Quality in Hard Times: Using Quality to Help Mitigate the Impact of Budget Cuts on Care/Building a Quality Management Program on a Shoestring
C-8
August 24, 2010

Popular excuses for not having time for quality improvement are:

• “With everything else we have to do, we can’t afford to dedicate someone to quality.”
• “I can barely keep up with patient care as it is.”
• “We would like to do quality improvement, but we don’t have electronic medical records.”
• “We have a quality manager who looks after that, I focus on patient care”

The workshop Quality in Hard Times, revealed ways programs can cut costs and increase revenue through quality improvement. Programs report seeing cost savings from reduction in: lab ordering, no shows, supply costs, duplication of services, and waste of meds by better feedback loop with the pharmacy. Increased revenue was reported from reduction in missing billing sheets, education to doctors about coding, added family planning billing options, and improved application rates for Medicaid.

Other helpful strategies include: not reinventing the wheel, networking with other programs working in similar areas to share experiences and models for success, aligning efforts with QI efforts in other areas of the organization, and leveraging technical support resources offered by HRSA funding and other interest groups.

For more information or to receive resources on building a case for quality improvement in hard economic times, visit the National Quality Center Exhibit table or go to NationalQualityCenter.org.

Don’t Be Number One: Sliding Fee Scales and Individual Patient Caps
C-3
August 24, 2010

The number one finding for site visits administered by the DCBP is the grantee’s lack of a sliding fee scale.  A close second is lack of a cap on individual charges.

This session, which drew a crowd of over 100 people from all Parts of the Ryan White Program, began with an overview of the Ryan White legislation and HRSA expectations related to sliding fee scale and patient caps.  Susan O’Brien followed up with a review of her Part C agency’s policy and how she worked to get it implemented.  She described working with middle-management on the organizational level and how she engages clients to take ownership of their care.  Karla Burnworth shared how a smaller organization with a much larger service area has been able to implement new fiscal policies.  One common theme is engaging both the client and middle-management. An effective way to do this is for the Project Officer to convey the importance of Ryan White Program fiscal policies to middle-management financial staff.

Over 30 questions about sliding fee and cap issues were written down on a flip chart.  Presenters will compile answers and send them out to attendees.  For more information, contactjfanning@hrsa.gov.

Medical Care Coordination: Implementing the Medical Home Concept
C-2
August 24, 2010

Major system change can be a challenging and time consuming process.  The LA County EMA shared lessons learned in making such a change in shifting from a case management to medical home model—insights they gained in the course of change that was guided by the planning council and grantee. 

The multi-year process, LA anticipates it will take about 6 years to implement from the planning stages to finish, brought together a range of stakeholders to engage in a variety of planning and implementation activities.

Consumers were the driving force behind the proposed changes.  Through various forms of feedback, including regular needs assessments, consumers emphasized that the psychosocial case management system was not meeting their needs, especially in terms of facilitating access to care.  In response, the council took the lead in a planning process that included conducting research to identify possible models.  Next steps included development of a framework, standards of care, and principals and priorities, followed by a financial analysis to determine the costs related to the proposed changes.

The grantee headed the implementation process, establishing a transition advisory group (TAG) that included council members, nurses and case managers, consumers, and providers.  The grantee also included representatives from other public health care systems, such as chronic disease management and maternal and child health—bringing much-needed insights and experience from those outside of the HIV/AIDS community.

Based on its efforts to bring about major system change, the EMA has several lessons to share.

• Involve stakeholders from the beginning and work toward consensus.
• The larger the change, the greater the resistance will be.  Opponents will challenge the data, cost, and the implementation (e.g., will call for pilot testing).  When proposing change, it is important to plan for resistance and be prepared (i.e., do your homework).
• The grantee and the council must work together.  Opponents will pick up on (and exploit) discord.
• Seek out TA resources.  LA County received technical assistance from a HRSA consultant.  It helped both in terms of the expertise and having a “neutral” party to guide the process.
• Training will be necessary to support the change.  This will need to target all stakeholders including staff, providers, and consumers.
• A comprehensive communication strategy is necessary to let stakeholders, especially consumers, know that change is coming.  It is also important to keep up the flow of information as people are likely to lose patience with the planning and implementation process as it stretches out.

A variety of tools using during the planning and implementation process are available from theLA HIV Commission.  Additional resources on planning and medical case management are available from the TARGET Center.

Getting the Most Out of Training: Feedback from AETCs
B-9
August 23, 2010

When a group of trainers from the HRSA/HAB-supported AIDS Education and Training Centers (AETCs) gets together to discuss ways to maximize learning and minimize barriers to training in clinical sites, there are likely to be one or two memorable stories.  Like the time one trainer showed up at a clinic expecting to find a blank white wall on which she could project her slides, only to have a stuffed deer rump (yes, it was real) mounted in the middle of the wall.

Fortunately, this example is the exception.  For the most part, trainers participating in the discussion focused on the importance of working closely with the clinical site to ensure a successful training.  While we all understand that time is an extremely precious commodity, a little investment on the part of the clinic can have big pay offs in terms of a successful training.

Assess Before You Train. In planning a training for staff, clinical sites should work with the trainer to conduct a needs assessment.  In some cases, a face-to-face meeting can allow the trainer to assess the facility to determine the most appropriate way to set up the training.  For example, if the clinic lacks a conference room, small group sessions might be the most appropriate.  A visit to the clinic can also allow the trainer to conduct some short, key-informant interviews with staff members to explore their training needs as staff needs may vary from the administrator’s or clinical director’s perceptions.

Think Outside, Yes, the Box. Given the time constraints, clinics should work with trainers to “think outside the box.”  Instead of have a single training that lasts all morning, the trainer can conduct a series of shorter trainings over time.  Trainers can also distill information to the bare essentials and design a 20-minute training that could take place during a staff meeting.  Another option that was suggested had to do with Web casts and other forms of recorded trainings.  The advantage of these are that they often are conducted by highly qualified trainers.  However, it can be difficult to engage participants because they are not interactive.  Group viewings can be held with a trainer present to answer questions and lead discussion.  Providing food is an added inducement.  Bottom line, all the trainers participating in the discussion were committed to tailoring their trainings to the needs of the site.

Finally, the AETCs are about building an ongoing training relationship with clinical sites.  To ensure that all parties are getting the most out of the relationship, they should share feedback and evaluations.  This can lead to better tailored trainings and improved buy-in on the part of staff.

Learn more about the AETC Network and other HRSA/HAB clinician training resources.

Enhancing HIV and Mental Health Services Linkage between Jail and Community: An Example of Two HRSA/SPNS Funded Programs
A-9
August 23, 2010

Jail based mental health and substance abuse counseling and community support can be a significant component to linking incarcerated and previously incarcerated PLWHA to care.  This workshop on the work of two SPNS projects included a video panel consisting of consumers, providers, and advocates who discussed best practices for identifying and engaging community partners.  Among their tips:

• Develop rapport with corrections staff.
• Appoint a liaison with community partners.
• Communicate often with jail staff, community providers and community case managers.
• Provide continuity of care by continuing the community care plan via discharge planning and coordinating services.

HIV/STI Screening and Post-Exposure Prophylaxis: Partnering to Improve Care
B-16
August 23, 2010

This workshop reviewed the benefits of a protocol for HIV screening and prophylaxis for victims of sexual assault. Key elements of the protocol include:

• Offering the patient information.
• Encouraging prophylaxis against HIV and STIs (determined on a case by case basis).
• Encouraging follow-up to HIV/STI exams.

Multidisciplinary collaborations were instrumental in developing the clinic’s protocols and algorithms and executing training plans. Key partners included the sexual assault nurse examiner, pharmacy, emergency department social worker, nurse, physician and infectious disease physician,   Activities significantly increased the number of sexual assault victims who were screened for HIV/STIs and provided with non-occupational exposure prophylaxis.

The Financial Impact of New 2009 Department of Health and Human Services (DHHS) Guidelines for the Use of Antiretrovirals
E-24, Tuesday, August 24, 2010

Dr. Keith Rawlings from the Peabody Health Center in Dallas, Texas, gave a provocative presentation analyzing the additional cost of HAART if the 2009 DHHS Guidelines are applied widely.  Analysis of his clinic population as well as those of local HIV providers suggested that 10% (5.6-12%) who were currently not on HAART would be eligible for therapy based on current guidelines (starting when CD4 count < or = 500 cells/cc rather than < or = 350 cells).  For the Dallas EMA, this would involve an estimated 1180 to 2550 persons.  The cost of antiretroviral therapy using 340B pricing for preferred ARV regimens would be $16-$35 million annually if 100% of the eligible population were treated, and $8-$17.5 million if 50% were treated.  Dr. Rawlings suggested that the resulting questions of financing this expansion, prioritizing Ryan White funds, and the real possibility of establishing disparity in the availability and choice of antiretroviral therapy due to lack of funding needs to be discussed immediately by the Ryan White grantee community and HIV providers.