Medical Case Management Performance Measures | Ryan White HIV/AIDS Program

Summary of changes

Updated August 2022

The HIV/AIDS Bureau reviewed previous versions of the Performance Measures and revised the text and references. Key updates include the following:

Updated links to the U.S. Department of Health and Human Services (US DHHS) Clinical Practice Guidelines
Updated US DHHS Clinical Practice Guidelines language for the following measures:
- Gap in HIV Medical Visits (Medical Case Management)
- HIV Medical Visit Frequency (Medical Case Management)
Updated comparison measure details for the following measure: Medical Case Management: Care Plan (numerator)
Included reference to the National HIV/AIDS Strategic Plan
Updated the HRSA contact email address in the Accessibility section

Performance Measure: Care Plan (Medical Case Management)

National Quality Forum #: None

Description: Percentage of medical case management patients, regardless of age, with a diagnosis of HIV who had a medical case management care plan¹ developed and/or updated two or more times in the measurement year

Numerator: Number of medical case management patients in the denominator who had a medical case management care plan developed and/or updated two or more times, which are at least three months apart in the measurement year

Denominator: Number of medical case management patients, regardless of age, with a diagnosis of HIV who had at least one medical case management encounter in the measurement year

Patient Exclusions:

Medical case management patients who initiated medical case management services in the last six months of the measurement year
Medical case management patients who were discharged from medical case management services prior to six months of service in the measurement year

Data Elements: Does the patient have a diagnosis of HIV? (Y/N)

If yes, did the patient have a medical case management encounter in the measurement year? (Y/N)
1. If yes, is there a medical case management care plan developed and/or updated two or more times at least three months apart during the measurement year? (Y/N)
  1. If yes, list the dates of these medical case management care plans and/or care plan updates.

National Goals, Target, or Benchmarks for Comparison: The HIV Quality Measures (HIVQM) Module is a tool within the Ryan White HIV/AIDS Services Report portal. It allows recipients to enter aggregate data specific to HRSA HAB Performance Measures. The HIVQM Module allows recipients to conduct point-in-time benchmarking across Ryan White HIV/AIDS Programs that use the module.

U.S. Department of Health and Human Services Clinical Practice Guidelines: None

Use in Other Federal Programs: None

References/Notes:
¹ Medical visits may be documented in either the patient’s medical case management record or the patient’s medical record (in the event that medical case management documentation is located in the patient’s medical record).

Performance Measure: Gap in HIV Medical Visits (Medical Case Management)

National Quality Forum #: None

Description: Percentage of medical case management patients, regardless of age, with a diagnosis of HIV who did not have a medical visit¹ in the last 6 months of the measurement year (that is documented in the medical case management record¹)

Numerator: Number of medical case management patients in the denominator who did not have a medical visit in the last 6 months of the measurement year (that is documented in the medical case management record¹)

Denominator: Number of medical case management patients, regardless of age, with a diagnosis of HIV who had at least one medical visit in the first 6 months of the measurement year

Data Elements: Does the patient, regardless of age, have a diagnosis of HIV? (Y/N)

If yes, did the patient have at least one medical case management visit in the first 6 months of the measurement year? (Y/N)
1. If yes, did the patient have at least one medical visit in the first 6 months of the measurement year? (Y/N)
  1. If yes, did the patient have one or more medical visits in the last 6 months of the measurement year?

Patient Exclusions: Medical case management patients who died at any time during the measurement year

Data Elements: Does the patient, regardless of age, have a diagnosis of HIV? (Y/N)

If yes, did the patient have at least one medical case management visit in the first 6 months of the measurement year? (Y/N)
1. If yes, did the patient have at least one medical visit in the first 6 months of the measurement year? (Y/N)
  1. If yes, did the patient have one or more medical visits in the last 6 months of the measurement year?

U.S. Department of Health & Human Services Clinical Practice Guidelines:

Adult guidelines: “Several laboratory tests are important for initial evaluation of people with HIV upon entry to care, and some tests should be performed before and after initiation or modification of antiretroviral therapy (ART) to assess the virologic and immunologic efficacy of ART and to monitor for laboratory abnormalities that may be associated with antiretroviral (ARV) drugs. Table 3 outlines recommendations on the frequency of testing from the Panel on Antiretroviral Guidelines for Adults and Adolescents. As noted in the table, some tests may be repeated more frequently if clinically indicated.” ²

Pediatric guidelines: “Frequent patient visits and intensive follow-up during the initial months after a new ART regimen is started are necessary to support and educate the family… Within 1 to 2 weeks of initiating therapy, children should be evaluated either in person or by phone call. During this evaluation, clinicians should identify clinical AEs and provide support for adherence. Many clinicians plan additional contacts (in person, through telemedicine, by telephone, or via email/texts/apps) with children and caregivers to support adherence during the first few weeks of therapy…

“After the initial phase of ART initiation (1 – 3 months), clinicians should assess a patient’s adherence to the regimen and the regimen’s effectiveness (as measured by CD4 count and plasma viral load) every 3 to 4 months in children receiving ART. Additionally, clinicians should review a patient’s history of toxicities and evaluate a patient for any new AEs using physical examinations and the relevant laboratory tests. If laboratory evidence of toxicity is identified, testing should be performed more frequently until the toxicity resolves… Some experts monitor CD4 cell counts less frequently (e.g., every 6 – 12 months) in children and adolescents who are adherent to therapy, who have CD4 count values well above the threshold for OI risk, and who have sustained virologic suppression and stable clinical status > 2 to 3 years.” ³

Use in Other Federal Programs: None

References/Notes:

¹ The medical visits may be documented in either the patient’s medical case management record or the patient’s medical record (in the event that medical case management documentation is located in the patient’s medical record).

² Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV. Department of Health and Human Services. Available online. Accessed August 2022. C-1 to C-5.

³ Panel on Antiretroviral Therapy and Medical Management of Children Living with HIV. Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection (PDF - 6 MB). Department of Health and Human Services. Available Online. Accessed February 2023. D-5.

Performance Measure: HIV Medical Visit Frequency (Medical Case Management)

National Quality Forum #: None

Description: Percentage of medical case management patients, regardless of age, with a diagnosis of HIV who had at least one medical visit¹ in each 6-month period of the 24-month measurement period with a minimum of 60 days between medical visits

Numerator: Number of medical case management patients in the denominator who had at least one medical visit in each 6-month period of the 24-month measurement period with a minimum of 60 days between the last medical visit in a 6-month period and the first medical visit in the subsequent 6-month period

Denominator: Number of medical case management patients, regardless of age, with a diagnosis of HIV with at least one medical visit¹ in the first 6 months of the 24-month measurement period

Patient Exclusions: Medical case management patients who died at any time during the 24-month measurement period

Data Elements: Does the patient, regardless of age, have a diagnosis of HIV? (Y/N)

If yes, did the patient have at least one medical case management visit in the first 6 months of the 24-month measurement period? (Y/N)
1. If yes, did the patient have at least one medical visit in the first 6 months of the 24- month measurement period? (Y/N)
  1. If yes, did the patient have at least one medical visit in the second 6-month period of the 24-month measurement period? AND was the patient's last visit in the second 6-month period 60 days or more from the first visit in the first 6-month period? (Y/N)
    1. Did the patient have at least one medical visit in the third 6-month period of the 24-month measurement period? AND was the patient's last visit in the third 6-month period 60 days or more from the first visit in the second 6-month period? (Y/N)
      1. If yes, did the patient have at least one medical visit in the fourth 6-month period of the 24-month measurement period? AND was the patient's last visit in the fourth 6-month period 60 days or more from the 1st visit in the third 6-month period? (Y/N)

U.S. Department of Health & Human Services Clinical Practice Guidelines:

Adult guidelines: “Several laboratory tests are important for initial evaluation of people with HIV upon entry into care, and some tests should be performed before and after initiation or modification of antiretroviral therapy (ART) to assess the virologic and immunologic efficacy of ART and to monitor for laboratory abnormalities that may be associated with antiretroviral (ARV) drugs. Table 3 outlines recommendations on the frequency of testing from the Panel on Antiretroviral Guidelines for Adults and Adolescents. As noted in the table, some tests may be repeated more frequently if clinically indicated.”²

Pediatric guidelines: “Within 1 to 2 weeks of initiating therapy, children should be evaluated either in person, through telemedicine, or by phone. During this evaluation, clinicians should identify clinical AEs and provide support for adherence. Many clinicians plan additional contacts (in person, through telemedicine, by telephone, or via email/texts/apps) with children and caregivers to support adherence during the first few weeks of therapy…

“After the initial phase of ART initiation (1 – 3 months), clinicians should assess a patient’s adherence to the regimen and the regimen’s effectiveness (as measured by CD4 count and plasma viral load) every 3 to 4 months. Additionally, clinicians should review a patient’s history of toxicities and evaluate a patient for any new AEs using physical examinations and the relevant laboratory tests. If laboratory evidence of toxicity is identified, testing should be performed more frequently until the toxicity resolves… Some experts monitor CD4 count less frequently (e.g., every 6 – 12 months) in children and adolescents who are adherent to therapy, who have CD4 count values well above the threshold for OI risk, and who have sustained virologic suppression and stable clinical status > 2 to 3 years.”³

Use in Other Federal Programs: This measure is linked to an exact or similar indicator(s) within the National HIV/AIDS Strategy (2022-2025).

References/Notes:

¹ Medical visits may be documented in the patient’s medical case management record or the patient’s medical record (in the event that medical case management documentation is located in the patient’s medical record).

³ Panel on Antiretroviral Therapy and Medical Management of Children Living with HIV. Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection (PDF - 6 MB). Available online. Department of Health and Human Services. Accessed February 2023. D-5.

Accessibility: If you need an alternative means of access to any information above, please contact us at RWHAPQuality@hrsa.gov. Please let us know the nature of your accessibility problem and the Web address of the requested information.

Date Last Reviewed:

March 2024