Central Texas hiv/aids planning Area



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The Current Care System
The Current Care System: Service Category Rankings and Explanation
Service Category Rankings and Explanations are available in Section One.
The Current Care System: Services Currently Available
Tables presenting the Ryan White and State Services funded service categories in each HSDA are available in Appendix D.
The Current Care System: Access Points and Process
The Central Texas HIV Administrative Service Area (CTHASA) contains five health service delivery areas (HSDAs). In four of the HSDAs, there is only one contracted provider, who serves as the primary access point into the Ryan White funded system. Due to the size of the PLWHA population in the Austin HSDA, there are five BVCOG-contracted agencies. All five agencies also receive Ryan White Part A funding from the City of Austin. There are four additional AIDS Services Organizations receiving Part A funding that are not BVCOG contractors. The Austin ASOs collaborate extensively to improve client care, and clients in the Austin HSDA often receive services from multiple agencies.
Historically, the care system in the CTHASA, with the exception of the Austin HSDA, has been built on a model with case management as a primary entry point. The previous model consisted of a needs assessment conducted upon entry to services, followed by developing a care plan to address the identified needs. The following model demonstrates that access to services moves downward, with the highest stated need for a medical service at the bottom left, and the least stated need at the bottom right. Under this model, a client must start accessing the Ryan White system of care through a case manager. Once food and housing needs were secure, access services (transportation and health insurance) were used to obtain medical care. If those access services are not needed by a client, then they proceed to access medical services independently. As seen in the discussion on out-of-care data from the needs assessment, receiving these supportive services first provides a means for PLWHA to focus on remaining in regular medical care.
access-need pyramid
Through the years, this model of entry into care, based on the notion that most (if not all) clients are indicated for case management became less sustainable for agencies. In the December 2011 DSHS Case Management Standards of Care, special considerations and guidance are provided to assess whether a given client is indicated for case management. Through the use of an acuity scale that indicates differing levels of contact based on client need for case management, clients are encouraged to take an appropriate level of responsibility for their care, which can lead to graduation from case management.
While the previous model placed case managers as gatekeepers to services, a more constructive way of viewing access to the Ryan White system of care in the four rural HSDAs is the current hub and spoke model. Under this model, central agencies provide the bulk of services (either directly or through referral) for the HSDA. Though each of the subcontractors is primarily a case management agency, the updated model does not require enrollment in case management services for clients to access care through these agencies.
Bryan-College Station, Concho Plateau, Temple-Killeen and Waco HSDA Access Points

Each of the outlying service points is accessible through the central agency. For example, an individual who requires transportation assistance in the form of a bus pass would contact the central agency to access the bus pass. However, it is not necessary that the individual speak with an assigned case manager, if other staff members are qualified to distribute the resource. This allows case managers to spend more time with clients truly in need of care coordination, and allows clients who do not need case management to quickly access the services they need.


A number of referral points, including community testing sites, prisons, and emergency rooms exist throughout the CTHASA to link PLWHA to the central agencies. One goal for service system improvement that BVCOG is working toward is an evaluation of this referral network to identify current strengths and potential opportunities for increased partnership and communication, to identify where clients appear to be falling through referral gaps. This goal is discussed in greater detail in Section Three.
The system of access points in the Austin HSDA differs from the rest of the CTHASA. Social services and medical services are separated, but there are strong linkages between the two. An individual may go to the David Powell Community Health Center and receive medical care or medical case management funded by Ryan White Parts A, B, and/or C, but may not need other social services. During intake and eligibility screening at David Powell, clients may be referred to another ASO to receive social services such as food bank, housing assistance, etc. The division results in two access points, medical care and agencies, both of which are able to provide Ryan White services.
Austin Access Points
Substance Abuse
Health Insurance

Service Agencies

Housing

Oral Health


Food

Bank
Mental Health

Medications/

THMP
Transpor-tation



OAMC/

MCM


THE CURRENT CARE SYSTEM: Monitoring and Evaluation Procedures
BVCOG monitors its contractors on an annual basis, or more often as needed, through desktop audits and on-site visits. The desktop audit portion of monitoring is performed by examining entries in the client care database, ARIES, to ensure the information conforms to standards and expectations as set forth in BVCOG and DSHS policies. The desktop audit also consists of a thorough review of the agency’s policies and procedures, quarterly reports, expenditures, and progress on performance measures. Site visits are performed to ensure that agencies are providing services and operating according to the terms of their BVCOG contract and that services provided meet or exceed professional and clinical standards as set forth by DSHS and BVCOG.
Any deficiencies identified through the monitoring process are addressed by an agency-developed corrective action plan, with specific time tables and action steps. At the end of the time table specified in the corrective action plan, the agency must submit evidence of implementation and resolution of the issue, or, in some circumstances, a follow up visit is conducted to ensure all problem areas have been addressed. The timeline for the next monitoring visit is decided through the use of a Priority Assessment Tool that determines whether the next visit will occur in one year, in six months, or a shorter time frame, based on the number and severity of the site visit findings.
The BVCOG HIV/Health Services program meets monthly to discuss emerging quality issues, and to reviewing expenditure and utilization data from each agency. Utilization and expenditure review can inform BVCOG of any emerging trends, or systemic problems with providing services. For example, under utilization of a particular service, indicated by a decrease in units provided to date, may indicate a barrier to care. Overuse of a service may represent a developing need among clients, or that other resources have decreased for that category, causing more clients to use BVCOG-funded services. The data reviewed are compared to the performance measures and objectives specified in the agencies’ contracts and applications, to ensure appropriate progress is being made. Performance measures and objectives include both a target number of clients to be served, and units of service to be provided during the contract period. HRSA HIV/AIDS Bureau (HAB) measures, such as the number of clients receiving CD4 or viral load tests, or influenza vaccinations are also examined quarterly to ensure that clients are receiving appropriate care for their HIV. This monitoring procedure allows BVCOG to make timely funding and administrative decisions that complement the needs of clients and agencies.
As monitoring and evaluation are based in large part on contractual requirements, the goals and objectives of this comprehensive services plan are incorporated in the request for applications/proposals process. Applicants are required to address in their applications how they intend to provide services and create a care system that supports and works toward the stated goals and objectives of the comprehensive plan. Quarterly reports ask questions about subcontractor progress on these goals, and allow continuous monitoring of the goals and objectives.
Each Brazos Valley Council of Governments funded agency must create, distribute, and evaluate the results of an annual anonymous client satisfaction survey. The agencies incorporate client feedback into program improvement efforts, and may make changes to how services are delivered, based on client responses to the survey. Results of the survey are also sent to BVCOG, and reviewed during the agency’s quality management meetings. Any issues that BVCOG identifies in the agency survey results are shared with the BVCOG HIV Administration Quality Management Committee and, if necessary, addressed with the subcontractor. To complement the annual client satisfactions surveys that providers administer, the BVCOG Planner has designed a survey for clients across all HSDAs to complete via telephone or website. The survey will be conducted annually during April-May, and will provide clients with an opportunity communicate directly with BVCOG to relay concerns, identify areas that clients feel need improvement, and share positive feedback about the agency serving them.

Section 2: Where Do We Need to Go: What System of Care do We Need?
This plan was written to serve as a three year strategic plan for BVCOG-HIV Administrative Services, that would guide the contracting and delivery of services for the next three years, and provide an illustration for others to understand the Ryan White funded system of care in the CTHASA. This section will explain BVCOG’s broad goals to achieve a more comprehensive and responsive system of care to serve PLWHA living in the CTHASA. Specific measures for achieving the system envisioned in this section are featured in Section 3.
At any point in the Ryan White system, from HRSA to a local AIDS service organization the overarching goal is to get people with HIV into care and keep them there. This will be accomplished through four broad goals that will guide this plan and the goals and objectives for the next three years.


  • Increase access to services through expansion of services and reduction of barriers

  • Improve the quality of services provided

  • Improve the care system through better planning and administration

  • Equip the care system to articulate with the changing nature of healthcare at national, state and local levels


Improve access to / reduce barriers to services

All services encompass issues of access and barriers to them, unique to the place in which they are provided and to sub-populations for which they are provided. This is particularly true as many clients belong to populations that are already marginalized. One role of the BVCOG is to reduce, to the extent possible, any barriers to services. The goals and objectives that pertain to this broad goal are primary to engaging and retaining people in care.


Improve the quality of services provided

Part of the mission, vision and values of BVCOG is a belief in continuous quality improvement. There is a strong desire within BVCOG to measure the quality of care that is being provided and find ways to improve. Goals and objectives that are related to quality are primary to keeping people in care.


Improve the system of care including planning and administration

Other goals and objectives in this plan are not directly related to access and barriers or directly impact the quality of care, but are improvements to the care system overall. The successful completion of systemic goals and objectives results in better planning and administration in the CTHASA. We believe that better planning and administration can lead to better access and better quality of care, and therefore an indirect improvement in accessing services.


Equip the care system to articulate with the changing nature of healthcare at national, state and local levels

The broad goal of equipping the care system to articulate with the changing nature of healthcare comes at a time when policy, legislature and changes in funding environments are actively reshaping the face of healthcare. Timely and appropriate responses to these changes are vital to ensure PLWHA are engaged and retained in care.



Section 3: How Will We Get There: How Does Our System Need to Change to Assure Availability of, and Accessibility to, Core Services?
The following improvement goals demonstrate both short and long-term objectives for expanding the current service care system to increase access and availability of services.
The first service system improvement goal to be addressed over the next three years is BVCOG’s Phase Two goal to reduce the number of out of care PLWHA in each HSDA, through engaging and retaining clients in care while closing referral gaps. The spectrum of engagement in HIV care (also called the Gardner Cascade) provides an illustration of the importance of engaging PLWHA in the care spectrum to both improve the health and quality of life for PLWHA, and prevent further transmission.18 This spectrum is at the core of the Texas HIV Plan as well as the National HIV/AIDS Strategy.
Spectrum of Engagement in HIV Care/Gardner Cascade

Not engaged in HIV Care

Engaged in HIV Care

As an individual progresses toward becoming fully engaged in HIV care, his or her risk of morbidity and/or transmission to another individual decreases greatly. The outline below demonstrates BVCOG’s current plan for achieving the goal of reducing the number of people out of care in each HSDA and maximizing the beneficial effects of the Gardner cascade.



GOAL 1: Out-of-care reduction: reduce the number of people out of care/with unmet need in each HSDA.

  • OBJECTIVE 1.A Assess referral link from initial testing sites to care services through inquiries with subcontractors and report findings to QMC.

  • OBJECTIVE 1.B Map referral networks in each HSDA for strengths and opportunities for improvement; utilize knowledge of these networks to inform surveys with PLWHA at high risk for falling OOC/never entering care.

  • OBJECTIVE 1.C Use DSHS OOC criteria to identify individuals in ARIES who may be out of care in each rural HSDA; provide subcontracted agencies with list of out of care clients

  • OBJECTIVE 1.D Identify HSDA for OOC reduction pilot project; research appropriate interventions for this HSDA; run OOC data in ARIES for this HSDA.

  • OBJECTIVE 1.E Collaborate with subcontractor(s) to implement OOC reduction pilot; inclusion in contracts in scope of work.

  • OBJECTIVE 1.F QMC review of monthly/quarterly ARIES reports to track and analyze OOC data in pilot HSDA.

  • OBJECTIVE 1.G Share process and results with DSHS and Planner’s Network.

  • OBJECTIVE 1.H Partner with TGA RTC collaborative for feedback on OOC pilot project development, implementation, evaluation and results.

  • OBJECTIVE 1.I Use lessons learned from the initial OOC pilot project to inform the implementation of OOC projects in other HSDAs, with regard to local strengths and opportunities for improvements.


This process will begin with BVCOG analyzing the referral to care networks already in place by asking subcontractors from where most clients are referred. This task is already underway, as providers in each of the rural HSDAs are already providing input on their primary referral relationships. BVCOG will then examine strengths and gaps in these relationships to identify opportunities for increased collaboration between the testing, or initial referral, site and the subcontractor. Using these gaps as a tool for recruitment, BVCOG will interview PLWHA with the highest risk for falling through the identified gaps, pending the establishment of more formal relationships between contracted agency and testing or initial referral sites.
Objective 1.C was developed following the successes of the Austin TGA Return to Care Collaborative. BVCOG will run brief ARIES reports to identify individuals who meet DSHS criteria for being out of care. Analysis of additional ARIES fields will allow the BVCOG Planner to identify emerging barriers in the HSDA to remaining in care. Identifying these barriers will inform BVCOG and subcontractor actions to remove the barriers and increase client access to care. This objective will also result in the creation of a list of clients who are out of care for the subcontractors to contact.
In addition to identifying out of care individuals and describing the area-specific barriers that prevent PLWHA from remaining in care, BVCOG will be working closely with one of its sub-contractors to develop, implement and evaluate a pilot project designed to increase the number of clients returning to and remaining in care within the HSDA. This portion of the improvement goal is also currently being executed, as the BVCOG Planner has identified a number of evidenced-based retention interventions suitable for the rural HSDAs. With these interventions as a framework, the project will be further developed by using input from clients that either have been out of care at some point, or share social networks with individuals who identify as being out of care. Other partners in the development of this pilot project will be the provider implementing the project, as well as providers who are currently participating in the Austin TGA Return to Care Collaborative. The anticipated output of this project will be fewer out of care clients as measured through indicators in ARIES data, in addition to a project framework that can be tailored to meet each HSDA’s unique culture and needs. The anticipated outcome is fewer out of care clients for the entire HSDA and CTHASA. This goal will take at least three years to complete as considerable time is required to plan, design, implement, evaluate and report such an undertaking.
The second service system improvement goal is to increase tracking of preventative vaccinations delivered to clients.


GOAL 2: Increase Tracking of Preventative Vaccinations and Screenings: increase tracking of preventative vaccinations and screenings delivered to clients through unaffiliated/external providers.

  • OBJECTIVE 2.A Contact subcontracted agencies to learn the extent and nature of the client underreporting of screenings and vaccinations received through retail health clinics (“minute clinics”).

  • OBJECTIVE 2.B Present findings to Planner’s Network for feedback on potential causes for under reporting and solutions.

  • OBJECTIVE 2.C Interview clients to gain perspective on what might be causing some to underreport vaccinations and screenings.

  • OBJECTIVE 2.D Implement intervention to increase reporting of vaccinations and screenings attained at retail health clinics in ARIES (dependent on cause for withholding this information from case managers; may entail case management staff clarifying with clients who can access and input ARIES data, providing clients with pocket vaccination records they can add on to).

  • OBJECTIVE 2.E Monitor client files and ARIES for increases HAB measure vaccinations and screenings. QMC to monitor results quarterly.
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