The Baltimore Eligible Metropolitan Area (EMA) Part A grantee has a comprehensive medical system in place. However, the city continues to bear high HIV infection rates, and compounding factors such as poverty, racial inequities, mental health issues, illicit substance use, and homelessness.

Since 2001, the Baltimore City Health Department (Health Department) has been charged with conducting Part A Ryan White Clinical Quality Management (CQM). The CQM team has performed chart reviews at all primary medical care agencies providing service to people living with HIV/AIDS (PLWHA).  Each year CQM reviews primary medical care (PMC); other funded service categories are reviewed in rotation. For medical categories such as PMC and oral health, the Health Department engages consultants who are medical providers to review the charts. All reviews compare agency performance with both local standards and mean EMA-wide performance. The Health Department incorporated the HRSA/HAB clinical performance measures as they were released. Reviews also include consumer surveys and organizational assessments of program quality improvement activities. 

Results are shared in individual debriefings at each agency reviewed and also presented at collaborative meetings where programs prioritize performance measures for improvement. For example, in 2010 the Health Department presented performance data and "just-in-time" training, which occurs in stages to support the work of quality improvement teams, to agency staff who selected to 1) increase the rate of cervical cancer screening, 2) increase completion of medical case management psycho-social assessments, and/or 3) proactively reschedule missed medical appointments. Programs reported back on their individual improvement projects around these three initiatives at two subsequent collaborative meetings during the year.

Following the training, the Health Department generated comprehensive reports on each category reviewed and presented the reports to the Planning Council and funded agencies.  They also give each agency a report comparing their performance with the rest of the EMA. Agencies are required to develop improvement plans when their rates fall more than 10% below the EMA-wide mean on any individual performance measure.

The Health Department has identified challenges that include 1) initial reluctance of agencies to participate in CQM visits, 2) agency concern that performance would directly link to funding available, and 3) sporadic agency support for quality improvement activities.

When reviewing charts, the Health Department uses a modified version of the HIVQUAL sampling methodology.

The Health Department does not "oversample" women's charts and provides agencies with instructions that allows them to pull a random set of charts. The HIVQUAL sampling table is carefully followed so that they audit enough records to establish 90% confidence intervals in the performance measure rates.

Patient retention as measured by the HAB medical visits measure has increased from 87% in 2009 to 93% in 2011. Mean CD4 count has also increased from 423 cells in 2007 to 462 in 2011. The proportion of all HIV primary care clients with an undetectable viral load has increased from 42% to 51% from 2007 to 2011. And finally in 2011, 75% of primary care clients on HAART had viral loads of less than 200 copies.

Providers are also required to submit client-level data twice annually to BCHD.  Although the quality of these data vary, the Baltimore EMA can track clients that migrate from one provider to another and are still in care. Part A is also collaborating with Part B grantees on strategies for data sharing to better track retention in care.

Keys to the Baltimore EMA's continuous quality improvement program:

• Gradually building a quality improvement culture and developing trusting relationships between CQM and agencies through collaborative efforts
• Ongoing performance measurement linked with the shared mission of improving the quality of care
• Non-punitive performance measurement and ongoing encouragement to improve from the grantee
• Clear and consistent HIV measures applied to Ryan White funded agencies over time
• Collaborative sharing and peer learning among agencies
• Consistent QM leadership at the system and agency level.

Next steps for the Baltimore EMA:

• Sharing cross-Part data
• Mining client-level data.