Outpatient Therapy Chart

Document Sample
Outpatient Therapy Chart Powered By Docstoc
					                                                                        Breakdown of Performance Measures GY 2010
                                                                             Ryan White Part A, Las Vegas TGA

     Indicator
       Type                          Label                                Indicator                              Numerator                             Denominator                    Target %       Source
                                                           A quality indicator is a tool to measure
                                                          specific aspects of care and services that                                                                                   National
                                                            are optimally linked to better health                                                                                      target or
                                                           outcomes while being consistent with             Who among those who                                                      benchmark/    Location of
    Key aspect             Short name of indicator for      current professional knowledge and              should have received                 Who should have received             our TGA's      data for
     of care.                      reference.                       meeting client needs.                    the care actually did.              the care being measured.                goal       collection
                                                                                                Core Medical Services
                                                                                       Ambulatory/Outpatient Medical Care

                                                                                                   Number of HIV-infected clients who
                                                                                                    had a medical visit with a provider
Accessibility of care                                                                              with prescribing privileges in an HIV Number of HIV-infected clients who
      HAB01                      Medical Visits           Percent of clients with HIV infection who care setting two or more times at     had a medical visit with a provider
     (see HAB                                             had two or more medical visits in an HIV   least 3 months apart during the      with prescribing privileges at least          80%
    exclusions)                                             care setting in the measurement year.           measurement year.              once in the measurement year.                           CAREWare

Accessibility of care                                                                            Number of HIV-infected clients who Number of HIV-infected clients who
      HAB02                                              Percent of clients with HIV-infection who had 2 or more CD4 T-cell counts    had a medical visit with a provider
     (see HAB                  CD4 T-Cell Count              had 2 or more CD4 T-cell counts      performed at least 3 months apart   with prescribing privileges at least
    exclusions)                                            performed in the measurement year.       during the measurement year.        once in the measurement year.                   63%        CAREWare
                                                                                                                                     Number of HIV-infected clients who:
 Appropriateness                                                                                                                      had a medical visit with a provider
     of care                                                                                     Number of HIV-infected clients with with prescribing privileges at least
     HAB03                                             Percent of clients with HIV-infection and    a CD4 T-cell count below 200      once in the measurement year, and
    (see HAB            CD4 < 200 with PCP Prophylaxis a CD4 T-cell count below 200 cells/mm³ cells/mm³ who were prescribed PCP        had a CD4 T-cell count below 200
   exclusions)                                          who were prescribed PCP prophylaxis.                 prophylaxis.                         cells/mm³.                            95%        CAREWare

                                                                                                                                           Number of clients who; have a
                                                                                                                                       diagnosis of AIDS (history of a CD4 T-
 Appropriateness                                                                                                                         cell count below 200 cells/mm³or
     of care                AIDS Clients on HAART                                                                                       other AIDS defining condition), and
     HAB04                                                  Percent of clients with AIDS who are       Number of clients with AIDS who  had at least one medical visit with a
    (see HAB                                                         prescribed HAART                  were prescribed a HAART regimen provider with prescribing privileges in
   exclusions)                                                                                           within the measurement year.          the measurement year.                    100%       CAREWare

                                                                                                       Number of HIV-infected pregnant       Number of HIV-infected pregnant
                                                           Percent of pregnant women with HIV-           women who were prescribed         women who had a medical visit with a
                         Percent of Pregnant Women              infection who are prescribed           antiretroviral therapy during the   provider with prescribing privileges at      80%
      HAB05                    Prescribed ART                      antiretroviral therapy.                  2nd and 3rd trimester.          least once in the measurement year.                    CAREWare




                                                                                                                                                                                                       1
                                                               Breakdown of Performance Measures GY 2010
                                                                    Ryan White Part A, Las Vegas TGA

 Appropriateness                                 Percent of clients with HIV-infection on Number of HIV-infected clients, as Number of HIV-infected clients on
     of care                                     ARVs who were assessed and counseled part of their primary care, who were ARV therapy who had a medical visit
     HAB06           Adherence Assessment and    for adherence two or more times in the      assessed and counseled for       with a provider with prescribing
    (see HAB                Counseling              measurement year as part of their      adherence two or more times at      privileges at least once in the
   exclusions)                                                 primary care.                  least three months apart.              measurement year.                      56%   CAREWare

                                                                                                                                     Number of HIV-infected female
                                                                                                                                  clients who: were ≥18 years old in the
 Appropriateness                                                                                                                  measurement year or reported having
     of care         Cervical Cancer Screening                                                Number of HIV-infected female       a history of sexual activity, and had a
     HAB07                                        Percent of women with HIV-infection        clients who had pap screen results     medical visit with a provider with
    (see HAB                                        who have a pap screening in the                documented within the          prescribing privileges at least once in
   exclusions)                                             measurement year.                         measurement year.                    the measurement year.             70%   CAREWare
 Appropriateness
     of care                                                                                Number of HIV-infected clients with Number of HIV-infected clients who
     HAB08                                       Percent of clients with HIV-infection who    documentation of having ever       had a medical visit with a provider
    (see HAB          Hepatitis B Vaccination    completed the vaccine series for Hepatitis completed the vaccination series for with prescribing privileges at least
   exclusions)                                                        B.                               Hepatitis B.               once in the measurement year.             45%   CAREWare

                                                                                                                                   Number of HIV-infected clients who
 Appropriateness                                  Percent of clients for who Hepatitis C Number of HIV-infected clients who         had a medical visit with a provider
     of care           Hepatitis C Screening     (HCV) screening was performed at least have a documented HCV status in             with prescribing privileges at least
     HAB09                                        once since diagnosis of HIV infection.              chart.                         once in the measurement year.          90%   CAREWare

                                                                                                                                Number of HIV-infected clients who
Appropriateness of                               Percent of clients with HIV-infection who Number of HIV-infected clients, as    had a medical visit with a provider
      care             HIV Risk Counseling        received HIV risk counseling within the   part of their primary care, who      with prescribing privileges at least
     HAB10                                                     last 12 months.               received HIV risk counseling.         once in the measurement year.            80%   CAREWare
                                                                                                                                Number of HIV-infected clients who
                                                                                              Number of HIV-infected clients   are on HAART and who had a medical
 Appropriateness                                 Percent of clients with HIV-infection on    who: were prescribed HAART, and visit with a provider with prescribing
     of care              Lipid Screening         HAART who had a fasting lipid panel         had a fasting lipid panel in the      privileges at least once in the
     HAB11                                             within the last 12 months.                   measurement year.                     measurement year.                 85%   CAREWare

                                                                                                                                 Number of HIV-infected clients who:
                                                                                                                                       1) were ≥18 years old in the
 Appropriateness                                                                            Number of HIV-infected clients who measurement year or had a history of
     of care                                                                                   had a serologic test for syphilis sexual activity at <18 years, and 2) had
      HAB13                                         Percent of adult clients with HIV-       performed at least once during the    a medical visit with a provider with
    (see HAB             Syphilis Screening        infection who had a test for syphilis             measurement year.            prescribing privileges at least once in
   exclusions)                                     performed within the last 12 months.                                                   the measurement year.             80%   CAREWare




                                                                                                                                                                                     2
                                                         Breakdown of Performance Measures GY 2010
                                                              Ryan White Part A, Las Vegas TGA


                                                                                                                              Number of HIV infected clients who:
                                                                                                                                do not have a history of previous
                                                                                          Number of clients who received        documented culture-positive TB
                                                                                         testing with results for LTBI with     disease or previous documented
                                                                                        any approved test (tuberculin skin      positive TST or IGRA; and had a
Appropriateness                             Percent of adult clients who received         test [TST] or interferon gamma        medical visit with a provider with
    of care           TB Screening         testing for LTBI (latent TB infection) at      release assay [IGRA]) since HIV     prescribing privileges at least once in
    HAB14                                       least once since HIV diagnosis.                      diagnosis.                      the measurement year.              56%   CAREWare

                                                                                                                        Number of HIV-infected clients who:
                                                                                                                        were either: a) newly enrolled in care;
Appropriateness                                                                                                           b) sexually active; or c) had a STI
    of care                                Percent of clients with HIV-infection at Number of HIV-infected clients who within the last 12 months, and had a
     HAB15                                 risk for sexually transmitted infections had a test for Chlamydia within the   medical visit with a provider with
   (see HAB       Chlamydia Screening        (STI) who had a test for Chlamydia                last 12 months.          prescribing privileges at least once in
  exclusions)                                   within the measurement year.                                                   the measurement year.                    80%   CAREWare

                                                                                                                           Number of HIV-infected clients who:
                                                                                                                           were either: a) newly enrolled in care;
Appropriateness                                Percent of clients with HIV-                                                  b) sexually active; or c) had a STI
    of care                                    infection at risk for sexually                                               within the last 12 months; and had a
    HAB16                                     transmitted infections (STI's)           Number of HIV-infected clients who    medical visit with a provider with
   (see HAB        Gonorrhea Testing        who had a test for gonorrhea within        had a test for gonorrhea within the prescribing privileges2 at least once in
  exclusions)                                     the measurement year.                           last 12 months.                  the measurement year.                80%   CAREWare
Appropriateness
    of care                                                                                                                   Number of HIV-infected clients who
     HAB17                                Percent of clients with HIV infection who Number of HIV-infected clients who         had a medical visit with a provider
   (see HAB       Hepatitis B Screening    have been screened for Hepatitis B virus     have documented Hepatitis B            with prescribing privileges at least
  exclusions)                                          infection status.            infection status in the health record.      once in the measurement year.           80%   CAREWare
Appropriateness
    of care                                                                                                                   Number of HIV-infected clients who
    HAB19                                 Percent of clients with HIV infection who Number of HIV-infected clients who         had a medical visit with a provider
   (see HAB       Influenza Vaccination      have received influenza vaccination      received influenza vaccination           with prescribing privileges at least
  exclusions)                                     within the last 12 months.          within the measurement year.              once in the measurement period.         80%   CAREWare

Appropriateness                           Percent of clients with HIV-infection and                                     Number of HIV-infected clients who
    of care                                 a CD4 count <50 cells/mm³ who were                                         had a: CD4 count <50 cells/mm³; and
    HAB20                                     prescribed Mycobacterium Acium        Number of HIV-infected clients with medical visit with a provider with
   (see HAB         MAC Prophylaxis        Complex (MAC) prophylaxis within the CD4 count <50 cells/mm³ who were prescribing privileges at least once in
  exclusions)                                         measurement year.               prescribed MAC prophylaxis.             the measurement year.                     85%   CAREWare




                                                                                                                                                                                 3
                                                                         Breakdown of Performance Measures GY 2010
                                                                              Ryan White Part A, Las Vegas TGA



                                                                                                                                    Number of HIV-infected clients who:
                                                                                                                                      were new during the measurement
Appropriateness of                                            Percent of new clients with HIV-   Number of HIV-infected clients who year, and had a medical visit with a
       care               Mental Health Screening         infection who have had a mental health received a mental health screening provider with prescribing privileges at
      HAB21                                                 screening within the last 12 months.   within the measurement year.      least once in the measurement year.                42%   CAREWare
 Appropriateness
     of care                                                                                                                                  Number of HIV-infected clients who
     HAB22                                                Percent of clients with HIV infection who                                            had a medical visit with a provider
    (see HAB             Pneumococcal Vaccination             have ever received pneumococcal       Number of HIV-infected clients who         with prescribing privileges at least
   exclusions)                                                             vaccine.                 ever received pneumococcal vaccine.         once in the measurement year.           80%   CAREWare

                                                                                                                                       Number of HIV-infected clients who:
 Appropriateness                                                                                                                        were new during the measurement
     of care                                              Percent of new clients with HIV-infection Number of new HIV-infected clients year, and had a medical visit with a
     HAB23                                                 who have been screened for substance      who were screened for substance    medical provider with prescribing
    (see HAB                   Substance Use                use (alcohol and drugs) in the last 12  use within the measurement year as    privileges at least once in the
   exclusions)                                                            months.                        part of their medical visit.           measurement year.                       80%   CAREWare
 Appropriateness
     of care                                              Percent of clients with HIV-infection for                                    Number of HIV-infected clients who
     HAB25                                                  whom a Toxoplasma screening was         Number of HIV-infected clients who had a medical visit with a provider
    (see HAB               Toxoplasma Screening              performed at least once since the       have a documented Toxoplasma       with prescribing privileges at least
   exclusions)                                                  diagnosis of HIV-infection.              status in health record.        once in the measurement year.                  80%   CAREWare

                                                                                                                                              Number of HIV-infected clients with
                                                                                                                                               initial CD4 T-cell count of who are
                         Stabilize CD4 T-Cell Count       Percent of clients who have stabalized or Number of HIV-infected clients with            currently in the care system
  Effectiveness of                                         increased their CD4 T-cell count from       an increased CD4 T-cell count of      recieveing at least one CD4 count lab      80%
        care                                                             initial count.                      ≥200 from initial count.             within the measurement year.                Chart Review
                                                                                                                                              Number of HIV-infected clients with
                                                                                                                                             initial viral load lab who are currently
                          Undetectable Viral Load              Percent of clients who have an                                                 in the care system receiving at least
  Effectiveness of                                        undetectable viral load count from initial Number of HIV-infected clients with           one viral load lab within the        80%
        care                                                                 count.                  a viral load of ≤50 from initial count.            measurement year.                     Chart Review

                                                                                                                                              Number of HIV-infected clients who
                                                                                                       Number of minority clients with at      had a medical visit with a provider
                        Increase service utilization in     Percent of minority clients accessing       least one medical visit within the     with prescribing privileges at least     60%
Accessibility of care    communities of color (MAI).       Ambulatory/Outpatient Medical Care.                 measurement year.                once in the measurement year.                 CAREWare




                                                                                                                                                                                                  4
                                                                   Breakdown of Performance Measures GY 2010
                                                                        Ryan White Part A, Las Vegas TGA


                                                                                                                                   Number of clients who; were
                                                                                                                              prescribed new medication and had at
                                                      Percent of clients who were prescribed Number of clients who received   least one medical visit with a provider
Patient perspective                                  new medication and received medication medication education concurrently    with prescribing privileges in the
      issues             Medication Education                education concurrently.              to their prescription.                measurement year.                     80%   Chart Review
                                                                                              Oral Health Care

                                                                                                                                 Number of HIV-infected patients
Appropriateness of Gingival/Periodontal Infection Percent of clients who received an annual Number of patients who received an accessing oral health care services at         70%
      care                   Avoidance                        periodontal exam.                 annual periodontal exam        least once in the measurement year.                  Chart Review

                                                                                                  Number of patients who have a        Number of HIV-infected patients
Appropriateness of                                      Percent of clients with an annually       written treatment plan that is     accessing oral health care services at   70%
      care              Updated Treatment Plan               updated treatment plan.                    updated annually.            least once in the measurement year.            Chart Review

                                                                                                  Number of patients who had an        Number of HIV-infected patients
Appropriateness of        HIV Associated Skin          Percent of clients who had an annual      annual extra-oral (head and neck)   accessing oral health care services at   70%
      care                  Manifestations            extra-oral (head and neck) examination.              examination.              least once in the measurement year.            Chart Review

                                                                                                 Number of clients who had an oral Number of HIV-infected clients who
Appropriateness of                                   Percent of clients with HIV-infection who       exam by a dentist during the   had a medical visit with a provider
      care                                           received an oral exam by a dentist at least measurement year, based on patient with prescribing privileges at least             CAREWare
     HAB12                 Oral Health Care               once during the last 12 months.        self report or other documentation  once in the measurement year.            40%   Chart Review

                                                        Percent of clients who had an annual   Number of patients who received an     Number of HIV-infected patients
Appropriateness of                                    intra-oral exam with a dental caries and annual intra-oral exam with a dental accessing oral health care services at    70%
      care         Dental Caries/Soft Tissue Exam                 soft tissues exam.               caries and soft tissue exam.     least once in the measurement year.             Chart Review
                                                                                           HIV Medications
                                                                                                 Number of clients who were
                                                                                             prescribed supplemental medication Number of HIV-infected clients who
                                                          Percent of clients who receive       from a provider with prescribing  had a medical visit with a provider
 Effectiveness of     Supplemental Medications to      supplemental medications to improve    privileges within the measurement  with prescribing privileges at least         25%   Chart Review
       care            Maintain or Improve Health             and maintain health.                            year.               once in the measurement period.                    CAREWare
                                                                                       Medical Case Management
                                                                                                 Number of clients who accessed      Number of clients who had a medical
                                                     Percent of clients who are in medical care medical case management services     visit with a provider with prescribing
                         Increase Medical Case           and in medical case management         at least once in the measurement          privileges at least once in the     85%
Continuity of care      Management Utilization                        services.                               period.                         measurement period.                   CAREWare




                                                                                                                                                                                        5
                                                                   Breakdown of Performance Measures GY 2010
                                                                        Ryan White Part A, Las Vegas TGA


                                                                                                 Number of clients who had a        Number of clients in the care system
                                                    Percent of clients in the care system thatmedical case management visit at that accessed medical and/or support           75%
                       Received Medical Case             have at least one medical case         least once in the measurement           services at least once in the
Continuity of care     Management Services                     management visit.                            period.                        measurement period.                       CAREWare
                                                                                                 Number of clients who had a
                                                   Percent of clients who are in medical case medical visit with a provider with Number of clients who had a medical
                            Medical Care               management and had at least one        prescribing privileges at least once case management visit at least once in     65%
Continuity of care                                                medical visit.                   in the measurement year.              the measurement period.                     CAREWare

Patient perspective                                                                                                                   Number of HIV-infected clients who
     issues-no                                      Percent of clients who are in compliance      Percentage of clients who are in     had a medical visit with a provider
    medication        Adherence to Prescription        with their prescription medication        compliance with their prescription    with prescribing privileges at least   80%
regimen prescribed          Medication                              regimen.                           medication regimen.              once in the measurement period.              Chart Review

                                                                                                 Number of clients with adherence to Number of HIV-infected clients who
                        Medical Appointment           Percent of clients with adherence to       primary care (ambulatory outpatient had a medical case management visit
Patient perspective         Adherence                 primary care (ambulatory outpatient           medical care) visits during the    at least once in the measurement       80%    Chart Review
      issues                                                  medical care) visits.                     measurement period.                          period.                          CAREWare

                                                                                          Number of clients who had a case Number of HIV-infected clients who
                                                      Percent of clients who have a case management care plan documented had a medical case management visit
                         Updated Care Plan          management care plan documented and    and updated every six months     at least once in the measurement
Continuity of care                                    updated at least every six months.  within the measurement period.                  period.                             100%   Chart Review

                                                                                           Number of clients who had a client         Number of HIV-infected clients who
                                                     Percent of clients who have a client acuity performed, documented and            had a medical case management visit
                                                   acuity documented and updated at least updated every six months within the           at least once in the measurement
                       Updated Client Acuity                  every six months.                  measurement period.                                  period.                 NA     Chart Review
                                                                                           Number of high acuity clients with
                                                      Percent of high acuity clients with      adherence to primary care     Number of HIV-infected clients who
                                                          adherence to primary care         (ambulatory/outpatient medical   had a medical case management visit
                   Maintain High Acuity Clients in (ambulatory/outpatient medical care) care) visits within the measurement    at least once in the measurement               5%
Continuity of care         Medical Care                             visits.                             period.                              period.                                 Chart Review
                                                                                                                             Number of HIV-infected clients who
                                                                                         Number of patients who are referred had a medical case management visit
Appropriateness of Substance Abuse Screening and Percent of clients who were in need and   to a substance use treatment        at least once in the measurement
care (NQC 111-2C)            Referrals           referred to a substance abuse program.              program.                                period.                          30%    Chart Review
                                                                               Substance Abuse Outpatient Treatment




                                                                                                                                                                                         6
                                                                      Breakdown of Performance Measures GY 2010
                                                                           Ryan White Part A, Las Vegas TGA




                                                                                                                                       Number of HIV-infected clients who
                                                                                                                                       1) had a medical visit with a provider
                                                                                                                                         with prescribing privileges at least
                                                                                                     Number of clients who have (at    once in the measurement period and
                                                        Percent of clients who had (at least) one least) one medical care consultation      2) accessed substance abuse
                       Medical Care Consultation         medical care consultation during the          during the substance abuse      outpatient treatment at least once in    90%   Chart Review
Continuity of care                                        substance abuse treatment episode.               treatment episode.                the measurement period .                  CAREWare

                                                                                                    Number of patients who were asked
                       Substance Use Screening in       Percent of clients who were asked about         about their use of alcohol,     Number of HIV-infected patients with
                       Patients with Documented         their use of alcohol, marijuana, cocaine,    marijuana, cocaine, crack cocaine, documented mental health disorder
Appropriateness of      Mental Health Disorder           crack cocaine, amphetamines, opiates,         amphetamines, opiates, and         and no current or past history of           Chart Review
 care (NQC 104)                                          and benzodiazepines in the past year.       benzodiazepines in the past year.        alcohol/substance use.            30%    CAREWare

                       Substance Use Screening in                                                   Number of patients who were asked
                       Patients with Documented         Percent of clients who were asked about         about their use of alcohol,     Number of HIV-infected patients with
                        Mental Health Disorder-         their use of alcohol, marijuana, cocaine,    marijuana, cocaine, crack cocaine, documented mental health disorder
Appropriateness of              quarterly                crack cocaine, amphetamines, opiates,         amphetamines, opiates, and          and current or past history of             Chart Review
 care (NQC 104)                                         and benzodiazepines in the last quarter.      benzodiazepines in the quarter.             substance use.                30%    CAREWare

                       Offering Tobacco Cessation                                             Number of current smokers or users Number of HIV-infected patients who
                                                         Percent of current smokers or users of
Appropriateness of        Programs to Tobacco-           other tobacco products who received      of other tobacco products who      are current smokers or users of other            Chart Review
 care (NQC 115)            Dependent Patients                  assistance with cessation.      received assistance with cessation.             tobacco products.                30%    CAREWare
                                                                                                                                       Number of HIV-infected patients
                                                                                                                                           accessed substance abuse
                      Discussion of Tobacco Use in                                                  Number of patients whose                outpatient treatment at
Appropriateness of      the Past Year with all HIV-    Percent of clients whose smoking            smoking status was assessed                  least once in the
 care (NQC 113)              infected Clients         status was assessed in the past year.              in the past year.                   measurement period .               30%   Chart Review
                                                                                                   Number if opioid-dependent          Number of HIV-infected patients
Appropriateness of     Opioid Agonist Therapy for     Percent of opioid-dependent clients           patients who are receiving         with current diagnosis of opioid               Chart Review
  care (NQC 111)        Opioid-Dependent Clients        receiving opioid agonist therapy.             opioid agonist therapy.                     dependence.                   30%    CAREWare
                                                                                                                                       Number of HIV-infected patients
                     Screening for HIV Transmission                                           Number of patients who were asked         who accessed Substance Abuse
                       Risk via Shared Intravenous Percent of clients who were asked at least at least once if they had injected any       Outpatient Treatment at
Appropriateness of   Drug Equipment and Referral to    once if they had injected any non-     non-prescribed drugs since their last     least once in the measurement                 Chart Review
 care (NQC 110-A)       Drug Treatment Program       prescribed drugs since their last visit.                   visit.                                 year.                    30%    CAREWare




                                                                                                                                                                                          7
                                                                    Breakdown of Performance Measures GY 2010
                                                                         Ryan White Part A, Las Vegas TGA


                                                                                                                                    Number of HIV-infected patients
                                                                                                                                     who accessed Substance Abuse
                   Screening for HIV Transmission                                                                                       Outpatient Treatment at
                     Risk via Shared Intravenous  Percent of clients who have been asked if Number of patients who have been         least once in the measurement
Appropriateness of Drug Equipment and Referral to    they are sharing needles and drug      asked if they are sharing needles and year and reported injecting any non-                Chart Review
 care (NQC 111-B)     Drug Treatment Program              injection paraphernalia.              drug injection paraphernalia.               prescribed drugs.                   50%    CAREWare
                                                                                           Mental Health Services
                                                                                                   Number of clients for whom a
                                                        Percent of clients for whom a mental       mental health assessment was          Number of HIV-infected clients that
 Appropriateness       Mental Health Screening        health assessment was performed during performed during the measurement             accessed mental health services at          Chart Review
     of care                                                        the past year.                             period.                  least once in the measurement period.   50%    CAREWare
                                                                                                    Number of clients who are
                                                                                                hospitalized and who receive at least
                                                       Percent of clients who are hospitalized        one consultation or case
                                                      and who receive at least one consultation    management encounter while                Number of clients who are
 Appropriateness         Discharge Planning             or case management encounter while            hospitalized within the              hospitalized at least once in the          Chart Review
     of care                                           hospitalized within the last 12 months.         measurement period.                      measurement period.             80%    CAREWare
                                                                                                  Number of clients who had a six
                                                                                                    month follow-up outcomes             Number of HIV-infected clients that
 Appropriateness                                       Percent of clients who had a six month assessment within the measurement           accessed mental health services at          Chart Review
     of care          Improve Functional Status            follow-up outcomes assessment.                       year.                   least once in the measurement period.   50%    CAREWare

                                                      Percent of clients who have one medical     Number of clients who have one         Number of HIV-infected clients that
 Appropriateness      Medical Care Consultation         care consultation during the mental      medical care consultation during the     accessed mental health services at    80%   Chart Review
     of care                                                 health treatment episode.            mental health treatment episode.      least once in the measurement period.          CAREWare
                                                                                                    Number of clients who have
                                                            Percent of clients who have             biopsychosocial assessment           Number of HIV-infected clients that
 Appropriateness     Biopsychosocial Assessment        biopsychosocial assessment completed completed within 30 days from first           accessed mental health services at    80%   Chart Review
     of care                                          within 30 days from first service contact.           service contact.             least once in the measurement period.          CAREWare

                                                      Percent of HIV-infected clients who have      Number of clients who have           Number of HIV-infected clients that
Appropriateness of      Depression Screening              received an annual screening for        received an annual screening for        accessed mental health services at    80%   Chart Review
  care (NQC 93)                                                     depression.                             depression.                 least once in the measurement period.          CAREWare

                                                                                                                                     Number of HIV-infected clients that
                                                                                                 Number of patients with depression   accessed mental health services at
                                                       Percent of clients with depression with     with documented response to      least once in the measurement period
Appropriateness of                                      documented response to treatment           treatment within 4 weeks of        and have undergone treatment for          80%   Chart Review
  care (NQC 97)      Management of Depression          within 4 weeks of treatment initiation.         treatment initiation.                      depression.                          CAREWare




                                                                                                                                                                                          8
                                                                  Breakdown of Performance Measures GY 2010
                                                                       Ryan White Part A, Las Vegas TGA

                                                                                                Number of patients who were asked
                                                    Percent of clients who were asked about         about their use of alcohol,     Number of HIV-infected patients with
                      Substance Use Screening in    their use of alcohol, marijuana, cocaine,    marijuana, cocaine, crack cocaine, documented mental health disorder
Appropriateness of     Clients with Documented       crack cocaine, amphetamines, opiates,         amphetamines, opiates, and         and no current or past history of             Chart Review
 care (NQC 95-A)        Mental Health Disorder       and benzodiazepines in the past year.       benzodiazepines in the past year.        alcohol/substance use.              50%    CAREWare

                                                                                                Number of patients who were asked
                      Substance Use Screening in    Percent of clients who were asked about         about their use of alcohol,      Number of HIV-infected patients with
                       Clients with Documented      their use of alcohol, marijuana, cocaine,    marijuana, cocaine, crack cocaine, documented mental health disorder
Appropriateness of     Mental Health Disorder-       crack cocaine, amphetamines, opiates,         amphetamines, opiates, and           and current or past history of              Chart Review
 care (NQC 95-B)               quarterly            and benzodiazepines in the last quarter.    benzodiazepines in the last quarter.           substance use.                 50%    CAREWare

                                                                                                 Number of patients whose records
                                                     Percent of clients whose records have        have specific documentation of
                     Coordination of Care between         specific documentation of             communication or exchange of data Number of HIV-infected clients that
Continuity of care     Medical and Psychiatric        communication or exchange of data         between mental health and medical   accessed mental health services at              Chart Review
   (NQC 99)                   Providers              between health and medical providers.                  providers.            least once in the measurement period.       50%    CAREWare
                                                                               Health Insurance Continuation Services
                                                                                                                                   Number of HIV-infected clients that
                                                      Percentage of clients notified of their  Number of clients notified of their      accessed Health Insurance
                         Notification of Status     status for Health Insurance Continuation      status for Health Insurance      Continuation Services at least once in           Chart Review
Efficiency of care                                            within 5 business days.         Continuation within 5 business days.       the measurement period.              90%    CAREWare

                                                    Percent of HIV-infected clients who had Number of HIV-infected clients who Number of HIV-infected clients that
                                                       a medical visit with a provider with     had a medical visit with a provider       accessed Health Insurance
                             Medical Care           prescribing privileges at least once in the with prescribing privileges at least Continuation Services at least once in   65%
Continuity of care                                             measurement year.                 once in the measurement year.             the measurement period.                  CAREWare
                                                                                      Medical Nutrition Therapy

                                                                                                    Number of clients who report
                                                     Percent of clients who report decreased decreased or maintained severity in Number of HIV-infected clients who
                       Prescribed Supplements          or maintained severity in their HIV       their HIV and/or HIV-medication- accessed Medical Nutrition Therapy
 Effectiveness of                                     and/or HIV-medication-related side          related side effects and symptoms     Services at least once in the               Chart Review
       care                                              effects and symptoms over time.             from utilizing supplements.           measurement period.                75%    CAREWare
                                                    Percent of HIV-infected clients who had
                                                       a medical visit with a provider with     Number of HIV-infected clients who Number of HIV-infected clients who
                                                    prescribing privileges at least once in the had a medical visit with a provider accessed Medical Nutrition Therapy
                             Medical Care           measurement year and accessed medical with prescribing privileges at least          Services at least once in the         65%
Continuity of care                                               nutrition therapy.                 once in the measurement year.          measurement period.                      CAREWare
                                                                                            Support Services
                                                                                  Case Management (non-Medical)



                                                                                                                                                                                        9
                                                                   Breakdown of Performance Measures GY 2010
                                                                        Ryan White Part A, Las Vegas TGA

                                                                                                                                       Number of clients that accessed
                                                       Percent of clients who received case   Number of clients that accessed case     medical care and/or supportive
                     Provide Continuity of Care to   management services that access medical management services at least once           services at least once in the         65%
Continuity of care             Clients                      and/or supportive services.             in the measurement year.                 measurement year.                       CAREWare
                                                                                              Number of clients that accessed non-
                                                           Percent of non-medical case         medical case management services
   Accessibility        Service Utilization in          management service utilization for     at least once in the measurement      Number of clients in communities          65%
     of care            Communities of Color             clients in communities of color.                     year.                of color during the measurement year.             CAREWare
                                                                                                 Number of clients who had a
                                                     Percent of clients receiving non-medical documented, complete psychosocial       Number of clients accessing case         80%
 Appropriateness      Psychosocial Assessments        case management and had at least one      assessment at least once in the     management services at least once in
     of care                                                 psychosocial assessment.                   measurement year.                  the measurement year.                     Chart Review

                                                                                                 Number of clients who are screened
                                                       Percent of clients who are screened          and referred, if necessary, for  Number of clients accessing case
                      Screening and Referrals for     annually and referred, if necessary, for    substance abuse services at least management services at least once in       65%
Continuity of care         Substance Abuse               substance abuse service needs.            once in the measurement year.         the measurement year.                       Chart Review

                                                                                                  Number of client who are screened
                                                       Percent of clients who are screened       and referred, if necessary, for mental  Number of clients accessing case
                      Screening and Referrals for     annually and referred, if necessary, for   health service needs at least once in management services at least once in    65%
                            Mental Health                 mental health service needs.                   the measurement year.               the measurement year.                   Chart Review
                                                                                                  Number of clients who have a case
                     Case Management Care Plan           Percent of clients who have a case      management care plan documented         Number of clients accessing case
 Appropriateness        Update Twice per Year        management care plan documented and             and updated twice during the       management services at least once in   65%
     of care                                             updated at least every six months.                measurement year.                 the measurement year.                   Chart Review
                                                     Percent of HIV-infected clients who had
                                                        a medical visit with a provider with     Number of HIV-infected clients who
                                                     prescribing privileges at least once in the had a medical visit with a provider     Number of clients accessing case
                                                       measurement year and accessed case         with prescribing privileges at least management services at least once in    65%
Continuity of care           Medical Care                      management services.                 once in the measurement year.            the measurement year.                   CAREWare
                                                                                                  Number of clients who had a client
                                                        Percent of clients who have a client      acuity performed and documented        Number of clients accessing case
Appropriateness of                                   acuity documented and updated at least        at least once in the measurement     management services at least once in
      care              Updated Client Acuity                     once annually.                                 period.                     the measurement year.             NA    Chart Review
                                                                          Emergency Financial Assistance-Utility Assistance
                                                                                                Number of clients who have
                         Resource Directory          Percentage of HIV infected clients who reported having received an updated         Number of clients who have had at               Client
                                                     received a current resource directory in  resource directory within the           least one medical or support service          satisfaction
Continuity of care                                                the past year.                    measurement year.                     visit in the measurement year.       75%      survey




                                                                                                                                                                                        10
                                                                        Breakdown of Performance Measures GY 2010
                                                                             Ryan White Part A, Las Vegas TGA
                         Requests Fulfilled Within 48        Percent of clients who received        Number of clients receiving EFA            Number clients with an approved
                                   Hours                   approved EFA payments within 48 of         payments within 48 hours of                request for EFA within the
Accessibility of care                                                    request.                                request.                           measurement year.                75%   Chart Review
                                                                                                        Number of client charts
                                                           Percent of clients requesting EFA that   documenting a planning session
                                                          have a planning session with a provider with provider and client regarding at        Number clients with an approved
                          Alternate Funding Sources       documenting alternate funding sources, least three alternate funding sources           request for EFA within the
Continuity of care                                                      at least three.                          for EFA.                           measurement year.                75%   Chart Review
                                                           Percent of clients requesting EFA that    Number of clients that have a
                                                          have a planning session with a provider documented planning session with a           Number clients with an approved
  Effectiveness of                                        regarding a plan to financially stabilize   provider regarding a plan to               request for EFA within the
        care                   Planning Session                           the client.                financially stabilize the client.              measurement year.                NA    Chart Review

                                                                                                      Number of HIV-infected clients who
                                                                                                       had a medical visit with a provider     Number of clients accessing EFA-
                                 Medical Care              Percent of clients accessing EFA-utility    with prescribing privileges at least      utility assistance within the       65%
Continuity of care                                             assistance and in medical care.          once in the measurement year.                 measurement year.                     CAREWare
                                                                                        Food Bank-Home Delivered Meals
                                                                                                                                                                                           Chart Review/
                                                                                                                                                                                            CAREWare
                                                                                                      Number of clients satisfied with the                                                     Client
  Effectiveness of                                           Percent of clients satisfied with the      overall quality of the program     Number of clients access food services           Satisfaction
        care                  Quality of Program           overall quality of the program services.                services.                  within the measurement year.           75%      Survey
                                                                                                                                                                                           Chart Review/
                                                                                                       Number of clients who received a                                                     CAREWare
                                                              Percent of clients who received a       resource list of community food and                                                      Client
                        Resource Directory of Nutrition     resource list of community food and           nutrition services within the      Number of clients accessing food               Satisfaction
Continuity of care                 Services                          nutrition services.                     measurement period.          services within the measurement year.      75%      Survey

                                                          Percent of HIV-infected clients who had Number of HIV-infected clients who
                                                             a medical visit with a provider with     had a medical visit with a provider
                                 Medical Care             prescribing privileges at least once in the with prescribing privileges at least Number of clients access food services    65%
Continuity of care                                                   measurement year.                 once in the measurement year.          within the measurement year.                  CAREWare
                                                                    Emergency Financial Assistance-Housing Services/Housing Services
                                                             Percent of clients with a housing    Number of clients having their Number of eligible clients accessing
                                                          payment made within 7 days of approved housing payment made within 7     Housing Assistance within the
 Efficiency of care            Timely Payments                         application.               days of approved application.       measurement period.                            90%   Chart Review

                                                              Percent of clients that received a    Number of clients that received a
                                                            planning session regarding alternate   planning session regarding alternate       Number of eligible clients accessing
                          Alternate Funding Sources       funding source investigation for housing   funding source investigation for           Housing Assistance within the
 Efficiency of care                                                      assistance.                       housing assistance.                     measurement period.               90%   Chart Review



                                                                                                                                                                                              11
                                                                    Breakdown of Performance Measures GY 2010
                                                                         Ryan White Part A, Las Vegas TGA




                                                                                              Number of HIV-infected clients who
                                                                                               had a medical visit with a provider     Number of eligible clients accessing
                             Medical Care            Percent of clients accessing EFA-housing with prescribing privileges at least     EFA-housing assistance within the      65%
Continuity of care                                        assistance and in medical care.       once in the measurement year.               measurement period.                     CAREWare
                                                                              Patient Perspective Issues/Client Satisfaction
                                                     Percent of clients indicating how satisfied     Number of clients who have
                                                       they are with their service provider's        reported being satisfied with
                                                     knowledge of other community services,         provider's knowledge of other
                                                        ability to connect them with those          community services, ability to
Patient Perspective   Increase Client Satisfaction     services, and the overall quality they    connect them with services, and the    Number of clients who have had at     80%      Client
   Issues/Client                                                       receive                     overall quality they receive from   least one medical or support service         Satisfaction
    Satisfaction                                                 from the agencies.                          that agency.                 visit in the measurement year.              Survey
                                                                                            Patient Retention
                                                                                                Number of clients who had at least     Number of clients who had at least
Patient Perspecitve                                                                              one visit with this provider in the   one visit with this provider in the
      Issues              Patient Retention                      Percent of clients                         current year.                          prior year.                75%   CAREWare
                                                                                       Psychosocial Support Services
                                                                                            Linguistic Services
                                                                                      Medical Transportation Services
                                                                             Referrals for Health Care/Supportive Services
                                                                                       Substance Abuse Residential
                                                                                            Child Care Services
                                                                                Substance Abuse Residential Treatment




                                                                                                                                                                                      12
           Las Vegas TGA Ryan White Part A Quality Management Program Tracking March 1, 2010-February 28, 2011




                   GOAL #1- Improve the quality of HIV/AIDS core medical and supportive services in the Las Vegas TGA.
                                                                  Staff/
                  Activities                       Lead         Resources      Deadline Finalized                Progress Notes

1.1 Review the agency specific QM annual plans
       and return evaluation to the agency.      QM Coordinator               April 30, 2010
  1.2 Establish a Quality Management Team to
 review data and initiate quality improvement
                    strategies.                  QM Coordinator               April 12, 2010




                                                                                                                                  3/7/201113

				
DOCUMENT INFO
Description: Outpatient Therapy Chart document sample