HIVQUAL INDICATOR DEFINITIONS GUIDE FOR PROVIDERS AMBULATORY CARE SERVICES

Transcription

1 HIVQUAL INDICATOR DEFINITIONS GUIDE FOR PROVIDERS AMBULATORY CARE SERVICES ehivqual DATA SUBMISSION FOR CALENDAR YEAR 2008 (1/1/ /31/2008) AND/OR CALENDAR YEAR 2009 (1/1/ /31/2009) New York State Department of Health AIDS Institute US Department of Health and Human Services HRSA/HAB/Division of Community Based Programs 6/2/2010 Indicator Definitions Guide Page 1 of 23

2 PREFACE This document presents indicators for the measurement of quality of care provided in HIV ambulatory care services. The set of indicators has been updated and expanded to reflect changes in the standard of practice for HIV care that have occurred since the last period during which data were submitted through the HIVQUAL-US and New York State Quality of Care (QOC) Programs. Definitions for each indicator have been included to guide participants in the use of ehivqual, the new online data collection system. Indicators for use outside of NYS were developed and refined with input from the HIVQUAL-US National Clinical Advisory Committee, which consists of HIV providers from clinics across the United States. Members were recruited from clinics that reflect the geographic distribution of Ryan White Care providers. NYS QOC indicators were developed and refined with input from the NYS Quality Advisory Committee, the members of which are experienced HIV providers from across New York State. Initially, indicators were developed by formal group decision-making methods, beginning with a nominal group technique (NGT) process. A modified Delphi process was conducted to refine the indicators and specify review criteria. For several indicators, New York State criteria were formally adopted by the Committee, including the HIV Specialist Policy and the definitions of stable and unstable clinical status for patients receiving antiretroviral therapy. The Advisory Committee is routinely convened to review and revise selected indicators based on changes in clinical guidelines and experience in the field concerning the validity of the measures and their relevance to care. Contact Us To schedule a phone call for application or indicator guidance, please contact our office at (212) /2/2010 Indicator Definitions Guide Page 2 of 23

3 HIVQUAL Indicators ehivqual collects performance data on up to 33 clinical indicators. While facilities are encouraged to collect data on all of the indicators that would be helpful for their quality management program, not all indicators are considered "core," or required, indicators for submission under the applicable program. For the purpose of data submission, there are sets of core and optional indicators. These sets differ for New York State QOC HIV programs and for HIVQUAL-US facilities outside on New York, which are Ryan White (RW) Part C or Part D grantees. Programs that are located in NYS and receive Part C or D funding must submit data for both NYS core indicators and HIVQUAL-US core indicators. Both NYS QOC and HIVQUAL-US participants may choose which optional indicators to enter data for submission. Adult Ambulatory Care core and optional indicators are listed below. Pediatric, adolescent, nursing home and case management indicators are explained in separate indicator guides. Indicator NYS non-c/d NYS Part C/D Outside NYS CLINICAL VISITS HIV MONITORING ARV THERAPY VIRAL LOAD SUPPRESSION ARV MANAGEMENT ADHERENCE ASSESSMENT PCP PROPHYLAXIS BASELINE RESISTANCE TEST HAART IN NAÏVE PATIENTS SUBSTANCE USE SCREENING MENTAL HEALTH SCREENING LIPID SCREENING TOBACCO USE SCREENING COLONOSCOPY PNEUMOCOCCAL VACCINE INFLUENZA VACCINE ANORRECTAL EXAM DENTAL CARE URINALYSIS GYNECOLOGY CARE MAMMOGRAPHY TB SCREENING HEPATITIS C MANAGEMENT STI MANAGEMENT DIABETES MANAGEMENT HYPERTENSION PREVENTION EDUCATION HEALTH LITERACY MAC PROPHYLAXIS OPTHALMOLOGIC CARE PERINATAL TRANSMISSION ANAL PAP SMEAR BASIC PATIENT EDUCATION = REQUIRED INDICATOR = OPTIONAL INDICATOR 6/2/2010 Indicator Definitions Guide Page 3 of 23

4 1. ENGAGEMENT IN CARE Clinical Visits & HIV-Experienced Provider Care ehivqual will ask for dates of all clinical visits during the review period. In addition to regular clinical visits, consultations with an HIV-experienced provider should occur at least once every four months. For each visit entered, ehivqual will ask you to specify whether the patient saw an HIV-experienced provider. There are several available definitions of what constitutes an HIV-experienced provider. During the specification of review parameters (review dates, optional indicators to be used, etc.), a drop-down list is provided for you to select the definition that has been adopted by your state or organization. If no matching definition is found, you can select Other and enter a different one. HIV-Experienced Provider Definition Practitioners who have been accorded HIV-Experienced Provider status by the American Academy of HIV Medicine (AAHIVM) or have met the HIV Medicine Association's (HIVMA) definition of an HIV-experienced provider are eligible for designation as an HIV Experienced Provider in New York State. Nurse practitioners and licensed midwives who provide clinical care to HIV-infected individuals in collaboration with a physician may be considered HIV Experienced Providers provided that all other practice agreements are met (8 NYCRR ; 10 NYCRR 85.36; 8 NYCRR ). Physician assistants who provide clinical care to HIV-infected individuals under the supervision of an HIV Specialist physician may also be considered HIV Experienced Providers (10 NYCRR 94.2). 2. HIV-SPECIFIC CARE HIV Monitoring All viral load and CD4 lab results obtained during the review period, and the dates of these results, are to be entered into ehivqual. These data are used in the assessment of ARV management, and must be entered before attempting to enter data for the ARV Therapy Management indicator. New this year, viral load values can be entered in three ways: (i) an exact value; (ii) below a specified threshold (which must be less than or equal to 400 copies/ml); or (iii) above a specified threshold (which must be greater than or equal to 75,000 copies/ml). The method used should reflect the way the results are specified in the lab report. Antiretroviral Therapy Monitoring All ARV drugs prescribed for the patient during the review period, including start and stop dates (if applicable), are entered into ehivqual. For patients already on ARV therapy prior to the beginning of the review period, please enter the actual start dates of drugs constituting the current regimen. If the start dates of drugs constituting the current regimen are before the start of the review period but not known 6/2/2010 Indicator Definitions Guide Page 4 of 23

5 precisely, enter an approximate date before the beginning of the review period. Do not enter stop dates for drugs that a patient continues to take. However, if there is documentation in the chart that the patient stopped taking medication, a stop date should be entered that reflects this, even if the patient s physician did not advise the patient to discontinue therapy. ehivqual will also ask if the patient received any ARV medications before the review period. This question refers to the patient s entire medical history. It is an assessment of whether the patient was ARV naïve, and it must be answered before proceeding to the next screen. These data are used to assess management of ARV therapy, and must be entered before attempting to enter data for the ARV Therapy Management indicator. Viral Load Suppression Based on the viral load values entered above, ehivqual separates patients into two categories: suppressed and not suppressed. This is derived from the last viral load measurement of the review period. If the value of this measurement is above 400 copies/ml, or if there was no measurement in the last half of the review period, the patient is considered not suppressed; if the value is less than or equal to 400 copies/ml the patient is considered suppressed. No additional data entry is required for this indicator. ARV Therapy Management Appropriate ARV Therapy management is assessed from the viral load dates and values and the ART medication information that the user has entered. Thus, all CD4, viral load, and ARV medication data must be entered before attempting to enter data for ARV Therapy Management. All patients whose viral loads were not suppressed according to definition above are eligible for this indicator From these patients, the last viral load measured before October 31 of the review period is used as a reference point. If this value is greater 400 copies/ml, then the patient s ARV drug regimen should have been changed within one week of the date of measurement. If ehivqual finds that ARV therapy has not been appropriately managed, it will ask if there was documented justification for not changing the regimen. If the regimen was stopped in the week following the reference viral load measurement, ehivqual will ask whether this was due to the patient s clinical status. Documentation Guide (ehivqual options) Justification for Not Changing Regimen Intercurrent Illness Adherence Intervention Documented Viral Load Test Repeated Resistance Test Ordered Clinical Judgment Justification for Stopping ARV Therapy Intolerance All Therapeutic Options Exhausted Documented Non-Adherence Patient Choice 6/2/2010 Indicator Definitions Guide Page 5 of 23

6 Insurance Issues Adherence Assessment A patient will be considered eligible for the adherence indicator if antiretroviral therapy was prescribed during the review period. 1) Adherence should be assessed with patients, at the very minimum, once a year. ehivqual prompts, "Was adherence assessed with the patient?" A qualitative or quantitative adherence assessment is documented (continue to 2). No documentation of adherence assessment (stop). 2) ehivqual prompts, How was adherence assessed? Adherence may be measured quantitatively or qualitatively. If adherence was assessed more than once during the review period, refer to the last assessment when answering this and any follow-up questions. A quantitative assessment is a percentage value which may have already been calculated and documented in the chart. If no percentage measure has been calculated, use the information from the quantitative assessment to estimate a percentage. For quantitative assessments, the general formula for rate of adherence is: Rate of adherence = Total doses taken / Total doses prescribed Documentation Guide (suggestions) Assessment of adherence Patient self-report Pill count Prescription refill Electronic monitoring (MEMS) Diaries Direct observational therapy Family reporting for individuals who cannot self report Quantitatively: Adherence was quantitatively assessed (continue to 2.1). Qualitatively: Adherence was qualitatively assessed (continue to 2.2). 2.1) If adherence was quantitatively assessed, ehivqual prompts, "Enter adherence % (continue to 3). 2.2) If adherence was qualitatively assessed, ehivqual prompts, Select qualitative category: Excellent, good, fair, and poor are the possible responses. If the chart does not indicate one of these categories, the assessment does not count as a qualitative assessment (continue to 3). 6/2/2010 Indicator Definitions Guide Page 6 of 23

7 3) ehivqual prompts, Was an adherence problem identified? Adherence problem identified and documented (continue to 4). There is no documentation of adherence problem (stop). 4) If a problem is identified, follow-up action should be documented. HIVQUAL prompts, "Was the adherence problem addressed?" Follow-up action documented (stop). No follow-up action documented (stop). Documentation Guide (suggestions) Problem follow-up Provider s note in record Intervention documented (referral, regimen change, device, e.g. pill box, calendar) PCP Prophylaxis All HIV+ patients who have a CD4 count < 200 cells / mm 3 during the 12 month review period are eligible for the PCP prophylaxis indicator (unless CD4 count subsequently rises above 200 cells/mm 3 for the last six months of the review period). ehivqual prompts, Enter the first date during the review period when PCP prophylaxis was prescribed. If PCP prophylaxis (TMP/SMX, atovaquone, dapsone) was prescribed, enter the first prescription date during the review period; if PCP prophylaxis was not prescribed (including patients who refuse prophylaxis or are intolerant) check the None documented box. If PCP prophylaxis was prescribed, ehivqual will prompt you to enter the specific drug. MAC Prophylaxis Optional for All Programs All HIV+ patients who have a CD4 count < 50 cells / mm 3 during the 12 month review period are eligible for the MAC prophylaxis indicator (unless CD4 count subsequently rises above 50 cells/mm 3 for the last six months of the review period). ehivqual prompts, Enter the first date during the review period when MAC prophylaxis was prescribed.. If MAC prophylaxis (rifabutin, clarithromycin, azithromycin) was prescribed, enter the first prescription date during the review period; if MAC prophylaxis was not prescribed (including patients who refuse prophylaxis or are intolerant) check the None documented box. If MAC prophylaxis was prescribed, ehivqual will prompt you to enter the specific drug. Ophthalmologic Care (CMV Screening) Optional for All Programs All HIV+ patients with a CD4 count < 50 cells / mm 3 are reviewed for being referred for ophthalmology exams and receiving exams within the review period. 6/2/2010 Indicator Definitions Guide Page 7 of 23

8 1) Ophthalmology Referral A referral for an ophthalmology exam was documented during the review period (continue to 2). No documentation of ophthalmology referral (continue to 2). 2) Ophthalmology Exam Exam was performed and documented (stop). No exam documented, including patient refusal (stop). Prevention of Perinatal Transmission Optional for All Programs All pregnant HIV+ female patients are evaluated for prevention of perinatal transmission. A female s pregnancy status is determined in the clinical visit screen. 1) Did the patient give birth during the review period? Yes: Enter the delivery date (continue to 1.1). No: (continue to 1.1) 1.1) Was a viral load measurement obtained during pregnancy? Yes: If a viral load measurement was obtained, enter the last VL before delivery (continue to 2). No: (continue to 2) 2) Was ZDV-containing ARV therapy offered or recommended? Yes: (continue to 2.1) No: (stop) 2.1) Regimen implemented Yes: The patient initiated ZDV-containing ARV therapy (continue to 2.2). No: The patient did not initiate ZDV-containing ARV therapy (continue to 2.1.1) ) Enter the reason(s) the ARV regimen was not initiated (and then stop): Medical Contraindication Therapy Declined Other 2.2) Was the therapy Prenatal Oral ARV? Yes (continue to 2.3) No (continue to 2.3) 2.3) Was the regimen Intrapartum ARV? Yes (continue to 2.4) No (continue to 2.4) 2.4) Was the regimen Neonatal ARV? Yes (stop) No (stop) 6/2/2010 Indicator Definitions Guide Page 8 of 23

9 Baseline Resistance Test Required for Part C/D Programs; Optional for non-c/d in NYS All ARV naïve HIV+ patients who begin therapy during the review period and who have a viral load greater than 1000 copies/ml are evaluated for a baseline resistance test. ehivqual prompts, Enter the date of the first genotypic resistance test performed during the review period. If resistance testing was ordered, enter the date of the first test; otherwise check the None documented box. ehivqual determines ARV naïve patients when ARV therapy is entered. HAART in Naïve Patients Required for Part C/D Programs; Optional for non-c/d in NYS ehivqual will calculate the percentage of ARV-naïve HIV+ patients starting ARV therapy for the first time during the review period who had an undetectable viral load 24 weeks after initiation of therapy. The calculation is based on data from the HIV Monitoring and ARV Therapy indicators, and no further data entry is required. 3. SUBSTANCE USE AND MENTAL HEALTH SCREENING Substance Use Screening, Except Drug Treatment Centers All HIV+ patients are evaluated for the use of illicit substances and alcohol during the past 12 months. Substance Use Discussion: Discussion of substance use and alcohol use during the review period was documented Discussion of substance use during the review period was not documented. The following diagram represents further information solicited by ehivqual for the substance use indicator. 6/2/2010 Indicator Definitions Guide Page 9 of 23

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11 Mental Health Care Screening ehivqual evaluates whether all HIV+ patients have received mental health screening during the 12 month review period. (A patient is deemed to have received a mental health screening if all of the specified components were provided; see tables below for details.) Additionally, the need and follow-up for a mental health referral is evaluated. 1) Mental Health Screening: ehivqual confirms funding information for the service when the mental health indicator page is opened during data entry on the first patient being reviewed. 2) Once funding has been determined ehivqual presents a list of the required Mental Health Screening components (see list below). Required components vary by location and funding. All components apply to NYS C/D funded programs. Please check all that are documented in the medical record. Documentation Guide NYS, not C/D-funded NYS, C/D funded Outside NYS Criteria developed by the New York State Quality of Care Advisory Committee include the following components for an annual Mental Health Screening for people with HIV: Cognitive function assessment, including mental status Depression screening Anxiety screening Psychiatric history Psychosocial assessment Sleeping habits assessment Appetite assessment Domestic violence screening (optional) Post Traumatic Stress Disorder screening (optional) Criteria developed by the New York State Quality of Care Advisory Committee and the Mental Health/Substance Use Subcommittee of the National HIVQUAL Clinical Advisory Committee include the following components for an annual Mental Health Screening for people with HIV: Cognitive function assessment, including mental status Depression screening Anxiety screening Psychiatric history Psychosocial assessment Sleeping habits assessment Appetite assessment Domestic violence screening Post Traumatic Stress Disorder screening Criteria developed by the Mental Health/Substance Use Subcommittee of the National HIVQUAL Clinical Advisory Committee include the following components for an annual Mental Health Screening for people with HIV: Cognitive function assessment, including mental status Depression screening 6/2/2010 Indicator Definitions Guide Page 11 of 23

12 Anxiety screening Sleeping habits assessment Appetite assessment Domestic violence screening Post Traumatic Stress Disorder screening Psychiatric history (optional) Psychosocial assessment (optional) For depression, anxiety, cognitive function and PTSD screening, the following questions apply: 6/2/2010 Indicator Definitions Guide Page 12 of 23

13 Documentation Guide (suggestions) ALREADY IN CARE Chart documents that the patient was already receiving mental health care during the review period. GIVEN TREATMENT The patient was treated in house (not including referral to a psychiatrist). REFERRAL INDICATED Neither of the above options applies. Choose 2 this regardless of whether or not a referral was. actually made. 2 For appetite assessment, sleep habits assessment, domestic violence screening, psychiatric history, and psychosocial assessment, ehivqual prompts whether the screening occurred but does not ask follow-up questions. 4. GENERAL MEDICINE & PREVENTIVE CARE Lipid Screening All HIV+ patients (not just those on ARV Therapy) are evaluated for an annual lipid screening. ehivqual prompts, Enter date of most recent fasting lipid profile (even if prior to review period). If a lipid profile has ever been documented for the patient, enter the most recent date; otherwise check the None documented box. At a minimum, lipid screening should include determination of cholesterol and triglyceride levels. ehivqual will prompt for the latest LDL Cholesterol reading. In cases where the LDL value could not be calculated because of elevated total triglycerides, refer to the next most recent lipid profile and enter the date and LDL value for that test. Tobacco Use Screening All HIV+ patients are evaluated for discussion of tobacco use during the past 12 months. 1) Tobacco Use Discussion: ehivqual prompts, Enter date of most recent tobacco use discussion (even if prior to review period). If a discussion of tobacco use with the patient has ever been documented, enter the most recent date (continue to 1.1 if that date falls within the current review period); otherwise check the None documented box. 1.1) A determination should be made whether the patient is a current tobacco user. ehivqual prompts, Was the patient a tobacco smoker during the review period? Current tobacco use (continue to 1.2). Patient did not use tobacco during review period (stop). 1.2) A discussion of smoking cessation should be conducted with all current tobacco users. ehivqual prompts, Enter date of most recent smoking 6/2/2010 Indicator Definitions Guide Page 13 of 23

14 cessation discussion (even if prior to review period). If a discussion with the patient about smoking cessation has ever been documented, enter the most recent date; otherwise check the None documented box. Colon Cancer Screening Required for All NYS Programs; Optional Outside NYS All HIV+ patients over 50 years of age are evaluated to determine whether they have received a colon cancer screening (colonoscopy) within the past ten years. 1) HIVQUAL will ask, Has a colonoscopy been performed within the past ten years? YES (Date Known): A colonoscopy exam has been performed within the past ten years, and the date of the most recent exam is known (continue to 1.1). YES (Date Unknown): The patient s chart documents that a colonoscopy exam has been performed within the past ten years, but the exact date is not available (stop). A colonoscopy has not been performed within the past ten years (stop). UNKNOWN: Status of colon cancer screening exam is not documented in the patient s chart (stop). 1.1) If available, enter the date of the patient s most recent colonoscopy exam (stop). Pneumococcal Vaccination All HIV+ patients should have been given a pneumococcal vaccination within the last 5 years. ehivqual prompts, Is the date of the patient s last pneumococcal vaccination known? NO, but vaccination given: A field to enter the date will appear (stop). Pneumococcal vaccination has been given but the date is not known (stop). No documented pneumococcal vaccination occurred (stop). Influenza Vaccination All HIV+ patients should receive an annual influenza vaccination. ehivqual prompts, Enter date of most recent influenza vaccination (even if prior to review period). If an influenza vaccination has ever been documented, enter the most recent date; otherwise check the None documented box. Dental Exam All HIV+ patients should receive an annual dental exam. ehivqual prompts, Enter date of most recent dental exam (even if prior to review period). If a dental exam has ever been documented, enter the most recent date; otherwise check the None documented box. 6/2/2010 Indicator Definitions Guide Page 14 of 23

15 Documentation Guide (suggestions) Dental exam Note by primary care provider, including patient self report Urinalysis A urinalysis is an important part of routine care for all HIV+ patients. ehivqual prompts, Enter date of most recent urinalysis (even if prior to review period). If lab results from a urinalysis have ever been documented, enter the most recent date; otherwise check the None documented box. Gynecology Care All HIV+ female patients are evaluated to determine whether an annual pelvic examination has been performed. If the pelvic exam was performed elsewhere (referred out), results must be documented in the clinic's medical record. ehivqual prompts, Enter date of most recent gynecology exam (even if prior to review period). If a gynecology exam has ever been documented, enter the most recent date; otherwise check the None documented box. The following diagram represents further information solicited for patients receiving pelvic examinations. Mammography Required for All NYS Programs; Optional Outside NYS All female HIV+ patients over 40 are evaluated on when they last received a mammogram, during or before the review period. 6/2/2010 Indicator Definitions Guide Page 15 of 23

16 Anorectal Exam Required for Part C/D Programs; Optional for non-c/d in NYS ehivqual evaluates whether all HIV+ patients have received an annual anorectal, prompting Enter date of most recent anorectal exam (even if prior to review period). If there is documentation in the medical chart that anorectal exam was ever performed, enter the most recent date; otherwise check the None documented box. An anorectal exam comprises an inquiry by the provider about anal symptoms, such as itching, bleeding, diarrhea or pain; visual inspection of the perianal region; and a digital anal exam. Anal Pap Smear Optional for All Programs In addition to an anorectal exam, all HIV+ MSM, females with an abnormal vaginal pap smear, and patients with a history of anogenital HPV infection are evaluated on whether they have received an anal pap smear. ehivqual identifies MSM patients in the exposure category of the patient entry screen and identifies females with an abnormal vaginal pap smear within the gynecological exam indicator. ehivqual will prompt, Does the patient have a documented history of anogenital HPV infection? If the patient is eligible, ehivqual will prompt, Did the patient have an anal pap smear during the review period? Yes: No: Anal pap smear was a performed within the 12-month review period (stop). An anal pap smear was not performed (stop). 5. INFECTIOUS DISEASE SCREENING & MANAGEMENT Tuberculosis Screening Required for Part C/D Programs; Optional for non-c/d in NYS All HIV+ patients without previous treatment for TB or a previous positive PPD test are evaluated to determine whether they have been screened for tuberculosis. The screen can be a skin test or something else, such as the QuantiFERON-TB test. 1) ehivqual asks, If the patient was not known to have tested positive for TB or to have had TB treatment before initiating care at your facility, has a TB screen ever been performed? Documention of a completed TB test is found in the patient s history No documented TB test ever occurred Tested but result unknown Previous positive TB test/previous TB treatment: Choose this option if the patient has not been tested within the last two years for TB due to previous history or previous positive screen. If a TB test was ever performed, the following fields, pertaining to the most recent test, are 6/2/2010 Indicator Definitions Guide Page 16 of 23

17 required: 1.1) The most recent TB test date, not necessarily during the review period (continue to 1.2) 1.2) What kind of TB test was performed? (continue to 1.3). - PPD - Other test (QuantiFERON tests are valid TB tests.) 1.3) What was the TB screening test result? (stop). - Negative - Positive Hepatitis C (HCV) Screening & Management The Hepatitis C status of all HIV+ patients should be ascertained. Patients who are HCV negative and are at a high risk for infection should be re-evaluated annually. Follow-up for HCV positive patients includes Hepatitis C RNA assay; if this is positive, further evaluation should be discussed with the patient. The ehivqual application uses the following algorithm to assess these aspects of care: 6/2/2010 Indicator Definitions Guide Page 17 of 23

18 Sexually Transmitted Infection (STI) Management All HIV+ patients are eligible for a syphilis screen. Chlamydia and gonorrhea screens are required indicators for all HIV+ female patients, while entry of this information is optional for HIV+ male patients who do not have MSM or MSM & IDU specified as exposure risk. If possible, the screen will be pre-filled with data from the Gyencology Care indicator. 1) Serum Syphilis. ehivqual prompts, "Enter date of most serum syphilis screening (i.e. VDRL or RPR), even if prior to review period." If a VDRL or RPR screen has ever been documented, enter the most recent date (continue to 1.1); otherwise check the None documented box (continue to 2). 1.1) Positive result? Syphilis screen performed with positive result (continue to 1.1.1). (continue to 2) ) Positive screen treated? YES (continue to 2). NO (continue to 2). 2) Gonorrhea screen. HIVQUAL prompts, "Enter date of most recent gonorrhea culture (even if prior to review period.) If a gonorrhea culture has ever been documented, enter date of most recent screen (continue to 2.1); otherwise check the None documented box (continue to 3). 2.1) Positive result? Gonorrhea screen performed with positive result (continue to 2.1.1). (continue to 3) ) Positive screen treated? YES (continue to 3). NO (continue to 3). 3) Chlamydia screen. HIVQUAL prompts, "Enter date of most recent Chlamydia screen (even if prior to review period.) If a Chlamydia screen has ever been documented, enter date of most recent screen (continue to 3.1); otherwise check the None documented box (stop). 3.1) Positive result? Chlamydia screen performed with positive result (continue to 3.1.1). (stop) ) Positive screen treated? YES (stop). NO (stop). 6/2/2010 Indicator Definitions Guide Page 18 of 23

19 6. CHRONIC DISEASE CARE Diabetes Management Required for All NYS Programs; Optional Outside NYS Screening and managing diabetes is an important part of routine patient care. All HIV+ patients are eligible for this indicator. 1) ehivqual prompts, Was a fasting blood glucose level obtained during the review period? A fasting blood glucose measurement from the review period is in the chart. Continue to 1.1. There is no documentation of a blood glucose measurement in the review period. Continue to ) ehivqual prompts for the date and value of the most recent measurement. Continue to 2. 2) ehivqual prompts, Was a plasma glucose level obtained from an OGTT during the review period? An oral glucose tolerance test (OGTT) during the review period is documented in the chart. Continue to 2.1. There is no documentation of an OGTT during the review period. Continue to ) ehivqual prompts for the date and value of the most recent test. Continue to 3. 3) ehivqual prompts, Was HbA1C test performed during the review period? The HbA1C screen is a laboratory blood test that is expressed as a percentage. A documented HbA1C test occurred in the review period (continue to 3.1). No HbA1C test was documented in the review period (continue to 4). 3.1) ehivqual prompts for the date and value of the most recent HbA1C measurement (continue to 4). 4) ehivqual checks whether the results of any of these screens were indicative of diabetes. If any of the tests met or exceeded these thresholds, continue to 4.1; otherwise stop: (a) Fasting Blood Glucose >= 126 mg/dl (b) Oral Glucose Tolerance Test (OGTT) >= 200 (c) HbA1c >= 6.5% 6/2/2010 Indicator Definitions Guide Page 19 of 23

20 4.1) ehivqual prompts, Was serum creatinine measured during the review period? A serum creatinine measurement from the review period is in the chart (continue to 4.1.1). There is no documentation of a blood glucose measurement in the review period (continue to 4.2) ) ehivqual prompts for the date and value (continue to 4.2). 4.2) ehivqual prompts, Was a retinal exam performed during the review period? The patient is documented to have seen an ophthalmologist who performed a retinal exam during the review period (stop). No retinal exam is documented (stop). Hypertension Required for All NYS Programs; Optional Outside NYS Screening and managing hypertension is an important part of routine patient care. All HIV+ patients are eligible for this indicator. 1) ehivqual prompts for the most recent blood pressure date and measurement, and whether the patient was treated for hypertension in the review period. Based on the entered blood pressure value, ehivqual categorizes the patient as hypertensive stage 2, hypertensive stage 1, or normotensive. Stage 2 Hypertensive: Systolic 160 or Diastolic 100 (continue to 2). Stage 1 Hypertensive: Not stage 2 Hypertensive; Systolic 140 or Diastolic 90 (skip 2 and continue to 3). Normotensive: Systolic < 140 and Diastolic < 90 (stop). 2) If the patient is Stage 2 Hypertensive, ehivqual prompts, Was patient treated with a two drug combination? There is documentation that the patient was prescribed a combination of two or more hypertension medications. There is no documentation that the patient was treated with a two-drug combination. 3) If the patient is Stage 1 Hypertensive, ehivqual prompts, Was patient treated with medication? There is documentation that the patient was prescribed medication to treat hypertension. NO, but plan for lifestyle modification: The patient was not prescribed medication to 6/2/2010 Indicator Definitions Guide Page 20 of 23

21 treat hypertension, but lifestyle modification was discussed with the patient. NO, without plan for lifestyle modification: The patient was neither prescribed medication to treat hypertension nor was lifestyle modification discussed. 7. PATIENT EDUCATION Patient Education Optional All Programs All HIV+ patients should receive patient education annually. Patient education includes, at a minimum, general HIV education and prevention and wellness information. ehivqual prompts, Enter date of most recent general HIV education (even if prior to review period). If general HIV education has ever been documented, enter most recent date; otherwise check the None documented box. Documentation Guide (suggestions) Topics of general HIV education Transmission ARV Therapy Effects on the immune system Prognosis Prevention Education Required for Part C/D Programs; Optional for non-c/d in NYS All HIV+ patients are evaluated for prevention education. ehivqual asks if the patient received prevention education during each six-month period of the review period. Different prevention education methods are allowed as long as they are documented in the medical record. Documentation Guide (suggestions) Topics of prevention education include Safer sexual relations Harm reduction Partner notification 8. HEALTH LITERACY Health Literacy Required for All NYS Programs; Optional outside NYS The health literacy of all HIV-infected patients has been assessed at least once while receiving HIV care at your facility. 1) Was the patient screened at least once for health literacy while receiving HIV care at your facility? Documentation of a health literacy screen exists in the patient s medical record. No documentation of a health literacy screen exists in the patient s medical record. Documentation Guide (suggestions): 6/2/2010 Indicator Definitions Guide Page 21 of 23

22 Please note that this question refers to the entire course of the patient s HIV treatment at your facility, and is not limited to the 12-month review period. A health literacy screen can be performed by any member of the health care team. Different health literacy screening tools may be used as long as documentation of the screening is noted in the medical record. Each HIV program should select a tool that is most appropriate for their clinic s use and which would provide information about the need for an intervention. The following screening tools are used by other HIV programs: - Single Item Literacy Screen (SILS) - Newest Vital Sign (NVS) - Brief Estimate of Health Knowledge and Action- HIV Version (BEHKA-HIV) - Peer Developed Screening Tool by Greater Hudson Valley Family Health Center - Rapid Estimate of Adult Literacy in Medicine (REALM); a revised version (REALM-R) is also available - Test of Functional Health Literacy in Adults (TOFHLA); a short form of TOFHLA (S- TOFHLA) is also available - Wide Range Achievement Test Revised (WRAT-R) 2) Was the need for a health literacy intervention documented during the 12-month review period? The patient s medical record documents a need for a health literacy intervention noted during the 12-month review-period. (continue to 2.1) No documentation of the need of a health literacy intervention exists in the medical record during the12-month review period. (stop) Documentation Guide (suggestions) Examples of documentation include, but are not limited to: existence of low health literacy on a problem list, sticker or flag in the chart or a note in the chart that documents the need for a health literacy intervention. This need can be documented by any member of the health care team. 2.1) Was a health literacy intervention implemented during the 12-month review period? The patient s medical record documents that a health literacy intervention was done in the 12-month review period. (stop) No documentation of a health literacy intervention exists in the medical record during the 12-month review period. (stop) 6/2/2010 Indicator Definitions Guide Page 22 of 23

23 Documentation Guide (suggestions): Examples of patient-specific health literacy interventions include, but are not limited to: - Teach Back Method - Ask Me 3 (encourage patients to understand answers to 3 questions: 1) What is my main problem? 2) What do I need to do? 3) Why is it important for me to do this?) - Patient educational intervention - Referral to an appropriate specialist Documentation Guide (suggestions): Health literacy is increasingly recognized as a significant public health issue. People with low health literacy levels receive less preventive care, have lower levels of understanding of their health information, and are hospitalized or use the emergency room more frequently (1). There continue to be a number of health literacy definitions, including the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions (2). Health literacy involves understanding instructions on prescription drug bottles, appointment slips, medical education brochures, doctor s directions and consent forms, and the ability to negotiate complex health care systems (3). Basic components of health literacy screening include, but not limited to: ability to read, basic numeracy skills, and comprehension of provided health-related information. For more information and guidance on health literacy screenings and interventions, please visit the HIV Guidelines website at References 1. Institute of Medicine. Report Brief: Health Literacy: A Prescription to End Confusion. Washington, D.C.: National Academies Press; U.S. Department of Health and Human Services. Health Communication (Chapter 11). In: Healthy People 2010: Understanding and Improving Health and Objectives for Improving Health. 2 nd ed. Washington, D.C.: U.S. Government Printing Office; Health Literacy. National Network of Libraries of Medicine Harvard School of Public Health, Health Literacy Studies. 6/2/2010 Indicator Definitions Guide Page 23 of 23