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This paper focuses on a state-based system for evaluating the quality of HIV clinical services in New York State using techniques of contin
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Regional Group Spotlight: Heartland Health Outreach and Erie Family Health Center
Midwest Overview

According to most recent estimates, 21,000 Chicagoans are currently living with HIV/AIDS, a rate three-times the national average. Heartland Health Outreach, Inc. (HHO), a participating Ryan White Part C grantee in the HIVQUAL-US Chicago Regional Group, provides primary care, mental health, substance use treatment and oral health care for the Chicago region’s under-served populations.  As a community-based health facility, HHO is a wholly owned subsidiary of the Heartland Alliance for Human Needs & Human Rights, a non-profit organization that offers health care, housing, and legal protection to immigrant, refugee and homeless residents of Chicago.  HHO delivers services at their health center, three oral health centers, outpatient and residential locations and outreach programs and over 100 shelters and outreach sites in the Chicago metropolitan area to an average of 275 HIV patients. 

Erie Family Health Center, another participating Part C grantee in the Chicago Regional Group, serves 34,000 patients annually at eleven sites across Chicago’s westside, including five school-based health centers, a teen health center and two oral health centers.  Erie’s Lending Hands for Life (LHL) program provides HIV/AIDS-specific care, operating primarily from the Erie Humboldt Park Health Center site to 221 HIVpatients during FY2010.
In 2009, the National Quality Center presented Erie Family Health Center with the Quality of Care Award for Excellence in Performance Measurement, which honors organizations that have demonstrated exceptional progress in improving the quality of HIV/ AIDS care.
Both HHO and Erie Family Health Center are partners in the Alliance of Chicago Community Health Services.  Established in 1997, the Alliance of Chicago began as a collaborative of four community-based health facilities in the Chicago metropolitan area in an effort to pool resources, improve quality of care and achieve shared objectives through information technology.  Among the many accomplishments of the Alliance, a centrally-hosted electronic health record (EHR) known as Centricity functions across the original partner health centers, including HHO and Erie Family.  Today, the Alliance has expanded to collaborate with thirty facilities across the United States, including nine federally-qualified health centers (FQHCs).
Alliance members’ patient populations vary significantly.  Eighty-two percent of Erie Family’s patients are Hispanic, with fifty-nine percent of all patients best served in Spanish. By contrast, a sizeable portion of HHO’s patients are Burmese, Burundian and Nigerian refugees.  Other Alliance members such as Near North Health Service Corp. (IL) and Wayne State University (MI) participate in the HIVQUAL-US program with HHO and Erie Family Health.
As a partner of the Institute of Nursing Centers (INC) since 2006, the Alliance supports the use of health information technology (HIT) for continuous quality improvement in service delivery and patient outcomes by providing INC members data reporting services and the use of Centricity.  Centricity was designed as a useful tool to incorporate evidence-based practices at the point of care and to provide data reporting for a multidisciplinary care model.  Various national performance indicators were integrated into Centricity as structured data elements to be completed by a physician, nurse practitioner, and/or case manager as appropriate.  Clinicians and other staff collaborated with the Alliance to determine the ideal placement of a given data element within Centricity’s templates to assure the practical and consistent completion by providers.
For each national performance measure to be used, the Alliance examines the prescribed denominator and numerator to see if the necessary information is already captured within Centricity or if not, to adapt the existing templates accordingly.  HIV/AIDS Bureau (HAB) Group 1 and Group 2 measures (For a list of all indicators, please visit: are used as HIV-specific indicators within Centricity.  As a result, providers are automatically prompted every four months to record a patient’s viral load and CD4 count as part of the lab values template.  The prompt can also be adjusted to every six months as needed for stable patients.
Each month, the Alliance generates and distributes a “dashboard” report to compare every participating clinic’s results to the larger group as well as to national benchmarks.  Additionally, Centricity can be used to produce provider-level perfor-mance data.  The clinician committees at each CHC discuss the dashboards in order to take note of areas in need of improvement and to share best practices in a peer-learning environment. 
As a next step, the Alliance has begun to focus on the most effective and efficient ways in which to help organizations introduce interventions in order to improve their quality of clinical care.  For example, if a female patient has not yet received a Pap test in a given measurement year, Centricity will then prompt the provider as he or she enters other primary care visit information.
HHO has used Centricity to track patients lost to care and systematize efforts to re-engage them.  With a significant homeless population, many HHO health care providers deliver mobile health care at shelters and outreach sites utilizing laptops that enable full access to the Alliance’s EHR.  If a patient lost to care is found at the facility, the provider may record his or her location into Centricity.  The results of frequent searches of the prison system registry are also entered. 
HHO has engaged in a QI project since September 2010 to increase rates for dental examinations for patients in the Early Intervention Prevention (EIP) program.  Of the 272 total participating patients seen between August 1, 2010 and May 10, 2011, only 59 (21.7%) received a dental examination before September 2010.  A revised protocol was then implemented: (1) medical case managers contacted every participating patient (by phone call, letter, and/or in-person) offering to schedule dental appointments; (2) “open access” periods were established every Tuesday in the dental examination schedule to allow EIP patients to make same day or walk-in appointments.
Subsequently, 110 participants (40.4%) had at least one on-site dental appointment between September 30, 2010  and May 10, 2011.  Of those, sixty patients had their first ever dental appointment at Heartland Health Outreach, twenty-six continued to have on-site dental appointments every 1-4 months, fifteen had appointments within 4-6 months of the intervention as recommended, and nine had appointments six months after the intervention.
HHO uses Centricity to notify providers, nurses, and case managers when there are new participants and to record a participant’s need for referral for a next dental examination.  Alice Wightman, Associate Director of Special Populations at HHO, routinely tracks oral health appointments made, cancelled or missed twice a month.  In an effort to sustain achieved gains, HHO staff continues to follow-up with those patients currently in oral care and call those individuals that have not yet been reached or have missed/cancelled scheduled appointments.
Erie Family Health Center’s LHL program uses Centricity to continuously monitor various primary care quality indicators including but not limited to viral load count, TB screening, and Pap tests.  At each monthly Continuous Quality Improvement (CQI) committee meeting, team members review customized reports generated with up-to-date data directly from Centricity.  Performance is calculated for each provider and compared to the aggregate results for the entire LHL program as a percent-variance.
In June 2010, LHL chose to address their clinic’s low referral completion rates (40% at baseline).  LHL providers often refer patients to outside specialists for such services as imaging, screenings, and diagnostic tests.  Because LHL clinicians depend so heavily on information from these referrals for diagnosis and treatment, patients who do not complete the referral process will often experience delays in diagnosis and thus poor health outcomes.
In June 2010, LHL’s CQI committee developed a workplan that outlined specific steps, timelines and responsible team members for this QI project.  CQI members agreed upon the “ideal referral process” in an effort to streamline expectations from the inefficient and barrier-ridden existing process.  Next, the CQI committee brainstormed obstacles that prevent patients from completing this “ideal process”.  These were then grouped into three major categories (Process, Patients, and Resources) and illustrated in a fishbone diagram, as seen to the right.  A decision table was created to prioritize the obstacles according to their impact on the referral process, the frequency with which the patient encounters them, and the feasibility of addressing the issue.  Within this schematic, “patients fail/miss appointment” and “patients do not understand procedure and its importance” received the highest score.
In order to tackle “patients fail/miss appointment” and reach the LHL’s goal referral completion rate of 75% by June 2011, the CQI committee generated an intervention procedure and subsequent PDSA cycle in which LHL staff would remind patients of upcoming appointments through a shared referral calendar.  This calendar details every external referral appointment including the date, time and location.  The LHL care coordinator is responsible for entering this information while all staff members must review the calendar daily and place reminder calls to patients the day prior to their referral appointment.  If a patient was case managed, they were contacted by the case manager.  If not, the LHL care coordinator contacted the individual.  The day after the scheduled appointment, LHL staff members called patients to check for completion.  The referral calendar was then updated with the results via color-coding.
Beginning in February 2011 rates for “ideal” referral completion were calculated and monitored on a weekly basis by the QI Analyst to be shared with the entire team.  By Week 5, LHL had exceeded the goal rate of 75% by reaching 80% referral completion.  The team has continued to sustain this achievement by incorporating the checking of the shared calendar and the reminder calls into the daily workflow of the facility.  Clinicians have also noted the significant improvement in provider satisfaction and patient care due to referral completion.
The work of Heartland Health Outreach, Inc. and Erie Family Health Center with the technical support of the Alliance of Chicago underscores the value of a comprehensive and practical electronic health record in quality improvement.  The grantees’ highlighted projects demonstrate significant innovation in quality improvement infrastructure and practice with a documented progress in patient health outcomes.


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