MEDICAL CASE MANAGEMENT QI NETWORK March 5, 2013 at 9:30 a.m. Ryan White Part A Program Office 115 S. Andrews Ave., Ft. Lauderdale, FL 33301

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1 Broward Regional Health Planning Council, Inc. Inc Oakwood Lane, Suite Hollywood, Florida T: T: (954) F: F: (954) MEDICAL CASE MANAGEMENT QI NETWORK March 5, 2013 at 9:30 a.m. Ryan White Part A Program Office 115 S. Andrews Ave., Ft. Lauderdale, FL AGENDA I. Call to Order II. III. IV. Welcome/Introductions Review March 5, 2013 Meeting Agenda and February 5, 2013 Meeting Minutes MCM Annual Work Plan ACTION ITEM: Review MCM annual work plan and discuss changes for the 2013/14 FY. V. Review Baseline HHS Data ACTION ITEM: Review and discuss potential interventions based on HHS data. VI. Client Level Retention Rates ACTION ITEM: Discuss client-level data review and define elements for Network analysis. VII. Old/New Business VIII. Resource Sharing IX. Review Agenda Items for Next Meeting X. Adjournment Next Meeting Date: April 2, 2013

2 COMMUNITY PARTNERSHIPS DIVISION Health Care Services Section 115 S Andrews Avenue, Room A300 Fort Lauderdale, Florida FAX MEMBERS PRESENT Pont, A., SBHD Johnson, T., NBHD Garcia, E. MDEI Thornberry, A. Broward House Haberle, R. AHF Alexis, G. BCFHC MEDICAL CASE MANAGEMENT QI NETWORK February 5, 2013 at 9:30 A.M. Ryan White Part A Program Office 115 S. Andrews Ave., Ft. Lauderdale MINUTES MEMBERS ABSENT Pietrogallo, T., Care Resource GUESTS Mercer, A. Majcher, B. Ettinger, R. CLINICAL QUALITY MANAGEMENT (CQM) SUPPORT STAFF Eshel, A. Solomon, R. PART A GRANTEE Degraffenreidt, S. Strong, K. Swanson, M. Jones, L. I. Call to Order The meeting was called to order at 9:44 A.M. II. III. IV. Welcome/Introductions CQM Staff welcomed everyone and individual introductions were made. Review February 5, 2013 Meeting Agenda and January 8, 2013 Meeting Minutes The February 5, 2013 Meeting Agenda and January 8, 2013 Meeting Minutes were approved via Network consensus. Ryan White Part B Representative Ann Mercer facilitated a discussion with the Network on Ryan White Part B services. Bus Passes: Current bus pass eligibility and possible change in income eligibility were discussed. The Network was asked to think about whether raising the income eligibility from 150% to 300% of the Federal Poverty Level (FPL) would be beneficial. The Broward County Health Department (BCHD) suggested that Medical Case Managers (MCMs) pick up extra bus passes so that there is always a buffer and clients do not have to wait for bus passes. MCMs were informed that they can come to the BCHD multiple times per month as needed to pick up bus passes. It was noted that Part A funded 10 ride bus passes are limited; Part A clients need to become Part B certified in order to continue to get bus passes once all 10 ride passes are utilized. It was also noted that the BCHD will only be purchasing 31 ride passes from this point on. MCMs discussed the process of returning expired bus passes in order to get new bus passes. It was suggested that MCMs remind clients to return expired passes. It was mentioned that MCMs can use discretion with clients that do not return expired bus passes. Home Delivered Meals: The criteria for Home Delivered Meals was provided to the Network. Clients need a prescription from a doctor and a referral form. Broward County Board of County Commissioners Sue Gunzburger Dale V.C. Holness Kristin Jacobs Chip LaMarca Ilene Lieberman Stacy Ritter John E. Rodstrom, Jr. Barbara Sharief Lois Wexler

3 Home Health Services: The Network was informed that there is funding available for this service and MCM s are encouraged to use it. The Network was given a list of providers that the BCHD has used in the past. BCHD welcomes new providers; they have to be registered on My Florida Marketplace, be a Medicaid approved provider, and fill out a W-9. The referral form and billing authorization form were given to the Network. The Network was reminded of home health eligibility. Clients have to be Part B eligible and have a prescription from their doctor. The prescription needs to include the reason why a particular service is needed (i.e. supplies, homemaker or home health aide). Approvals are only done a month at a time based on yearly funding. Sabrina is the point of contact; if Sabrina cannot be reached Ann Mercer can be contacted. The Network was also encouraged to follow up with an (without giving specific client information) if a fax is not answered. ADAP: The Network was reminded that there is no longer a waiting list for ADAP. Clients are usually off the list within 3-5 days. If clients are out of medication they will be given a 7-10 day supply. If a client is brand new to ADAP and out of medicine, they will be given a 30 day supply. A consumer noted that the ADAP follow up process is not easy and needs to be improved. The Grantee suggested that clients be reminded to call ADAP. BCHD agreed to talk to ADAP staff to remind them to encourage clients to follow up. It was also noted that MCMs can be the point of contact on their clients behalf. V. NQC In+Care Campaign Measure Report An annual summary of the In+Care Campaign was reviewed (copy on file). VI. MCM Service Delivery Model (SDM) The Network agreed on the following revisions to the SDM. Definition A range of client-centered services that link clients with health care, psychosocial, and other services. A range of client-centered services that link clients with health care, psychosocial, and other services including benefits/ entitlement, counseling and referral activities assisting them to access other public and private programs for which they may be eligible (e.g., Medicaid, Medicare Part D, State Pharmacy Assistance Programs, Pharmaceutical Manufacturers Patient Assistance Programs, and other State or local health care and supportive services). The coordination and follow-up of medical treatments is a component of medical case management. Protocols The Medical Case Management and Peer Counseling Protocol identifies the specific ways to implement the Medical Case Management and Peer Counseling Standards and processes inherent to medical case management and peer counseling services. Service delivery shall be conducted with cultural competency by culturally competent service providers. Providers are also expected to comply with applicable standards and guidelines that are relevant to individual service categories (i.e, HAB HIV Medical Case Management Performance Measures, etc.). Eligibility Verification The medical case manger shall verify client s eligibility is established by reviewing the certification in the designated HIV MIS System. MCM (or other authorized individual such as Peer Educator), shall perform an eligibility and financial assessment at each visit in addition to reviewing client s eligibility certification in the designated HIV MIS System. MCM (or designee) will review client s eligibility for all funding streams and services for which client may qualify. MCM s will follow-up with referrals as appropriate. The purpose of the assessment is to ensure 1) client s access to all services client may be eligible for and 2) the status of Ryan White as payer of last resort. Goals As a member of the clinical care team, the medical case manager shall assist the client to define both medical and social service goals for the needs identified in the Action Plan. The expected results/benefits shall be documented in the Action Plan. The medical case manager shall document the specific assistance provided to the client in the Progress Notes. Reassessment The medical case manager shall conduct: a) continuous client monitoring to assess the efficacy of the Action Plan and b) Periodic re-evaluation and adaptation of the plan at least every 6 months, as necessary a reassessment of each active client as indicated by the Action Plan and at a minimum once annually. The medical case manager shall document the reassessment in the Progress Notes. The medical case manager shall revise and update the Action Plan at reassessment. Professional Requirements and Training Training of the Medical Case Manager: 2

4 HIV Basic Training Annual HIV Update Medical Case Manager must have a minimum of 8 hours of training annually on medicallyrelated topics Training of Medical Case Manager Supervisor: Updates on management issues and/or skills Other appropriate to the position Medical Case Manager must have a minimum of 8 hours of training annually on medicallyrelated topics Outcomes, Outcome Indicators, Strategies and Data Sources: Client Outcomes 1. Improved ability to independently navigate and access needed services. Outcome Indicators % of new clients receive information regarding available services and corresponding eligibility criteria % of clients achieve initial Plan Of Care (POC) goals by designated target dates. Funding Clients Staff Inputs Strategies Data Sources (Only one required for each strategy) Facilities Supplies Explain RW eligibility by service Obtain client signature Assess client needs Create POC with client input Provide necessary support and referrals Follow-up by designated target dates Revise target dates to POC as needed Progress Notes Clients Rights, Responsibilities and Acknowledgement form Needs Assessment Signed Action Plan by CM and client Action Plan Referrals and Progress Notes Action Plan Action Plan Client Outcomes Outcome Indicators Inputs Strategies Data Sources (Only one required for each strategy) 1-Increased access, retention and adherence to Outpatient/ Ambulatory Medical Care NOTE: Retention in care reflects an OAMC visit with a provider in the first 6 months and the % of clients achieve POC goals related to Outpatient/ Ambulato ry Medical Care services by designated target dates % of clients are retained in Outpatient/ Funding Clients Staff Facilities Supplies Collaborate with client to assess client medical needs Develop POC goals that reflect client s medical Progress Notes Action Plan Progress Notes Action Plan Progress

5 last 6 months of a 12 month measurement period Ambulatory Care. Medical needs Develop obtainable target dates Assist client in making medical appointments as needed Follow-up to ensure client attended medical appointments Educate clients on the importance of attending medical appointments. Notes Action Plan Needs Assessment Client appointment record Action Plan Client appointment record Action Plan Progress Notes Action Plan VII. MCM Annual Training Plan CQM Support Staff facilitated a discussion about MCM training to get Network suggestions on future trainings and follow up at the agency level. Comments from previous trainings were reviewed. The Network suggested announcing mandatory trainings at least 30 days in advance to ensure participation, using other presentation sources other than PowerPoint, and utilizing interactive methods such as role playing. There was a discussion with the Network about MCM supervision. The Network was reminded that they can call the PE help desk for dummy numbers for supervisory billing in PE. The Network agreed that there is a disconnect between training and actual improvement; in some cases, MCMs may find it difficult to change the way they have been operating. VIII. Old/New Business The Grantee informed the Network that HIVPC approved and changed food bank eligibility to increase food allotment from 12 annual allotments to 15. A food allotment may be a combination of food bank and food vouchers; clients can receive up to 3 food vouchers a year. The eligibility criteria remains the same with the exception that clients can now choose between food bank or a food voucher with the option to receive a box and a voucher at the same time. A notice will be put in PE to inform users of the effective date. The Network was reminded that clients need to bring their food voucher receipts to Poverello for review to ensure that voucher money is spent for nutritional needs. The criteria for emergency food provisions did not change. FOOD BANK/FOOD VOUCHERS Application status for food stamps and/or WIC (undocumented residents exempt) FOOD BANK 150% FPL 15 Food Bank allotments per year. A maximum of 3 allotments may be vouchers. A single voucher can be provided simultaneously with a box. FOOD VOUCHERS (Emergency Provision) % FPL Maximum of 3 food bank allotments per year (food box or food voucher) Must demonstrate an emergency need and a plan to meet their need. Emergency defined as a verified loss of, or reduction in income due to unexpected or unbudgeted expense or event beyond client s control. Emergency must be documented in Progress Log and Plan of Care 4

6 IX. Resource Sharing BCHD and Network providers agreed to share upcoming training announcements with each other. X. Review Agenda Items for Next Meeting Standing agenda items XI. Adjournment The meeting was adjourned at 11:13 A.M. Next Meeting Date: March 5,

7 Medical MCM MH/SA OHC Combined All MCM Training March X X April X X X X X May X X June X X X July X X X X August X X X X September X X October X X X X X November X X December X X X January X X X X February X X X X X FY Medical Case Management Network Work Plan March April May In+Care Data Review Discuss findings from agency CLD review Review Findings from Client Survey Review Annual WP Review baseline HHS Data Discuss Analysis of Gap Measure CLD Develop retention QIP Review training evaluations and pre/post test results June July August Assess progress of QIP In+Care Data Review Review baseline Broward Client-Level Outcomes and Indicators Review Do stage of PDSA Review HHS data Review HHS data Review Act Stage of PDSA In+Care Data Review Review training evaluations and pre/post test results Agency specific presentation on QIP implementation September October November In+Care Data Review Review summary of desktop review In+Care Data Review Review HHS data and develop QIP Review supervisory action plan Review training evaluations and pre/post test results December January February Annual Breakfast Annual SDM Review In+Care Data Review Annual evaluation of Accomplishments and Challenges Review training evaluations and pre/post test results Update WP 1

8 + MCM Network Retention in Care QIP Development

9 + MCM QIP Development In June 2012, the MCM Network received agency specific client level data for the Gap Measure 04/01/ /31/2012 Each provider was asked to document the following: Last Attended Medical Appointment Reasons for Missed Appointment Next Scheduled Medical Appointment Date and Result of Last CD4 Test Date and Result of Last VL Data Source for Each Element (e.g., PE, EMR, client self-report)

10 + Gap Measure Definition Definition: Percentage of patients, regardless of age, with a diagnosis of HIV/AIDS who did not have a medical visit with a provider with prescribing privileges in the last 180 days of the measurement year Numerator: Number of patients who had no medical visits in the last 180 days of the measurement year Denominator: Number of patients, regardless of age, with a diagnosis of HIV/AIDS who had at least one medical visit with a provider with prescribing privileges in the first 6 months of the measurement year

11 + Exclusions Patients documented to be deceased at any time in the measurement year Patients who were incarcerated for greater than 90 days of the measurement year Patients who relocated out of the service area or transferred medical care at any time in the measurement year

12 + Last Attended Medical Appointment Agency A Agency B Agency C Agency D Agency E Agency F N Last Attended Medical Appt. Range: Range: Range: Range: Range: Range: Data Source PE, EMR PE, Client, Client s PCP, Another Agency EMR EMR PE, Client s PCP PE, EMR

13 + Reasons for Missed Appointments Agency A Agency B Agency C Agency D Agency E Agency F N Reason for Missed Appt. None Too Busy with Work None Case Closed (Client Transferred) Private Insurance/ Medicaid Unable to Contact Client Incarcerated Unaware of Appt. Unknown Appt. Was Attended Receives Care through Another RW Provider Fallen Out of Care New Client Failed to Recertify for RW Incarcerated Moved Medicare/ Medicaid Incarcerated Appt. Was Attended Incarcerated Client Moved Private Insurance/ Medicaid Unable to Locate Client SA Treatment No Longer Eligible Data Source Client PE, No Source Listed Client, BSO, EMR Client, Client s Emergency Contact PE, PCP PE, EMR, DOC/BSO Website

14 + Next Scheduled Appointment Agency A Agency B Agency C Agency D Agency E Agency F N Next Sch. Med Appt. Range: Range: Range: Range: 6.12 Range: Range: Data Source EMR, PE PE, Client s PCP EMR EMR MCM, PCP, Client EMR, PE

15 + CD4 and VL Results Agency A: 58% detectable, 33% CD4<200 Agency B: 21% detectable, 16% CD4<200 Agency C: 47% detectable, 20% CD4<200 Agency D: 100% detectable, 33% CD4<200 Agency E: 90% detectable, 40% CD4<200 Agency F: No results submitted

16 + Discussion Data Entry EMR indicates client attended appointment Medical appointment not entered in PE Client included in the Gap Measure Case Closure Incarceration, moving, transferring to another provider, Private Insurance/Medicaid/Medicare These cases should have been excluded In some cases, the last documented medical appointment was in May of 2011 with the case remaining open Progress Note Documentation Little to no indication that MCMs are tracking medical appointments In some cases, no communication with client for six months

17 + Questions How are appointments scheduled and tracked in the MCM Plan of Care to ensure compliance with medical care? Detectable Viral Load and CD4<200 may indicate noncompliance with care as well as possible eligibility for non- RW funded services (e.g., PAC Waiver). How are MCMs utilizing lab results? How can MCMs proactively work to prevent clients from falling out of care?

18 + Gap Measure 35% 30% 25% 20% 15% 10% 5% 0% All 30% 28% 22% 23% 23% 23% 22% 20% MCM 17% 15% 12% 10% 12% 12% 9% 8%

19 + Medical Visit Frequency 80% 70% 60% 50% 40% 30% 20% 10% 0% All 49% 47% 48% 49% 49% 51% 51% 52% MCM 70% 67% 67% 68% 68% 69% 73% 73%

20 + Patients Newly Enrolled In Medical Care 80% 70% 60% 50% 40% 30% 20% 10% 0% All 35% 44% 46% 41% 40% 47% 50% 53% MCM 55% 58% 55% 57% 56% 65% 69% 72%

21 + Viral Load Suppression 72% 70% 68% 66% 64% 62% 60% 58% 56% All 66% 67% 61% 61% 61% 62% 70% 70% MCM 61% 62% 64% 66% 67% 68% 68% 68%

22 + NHAS Indicators 120% 100% 98% 80% 69% 60% 53% 40% 36% 20% 0% HIV Positivity Retention in HIV Medical Care 1% Late HIV Diagnosis Linkage to HIV Medical Care 9% ART Among Persons in HIV Medical Care Viral Load Suppression 19% Housing Status

23 + Viral Load Analysis Report Undetectable by Gender/Race/Ethnicity Transgender MTF White Non-Hisp Lat 71.4% Transgender MTF White Hisp Lat 44.4% Transgender MTF Black/AA Non-Hisp Lat 59.3% Male White Non-Hisp Lat Male White Hisp Lat Male Pac Islander Non-Hisp Lat 71.1% 73.1% 70.0% Male Black/AA Non-Hisp Lat 59.8% Male Black/AA Hisp Lat 46.9% Male Asian Non-Hisp Lat 83.9% Female White Non-Hisp Lat Female White Hisp Lat 72.7% 71.8% Female Native Hawaiian Non-Hisp Lat Female Black/AANon-Hisp Lat Female Black/AA Hisp Lat Female Asian 50.0% 57.1% 46.2% 57.1%

24 + Viral Load Analysis Report Undetectable by Age 80.0% 75.9% 70.0% 64.2% 68.8% 60.0% 54.3% 50.0% 40.0% 39.3% 30.0% 20.0% 10.0% 0.0% years of age or older

25 + Our Goal To transition clients along the treatment cascade to full engagement in HIV care and viral load suppression