Unity Health Care, Inc.

3020 14th Street, NW
Washington, D.C. 20009
Contact: Michelle R. Madison
Phone: (202) 518-6416
Key words: standard of care; quality assurance; chart reviews

OBJECTIVE

The purpose of this study was to evaluate 1 of 13 health care delivery sites to determine the quality of the services being provided.

METHODS
This study was completed in part as a follow-up to a BPHC Primary Care Effectiveness Review that had been completed in April 1996. The site selected for evaluation was the Federal City Shelter, better known as the Community for Creative Non- Violence (CCNV), the largest shelter-based facility within the District of Columbia, with more than 1400 adult male and female residents. Over 88 percent of the residents are Black and 30 percent are female. Unity Health Cares (UHC) health service area at CCNV, which is located on the lower level of the CCNV building, provides services to more than 4000 individuals annually, a little less than half of UHCs homeless clients. Based in part on the uniqueness of CCNVs integration of multiple support and health services, the original objectives of the study were the following: 1) to determine the level of effectiveness of the service provided to clients; 2) to document whether or not the programs objectives were being met; 3) to provide useful service delivery information to staff and others; 4) to ensure that the charting system was consistent and accurate; and 5) to enable staff to increase the effectiveness of service delivery at CCNV. After taking into consideration the numerous types of diagnoses among the clients, it was decided that the study might be more successful if a particular area of concentration was chosen. In so doing, it was hoped that clinical staff and administrators would be better able to hone in on specific service delivery and treatment trends. With the growing number of HIV cases among the homeless, it was determined that this would be the focal point of the study. A random sample of 30 active charts was identified. A grouping of 10 Stage I, Asymptomatic; Stage II, Symptomatic; and Stage III, HIV/AIDS cases were specifically identified. An extensive chart audit was completed. The following items where targeted for review:

Consistency of chart uniformity Baseline physicals Client_s history Eye and dental exams Complete demographics Annual Chest X-rays Vital signs and weight Presence of medication and problem lists, as well as flow sheets Consistency of pap smears among female patients Urine analysis Annual Purified Protein Derivative (PPD) Sexually Transmitted Diseases (STD) and Hepatitis Screenings Immunizations (i.e., flu and pneumovax) The appropriate dispensing of Antiretrovirals and combination therapies Cluster Designation 4 (CD4) and Complete Blood Count (CBC) was given within 6 months or at the last visit

In addition, a patient focus group consisting of seven HIV positive clients (4 females and 3 males) who were active users of UHC at CCNV in 1996 was formed. In a group setting, an independent moderator questioned the clients on topics such as the following: 1) staffing patterns; 2) the facility (e.g., cleanliness/appearance, location/accessibility); 3) the quality of care provided; 4) the treatment of clients and level of professionalism exhibited by staff; and 5) sensitivity to clients cultural issues.

RESULTS

A number of charting system inconsistencies were revealed. The statistical information derived from the process included the following:

General Charting Procedures	Percentage of Completion
Overall consistency of chart uniformity	84%
Baseline physicals	72%
The completion of the clients history as well as demographic information form	80%
General Charting Procedures Percentage of Completion Eye exam referrals	113%*
Dental exam referrals	110%*
Confidentiality statement was signed	78%
Vital signs and weight	100%
Presence of medication lists	91%
Problem lists	78%
Flow sheets	65%
Bi-annual pap smears conducted for women	65%
Urine analysis	69%
Annual PPD	78%
STD and Hepatitis Screenings	81%
Immunizations (i.e., flu and pneumovax)	85%
The appropriate dispensing of Antiretrovirals and combination therapies based on the Stage of the HIV virus	82%
CD4/CBC was taken bi-annually or at the last scheduled visits	93%

(*=Due to the nature of the item listed, these numbers are higher than 100 percent. The figures primarily reflect the fact that multiple referrals may have been given for a single procedure that was needed.) The results of the focus group were very positive. Each of the seven participants expressed that they were quite happy with UHCs delivery system. They appreciated the convenience of the facility and seemed very pleased with both the cultural sensitivity and the overall friendliness of the clinical staff.

DISCUSSION

The charting inconsistencies observed were most likely due to the uniqueness of the target population being served. That is, homeless people are often unable or unwilling to provide essential personal and health-related information that is often taken for granted in health care settings for the general population. For example, it was discovered that only 80 percent of the actual clients seen at the UHC-CCNV health center completed their history information form. In a more standard health care setting, a client would not be allowed to receive services without first completing this pertinent information. However, research has shown that mental illness often plays a significant role in a persons descent into homelessness and health care practitioners must always be sensitive to this fact. Therefore, in the interest of the patient, an absence of relevant information is disregarded in an effort to ensure the client is not alienated from seeking necessary services. In addition, it was determined that a number of clients refused essential medical procedures during their actual exam. Consequently, only 65 percent of UHCs female client population received biannual pap smears; the rest declined the procedure. There were also a high number of no shows for return visits associated with clients follow-up treatments. As a result, individuals who were diagnosed as having CD4 counts of 300 and below, who would normally be placed on combination therapies, often did not return for follow-up appointments. Consequently, the clinical staff were left with no means of contacting these individuals, particularly because of the clients migrational tendencies. Instead staff was forced to wait until those clients returned for medical and/or social service assistance in the future to revisit prior treatment issues.

CONCLUSION

This study has shown the vital importance of the ongoing analysis of any service delivery system. As a response to this study_s findings, a search for a full-time Continuous Quality Improvement (CQI) Associate Medical Director has been initiated. It is anticipated that this individual will help to address issues raised by this UHC-CCNV study as well as helping to promote ongoing CQI within all of Unity Health Care. A Medical Records Supervisor is also being recruited to help structure a uniformed charting system that will be implemented throughout all of UHCs thirteen clinical locations.