3-minute cartoon

• https://www.youtube.com/watch?v=P5QVL9nWo5M

5-minute talk

• http://www.ihi.org/resources/pages/tools/causeandeffectdi

agram.aspx PDF document

• NQC – search “fishbone diagram”

Quality Improvement Team Discussion

• Share QIP challenges and successes
• Give and receive support and feedback from colleagues

Meet with Your Coach & Team

Team 1: Charlotte Detournay Austin CBC Michael Reese Regional Care Association Team 2: Silas Hyzer Loyola Medical Center Lurie Children’s Hospital Mount Sinai Team 5: Katie Morin Access Community Health Network Erie Family Health Center Heartland Health Outreach Howard Brown Health Center Team 6: Barbara Schechtman South Suburban HIV/AIDS Regional Clinics Provident Hospital Core Center Team 3: Rod Kaup AIDS Healthcare Foundation Lawndale Christian Community Health Center Open Door Clinic South Shore Hospital Team 4: Laura Kuever Lake County Health Department University of Illinois, Chicago University of Chicago

Upcoming Learning Collaboratives

• Thursday, November 17th, 9:30 AM- 12:30 PM
• Wednesday, January 25th, 9:30 AM- 3:30 PM

Other Upcoming CDPH QM activities

• QM Webinar 3 “QM 102” by Barbara Schechtman coming up in

November 2016

• Online QM Resource Hub: update
• 2016 QM site visits are underway: 4 down and 24 to go!

Questions?

Thank You!

Ayla Karamustafa, Quality and Prevention Manager Public Health Institute of Metropolitan Chicago Ayla.Karamustafa@phimc.org Barbara Schechtman, Quality Management Consultant Public Health Institute of Metropolitan Chicago Barbaraschechtman@gmail.com