The AIDS Activities Coordinating Office's (AACO) goal for quality management is to use high quality data to continually improve access to high quality HIV care and prevention services.   We seek to know if clients are better off today than yesterday, and how to make improvements for the care and prevention system to be better tomorrow.  An important component of access to care is ensuring that hard to reach populations are entering and retained in services. 

The quality management (QM) plan is overseen by AACO's Performance Management Committee.  The committee is convened by AACO's director and includes AACO's medical director, managers of the program services, client services, education, surveillance, and information services units.  The committee meets monthly to review both HIV care and prevention activities and thus coordinates efforts between these systems.  The meetings conclude with concrete action steps that are undertaken to further investigate or improve the quality of services.  Progress for each action step is reported at subsequent meetings.  The performance management committee is responsible for tracking trends, deciding the next steps for QM activities and monitoring ongoing performance.

AACO's quality management program includes three areas: (1) quality assurance, (2) outcomes evaluation, and (3) continuous quality improvement.   Activities for these areas include:

• Efforts to support a culture of quality at all levels of the system
• Defined service standards
• Defined client and system level outcomes
• High quality data for decision-making: at the clinical level, for planning, for program monitoring, and service procurement
• Improvement efforts at the service provider and system levels.

Quality assurance encompasses the degree to which the service providers adhere to the service provisions that define the administrative and programmatic requirements for each service category.  These standards are based on Health Resources and Services Administration (HRSA)Public Health Service guidelines for medical care for people living with HIV/AIDS, other federal guidance such as the Center for Disease Controls' Morbidity and Mortality Weekly Report (MMWR) for prevention with positives, professional standards and locally developed standards case management standards.  The service provisions describe requirements for staff training and accreditation, service procedures, documentation, reporting, and participation in the region's quality management activities.  These standards are promulgated in Request for Proposal and continuation funding processes and incorporated into contracts.  Another component of quality assurance is AACO's Consumer Grievance process.  This formal process responds to objectives in the region's Comprehensive Plan calling for an efficient process to handle consumer conflicts and concerns with their services' and to analyze trends for use in planning.

Outcomes monitoring and evaluation tracks performance with respect to client outcomes: how the client has benefited from the service.  The outcomes are derived from PHS guidelines or other professional standards.  In addition to client level outcomes, the quality management plan monitors systemic outcomes including the accessibility of services to minority populations, the uninsured and other populations of concern.

Continuous quality improvement (CQI) focuses on solving problems to improve processes and ensure delivery of exceptionally high quality services and customer satisfaction.  CQI links to outcomes evaluation and performance management in that low performance for an outcome is one factor that triggers initiating a CQI plan.  CQI projects are required of Title I funded providers and a CQI approach is taken by AACO in administration of services on a system-wide level.

The QM program is a shared responsibility among all of the AACO staff.  The AACO's Information Services Unit is responsible for developing, implementing, and coordinating the QM plan for both HIV care and prevention services.  The Program Services Unit staff provides quality assurance activities, monitor provider CQI projects, and provide technical assistance to providers.  AACO's Medical Director/Epidemiologist, a board certified, practicing infectious disease practitioner, provides leadership and guidance for the QM program.  The Client Services Unit is responsible for the consumer grievance process and provides expertise for case management services.  The Education Unit assists with training needs identified as part of quality improvement efforts.

HIV Care Services Program Evaluation

AACO's program evaluation plan for HIV care services is focused on developing data systems that support clinical management and provide the reports the grantee needs for quality management activities.  Data are collected to monitor adherence to PHS guidelines.  All data are generated through one data collection process; including data for individual patient management, contract reporting, and quality management.  RW CAREWare is the tool used for CQM data collection and data management.  (RW CAREWare is a data system designed by the Federal Health Services and Resources Administration for use by HIV care programs.)  This effort expands the data available to providers to manage their services and provides an unduplicated client data set for system-wide planning and evaluation. 

Indicators for primary medical care include measures of adherence to PHS standards of HIV care, measures related to prevention with positives, and improvements in health outcomes: 

Laboratory monitoring according to PHS standards of care

Percent of medical patients with 1, 2, or 3 viral load tests/year
Percent of medical patients with 1 or 2 CD4 tests/year

Antiretroviral therapy according to PHS standards of care

HAART - percent of patients reported on HAART per CADR
Recommended regimens - prescribed HIV medication combinations analyzed against listing of PHS not-recommended regimens; patients staged according PHS indications for treatment categories

Opportunistic Infection Prophylaxis according to PHS standards of care

PCP prophylaxis - percent of patients with a CD4 count < 200 receiving appropriate medication
MAI prophylaxis - percent of patients with a CD4 count <200 receiving appropriate medication

Other Health Indicators

Screening for TB - percent of patients with PPD placed; percent with PPD read
Gynecologic screening - Percent of women with PAP performed; percent of abnormal PAPs with colposcopy performed
Prevention with positives
STD screening - percent of MSM screened for syphilis

Health outcomes

Undetectable viral burden - percent of patients with viral load documented with most recent result <85

Retention

Percent of patients who received a medical visit in the preceding year who have at least one medical visit in the current year.

Indicators for medical case management are focused on client outcomes rather than case management processes:

Case Management access, retention, and discharge

Access - percent of clients who have received case management within six weeks of contact with EMA central intake hotline
Discharge - percent of clients discharged as of 12 months after initial intake
Retention - percent of clients who have not had cases completed or who are otherwise closed who are retained in case management 12 months after initial contact with EMA central intake hotline

Facilitation of access to behavioral health

Access to mental health services - percent of clients with active MH history in past three months who are receiving mental health therapy
Access to substance abuse treatment - percent of clients with active substance abuse history in past three months who are receiving substance abuse treatment

Access to HIV Medical Care

Linkage to HIV medical care - percent of CM clients who have not received HIV medical care within 90 days of intake who have attended HIV medical appoint at 6 weeks
Retention in HIV medical care - percent of CM clients who have recent medical appoint at 12-month follow-up

Targeting

Seropositivity - percent of HIV tests that are newly identified positive results

Linkage to and Retention in HIV Medical Care

Number and percent of clients who are newly identified positives or have not been in HIV medical care in the past 180 days who have documented attendance at 1, 2 and 3 medical visits.

HIV Prevention Services Program Evaluation

The overarching goal of HIV prevention programs is to reduce the number of new HIV infections. The AIDS Activities Coordinating Office's (AACO) HIV prevention evaluation system is currently undergoing a substantial transition to a national data reporting system, he Program Evaluation and Monitoring System (PEMS), developed by the Centers for Disease Control and Prevention (CDC) and representatives from health departments, community based organizations (CBOs), and other national prevention partners. PEMS will contribute to the goal of decreased HIV transmission by strengthening accountability and improving organizational capacity to monitor and evaluate HIV prevention programs.

PEMS will enhance prevention evaluation and enable prevention programs to better meet their goal by offering a systematic and standardized method of tracking the status of prevention programs. This method allows the CDC, health departments, and CBOs to improve planning efforts, resource targeting, and coordination at all levels.

The purpose of evaluation data collection and analysis is to assess progress and improve HIV prevention activities. PEMS will assess why programs are or are not able to achieve their intended goals and objectives by measuring agency, program and client characteristics. The three primary purposes for prevention evaluation are: 1) to determine the extent to which HIV prevention efforts have contributed to a reduction in HIV transmission, 2) to improve programs to better meet that goal, and 3) to be accountable to stakeholders by informing them of progress made in HIV prevention.

AACOs focus will remain implementation evaluation and monitoring, also known as process evaluation and monitoring for HIV prevention programs. However, AACO will continue to build the capacity to conduct outcome monitoring.

The purpose of implementation evaluation and monitoring is to objectively examine the qualities of intervention implementation and to improve implementation activities if necessary. More specifically, it includes routine documentation of characteristics of the people served, the services that were provided, and the resources used to provide those services. The intervention plan serves as one reference point with which progress made in achieving the intended objectives of the intervention can be compared. Outcome monitoring refers to efforts to track the progress of clients participating in an HIV prevention intervention. Anticipated outcomes should be stated in measurable terms in intervention plans and based on a program model. Client outcomes should relate to knowledge, attitudes, beliefs, or behaviors.

The CDC is currently revising a set of performance indicators for each modality of service.  AACO will use these indicators as the basis of its evaluation efforts for HIV prevention services.