Impact of DC EMA Cross-Part
Collaborative on DC/WV/VA AIDS
Drugs Assistance Programs
Panel of Presenters:
Lena Lago, MPH, M&E Branch Manager, Care Bureau, HAHSTA/DC DOH
Damber K. Gurung, Ph.D., M&E Specialist, Care Bureau, HAHSTA/DC DOH
Jay Adams, MA, Ryan White Part B Program, WV DOH
Anne Rhodes, MS, Services Analyst, HIV Care Services, Virginia DOH
1
Organization of Panel Presentation
 Overview of DC EMA Cross-Part Collaborative
 Impact of the Collaborative on DC ADAP Client
Enrollment Process
 Virginia Experience with DC EMA Cross part
Collaborative
 West Virginia Experience with DC EMA Cross part
Collaborative
2
Lena Lago
3
DC EMA Collaborative:
Overview
 Sponsored by HRSA and managed by the National
Quality Center (NQC)
 All-Parts (A, B, C, D, and F) Ryan White Programfunded grantees in the Washington, D.C. EMA,
including
 Maryland
 Virginia and
 West Virginia
 Initiated March 2011 to continue to September 2012
4
DC EMA Collaborative: Activities and Timeline
2011
SEP
AUG
JUL
JUN
MAY
APR
MAR
4
X
1
FEB
JAN
3
DEC
NOV
2
OCT
SEP
AUG
JUL
1
Technical Support
& Capacity
Building
Reporting
Cycle/Rounds
JUN
MAY
Learning Sessions
APR
X
MAR
JAN
Vanguard Meeting
FEB
Activities
2012
5
X
2
3
4
5
6
7
Q1
Q2
5
IHI Breakthrough Series Collaborative Model
Source: National Quality Center application of The Breakthrough Series: Institute for Health
Improvement (IHI) Collaborative Model for Achieving Breakthrough Improvement; 2003
6
DC EMA Collaborative: Purpose Statement
The HRSA HIV/AIDS Bureau (HAB) sponsored the
development of the D.C. Quality Management Cross-Part
Collaborative:
 To strengthen the regional capacity for collaboration across
Ryan White Parts (Parts A, B, C, D and F),
 For alignment of quality management goals to jointly meet
the Ryan White HIV/AIDS Program legislative mandates,
 For joint quality improvement activities to advance the
quality of care for people living with HIV across constituencies
within a region, and
 To coordinate HIV services seamlessly across Parts.
7
DC EMA Collaborative: Performance Measures
Adult/Adolescent Measures (6):
 Viral Load Testing Frequency
 Viral Load Suppression
 Medical Visits
 Syphilis Screening
 PCP Prophylaxis
 Oral Exam
8
DC EMA Collaborative: Performance
Measures
ADAP Measures (2):
 ADAP Applications (Measure #14) - Percentage of
ADAP applications approved or denied for new ADAP
enrollment within 14 days (two weeks) of ADAP
receiving a complete application in the measurement
year
 ADAP Eligibility Recertification (Measure #15) Percentage of ADAP enrollees who are reviewed for
continued ADAP eligibility two or more times in the
measurement year
9
DC EMA Collaborative: EMA-Wide ADAP Data Rounds 1-6 Trends
Performance Measure
May 2011 March 2012
ADAP Application (#14)
82%
90%
ADAP Recertification (#15)
21%
46%
Change
10
DC EMA Collaborative:
Accomplishments
 Strengthened partnerships across Parts in the
Washington, D.C. EMA as evidenced by established
communication strategies for the purpose of collaboration
for quality management; region-wide quality management
priorities; and joint training opportunities.
 A portfolio of performance measures in place for
strategic planning and quality improvement processes and
data are routinely collected based on standardized data
collection methodologies.
 A unified, regional Cross-Part quality management
plan in place for the Washington, D.C. EMA area;
supported by a work plan for implementation.
 Joint quality improvement projects initiated and each
grantee contributes to the success.
11
Damber K. Gurung
12
DC ADAP: Client Enrollment
 Client eligibility criteria:
 DC Resident, 500% FPL, Asset Limit ($25,000),
HIV+
 Clients must recertify every six months
 Clients must fill prescriptions at participating
pharmacies (#21):
 Use one proprietary pharmacy database
(Pharmacy Benefit Manager)
 Formulary - 105 drugs including all
antiretroviral drugs (n = 28 in 2010/2011)
13
DC ADAP Profile: Clients Enrolled
(June, 2010–2012)
Enrolled (Med)
C
L
I
E
N
T
S
Enrolled (Ins)
25%
46%
50%
54%
50%
June '11
June '12
75%
June
'10
14
DC ADAP Profile: Clients Served
(June, 2010 – 2012)
Served (Med)
CLIENTS
18%
82%
June
'10
Served (Ins)
32%
32%
68%
68%
June '11
June '12
15
DC ADAP Client: Monthly Enrolled and Served
(Trend: 2007 to 2012)
Total Enrolled
Total Served
3,000
2,500
2,000
1,500
1,000
500
0
16
DC ADAP Client Enrollment Business Process
To be inserted
17
(Measures #14): Process or
Challenges
DENOMINATOR: # Clients who have newly
applied for ADAP assistance;
 New client applications
 Identifying New clients vs. Recertified clients;
Unidentified clients
 Missing data: dates, approval
 Data error: approval dates earlier than Application
received dates
 Duplicate new applications
 Applicants multiple ethnicities
18
ADAP (New) Applications (Measures
#14): Process or Challenges (contd.)
NUMERATOR: # New clients’ approved/denied
within 2 weeks of ADAP receiving a complete
application
 Exclude applicants who were approved >14 days after
(complete) application was received
 Adjusting applicants’ multiple ethnicities
19
ADAP Recertification (Measures #15):
Process or Challenges
DENOMINATOR: ADAP Enrollees reviewed for
continuous eligibility
 Identify Recertifying clients
 Include recertifying clients from “New client” category
 Exclude clients who were termed within 180 days of
the measuring period
 Exclude applications with data error or data missing
 Adjusting applicants’ multiple ethnicities
20
ADAP Recertification (Measures #15):
Process or Challenges (Contd.)
NUMERATOR: ADAP Enrollees reviewed 2 or more
times (150 days part) for continued eligibility –
Process or Challenge
 Selection of clients - recertified 2 or more times
 Selection of clients - recertified 2 or more times at
least 150 days apart
21
The PDSA Cycle
for Learning and Improvement
The
Source:Cycle
National Quality Center (NQC), The Quality Academy Tutorial
The PDSA
22
PDSA Cycle: PLAN
(Plan a change)
 OBJECTIVE: Continuous Quality Improvement
(CQI) in client enrollment process
 The plan was implemented by CHSS Bureau’s
M&E team and involved ADAP log (access
database) as well as all ADAP staff.
 Planning started in October 2011; Plan included
 System change: Changes in database
parameters
 Process improvement: Standardizing
processes of data field identification and
data entry; Training
23
PDSA Cycle: DO
(Try it out on small scale)
 Data manager & ADAP staff
collaborated to identify action steps
for projected system change and
process improvement
 Identification of parameters for
change- data fields, date ranges
24
PDSA Cycle: DO
(Action Items)
 Reconfigure database making relevant fields
required for approved clients
 Communicate with program staff on client type
(New or Recert) definition and classification
 Reconfigure data system using validation rule to
avoid errors
 Development/implementation of standard data
entry procedure
 Brainstorm corrective measures with program staff
25
PDSA Cycle : STUDY
(Observe the Results)
 Measuring rate of completion:
 Client type (new or recertification) identification
 Approval date
 Approval date together with approved by
(Enrollment Specialist’s Name)
 Comparison: Rate of completion were to be
compared between before and after the
changes
26
PDSA Cycle : STUDY
QI Results
R3
1. INCOMPLETE DATA
Percent of New clients
applications with missing
data
Percent of duplicate New
client applications
Percent of recert
applications with missing
data
Percent of new clients
actually recert clients
R4
R5
R6
Q1
Q2
Av.
Change CHANGE
2%
9% 13%
8%
3%
5%
5%
5%
4%
-3%
11% 17%
2%
1%
7% 14%
-3%
12% 14% 14% 14% 12% 13%
0%
7% 12%
12%
None
2. DATA QUALITY
Percent Error in dates:
New clients
39% 23% 15%
6%
2%
0%
-23%
27
PDSA Cycle: ACT
(Action Items)
 Communicate with program staff on issues
 Brainstorm corrective measures with
program staff
 Development/implementation of standard
data entry procedure
 Plan System Interventions
 Plan Mini Projects for continuous
Improvement
28
DC ADAP New Application (Measure # 14)
Trend
P
E
R
C
E
N
T
90
80
70
60
50
40
30
20
10
0
72
61
60
70
78
58
29
29
DC ADAP Recertification (Measure # 15)
Trend
16
14
p
E 12
R 10
C 8
E 6
N 4
T 2
13
9
8
4
5
6
4
0
30
DC ADAP Enrollment -Collaborative Measures
Trend (2011-2012)
ADAP Application #14
ADAP Certification #15
78
80
P
E
R
C
E
N
T
72
70
60
61
60
70
58
50
40
29
30
20
10
13
4
5
8
6
9
4
0
31
LESSONS LEARNED & Challenges
 Measurements reveal inadequacies in data, systems
and processes
 Mini-projects can sustainably improve data quality
impacting program outcome
 Engaging stakeholders is crucial for sustained quality
improvement
 QI must continue regardless of changing environment
32
Anne Rhodes
33
VA ADAP: Persons and Cost, 2010-2012
4000
3.5
3500
3
3000
Clients
2500
2
2000
1.5
1500
Million of Dollars
2.5
1
1000
0.5
500
0
0
Number of Active Persons
Total Cost Per Month
Source: VA-ADAP database, Division of Disease Prevention, Virginia Department of Health, August 2012
34
VA-ADAP: Eligibility Process 2010
 Contractor site conducted eligibility
 Data sent monthly to VDH
 Prescription data stored in a separate database housed
at a university contractor
 Data completeness/data matching issues
35
VA-ADAP Current Eligibility Process
Clients and/or case
worker submit ADAP
applications to VDH.
ADAP Operations
Technicians (AOT)
process client
applications.
A peer reviews
application and
supporting documents.
AOT sends letter to client.
ADAP Data Manager
enters client
information into ADAP
database.
AOT faxes statement to provider.
ADAP Operation
Specialist determines
final disposition for
client applications.
AOT faxes statement to local
health department.
AOT faxes statement to Central
Pharmacy.
36
VMARS: VA Medication Access Reporting System
 Online report that provides updated eligibility
information to local health departments and medical
providers
 Includes date of last fill for ADAP Rx (if available),
along with application approval date
 LHD Staff and medical site complete application and
send to VDH ADAP for approval before being assigned
logon for system
37
Database(s)
Centralized
Intake, Rx
(VCU)
Medicaid
Backbilling
(VDH - fiscal)
Contacts
Tracking
(VDH)
Waitlist
(VDH)
Medicare Part
D (contractor)
38
PDSA Cycle: PLAN
 OBJECTIVE: Improve application and recertification
process for ADAP to ensure all needed data were
collected and potential payer sources were checked
 The plan was implemented by VDH’s HIV Care
Services unit
 The plan included
 System change: Move of ADAP eligibility processes in-
house to VDH
 Process improvement: Data matches, uniform
recertification processes
39
PDSA Cycle: DO
 Contract staff were hired at VDH to conduct re-
certifications and to be trained in conducting
eligibilities
 ADAP application redesigned to include all ADR
elements and to capture more insurance and
other payer source information
 Contract with eligibility company was phased out
in June 2012
40
PDSA Cycle : STUDY
 Measuring time of application completion:
 Client type (new or recertification)
 Application date
 Approval date
 Measuring percent of clients found to have
other payer sources
41
VA-ADAP Indicators
42
PDSA Cycle: ACT
Anticipated Outcomes
 % of clients found to have other payer source
will increase from 11% to 15%
 Time from application to disposition will
decrease from 7.6 days to 4 days
 Data currently show average time to disposition
of 5.4 days
43
QUESTIONS
&
ANSWERS?
Contact: damber.gurung@dc.gov
44