VCU Peer Review FY2020 Final ReportVirginia Commonwealth UniversityVirginia Ryan White Part BPeer Review ProgramFiscal Year 2020 Final ReportSuzanne Lavoie, M.D.Medical director/principal investigator of Ryan White grantsC. Michelle Shearer, MSWQuality SpecialistKatrina Comolli, MPA, MURPRyan White Quality Coordinator1

VCU Peer Review FY2020 Final ReportContents . 2Executive Summary . 4VCU Peer Review Program Virginia Ryan White Part B Program 2020 Final Report . 5Background . 5Selected Agencies and Funded Service Categories . 5Process and Methodology . 5Virtual Peer Review Process . 5Schedule Site Visits, Obtain Site Information and Pre-visit Conference Calls . 6Data Collection Tools. 7Post-Visit Activities . 7Qualified Peer Reviewers . 8Peer Reviewer Training . 8Added & Removed Service Categories in 2020 . 9Mental Health . 9Key Findings . 9Substance Abuse Outpatient. 10Non-Medical Case Management . 10Standards of Care Assessment: Chart Review, Documentation Assessment & Recommendations11Outpatient/Ambulatory Health Services . 11Medical Case Management - Peer Reviewed Sites . 13MCM – TA Sites . 14Oral Health . 14Client Interviews . 15Recommendations . 17Corrective Action Plans . 17Peer Review Evaluation . 18Summary and Key Findings. 20Attachment A: Peer Reviewed Site Outpatient/Ambulatory Medical Care Raw Data . 21Attachment B: All Levels of Case Management Raw Data . 33Case Management TA Sites . 402

VCU Peer Review FY2020 Final ReportAttachment C: Oral Health Raw Data . 42Attachment D: Client Interview Raw Data . 47Report Acronyms . 51Peer Reviewers. 523

VCU Peer Review FY2020 Final ReportExecutive SummaryThis report outlines the Virginia Commonwealth University (VCU) Ryan White Peer Reviewprogram outcomes for 2020/2021 Virginia Department of Health Contract Year. The followingsites were selected by the Virginia Department of Health (VDH) to be reviewed forOutpatient/Ambulatory Health Services (OAHS), Medical Case Management (MCM), OralHealth Services (OH), and Client Interviews.1. Inova Juniper (Inova)2. AIDS Response Effort (ARE)3. Capital Area Health Network / Vernon J.Harris (CAHN)4. CrossOver Healthcare Ministries (COHM)5. Carilion Clinic Infectious Disease (Carilion)6. Fredericksburg Area HIV/AIDS SupportServices (FAHASS)7. Mary Washington Health Center (MWHC)8. Neighborhood Health (NH)9. Three Rivers Health District (TRHD)10.Daily Planet11.Virginia Health OptionsMedical Transportation Services and the Administrative reviews were removed in 2020/2021 byVDH and replaced with Substance Abuse, Mental Health Services, and Non-Medical CaseManagement which was piloted at selected sites in 2021.Due to the travel restrictions associated with COVID-19 the Peer Review program was instructedby VDH to conduct all Peer Reviews virtually until the end of the contract year in March 2021.Through collaborative efforts with the Peer Review Team and the eleven Peer-Reviewed sites,the Peer Reviewers successfully completed the reviews through HIPAA compliant virtualplatforms such as Zoom, Microsoft Teams, VCU FileLocker, and RedCap. Due to the limitationsof file sharing at Peer-Reviewed sites, VDH stated that Performance Measure collection was notnecessary for the 2020/2021contract year.The key findings for OAHS overall were positive for most sites reviewed. However, it wasobserved at sites with multiple healthcare providers the notes and patient information were notconsistent and the Peer Reviewers recommended a template based on the RWHAP B standardsof care. The Peer Reviewers for MCM reported that when the documentation was available forreview, most forms were completed and included the Individualized Service Plan (ISP),Assessments, and Acuities as needed. However, areas of improvement for some sites includedtimelines for goals, updated Service Plans based on Acuity Level, and documentation the clientwas offered a copy of their Service Plan. Oral Health services reviewed were commended forproviding excellent Oral Health Care to clients as documented in their charts. Virtual PeerReviews included 59 client interviews conducted by phone. These interviews were encouragingto the RWHAP B providers as most of the clients interviewed stated they appreciate the MCMand OAHS services they receive and ‘Agreed’ or ‘Agreed Strongly’ they are satisfied with thecare they receive for OH.4

VCU Peer Review FY2020 Final ReportVCU Peer Review Program Virginia Ryan White Part B Program 2020 FinalReportBackgroundIn 2002, the Virginia Department of Health (VDH), Division of Disease Prevention established astatewide independent Peer Review (PR) team. Their mission is to monitor sub-recipientsreceiving Ryan White HIV/AIDS Program Part B (RWHAP B) funding and to measure thequality of care provided to consumers with Human Immunodeficiency Virus (HIV) eligible forRWHAP B services. In 2012, Virginia Commonwealth University (VCU) was awarded thecontract by VDH to complete PR activities and collect HIV Performance Measure data for thestate of Virginia (VA). The following report summarizes the VCU PR process for Grant Year2020.Selected Agencies and Funded Service CategoriesSub-recipients receiving RWHAP B funding are reviewed on a biennial schedule. In 2020, siteswere selected by VDH for review. These sites included:12. Inova Juniper (Inova)13. AIDS Response Effort (ARE)14. Capital Area Health Network / VernonJ. Harris (CAHN)15. CrossOver Healthcare Ministries(COHM)16. Carilion Clinic Infectious Disease(Carilion)17. Fredericksburg Area HIV/AIDS SupportServices (FAHASS)18. Mary Washington Health Center (MWHC)19. Neighborhood Health (NH)20. Three Rivers Health District (TRHD)21. Daily PlanetTechnical Assistance (TA) was conducted at Virginia Health Options (VHO) because theirfirst year of RWHAP B funding was in 2019 and their services for RWHAP B expanded.The PR site visit is the same process as the TA site visit. No corrective actions arerequired for a TA site visit as this is a preliminary visit to help those sites prepare for a PRvisit. The total number of reviews in 2020 was ten.Process and MethodologyIn the previous contracts awarded by VDH, the PR site visit was a two-day onsite reviewat the selected RWHAP B agency. The processes for Peer Reviews in 2020/2021 reflectguidance from the Virginia Department of Health regarding no on-site Peer Reviews untilMarch 2021 due to COVID-19.Virtual Peer Review Process5

VCU Peer Review FY2020 Final ReportSchedule Site Visits, Obtain Site Information and Pre-visit Conference CallsThe PR staff notified agencies selected for PR in 2020 by email to establish a traceablereference for communication and by phone for follow-up correspondence; their VDH HIVServices Coordinators and lead agency (if any) were also notified. Following the initialemail, site review dates were scheduled and confirmed by email. After confirming themethod of virtual data collection and the PR virtual review dates with the agency, at leasttwo web conferences between the PR Program staff and the agency were scheduled. ThePR staff and agency staff web-conferenced via Microsoft Teams and Zoom at least threemonths before and one week before the virtual PR. Confirmation emails were sent to theagency and their lead agency before the web conferences. During the web conferences, PRstaff reviewed the necessary data for collection with the PR sites. The PR process andprocedures were outlined in the preliminary meetings as well as in checklists submitted byemail. PR staff also explained to RWHAP B staff how to prepare for the site visit,reviewed their previous PR reports and TA resources available, and answered anyquestions that came up during the meeting.Each site was contacted to determine if they use an electronic health record or papercharts. The sites stated their document sharing capabilities for the Peer Review such asdata and Ryan White client charts for review. Through collaborative meetings with eachsite, it was determined since each site has a different method of collecting and storingclient charts the PR process to collect information would be amended for each site toaccommodate their file-sharing capabilities. Therefore, the staff at each site determinedthe most practical method to conduct a Peer Review with the Peer Review Team.Additionally, all Peer Reviewers were contacted to verify their virtual review and filesharing capabilities to conduct off-site Peer Reviews.Multiple virtual meetings were conducted with each site before the virtual PR to determinethe following: Primary contacts: Medical Case Managers, Quality Team, Non-Medical CaseManagers, Medical Providers, Oral Health Providers, etc. Verification of their RW services and number of RW clients Determine the type of charts for Ryan White clients; paper chart or electronichealth record The timeline for meetings to prepare for their Peer Review The date or month, they can be prepared and conduct a Peer ReviewAll TA was conducted virtually. All RWHAP B Peer Review client interviews wereconducted by phone in a private and secure location. Once the chart reviews for the6

VCU Peer Review FY2020 Final ReportRWHAP B reviewed services were complete, the Peer Reviewers met by Zoom tocollaborate and developed their summary reports. The Peer Reviewers then met with thesite by Zoom to report their findings and schedule follow-up TA, if necessary.Data Collection ToolsThe PR Program employs REDCap as its primary data collection tool. REDCap is a webbased application created in 2004 at Vanderbilt University to securely manage data onlineand build surveys and databases.VDH Part B Standards of Care modules and the data collection tool for RWHAP B caremarkers were built into the online PR database in REDCap. The PR team collects the datafrom the site using a secure remote internet access card to ensure confidentiality & HealthInsurance Portability and Accountability Act (HIPAA) compliance.Peer-Reviewed sites with paper charts were scanned and uploaded into the VCU securedfile-sharing portal, FileLocker, before the PR and securely shared with the Peer Reviewersthrough an encrypted link to FileLocker and reviewed on a secured Peer Review laptopassigned to the Peer Reviewer to use offsite.Electronic Health Records were screen shared by Zoom, which is secured through VCUHealth IT. The Peer Reviewers reviewed the charts with the site in real-time. The PeerReviewed sites navigated the charts and screen shared with the Peer Reviewers to locatethe necessary information. Medical providers were given secured read-only access to theelectronic health records for sites with Outpatient Ambulatory Health Services.Using VDH PR Standards and Modules, the Peer-Reviewed RWHAP B categories OAHS,MCM, Oral Health Services, and Client Interviews were conducted in close collaborationwith RWHAP B agency personnel. The PR Program selected 10% of the eligible charts,with a minimum of 10 charts for each funded service category. Peer Reviewers for thefunded RWHAP B categories randomly selected clinical charts from a preselectedqualifying list of RWHAP B eligible clients. The Peer Reviewers entered the resultsdirectly into REDCap for data collection. After the collection of all data, the PeerReviewers and the PR team reviewed all data and composed a summary of theinformation.It was determined by VDH through TA with the PR Team that due to the limitations offile sharing and the administrative problems of working offsite for many agencies the datacollection for RWHAP B Performance Measures would be suspended in 2020.Post-Visit ActivitiesFinal site visit reports were prepared by the PR staff and submitted to VDH Quality stafffor review and final approval; reports were due to the agency within 45 days of the visit.After VDH’s final approval, the reports were sent to each agency by email. The final sitevisit reports identified strengths and challenges. A Corrective Action Plan was required for7

VCU Peer Review FY2020 Final Reportidentified challenges requiring corrective action steps. The Corrective Action Plan wassubmitted by the Peer-Reviewed site within 90 days of receiving the report to the VDHQuality and Peer Review staff.Qualified Peer ReviewersThe PR Program is comprised of a group of experts in the HIV field recruited throughoutthe state of VA. These individuals are professionals in Ryan White (RW) services andinclude medical providers, dental providers, and medical and non-medical case managers.A thoroughly vetted team of RWHAP B consumers has been selected to conduct the clientinterviews. To have a range of Peer Reviewers and not have a conflict for regionalreviewers, PR staff sought to select reviewers from each of the five VA health regions andplace them in areas where they have not practiced or received HIV care.Peer Reviewer TrainingA virtual training was conducted in August 2020 and required for all current and new PeerReviewers. The multi-day training included a one-day review for all Reviewers about PRconduct, mission, goals, confidentiality agreement, conflicts of interest, honorariumguidelines, and travel restrictions. A second virtual training was conducted for all PeerReviewed RWHAP B categories; OAHS, MCM, OH, Client Interviews. The training forPeer-Reviewed RWHAP B categories included current implemented standards andmodules for PR and updates to the modules. The training also included data collection andreporting standards. It was concluded by the Review team the training would be an annualmeeting moving forward in 2021.8

VCU Peer Review FY2020 Final ReportAdded & Removed Service Categories in 2020In 2019, the Quality team at VDH proposed adding three new RWHAP B servicecategories for review, Mental Health (MH), Substance Abuse (SA), and Non-MedicalCase Management (NMCM). The reviews for Medical Transportation and theAdministrative Review were removed as determined by VDH. Using the skills, expertise,and resources of recruited Peer Reviewers a pilot test, or field test, was developed andimplemented for MH, SA, and NMCM. Through a series of collaborative meetings, amodule in REDCap was developed using the RWHAP B standards. The pilot testing wasdesigned to test the quality of the data from the questions, as well as to test the viability ofthe module as a whole, and the coordination of the PR team’s procedures and systems.Mental HealthThree Peer Reviewers were recruited to collaborate with the VCU Peer Review to developa MH module based on the RWHAP B service standards. The reviewers are licensedpracticing MH professionals in the Ryan White field. These reviewers were engaged in thedevelopment of the module by participating in four virtual meetings. These meetings alsocreated a plan to pilot the MH module at two test sites. The chosen test sites were AREand Inova which provide on-site individualized MH services to RWHAP B clients.Twelve charts were virtually reviewed from ARE and ten charts were reviewed fromInova.Key FindingsStrengthsThe MH module was developed directly from the RWPB service standards. The reviewerswere able to find initial assessments, treatment plans, documentation of contacts, andreassessments when available in the client records.ChallengesOne of the two sites reviewed provided support groups under the MH service category.RWPB service standards and the proposed module created by Peer Reviewers reflectindividual (one-on-one) mental health services and are not designed for group therapy.The MH peer reviewers felt that testing/diagnosis (initial assessments and mental healthscreenings) was not appropriate for group work and create additional barriers to gettingsupport group participants.RecommendationsThe MH reviewers recommended the RWPB standards and module be modified toaccurately capture group therapies which consist of referrals from the MCM or MHprovider with identified needs and goals for the clients. These clients could be reviewed9

VCU Peer Review FY2020 Final Reportevery 90 days and summary notes provided for every session. It was suggested the MHmodule be separated into two sections, one for individual clients, and one for groupclients. It was also suggested that support group services be provided under PsychosocialSupport as described in PCN 16-02 which lists the support group services as anappropriate service activity.Substance Abuse OutpatientOne Peer Review was recruited to collaborate with the VCU Peer Review to develop a SAmodule based on the RWHAP B service standards. The reviewer holds a Ph.D. inPsychology with a specific focus on substance abuse and HIV. The reviewer engaged inthe development of the module by participating in two virtual meetings. INOVA waschosen as the test site. Nine charts were reviewed as part of the test pilot.StrengthsThe SA module was developed directly from the RWPB service standards. The SAreviewers reported the REDCap module was generally straightforward to complete duringthe evaluation of each chart. The reviewer was able to find initial assessments, treatmentplans, documentation of contacts, and reassessments when available in the client records.ChallengesThe reviewer identified three areas of the module that need further guidance from VDHregarding standards of care. The questions needing further guidance from VDH areconcerning determining the areas that qualify as necessary for Substance Abuse reviewssuch as nicotine addiction, a history of long-term recovery, and the criteria for substanceuse disorder (abuse or dependence) for drug and alcohol use.RecommendationsNo recommendations at this time.Non-Medical Case ManagementTwo Peer Reviewers were recruited to collaborate with the VCU Peer Review to developa NMCM module based on the RWHAP B service standards. The reviewers are activeRyan White NMCMs professionals. These reviewers were engaged in the development ofthe module by participating in two virtual meetings. INOVA was chosen as the test site.Fourteen charts were reviewed as part of the test pilot.Strengths10

VCU Peer Review FY2020 Final ReportThe NMCM module was developed directly from the RWPB service standards. Thereviewer was able to find eligibility intake, supporting documentation, six-monthcertification, and referrals when available in the client records.ChallengesNo challenges were identified.RecommendationsNo recommendations at this time.Standards of Care Assessment: Chart Review, DocumentationAssessment & RecommendationsOutpatient/Ambulatory Health ServicesKey FindingsOf the sites reviewed in Peer Review 2020/2021, four reported providing OAHS. The databelow is based on the aggregate data collected. See Attachment A for raw data. The PeerReviewed sites presented client-level data through progress notes and documentationshared through their Electronic Health Record systems. When present in the reviewedcharts, the documentation was clear and available. However, it was observed at sites withmultiple healthcare providers the notes and patient information were not consistent and thePeer Reviewers recommended a template based on the RWHAP B standards of care. Thechallenges were to ensure that documentation, regarding the assessment of all relativesymptoms and risks, are present in the medical record as well as referrals and vaccineinformation.StrengthsA total of 62 charts were Peer Reviewed for OAHS, 7 of the 62 charts reviewed hadinformation regarding patients diagnosed in the previous 12 months. The charts revieweddetermined that clients diagnosed in the previous 12 months were given an initial MedicalHistory within 30 days of client contact with the provider (n 7/7), the (Initial) PhysicalExamination was documented within 30 days of client contact with the provider (n 7/7),the medication history which includes: drug allergies; current medications; drug/substanceabuse was present in the charts (n 7/7), the initial laboratory results or orders weredocumented as a component of the initial assessment (n 7/7), Oral Healthassessment/referral was documented (n 7/7), Psychosocial/Mental Health assessmentand/or referral (n 7/7), and Substance Abuse assessment and/or referral was documentedas a component of the initial assessment (n 7/7).The sites reviewed were commended for reaching over 90% for the following measures inOAHS when ten or more charts were reviewed: RWHAP B clients were seen at least twicein the last 12 months or as needed (90% n 56/62); CD4 and CBC documentation within12 months or as necessary (98% n 61/62); Chemistry Panel, every six months or as11

VCU Peer Review FY2020 Final Reportneeded (90% n 54/60). There was documentation the charts reviewed the initial, 6months, or annual Liver/Hepatic Panel was collected (98% n 61/62) and the panels forGlucose (if not in Chemistry Panel); Hemoglobin A1C were collected at baseline, 6months or as needed (98% n 61/62). The reviewed charts indicted that Hepatitis B (93%n 57/61) and C (90% n 56/62) serology at baseline and as need along with ongoing riskfactor behavior was present in the charts. The Rapid Plasma Reagin (RPR) and Venerealdisease research laboratory (VDRL) tests were present in the reviewed charts initially andevery 12 months as applicable (92% n 57/62).Tuberculosis (TB) testing (purified protein derivative (PPD) skin test or interferon-basedtesting) was present in the chart at initial presentation, repeated if baseline if the CD4 was 200 but has risen to 200, and as needed based on risk factors (98%n 56/57).Documentation of all current medications; medication history which includesdrug allergies and side effects was present in 100% of the reviewed charts (n 62/62).Medication adherence was present in 97% of the charts (n 60/62), and medication sideeffects were addressed in 90% of the reviewed charts (n 56/62).It was noted in the charts that 100% (n 62/62) clients were offered Highly ActiveAntiretroviral Therapy (HAART), and 98% (n 61/62) are currently on HAART andHAART is consistent with the current U.S. Public Health Service (PHS) Guidelines (98%n 61/62). All progress notes were present, current, legible, signed, and dated in theclient’s record (100% n 62/62). The charts determined an appropriate out-come basedmedical plan of treatment developed with the client and present in the client’s record forall reviewed records (100% 62/62).ChallengesThe agencies reviewed with any total standard not met at 70% with a minimum of 10charts were deemed as challenges. Documentation of an annual Lipid panel was present in68% (n 42/62) of the charts reviewed. When a Hepatitis A serology was negative, 67%(n 14/21) of patients were referred for immunization. Documentation was present in 66%of the reviewed charts (n 41/62) about whether the patient was asked about SexuallyTransmitted Disease (STD) symptoms at each visit. Of the reviewed charts, five out of 11(45%) indicted a record of a Pap Smear, twice in the first year and then annuallythereafter.RecommendationsIt was recommended by the PR team that each site create a process for all providers tochart consistently or develop a template for medical notes that includes a checklist ofneeded labs, vaccines, assessments, and outpatient standards of care; this template shouldreflect the PR module for OAHS. A Peer Reviewer noted that medical templates makedocumentation easier to review and manage, and also serve as a reminder for upcomingcare markers and patient follow-up at future visits.Documentation needs to be present within each progress note stating the medical provideracquired labs for an annual Lipid panel, referrals for immunization such as Hepatitis A12

VCU Peer Review FY2020 Final Reportserology, and Pap Smears (as necessary for selected patients). Medical providers mustdocument they have asked about STD symptoms at each visit.Medical Case Management - Peer-Reviewed SitesKey FindingsPeer Reviewers analyzed 145 MCM files from all three MCM levels at eight RWHAP Bsites in Virginia. See Attachment B for raw data. It was reported by Peer Reviewers, whenproperly documented and recorded in the client’s files, the agencies had detailed casenotes, indicated a high level of client contact which resulted in the setting of and progresstoward goals for the clients. The Peer Reviewers for MCM reported that when thedocumentation was available for review, most forms were completed and included theIndividualized Service Plan (ISP), Assessments, and Acuities as needed.StrengthsThe following strengths were evaluated by the MCM Peer Reviewers at over 90% for 10or more charts reviewed.MCM records showed that at the time of the PR, 49 newly diagnosed client chartsrevealed the initial assessment was completed in the first 30 days of intake for 98%(n 48/49); the initial assessment was signed and dated by MCM at 92% (n 45/49), and atleast one face to face interview was conducted (100% n 49/49).A summary of the MCM's findings was noted on the last page of the MCM Assessment in96% (n 118/123) of the reviewed charts, and Treatment Adherence was addressed on theMCM Assessment Form in 99% (n 143/145) of the charts. An Acuity Scale was presentin the Peer-Reviewed charts reflecting the client's current Acuity Level at 90%(n 130/145). Progress notes were completed within 48 hours of the client encounteroverall at 99% (n 144/145). There was documentation the client participated in thedevelopment of the Service Plan as indicated by client signatures in 90% (n 92/102) ofthe reviewed charts.ChallengesThe MCM data for all agencies reviewed at every level showed the following standardsnot met at 70% with a minimum of 10 charts.The charts reviewed indicated that 15 of the 104 eligible charts did not have a ServicePlan developed in 45 days; of those 15 charts, there was not documentation as to why theAssessment was not completed (27% n 4/15).The client Service Plan was updated within the appropriate time frame for the client’sAcuity Level in 62% of the charts reviewed (n 56/91). The records reviewed by the PRteam indicated that overall 63% of the charts had documentation the clients were offered acopy of their Service Plan (n 64/101).Medical Case Management Recommendations13

VCU Peer Review FY2020 Final ReportFive sites reviewed had recommendations to develop a system to ensure the Service Plansand Assessments were updated and scored according to the RWHAP B Case ManagementStandards and within the appropriate time frame for the Acuity Level. Four PeerReviewed sites had recommendations to document the clients had been offered a copy oftheir Service Plan.MCM – TA SitesKey FindingsOne site received PR TA in 2020/2021, Virginia Health Options (VHO). Twelve MCMcharts were reviewed at VHO to evaluate their new MCM services offered in 2020. ThePeer Reviewer commended VHO for their compliance with the RWHAP B CaseManagement Standards and overall client care.

VCU Peer Review FY2020 Final Report 1 Virginia Commonwealth University Virginia Ryan White Part B Peer Review Program Fiscal Year 2020 Final Report Suzanne Lavoie, M.D. Medical director/principal investigator of Ryan White grants C. Michelle Shearer, MSW Quality Specialist