TITLE I HIV QUALITY MANAGEMENT PROGRAM

HIV CASE MANAGEMENT INDICATORS

Review Eligibility:
Patients admitted in 2002 that have been enrolled in the Case Management program for a minimum of 3 months.

Review Periods:
The review period is defined as the (2002) calendar year. For patients discharged during this calendar year, the review period will extend from the beginning of the year, to the date of discharge.

Applicability of Review Periods to Patients Reviewed: For three month indicators: In order to be reviewed for activities that should take place quarterly, the patient should have been in the program for a minimum of 3 months. For indicators where the patient has been enrolled in the program for a shorter amount of time than the indicator measures, a “yes” will be added to the numerator if the activity was performed in that period, but a “no” will not be given if the activity was not performed.

Calculations:

Scores will be calculated in three separate ways:

1. Performance in the most recent period: the number of patients who met the indicator in the most recent period is divided by the total number of eligible patients.
2. Performance in all periods: the number of periods where the indicator was met in any applicable period is divided by the number of eligible review periods.
3. Performance over the entire review period: the number of patients who met the indicator in all applicable periods is divided by the entire number of eligible patients in the population.

A description of any patients excluded from review for a particular indicator can be found under the definition of that indicator.

Indicator 1: Comprehensive case management assessment.

A comprehensive case management assessment of client needs occurs within 30 days of initial client contact. Components of the assessment include need for the following services:

• Medical care
• Financial status
• Health insurance
• Housing status
• Food and nutrition
• Mental health services/Supportive counseling
• Substance use/Harm reduction

Note: Performance on each of the seven components of a comprehensive case management assessment is assessed separately.

Patients Reviewed: All patients are included.

Yes: Patient is assessed for the particular need areas, within 30 days of the initial client contact.
No: No documentation that the patient is assessed for the particular need areas, within 30 days of the initial client contact.

Indicator 2: Service Plan Development

A service plan is developed with client participation within 45 days of initial client contact and is based upon needs identified in the case management assessment. The service plan includes:

• Long and short-term goals
• Referrals

Note: The parts of this indicator are assessed as well as performance on all components.

2a. An initial service plan is developed within 45 days of initial client contact.

Patients Reviewed: All patients are included.

Yes: A service plan is developed within 45 days of initial client contact.
No: No documentation that service plan is developed within 45 days of initial client contact.

2b. The service plan is developed with client participation.

Note: Client participation means that the client signed the service plan.

Patients Reviewed: Patients are included if there was an initial service plan.

Yes: The service plan is developed with client participation.
No: No documentation that service plan is developed with client participation.

2c. For each of the seven need areas, there is a service plan that is based upon needs identified in the case management assessment.

The seven need areas are:

• Medical Care
• Financial Status
• Health Insurance
• Housing Status
• Food and Nutrition
• Mental Health Services / Supportive Counseling
• Substance use / Harm Reduction

Patients Reviewed: For each need area, a patient is included if that area is assessed, and a need in that area is identified.

Yes: The service plan addresses the need identified in the case management assessment.
No: No documentation that the need identified is addressed in the service plan.

2d. For each of the seven need areas identified in 2c, there is a service plan which includes long and/or short term goals.

Patients Reviewed: For each need area, a patient is included if there is a service plan for that particular need.

Yes: The service plan includes long and/or short term goals to address the need identified in the case management assessment.
No: No documentation that the service plan includes long and/or short term goals to address the need identified in the case management assessment.

2e. For each of the seven need areas identified in 2c, there is a service plan which includes referrals.

Patients Reviewed: For each need area, a patient is included if there is a service plan for that particular need.

Yes: The service plan includes referrals to address the need identified in the case management assessment.
No: No documentation that the service plan includes referrals to address the need identified in the case management assessment.

Indicator 3: Follow-up on Service Plan Goals and Referrals

Follow-up regarding service plan goals, referrals and patient attendance at appointments is documented in the client record every 120 days. All goals and referrals identified in the service plan are addressed.

Note: The parts of this indicator are assessed as well as performance on all components.

3a. For each of the seven need areas identified in 2c, goals identified in the service plan are followed up every 120 days until achieved.

Patients Reviewed: For each need area, patients are included if there is a service plan that includes goals.

Yes: There is follow-up regarding service plan goals every 120 days until achieved.
No: No documentation of follow-up regarding service plan goals every 120 days until achieved.

3b. For each of the seven need areas identified in 2c, referrals identified in the service plan are followed up every 120 days until achieved.

Note: Follow-up of a referral is defined as checking with the provider, agency, or client, to assess whether or not the client attended his/her appointment.

Patients Reviewed: For each need area, patients are included if there is a service plan that includes referrals.

Yes: There is follow-up regarding service plan referrals every 120 days until achieved.
No: No documentation of follow-up regarding service plan referrals every 120 days until achieved.

Indicator 4: Coordination of services (quarterly)

Coordination of services is documented on a quarterly basis in the client’s record. Coordination of services entails communication between the case manager and any health or social service provider. Acceptable documentation includes:

• Case conference notes (internal or external)
• Progress notes which record results of a phone conversation
• Other activities involving coordination of services

Patients Reviewed: All patients are included.

Yes: There is coordination of services on a quarterly basis.
No: No documentation that there is coordination of services on a quarterly basis.

Indicator 5: Clear, concise progress notes

Progress notes that are clear and concise, comprising at a minimum the following elements, are documented in the client record:

• Notes are dated and signed
• Notes indicate type of service delivered
• Notes indicate the nature and extent of the service
• Notes indicate next steps or future actions

Patients Reviewed: All patients are included.

Yes: Clear and concise progress notes, comprising at a minimum the above elements, are documented in the client record for up to five (5) of the most recent progress notes that involve face-to-face contact.
No: No documentation in the most recent five (5) progress notes that involve face-to-face contact, of clear and concise progress notes as defined above.

Indicator 6: Cultural Competency

Staff members are competent in terms of issues regarding culture, ethnicity, linguistics/language, gender and sexual orientation. Acceptable documentation includes policy and procedure manual entries which detail agency procedures for training staff in these areas.

Patients Reviewed: Individual patients are not reviewed for this indicator. Each agency is reviewed.

Yes: Either as one set of policies/procedures unspecified as to type, or for each of the five areas of client diversity (culture, ethnicity, linguistics/language, gender and sexual orientation), the agency has policies/procedures to train staff.
No: No documentation that the agency has policies/procedures to train staff in the areas of client diversity.

Indicator 7: Family-centered case management

Evidence that family-centered management is available and includes the following:

• Written agency policy regarding provision of family-centered case management, PLUS
• Supporting documentation in a select number of charts showing that at least some clients are receiving the service on site. Charts specifically include the following:
• Identification of household family members
• Assessment of family members’ needs, and
• If needs of family members identified, a service plan addressing them.

Note: The parts of this indicator are assessed as well as performance on all components.

7a. The agency has a written policy regarding provision of family-centered case management.

Patients Reviewed: Individual patients are not reviewed for this indicator. Each agency is reviewed.

Yes: The agency has a written policy regarding family-centered case management.
No: No documentation that the agency has a written policy regarding family-centered case management.

7b. Supporting documentation in a select number of charts showing that at least some clients are receiving the service on site. Charts specifically include the following:

• Identification of household family members
• Assessment of family members’ needs, and
• If needs of family members identified, a service plan addressing them.

Patients Reviewed: A patients is reviewed if the record indicates whether or not there are household members.

Yes: Family-centered case management is available and includes the above elements.
No: No documentation that family-centered case management is available and includes the above.

Primary Care Indicators
1. Access to Primary Care
Clients should have one visit with their primary care provider at least every six months.

• For clients who have not had a visit with their primary care provider in the first or last six months of the calendar year, there should be documentation of referral to primary care
• For patients with a referral to primary care, there should be documentation of follow up within 30 days to determine whether the primary care appointment was kept
• If documentation of follow up exists, there should be documentation that the client kept the appointment

2. Assessment of whether clients eligible for ARV Therapy are receiving it.
Clients will be reassessed for ARV status at least once every six months.

• For clients not on ARV, is there information on viral load or CD4 test results?
• If yes, is the patient eligible for therapy based on viral load (>100,000 copies) or CD4 count (< 350 cells)?
• If yes, is the patient referred to primary care for assessment of treatment eligibility?
• If yes, is there documentation of follow up on patient’s status within 30 days?
• If yes, was the patient placed on ART?

3. Viral load and CD4 Counts
Clients will have lab work completed to assess their viral load and CD4 counts at least once every six months.

• For clients who have not had a CD4 or viral load test performed in the first or last six months of the calendar year, is there documentation of referral to primary care for these tests?
• For patients with a referral to primary care, was there documentation of follow up within 30 days to determine whether the laboratory tests were performed?
• If documentation of follow up exists, is there documentation that the client received the viral load and/or CD4 tests?