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Cross-Part Collaborative: An Opportunity to Provide Seamless HIV Care in Your State Washington, DC Cross-Part Collaborative: An Opportunity to Provide Seamless HIV Care in Your State Washington, DC October 23, 2008 Clemens Steinbock, MBA Clemens@National. Quality. Center. org 212 -417 -4730

What are my options? • Use pictures 2 What are my options? • Use pictures 2

What are my options? • Use quotes 3 What are my options? • Use quotes 3

What are my options? • Use humor 4 What are my options? • Use humor 4

Participants • • • 5 Connecticut New Jersey Pennsylvania Texas Virginia Participants • • • 5 Connecticut New Jersey Pennsylvania Texas Virginia

Statue of Sam Houston in Huntsville Mark Twain’s House/Mansion Rocky Statue – Philadelphia 6 Statue of Sam Houston in Huntsville Mark Twain’s House/Mansion Rocky Statue – Philadelphia 6 USMC War Memorial Rosslyn, Virginia Lucy the Elephant – Atlantic City

Alternative Titles: 7 Alternative Titles: 7

Can we play all in the same sandbox? 8 Can we play all in the same sandbox? 8

Can the parts be greater than whole? 9 Can the parts be greater than whole? 9

Can patients in your state receive seamless HIV care? 10 Can patients in your state receive seamless HIV care? 10

Can individual agencies pull on the same rope? 11 Can individual agencies pull on the same rope? 11

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We have a problem. We don’t have HIV indicators and I can’t find them We have a problem. We don’t have HIV indicators and I can’t find them anywhere… 13 I have no idea how to write a cross-Part QM Plan…

We have to act quickly. Write the indicator definitions down as I say… 14 We have to act quickly. Write the indicator definitions down as I say… 14 …and here is QM plan from a different state…

Amazing! Perfect! This is exactly what we needed… 15 Amazing! Perfect! This is exactly what we needed… 15

You must be the new faculty! 16 You must be the new faculty! 16

Actually, I am a patient and on the way to the bathroom… 17 …but Actually, I am a patient and on the way to the bathroom… 17 …but I attended the Cross-Part Collaborative yesterday!

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Overview • The Stakes • The Charge • The Opportunity 19 Overview • The Stakes • The Charge • The Opportunity 19

The Stakes 20 The Stakes 20

AIDS Cases: Cumulative & Current • Reported Number of AIDS Cases, All Ages, Cumulative AIDS Cases: Cumulative & Current • Reported Number of AIDS Cases, All Ages, Cumulative through 2006: 992, 865 • New AIDS Cases, 2006: 44, 232 • Estimated Number of Persons Living with AIDS, All Ages, 2006: 448, 871 Source: www. statehealthfacts. org - HIV/AIDS Surveillance Report: Cases of HIV Infection and AIDS in the United States, 2006, National Center for HIV, STD and TB Prevention, Centers for Disease Control and Prevention, Department of Health and Human Services, 2008. 21

Reported Number of AIDS Cases, All Ages, Cumulative through 2006 Source: www. statehealthfacts. org Reported Number of AIDS Cases, All Ages, Cumulative through 2006 Source: www. statehealthfacts. org 22

Reported Number of AIDS Cases, All Ages, Cumulative through 2006 Source: www. statehealthfacts. org Reported Number of AIDS Cases, All Ages, Cumulative through 2006 Source: www. statehealthfacts. org 23

New AIDS Cases, 2006 Source: www. statehealthfacts. org 24 New AIDS Cases, 2006 Source: www. statehealthfacts. org 24

New AIDS Cases, 2006 Source: www. statehealthfacts. org 25 New AIDS Cases, 2006 Source: www. statehealthfacts. org 25

Estimated Number of Persons Living with AIDS, All Ages, 2006 Source: www. statehealthfacts. org Estimated Number of Persons Living with AIDS, All Ages, 2006 Source: www. statehealthfacts. org 26

Distribution of Ryan White Program Funding By Part, FY 2006 States Part A Part Distribution of Ryan White Program Funding By Part, FY 2006 States Part A Part B Part C Part D Other Total Connecticut $11, 350, 875 $15, 824, 810 $3, 740, 613 $1, 076, 528 $704, 570 $32, 697, 396 New Jersey $27, 828, 424 $47, 641, 537 $5, 544, 517 $2, 260, 049 $1, 364, 174 $84, 638, 701 Pennsylvania $22, 384, 551 $39, 891, 047 $10, 447, 049 $2, 772, 870 $4, 703, 715 $80, 199, 232 Texas $43, 604, 673 $76, 656, 747 $7, 430, 263 $4, 836, 777 $2, 256, 404 $134, 784, 864 Virginia $4, 414, 760 $21, 832, 964 $2, 161, 724 $810, 847 $0 $29, 220, 295 Total US $579, 682, 392 $1, 078, 734, 384 $178, 736, 109 $65, 346, 380 $69, 114, 686 $1, 971, 613, 951 Source: www. statehealthfacts. org - National Alliance of State and Territorial AIDS Directors (NASTAD) at http: //www. nastad. org, Special Data Request, 2007. 27

The Stake for the Cross-Part Collaborative • % of AIDS Cases in the US: The Stake for the Cross-Part Collaborative • % of AIDS Cases in the US: 19% • % of New AIDS Cases in the US : 18% • % of Persons Living with AIDS in the US : 19% Source: www. statehealthfacts. org - HIV/AIDS Surveillance Report: Cases of HIV Infection and AIDS in the United States, 2006, National Center for HIV, STD and TB Prevention, Centers for Disease Control and Prevention, Department of Health and Human Services, 2008. 28

The Charge 29 The Charge 29

Ryan White HIV/AIDS Treatment Modernization Act of 2006 – PL 109 -415 30 Ryan White HIV/AIDS Treatment Modernization Act of 2006 – PL 109 -415 30

HAB Expectations for Quality Management • Patient-centeredness is a fundamental focus of quality care HAB Expectations for Quality Management • Patient-centeredness is a fundamental focus of quality care and undergirds the 5 characteristics that follow. § Systematic with identified leadership, accountability and dedicated resources § Use data & measurable outcomes to determine progress toward relevant, evidence-based benchmarks § Focus on linkages, efficiencies and both provider & client expectations § Continuous process adaptive to change, fitting within framework of other quality activities, e. g. Medicaid, JCAHO § Ensure that data are fed back into the QI process to assure that goals are accomplished 31

Measuring What Matters: Allocation, Planning and Quality Assessment for the Ryan White CARE Act Measuring What Matters: Allocation, Planning and Quality Assessment for the Ryan White CARE Act (2004) – Institute of Medicine • HRSA should adopt quality measures that are comprehensive with respect to level of assessment: § Provider § Population 32

HIV/AIDS Q & A HIV/AIDS Q & A

Hispanics, who represent about 14% of the US population, accounted for 18 __ % Hispanics, who represent about 14% of the US population, accounted for 18 __ % of new HIV or AIDS diagnoses in 2005. 5 a. 18% b. 25% c. 34% d. 48% 34

Although African Americans represent about 13% of the US population, 3 they accounted for Although African Americans represent about 13% of the US population, 3 they accounted for 48 % __ of new HIV or AIDS diagnoses in 2005. 4 a. b. c. d. 35 13% 20% 34% 48%

Approximate percentage of new HIV infections every year occur among people ages 15 -24. Approximate percentage of new HIV infections every year occur among people ages 15 -24. 12 a. b. c. d. 36 25% 41% 50% 65%

Percentage of new HIV cases among women each year in the United States in Percentage of new HIV cases among women each year in the United States in African American women? 12 a. b. c. d. 37 36% 44% 52% 65%

What was the leading cause of death for non-Hispanic white men ages 25 to What was the leading cause of death for non-Hispanic white men ages 25 to 44? a. Unintentional injury b. Heart disease c. Homicide d. HIV disease 38

What was the leading cause of death for non-Hispanic black men ages 25 to What was the leading cause of death for non-Hispanic black men ages 25 to 44 in the year 2006? 18 a. Unintentional injury b. Heart disease c. Homicide d. HIV disease 39

63% of African-Americans had an undetectable viral load after one year of treatment vs. 63% of African-Americans had an undetectable viral load after one year of treatment vs. ___ % of whites. 16 a. 55% b. 63% c. 75% d. 92% 40

African-Americans in one large national 59 sample study were ___ % less likely than African-Americans in one large national 59 sample study were ___ % less likely than whites to be receiving HAART. 17 41

A 2003 Federal Government study reports 30 million that the United States has _____ A 2003 Federal Government study reports 30 million that the United States has _____ adults with “Below Basic” prose literacy. They cannot do much more than sign a form or search a simple document to find out what they can or can’t drink before a medical test. 19 42

50 Nearly ____ % of all American adults, 90 or ___ million people, have 50 Nearly ____ % of all American adults, 90 or ___ million people, have difficulty understanding and acting upon health information. 21 43

According to the CDC, what percentage of the population harbors HIV/AIDS-related stigma? a. 11. According to the CDC, what percentage of the population harbors HIV/AIDS-related stigma? a. 11. 7% b. 15. 6% c. 18. 1% d. 28. 9% 44

The Opportunity 45 The Opportunity 45

Be the first to participate in this national demonstration project and take advantage from Be the first to participate in this national demonstration project and take advantage from peer learning and expert faculty. 46

Not just talk about statewide collaboration across Ryan White HIV/AIDS Program Parts but actually Not just talk about statewide collaboration across Ryan White HIV/AIDS Program Parts but actually develop state-of-the-art strategies other states can learn from – be a pioneer! 47

Use this collaborative as the impetus in your state to prioritize cross-Part quality management Use this collaborative as the impetus in your state to prioritize cross-Part quality management goals and jointly conduct quality improvement activities across Parts 48

Use the momentum to develop unified processes for better care coordination and performance data Use the momentum to develop unified processes for better care coordination and performance data systems (avoiding resourceconsuming redundancies) 49

Champion quality improvement that is not only driven by individual efforts but allows for Champion quality improvement that is not only driven by individual efforts but allows for sharing of successes across (why re-invent the wheel) 50

Goal: One Sandbox! a ips t sh ner Par c tew arts s. P Goal: One Sandbox! a ips t sh ner Par c tew arts s. P ros Cro ss-P ide Per form anc e. M eas ure s lity Impro vement P roject Joint Qua art Q 51 Sta MP lan

Challenges Ahead! • • • 52 Fragmentation and Bureaucracy Interest and Motivation Skills and Challenges Ahead! • • • 52 Fragmentation and Bureaucracy Interest and Motivation Skills and Experiences Technology and Know-how Time and Resources

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Good Luck! National Quality Center (NQC) 212 -417 -4730 National. Quality. Center. org Info@National. Good Luck! National Quality Center (NQC) 212 -417 -4730 National. Quality. Center. org Info@National. Quality. Center. org

Sources • • 60 (1) Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Sources • • 60 (1) Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO) (2008). North America, Western and Central Europe: AIDS epidemic update regional summary. 1 -2. (2) US Centers for Disease Control and Prevention (2007 b). HIV/AIDS surveillance report: cases of HIV infection and AIDS in the United States and dependent areas, 2005. Vol. 17. Revised June 2007. Atlanta. (3) US Census Bureau (2006). Population estimates: entire data set. Washington. Available http: //www. census. gov. (4) US Centers for Disease Control and Prevention (2006). Revised recommendations for HIV testing of adults, adolescents, and pregnant women I health-care settings. Morbidity and Mortality Weekly Report, 55 (14): 1 -17. (5) US Centers for Disease Control and Prevention (2007 c). HIV/AIDS among blacks – Florida, 1999 -2004. Morbidity and Mortality Weekly Report, 56: 69 -73. (6) US Centers for Disease Control and Prevention (2007 b). Update to racial/ethnic disparities in diagnoses of HIV/AIDS – 33 states, 2001 -2005. Morbidity and Mortality Weekly Report, 56: 189 -293. (7) Crum NF et al. (2006). Comparisons of causes of death and mortality rates among HIV-Infected patients. Analysis of the pre-. Early, and late HAART (highly active antiretroviral therapy) eras. Journal of Acquired Immune Deficiency Syndromes, 41: 194 -200.

Sources (continued) • • • 61 (8) Glynn M, Rhodes P (2005). Estimated HIV Sources (continued) • • • 61 (8) Glynn M, Rhodes P (2005). Estimated HIV prevalence in the United States at the end of 2003. In: Programs and abstracts of the 2005 National HIV Prevention Conference (Atlanta). Abstract 545. Atlanta, US Centers for Disease Control and Prevention. (9) Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO) (2008). Report on the global HIV/AIDS epidemic 2008: executive summary. (10) UNAIDS/WHO unpublished estimates, 2007. (11) UNGASS Country Progress Reports 2008. (12) Until There’s a Cure Foundation. (2003). http: //www. until. org/statistics. shtml? gclid=CNzr 2 Irgn 5 UCFQOb. FQod. Zg. Svj. A. (13) Avert. org. (2008). http: //www. avert. org/worldstats. htm (14) Center for Disease Control Site. http: //www. cdc. gov/hiv/topics/surveillance/basic. htm#ddaids. (15) Losina E, Schackman R, Sadownik S, et al. Disparities in survival attributable to suboptimal HIV care in the US: Influence of gender and race/ethnicity [abstract 142]. Presented at: 14 th Conference on Retroviruses and Opportunistic Infections; February 25 -28, 2007; Los Angeles, California. (16) Hartzell J, Spooner K, Howard R et al. Race and mental health diagnosis are risk factors for Highly Active Antiretroviral Therapy failure in military cohort despite equal access to care. Journal of Acquired Immune Deficiency Syndrome. 2007; 44(4): 411 -416.

 • • • • 62 Sources (continued) (17) Wilson Lucy, Korthuis P, Conviser • • • • 62 Sources (continued) (17) Wilson Lucy, Korthuis P, Conviser R, et al. Rural Versus Urban HIV/AIDS Clinical Outcomes: A Multi-state Perspective [abstract 974]. Presented at: 14 th Conference on Retroviruses and Opportunistic Infections; February 26, 2007; Los Angeles, California. (18) Divisions of HIV/AIDS Prevention National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. http: //www. cdc. gov/hiv/topics/aa/index. htm (19) Overview of the National Assessment of Adult Literacy: http: //nces. ed. gov/NAAL/ (20) http: //www. mmia. org/uploads/pages/215. pdf (21) Health Literacy: A Prescription to End Confusion. Institute of Medicine, 2004. (22) Understanding and Addressing Health Literacy. The Quality Academy. Tutorial 23. The National Quality Center 2008. (23) United States President’s Plan for Emergency AIDS Relief Wesite. http: //www. pepfar. gov/ (24) Henry J. Kaiser Family Foundation. http: //www. kff. org/hivaids/upload/6089 -03. pdf (25) CDC, HIV/AIDS Surveillance Report, Vol. 16, 2005. (26) Mc. Quillan G et al. , “The Prevalence of HIV in the United States Household Population: The National Health and Nutrition Examination Surveys, 1988 to 2002, ” Abstract #166, 12 th Conference on Retroviruses and Opportunistic Infections, February 2005. Note, among those ages 18– 49.