Materials, Publications, and Resources

Materials, Publications, and Resources

Advisory Committee Meetings

2018 Advisory Committee Meetings

March 15, 2018

Meeting Materials


  • QAC/CAC Joint Meeting Report
    Anna Bezruki and Freda Coren │View Slides
  • VBP Arrangements and Quality Measurement
    Doug Fish, MD and Lindsay Cogan, PhD, MSView Slides
  • SUNY Downstate Medical Center Care Cascade 2016
    Jameela Yusuff, MD, MPH, FACPView Slides
  • Identifying Open and Active Patients using Azara Data
    Christine Kerr, MD, AAHIVS and Greg AugustineView Slides
  • Patient Reported Experience Measures (PREMs) 
    Freda CorenView Slides
  • PREMS: Utilizing CAHPS® Survey as part of Quality Management/Improvement 
    Andrew KienerView Slides
  • Quality of Care Program 2018 Quality Management Plan 
    Daniel Belanger View Slides
  • Quality of Care Program Mortality Review: March Update 
    Leah HollanderView Slides
  • Stigma Update 
    Kelly Hancock View Slides

2017 Advisory Committee Meetings

September 19, 2017

Meeting Materials


  • Beyond Satisfaction: Integrating Patient-Reported Experience and Outcomes into Quality Measurement and Improvement
    Lisa Hirschhorn, MD, MPH | View Slides
  • Open and Active HIV Patients at Callen-Lorde: Engagement in Care
    Peter Meacher, MD | View Slides
  • New York Presbyterian’s HIV Care Cascade: Methodology & Next Steps
    Pete Gordon, MD, and Sam Merrick, MD | View Slides
  • Measuring and Addressing Stigma in Health Care Settings: Panel
    View Slides
  • Louisiana HIV Clinical Quality Group
    DeAnn Gruber, PhD, and Debbie Wendell, PhD, MPH | View Slides
  • New York State’s Health Care Transformation: The Path to Medicaid Payment Reform through Value-Based Payment Programs
    Douglas G. Fish, MD | View Slides
  • Quality of Care Program Mortality Review
    Leah Hollander | View Slides

June 15, 2017

Meeting Materials


  • HIV Treatment Cascade Panel
    View Slides
  • HIV on Long Island: Heat Maps and REDCaps
    Joseph P. McGowan, MD, FACP, FIDSA | View Slides
  • New York State Ending the Epidemic Update
    Johanne Morne, MS | View Slides
  • AI Ending the Epidemic Metrics
    James M. Tesoriero, PhD | View Slides
  • Using Mortality (and Morbidity) Data to Drive Positive Changes
    Peter Meacher, MD | View Slides

March 16, 2017

Meeting Materials


  • Mortality in HIV Infection: Monitoring Quality Outcomes
    Steven Johnson, MD | View Slides
  • Sentinel Events: AIDS Mortality: HIV-Related vs. Not HIV-Related Death as Categorized in HIV Surveillance
    View Slides
  • Expanded HIV Testing and Finding the Undiagnosed: Challenges, Insights, and Successes
    Uriel R. Felson, MD, MPH | View Slides
  • The High Priority Project: An EtE Pilot
    Bill LaRock, PhD; Jay Dobkin, MD; Eli Camhi | View Slides
  • Expanded HIV Mortality Surveillance
    Sandy Schwarcz | View Slides

2016 Advisory Committee Meetings

December 15, 2016

Meeting Materials


  • 2016 NYS HIV Quality of Care Review: A New Way Forward in Four Parts
    Bruce Agins, MD, MPH | View Slides
  • Results of eHEPQUAL Pilot Test (4/1/2015-3/31/2016)
    View Slides
  • Assessing Clinic-Level Factors that Impact Viral Load Suppression
    Bisrat Abraham, MD, MPH; Carly Skinner, FNP-BC; Erica Crittendon, MS; Muhammad Daud, MD | View Slides
  • Engaging Primary Care Providers in Quality Improvement Strategies for Chlamydia Screening
    Gale Burstein, MD, MPH, FAAP; Susan Mancuso, FNP, MSN; Alison Muse, MPH; Gowri Nagendra, MPH; Amanda Cornett, MPH | View Slides
  • HIV Stigma in Healthcare Settings: Health Effects and Mechanisms of Intervention
    Whitney S. Rice | View Slides
  • Value-Based Care and the Role of Health Information Technology
    Andrew Hamilton, RN, BS, MS | View Slides
  • MetroPlus Partnership in Care: EtE Peer Care Connection Pilot
    Ross G. Hewitt, MD; Debra Williams, EdD | View Slides
  • Pharmacy Planning and Partnership Committee
    View Slides
  • Stigma Subcommitee
    Kelly Hancock; Barry Zingman | View Slides
  • HIV Tobacco Cessation Campaign Update
    View Slides

September 8, 2016

Meeting Materials


  • Pharmacy Planning and Partnership Committee
    Maggie Brown | View Slides
  • Tobacco Cessation Improvement Campaign Update
    Kelly Hancock | View Slides
  • New York Presbyterian DSRIP and Practice Transformation Initiative
    New York-Presbyterian | View Slides
  • The Undetectables Viral Load Suppression (VLS) Project
    Vaty Poitevien, MD, Chief Medical Officer, Housing Works, Inc. | View Slides
  • Ending the Epidemic in NYS Together
    View Slides
  • Stigma Site Survey Update
    Kelly Hancock | View Slides
  • NYS eHEPQUAL Launch
    View Slides

 June 9, 2016

Meeting Materials


  • The G.R.E.A.T. Study: Empowering People Living with HIV
    Kevin Fiscella and Michelle Boyd | View Slides
  • Transforming a Healthcare Organization Through Quality Improvement Projects
    Leonard Kabongo, MD, Msc GH, Gobabis District Hospital Namibia | View Slides
  • Health Information EcoSystem for HIV in Haiti: Using Data and Information Systems to fight against HIV in HAITI | View Slides
  • Survey Results: Prioritization of Key Populations for Targeted HIV-related Stigma Reduction Efforts | View Slides
  • 2016 HIV Medication Access Survey Results
    Dr. Rona Vail and Maggie Brown | View Slides
  • Update: HIV Tobacco Cessation Improvement Campaign
    Daniel Tietz and Dr. Kelly Ramsey | View Slides

March 10, 2016

Meeting Materials


  • Update: Access to HIV Medications Subcommittee
    Dr. Rona Vail and Maggie Brown | View Slides
  • Evaluating the Effects of an Interdisciplinary Practice Model with Pharmacist Collaboration on HIV Patient Co-morbidities
    Rebecca Cope, Pharm.D., and Agnes Cha, Pharm.D., AAHIVP, BCACP | View Slides
  • Update: HIV Tobacco Cessation Improvement Campaign
    Emily Schlussel Markovic | View Slides
  • Azara Healthcare and eHIVQUAL
    Greg Augustine and Chris Wells | View Slides
  • An Electronic Web-based HCV Quality of Care Performance Measurement Program for NYC and NYS
    Jeremy Fagan, PhD | View Slides
  • Ending the Epidemic Medicaid Managed Care Pilot 
    Clinical Advisory Committee, March 10, 2016 | View Slides
  • healthfirst Ending the Epidemic Update | View Slides
  • Ending The Epidemic Comprehensive Viral Suppression & Care Connection Pilot Program
    Ross G. Hewitt, MD, and Debra Williams, EdD | View Slides
  • ETE MCO Pilot Data Reporting
    Amida Care | View Slides
  • VNSNY CHOICE SelectHealth High Priority Project | View Slides

Healthcare Stories Project



Welcome to the Healthcare Stories Project, a series of healthcare improvement strategies that capture and learn from health user experiences.

The Healthcare Stories Project offers healthcare programs tools to capture how healthcare users experience their healthcare services. This three-activity campaign also aims to strengthen user participation in processes of care, and in doing so, improve the quality of care provided.

This quality of care campaign kicked off in Spring 2014 and is ongoing throughout New York State. This project consists of three activities, each with a poster and instructional guide (see below). 

Implement any of the activities that may be useful for your agency. They do not have to be done in order to be effective tools—each one captures patient experience from a different angle.

To join the Healthcare Stories Project, sign up here for the Program Management Tool, an interactive platform that connects a community of healthcare agencies, provides materials, and keeps up to date on the latest news about the project.

Participating agencies say that the Healthcare Stories Project:

  • Offers a creative, fun project that motivates staff.
  • Engages healthcare users in QI.
  • Generates helpful, clinic-specific information.
  • Provides organizational benefits beyond an HIV program.

For more information or to receive assistance, please contact:

Daniel Tietz
AIDS Program Manager for Consumer Affairs
New York State Department of Health AIDS Institute
Albany, New York
Phone: 1-518-473-7542
Fax: 1-518-486-1315


Activity 1: Word Cloud


What Words Would You Use? 

Patients share the words and stories they associate with ‘quality of care’. The words are visually displayed to create a word cloud to be shared and discussed with everyone in the clinic.


Activity 3: The Co-Production of Quality



Patients and providers examine how each play a role in the production of service delivery and quality of care at their clinic.

Do You Know Where Your Patients Are?

Using an Active Patient List

Monitor Patient Retention In HIV Care And Improve Health Outcomes

The NYSDOH AIDS Institute’s ‘Do You Know Where Your Patients Are’ brochure presents information and tips help care providers address retention issues at their facility.

Benefits of Focusing on Patient Retention

Patient engagement in care is directly correlated with positive health outcomes. For people living with HIV/AIDS, regular medical visits facilitate treatment adherence and clinical monitoring, which consequently lead to improved viral load suppression, reduced occurrence of opportunistic infection, decreased odds of antiretroviral drug resistance, and reductions in mortality [1-4]. Patients who are engaged in regular medical care and become virologically suppressed are also less likely to transmit the virus to others, establishing retention as a key strategy for HIV prevention. Furthermore, patients with regular clinic visits are more likely to receive comprehensive care, including preventive care, reducing the frequency of hospitalizations and emergency department visits, and decreasing overall healthcare expenditures.

Monitoring Patient Retention

A key tool for monitoring patient retention is an active patient list: a record of every patient who visited your clinic for medical services within a given time period, often the previous 12 months. An up-to-date list provides the necessary information to:

  • Identify patients who have fallen out of care
  • Monitor patient attendance over time
  • Track individual patient attendance patterns
  • Measure the rate of patient retention at your clinic
  • Observe trends in patient retention and demographics

Frequently updating the active patient list allows you to dynamically monitor patient retention in your clinic for different time intervals, varying in duration and starting point. This flexibility allows you to focus on different aspects of patient retention and levels of patient engagement at your clinic. For example, your clinic may choose to update its active patient list quarterly, reviewing patient retention for a shifting 12-month interval each quarter, rather than just within a calendar year. In this case, patients that should be seen bimonthly but have become lost to follow-up, for example, would be identified sooner.

Ultimately, your clinic will be able to monitor the retention of a previously identified cohort of active patients longitudinally (e.g., 1 clinical visit in each 6-month interval of a 24-month period, or longer). This will allow you to monitor the same patients over an extended period of time to track retention more meaningfully and correlate retention with long-term health outcomes.

Helpful Tips:

  • Designate a person in your clinic to manage the patient list.
  • Orient staff to the importance of retention in care.
  • Systematize the process of regularly identifying patients lost to follow-up in the patient list.
  • Develop a routine method for updating your active patient list. Include such items as established update schedule, staff responsibility, data validation, and security.
  • Identify and access all data sources to obtain the information needed for your active patient list.
  • Regularly verify accuracy of your active patient list. Check for red flags. Are there obvious errors or omissions?
  • Implement a policy for designating patients as inactive. Decide whether a certain number of unsuccessful intervention attempts is sufficient to consider follow-up patients inactive.
  • Consider monitoring missed patient visits, which can provide additional information regarding patient retention at your clinic.
  • Incorporate enough elements to uniquely identify patients in your list. Include all dates of clinical visits in chronological order. In addition to this basic information, consider including elements such as contact, clinical, or other demographic information
Example Active Patient List
First Name Last Name Middle Initial Gender DOB Clinical Visit Date 1 Clinical Visit Date 2
John Doe B. Male 7/11/1977 9/23/11 2/12/12

Strategies for locating patients: If contacting a patient directly is unsuccessful, other resources for locating patients may include:

  • Internal: Registries for within-clinic services (e.g., mental health), electronic medical records (EMR) for hospitalization or death.
  • External: Other local clinics and support service providers, Social Security Death Index, state or local incarceration directory, local health department, case managers, pharmacies.
Intervention Examples
Telephone calls to patients as well as their friends and family, SMS (text) message appointment reminders, open access scheduling, counseling, mental health support, substance abuse treatment, transportation services, case management, peer and near-peer coaches or navigators, preemptive interventions for patients at high-risk for non-retention, secure message line for appointment requests (after-hours calls), collect/verify contact information regularly (telephone numbers, email, etc.).
  1. Berg MB, Safren SA, Mimiaga MJ, et al. Nonadherence to medical appointments is associated with increased plasma HIV RNA and decreased CD4 cell counts in a community-based HIV primary care clinic. AIDS Care 2005;17(7):902-907.
  2. Giordano TP, Gifford AL, White AC Jr, et al. Retention in care: A challenge to survival with HIV infection. Clin Infect Dis 2007;44(11):1493–1499.
  3. Mugavero MJ, Lin HY, Willig JH, et al. Missed visits and mortality among patients establishing initial outpatient HIV treatment. Clin Infect Dis 2009;48(2):248-256.
  4. Tripathi A, Youmans E, Gibson JJ, et al. The impact of retention in early HIV medical care on viro-immunological parameters and survival: A statewide study. AIDS Res Hum Retroviruses 2011;27(7):751-758.

Four Steps in Creating and Maintaining Your Active Patient List

Four Steps in Creating and Maintaining Your Active Patient List
Download PDF

Selected Bibliography


  • Gardner EM, McLees MP, Steiner JF, et al. The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis 2011;52(6):793-800.
  • Geng, EH, Nash, D, Kambugu, A, et al. Retention in care among HIV-infected patients in resource-limited settings: Emerging insights and new directions. Curr HIV/AIDS Rep 2010;7:234-244.
  • Horstmann E, Brown J, Islam F, et al. Retaining HIV-infected patients in care: Where are we? Where do we go from here? Clin Infect Dis 2010;50:752-761.
  • Mugavero MJ, Norton WE, Saag MS. Health care system and policy factors influencing engagement in HIV medical care: piecing together the fragments of a fractured health care delivery system. Clin Infect Dis 2011;52(suppl 2):S238-S246.
  • Mayer KH. Linkage, engagement, and retention in HIV care: essential for optimal individual- and community-level outcomes in the era of highly active antiretroviral therapy. Clin Infect Dis 2011;52(suppl 2):S205-S207.

Outcomes/Risk Factors

  • Berg MB, Safren SA, Mimiaga M J, et al. Nonadherence to medical appointments is associated with increased plasma HIV RNA and decreased CD4 cell counts in a community-based HIV primary care clinic. AIDS Care 2005;17(7):902-907.
  • Giordano TP, Gifford AL, White AC Jr, et al. Retention in care: a challenge to survival with HIV infection. Clin Infect Dis 2007;44(11):1493–1499.
  • Giordano TP, Hartman C, Gifford AL, et al. Predictors of retention in HIV care among a national cohort of US veterans. HIV Clin Trials 2009;10(5):299-305.
  • Moore RD, Bartlett JG. Dramatic decline in the HIV-1 RNA level over calendar time in a large urban HIV practice. Clin Infect Dis 2011;53(6):600-604.
  • Mugavero MJ, Lin HY, Willig JH, et al. Missed visits and mortality among patients establishing initial outpatient HIV treatment. Clin Infect Dis 2009;48(2):248-256.
  • Mugavero MJ, Amico KR, Westfall, AO, et al. Early retention in HIV care and viral load suppression: implications for a test and treat approach to HIV prevention. J Acquir Immune Defic Syndr 2012;59(1):86-93.
  • Mugavero MJ, Napravnik S, Cole SR, et al. Viremia copy-years predicts mortality among treatment-naive HIV-infected patients initiating antiretroviral therapy. Clin Infect Dis 2011;53(9):927-935.
  • Tripathi A, Youmans E, Gibson JJ, et al. The impact of retention in early HIV medical care on viro-immunological parameters and survival: A statewide study. AIDS Res Hum Retroviruses 2011;27(7):751-758.


  • Dombrowski JC, Kent JB, Buskin SE, et al. Population-based metrics for the timing of HIV diagnosis, engagement in HIV care, and virologic suppression. AIDS 2012;26(1):77-86.
  • Mugavero MJ, Davila JA, Nevin CR, et al. From access to engagement: measuring retention in outpatient HIV clinical care. AIDS Patient Care STDS 2010;24(10):607-613. Interventions
  • Aziz M, Smith KY. Challenges and successes in linking HIV-infected women to care in the United States. Clin Infect Dis 2011;52(suppl 2):S231-S237.
  • Cabral HJ, Tobias C, Rajabiun S, et al. Outreach program contacts: do they increase the likelihood of engagement and retention in HIV primary care for hard-to-reach patients? AIDS Patient Care STDS 2007;21(suppl 1):S59–S67.
  • Bradford J, Coleman S, Cunningham W. HIV system navigation: an emerging model to improve HIV care access. AIDS Patient Care STDS 2007;21(suppl 1):S49-S58.
  • Zaller ND, Fu JJ, Nunn A, et al. Linkage to care for HIV-infected heterosexual men in the United States. Clin Infect Dis 2011;52 (suppl 2):S223-S230.


Selected Resources

New York State Department of Health Quality of Care Programs

“The AIDS Institute is committed to promoting, monitoring, and supporting the quality of HIV clinical services for people with HIV in New York State. The Office of the Medical Director coordinates quality improvement activities including the development of clinical performance measures derived from practice guidelines, on-site quality of care reviews, as well as the promotion of quality improvement activities, peer learning opportunities for HIV providers, and consultations to support on-site quality improvement efforts. The ultimate objective for each HIV program in New York State remains the development of a sustainable independent quality management program that reflects the capacity to dynamically analyze and continuously improve HIV treatment, care, and supportive services.

The Office of the Medical Director coordinates the participation of several groups of stakeholders to accomplish these tasks including:  (1) an internal Quality of Care Workgroup based at the AIDS Institute, responsible for implementation and refinement of the program within the New York State Department of Health AIDS Institute; (2) the AIDS Institute’s Medical Care Criteria Committee chaired by Dr. Judith Aberg, responsible for clinical guidelines development; (3) the HIV Quality of Care Clinical Advisory Committee chaired by Dr. Peter Gordon, comprised of expert HIV providers who advise on the development, implementation, and refinement of the Quality of Care Program; (4) the New York City Part A Quality Management Program Advisory Committee; and (5) the AIDS Institute’s Consumer HIV Quality Committees. The AIDS Institute solicits feedback through these committees in planning, implementing, and evaluating quality of care program activities.  The interaction of providers and consumers with the AIDS Institute through these various groups allows New York State to remain responsive to the needs of the communities that it serves, while responding to changes in clinical and scientific knowledge.” 
⇒ Learn more


eHIVQUAL is an online HIV performance measurement tool for HIV providers that allows them enter data on their patients on a variety of quality  indicators and track performance results in order to identify areas for improvement.  eHIVQUAL provides users with a number of reports to highlight and diagnose their data. 
⇒ Learn more

Health Data NY

As part of New York State’s commitment to transparency of data, the finalized eHIVQUAL performance data report from HIV ambulatory care programs is available online. 
⇒ Learn more

NY Links

“NY Links focuses on improving linkage to care and retention in care and supports the delivery of routine, timely, and effective care for Persons living with HIV/AIDS (PLWHA) in New York State. We also bridge systemic gaps between HIV related services in order to achieve better outcomes for PLWHA through improving systems for monitoring, recording, and accessing information about HIV care in NYS. We use a regional approach, utilizing the learning collaborative model, to fortify the links holding together communities of practice, and the links grounding them in the communities of consumers they serve. New York Links was created through a HRSA HIV/AIDS Bureau (HAB)-sponsored Special Projects of National Significance (SPNS).  Since September of 2015 it is under the Governor’s Ending the Epidemic Initiative through the NYSDOH AIDS Institute.”
⇒ Learn more

National Quality Center

“The aim of this initiative is to build the capacity to improve the quality of HIV/AIDS care and services across the United States and its territories. NQC provides support and assistance that enable grantees to respond to and to implement quality management legislative mandates. Think of the National Quality Center as a personal quality improvement expert, a hands-on assistant that will help advance quality management programs, provide access to a central repository of key quality improvement resources, and help connect HIV providers across the country. NQC can give the support needed to improve the care and services provided to individuals with HIV/AIDS.”
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HealthQual International 

“HEALTHQUAL International is a capacity building initiative to facilitate sustainable national and clinic-based quality management programs with the goal of enhanced patient outcomes and improved population health in low- and middle-income countries. The HEALTHQUAL framework consists of three main elements: Performance measurement, quality improvement, quality management program. HEALTHQUAL offers a unique public health, peer-to-peer government-led approach to quality management (QM). Our experienced staff focuses technical assistance and support through partnerships with Ministries of Health to implement and reinforce health care systems to build sustainable national QM programs.”
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