231.003 TCT Data Improvement Plan
| Policy Number | 231.003 |
|---|---|
| Effective Date | August 18, 2010 |
| Revision Date | August 17, 2023 |
| Subject Matter Expert | Medication Data and Analysis Group Manager |
| Approval Authority | HIV/STD Section Director |
| Signed by | Josh Hutchison |
1.0 Purpose
This policy provides guidance to Administrative Agencies (AAs) regarding the submission of the Annual TakeChargeTexas (TCT) Data Improvement Plan (DIP) Narrative Report and Quarterly Updates.
2.0 Background
The TakeChargeTexas (TCT) application facilitates reporting of eligibility, demographics, delivery of HIV medical and psychosocial supportive services by agencies receiving Ryan White and State Services funds, and medications provided by the Texas HIV Medication Program (THMP). As a condition of their grant awards, Ryan White HIV/AIDS Program (RWHAP) recipients report data on eligibility, clients, services provided, and expenditures through the Ryan White Services Report (RSR) and the AIDS Drug Assistance Program Data Report (ADR). The Department of State Health Services (DSHS) ensures TCT data entries are timely, complete, and accurate in partnership with Administrative Agencies.
3.0 Authority
Ryan White HIV/AIDS Extension Act of 2009, Texas Health and Safety Code (THSC) §12.052, §85.032
4.0 Definitions
Administrative Agency – Entity responsible for ensuring a comprehensive continuum of care exists in their funded areas. AAs accomplish this through the management and oversight of HIV care and treatment services funded by federal and state funds under a contractual agreement with DSHS. For a list of AAs, their contact information, and coverage areas, see HIV Administrative Agencies.
AIDS Drug Assistance Program (ADAP) Data Report (ADR) – The ADR is an annual reporting requirement for ADAPs. The report contains client-level data about individuals who receive services, the services they receive, and the costs associated with these services.
Data Improvement Plan (DIP) – A documented plan to improve data quality using recommended improvement strategies.
Data Manager (DM) – Staff at the AA who provide support to local partner organizations and subcontractors to assure the quality and use of data in TCT.
Eligible Reporting Scope – Ryan White HIV/AIDS Program data including clients receiving services eligible for Ryan White HIV/AIDS Program funds, regardless of whether the provider used Ryan White HIV/AIDS Program funds to pay for the services.
Funding Stream – A source of available funds for client services associated with a contract.
Health Resources and Services Administration (HRSA) – An agency of the U.S. Department of Health and Human Services dedicated to providing equitable health care to the nation’s highest-need communities. They serve people who are geographically isolated and economically or medically vulnerable. HRSA programs support people with low incomes, people with HIV, pregnant people, children, parents, rural communities, transplant patients, and other communities in need, as well as the health workforce, health systems, and facilities caring for them.
HIV Service Provider – Organization(s) under contractual agreement with AA to provide HIV-related medical and support services to a person(s) living with HIV. A contractual agreement with the AA requires Service Provider Agencies to enter relevant data into TCT.
HRSA HIV/AIDS Bureau – The HIV/AIDS Bureau (HAB) administers the Ryan White HIV/AIDS Program (RWHAP) and plays a critical role in helping diagnose, treat, prevent, and respond as part of the Ending the HIV Epidemic in the U.S. initiative.
Ryan White HIV/AIDS Program (RWHAP) – RWHAP is a program authorized in 1990 and administered by the HIV/AIDS Bureau. The program provides grant funds to states and metropolitan areas with high numbers of people living with HIV (PLWH) and selected treatment providers to fill gaps in the system of outpatient medical and social support services for low-income PLWH. HRSA requires that the RWHAP use funds as a payment of last resort. Program beneficiaries must be low-income, as identified by each recipient.
RWHAP Services Report (RSR) – The RSR is a client-level data reporting requirement that monitors the characteristics of Ryan White HIV/AIDS Program Parts recipients, providers, and clients served. HRSA requires Ryan White HIV/AIDS Program Parts A–D funded recipients and their contracted service providers (subrecipients) to report client-level data annually to the HIV/AIDS Bureau through the RSR. See RSR reporting requirements.
5.0 Policy
Each AA submits and reports progress towards the Data Improvement Plan (DIP) goals.
6.0 Responsibilities
6.1 DSHS HIV/STD Section
- Develops and provides the AA with data improvement training and technical support.
- Provides feedback on the Annual Data Improvement Plan Narrative Reports (DIPs) and Quarterly Updates to the AA Data Managers, when needed.
- Approves the Annual DIP Narrative Report and Quarterly Update for each AA.
- Provides Annual DIP Narrative Reports and Quarterly Updates to the Contract Management Section (CMS).
6.2 Administrative Agencies (AA)
- Develop local procedures to implement the DIP policy with service providers.
- Attend data improvement training and technical support meetings provided by DSHS.
- Ensure agencies have adequate policies concerning the completeness, accuracy, lack of duplication, and timeliness of TCT data entry.
- Continuously monitor the completeness, accuracy, and timeliness of TCT data for each service provider in their assigned area and the overall AA area.
- Provide training and technical assistance to service providers to assist with data improvement.
- Prepare and submit the Annual DIP Narrative Report and quarterly updates, in accordance with contractual deadlines.
6.3 Subrecipients and Providers
- Enter data into TCT for clients as defined by HRSA’s eligible reporting scope.
- Ensure data entry in TCT is complete, accurate, and entered in a timely manner.
- Improve deficiencies identified in provider data.
- Attend training and technical assistance provided by the AA.
- Have adequate policies concerning the completeness, accuracy, lack of duplication, and timeliness of TCT data entry.
- Follow the local procedures set by the AAs for the implementation of this policy.
7.0 DIP Review Procedures and Process
- Administrative Agency Data Managers email the Medication Data and Analysis Group and HIV Care Consultant contacts with the completed Annual DIP Narrative Report and subsequent DIP Quarterly Reports by the due date.
- The Medication Data and Analysis Group reviews the Annual DIP Narrative Report and subsequent DIP Quarterly Reports and returns reports to the Administrative Agency Data Manager with feedback, if needed, or forwards them to the HIV Care Services team if no feedback is required. The Care Services Group reviews submitted reports and provides feedback to the Contract Management Section (CMS) when applicable.
8.0 Annual DIP Narrative Report Requirements
The DIP should include:
- An implementation plan which provides training to contracted service providers and AA staff.
- Plans for site visits by AA data managers, which include data quality audits and a description of the audit methods used. The routine audits will assess the following:
- Timeliness of TCT data entry: Data entered within ten business days of the service delivery.
- Validity of TCT data.
- Completeness of TCT data.
- Completeness of aggregate and client data reports the RWHAP RSR and ADR require.
- Identification of areas needing improvement relating to data quality. Data managers may focus improvement efforts for the domains of data quality on selected service providers with deficiencies or across service providers on selected fields to achieve improvements in data quality.
- Establishment of goals for the improvement in (a) the timeliness of TCT data entry, (b) the validity of TCT data, (c) the completeness of TCT data, and (d) the completeness of aggregate and client data reports the RWHAP requires generated by RSR or ad hoc reports.
- The DIP should establish progressively increasing goals aimed at meeting the minimum requirements (Progressive goal setting for subrecipients who have not met the minimum requirements).
- DM maintains minimum data quality requirements (See Section 9.0) where providers meet the minimum. Data managers ensure subrecipients maintain minimum data requirements.
- See the appendix for the DIP Schedule and Due Dates.
9.0 Data Quality Review and Minimum Requirements
Each AA plan for routinely assessing the domains of data quality includes the following types of monitoring and assessment for data elements that DSHS and HRSA require:
- Timeliness of TCT Data Entry: Data managers routinely assess the timeliness of TCT data entry and work with HIV service providers with consistently late entries to improve timeliness.
- Enter data associated with medications, outpatient/ambulatory medical care, and laboratory services, including the cost of these services, into TCT within ten business days of the date of the service or encounter.
- Enter client descriptive information and information associated with other service entries, including the cost of service, into TCT within five business days from the date of service or encounter.
- Validity of TCT Data: Data managers verify the information in randomly selected TCT records against documentation or records available at the service site on at least an annual basis.
- A random sample selection of TCT records consists of ten percent or at least ten records within a specified review period. This should include validating the information on services delivered and the values of health indicators, such as CD4 and viral load test reports, if included in the record.
- The AA specifies methods and schedules for conducting audits in the DIP, which may be satisfied through reference to written policy or procedure at the AA.
- Completeness of TCT Data:
- Missing or Unknown Data: DSHS and HRSA HAB-required data elements cannot contain more than 5 percent missing or unknown data. Data managers ensure the completeness, accuracy, and consistency of Ryan White HIV/AIDS Program (RWHAP) client-level data by reviewing: (a) unknown, (b) missing, and (c) invalid data fields by running data completeness and ad-hoc reports and evaluating data entry procedures at HIV service providers.
- Duplicate Client: Data managers routinely assess the degree of duplication within client accounts and provide training and technical support to providers to ensure there are no duplicate client records in TCT. Data managers are also responsible for using the "Potential Duplicate Client Report" to merge duplicates.
- Cost Reporting: Data Managers ensure each service entry has an allowable associated cost allocated to the appropriate funding stream.
10.0 DIP Quarterly Update Requirements
Progress reports include an outline of the method and timeline to address and resolve identified areas needing improvement each quarter.
11.0 Annual DIP Narrative Report and Quarterly Update Review Procedures and Process
- Administrative Agency Data Managers email the assigned Medication Data and Analysis Group and HIV Care Consultant contacts with the completed Annual DIP Narrative Report and subsequent DIP Quarterly Updates by the due date.
- The Medication Data and Analysis Group reviews the Annual DIP Narrative Report and subsequent DIP Quarterly Updates and returns reports to the Administrative Agency Data Manager with feedback within 30 days, if needed, or forwards the report to the HIV Care Services team when complete.
- The AA sends, through email, written feedback back to the Medication Data and Analysis Group and HIV Care Consultant contacts within ten days.
- The Care Services Group reviews, provides feedback, and accepts the final Annual DIP Narrative Reports and Quarterly Updates.
- The Care Services group provides Annual DIP Narrative Reports, quarterly updates, and any report feedback to CMS.
- The Medication Data and Analysis Group provides training and technical support to the data managers to address issues identified in the DIP, as needed.
12.0 Revision History
| Date | Action | Section |
|---|---|---|
| 8/17/2023 | Policy updated for TCT | All |
| 9/26/2014 | Converted format (Word to HTML) | - |
| 7/7/2010 | This is a new policy | - |
13.0 Associated Requirements and Documentation
| Requirements/Document Name |
|---|
| DIP Report Guide |
Appendix: DIP Schedule and Due Dates
| Time Frame | Due Date | Comments |
|---|---|---|
| 1st Quarter 01/01/XX to 03/31/XX | 04/30/XX | |
| 2nd Quarter 01/01/XX to 06/30/XX | 07/31/XX | |
| 3rd Quarter 01/01/XX to 09/30/XX | 10/31/XX | |
| 4th Quarter 01/01/XX to 12/31/XX | 01/30/XX | |
| Yearly/Baseline Complete Calendar Year from 01/01/XX to 12/31/XX | 04/30/XX | For the previous year |