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Campaign Webinar Viral Suppression is the Ultimate Goal April 30, 2013. Ground Rules for Webinar Participation. Actively participate and write your questions into the chat area during the presentation(s) Do not put us on hold - PowerPoint PPT Presentation
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Campaign WebinarViral Suppression is the Ultimate Goal
April 30, 2013
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Ground Rules for Webinar Participation
• Actively participate and write your questions into the chat area during the presentation(s)
• Do not put us on hold• Mute your line if you are not speaking
(press *6, to unmute your line press #6)• Slides and other resources are available
on our website at incareCampaign.org• All webinars are being recorded
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Agenda1. Welcome & Introductions, 5min2. Campaign Data Review, 10min3. Washington, DC Part A EMA, 10min4. Commonwealth of Virginia Part B, 10min5. University of Kansas Part C, 10min6. Question & Answer, 10min7. Updates & Reminders, 5min
In the chat room, Enter
your: 1. name, 2. agency, 3. city/state, and 4. professional role at agency
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Viral Suppression by RW Part Funding
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Viral Suppression by Caseload
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Viral Suppression by Facility Type
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Viral Suppression by Ambulatory Care Type
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Interventions Related to Viral Suppression
Operational Activities• Process Mapping• Fishbone MappingClient Activities• Adherence Counseling• Health Education / Health Literacy
Improvement• Journaling or verbal description of how
patient takes meds
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Interventions Related to Viral Suppression
Provider Activities• Motivational Interviewing Training• Cultural Competence Training• Utilization of Patient Portals / Electronic
Communications• Pharmacokinetic Assessment• Absorption Analyses
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Submit Improvement Updates!
VIRAL SUPPRESSION:
THE ULTIMATE GOALJustin BritanikDistrict of ColumbiaHIV/AIDS, Hepatitis, STD, and TB Administration
Background• HAHSTA (HIV/AIDS, Hepatitis, STD, and Tuberculosis Administration)
is the Part A grantee for the DC EMA.• The EMA is uniquely diverse, comprised of 3 states, 18 counties, and
the District of Columbia.• Sub-recipients include providers of all types and sizes, from county
health departments, large hospital systems, Federally Qualified Health Centers (FQHCs), specialized HIV/AIDS clinics, to small community based organizations.
• HAHSTA also administers DC ADAP and Part B services for the District of Columbia.
Death Surveillance
HAHSTA Programs and Activities
Peri-incarcerated MCM
Targeted Treatment Adherence
Lab Surveillance
National HIV Behavioral Surveillance (NHBS)
Case Management Operating Committee
DC EMA Cross-Part Quality Collaborative
Program Coordination and Service IntegrationComprehensive
HIV Care Plan
Recapture Blitz
Strategic Planning for Target Populations
Enhanced Comprehensive HIV Prevention Planning
HIV Implementation Plan “Ending the Epidemic”
Priorities throughout the Continuum of Care
• HAHSTA recognizes the relevance of measurable outcomes to evaluate programs• Using program data and surveillance data together to increase
linkage and retention to care• The administration envisions that providers will
coordinate, and collaborate to maximize client access, enrollment and retention in outpatient/ambulatory medical care.
• Durable Viral Suppression is the goal, and the Administration understands that retention and adherence activities are the means to achieving this.
•
DC Treatment CascadeHIV Continuum of Care for HIV Cases Diagnosed in the District of Columbia, 2005-2009
Ryan White Cascade, 2011
Latest Request for ApplicationsPurpose of the Retention for Results: Towards Durable Viral Suppression in the District of Columbia RFA is to create a system of services that serves individuals with HIV as they achieve durable viral suppression• Prepare client for HIV-related care services• Increase the extent to which clients are retained in a
system of HIV-related care services• Improve the ability of clients to access and consume
services by increasing the coordination of services• Assist clients to achieve durable viral suppression
Outcomes of Viral Load Suppression• Fewer new infections from reduced community viral load• Avoiding drug resistance• Fewer adverse health outcomes (i.e. opportunistic
infections, immune system damage)• Savings to healthcare system (i.e. avoiding
hospitalization, decreased ED visits)
Healthier and happier patients!
Durable Viral load suppression is the goal, but in order to achieve this goal, patients have to be tested, linked to care, placed on ART, and retained in care…
So QI efforts around Viral Load suppression need to address all these
factors!
QI Projects to Address VL Suppression
• DC Collaborative• In+Care Measures
• Recapture Blitz• A city-wide outreach initiative to support all Ryan White funded
outpatient ambulatory medical care providers in identifying the clients that have truly fallen out of care to focus intensive “blitz” activities to re-engage clients that are no longer accessing care
• ADAP Project• Using ADAP data to look at trends in enrollment in the AIDS Drug
Assistance Program in Washington DC and quantify virologic response to antiretroviral therapy.
DC EMA Collaborative• Providers have been submitting data on Viral Load
Monitoring and Viral Load suppression since 2011.• Focusing on small steps in the right direction, getting full
participation
Viral Load Monitoring (#2) Viral Load Suppression (#3)68%
70%
72%
74%
76%
78%
80%
82%
84%
86%
88%
May-11Jul-11Sep-11Nov-11Jan-12Mar-1212-May12-Aug12-Dec
DC Collaborative Project 2013:Viral Suppression• In+Care Campaign Measure: Retention Measure 4: Viral
Load Suppression• Percentage of patients, regardless of age, with a diagnosis of
HIV/AIDS with a viral load less than 200 copies/mL at last viral load test during the measurement period
• Why look at this for retention?• Critical link between early linkage to medical care and healthy
patient survival.• Recent indication of viral suppression as means of preventing
transmission.• This is the ultimate goal, it gives us an overview of the big picture
of the continuum of care.
2013 Project Continued• Beginning this Grant Year Grantees will report quarterly
on In+Care viral load suppression measure.• Providers will conduct and share PDSA cycles via online
workspace.• Quarterly in-person meetings about joint quality
improvement training activity.• Regional approach: each agency works to reduce it’s own
viral load among patient population, the outcome will be profound from over 30+ agencies working in unison to reduce community viral load.
Recapture Blitz• During Spring of 2013, HAHSTA will redouble outreach
efforts to re-engage clients in care through a “Recapture Blitz.”
• Conducting evidence-based interventions and outreach activities to improve retention in care and treatment on an ongoing basis are standing expectations of the grant agreement.
• By coordinating a city-wide outreach initiative, HAHSTA can support providers in identifying the clients that have fallen out of care to focus intensive “blitz” activities and re-engage clients in care.
Recapture Blitz• Providers submit lists of patient believed to be out of care• Matching against HAHSTA datasets:
• Ryan White Services Report• AIDS Drug Assistance Program (ADAP)• Surveillance• Labs data
• Matching Process - Time since last contact with health care system will be calculated by comparing dates of last: • Ryan White-funded service at another facility across EMA• prescription fill date• lab test
• Lists of Clients actually out of care returned to providers• Providers conduct recapture activities to focus on this narrowed list of
patients
Assessment of Factors that Influence Care
Challenges to retention, adherence, and VL suppression • Language barrier• Discrimination• Stigma• Difficulties finding out where to go for care• Difficulties making an appointment • Difficulties getting to the appointment• Difficulties keeping appointment • Difficulties paying for care – transitioning from RW to Medicaid, etc.
ADAP Project• The DC ADAP absorbed a large increase in clients and
prescription volume. • Most clients achieved a desirable clinical benefit, as
measured by viral load.• Among patients who are on ART from ADAP Percentage of VL
Suppression (<400 copies/mL) 74.0% in 2007 to 90.4% in 2010• During the same span, from 44.0% in 2007 to 71.0% in 2010
among patients who are not on ART from ADAP
Questions and Contact InfoJustin BritanikQuality Management SpecialistHIV/AIDS, Hepatitis, STD, and TB AdministrationDistrict of Columbia Department of Health (DOH)Government of the District of Columbia899 North Capitol Street, NE, 4th [email protected]
VIRGINIA: VIRAL SUPPRESSION
INTERVENTIONS
Anne RhodesVirginia Department of Health
Background
Cross-Parts
NHASSPNS/CAPUS
Past Collaboratives Cross-State Collaborative (5 States) –
focused on improvements in data collection/service provision for Ryan White clients, including medical care and labs
DC Collaborative – involved 3 states and District of Columbia, focused on improved collaboration among the jurisdictions and reporting quality measures
Unaware of HIV Status(never tested or never
received results)Know HIV Status
(not referred to care or didn’t keep referral)
May Be Receiving Other Medical Care But Not HIV Care
Entered HIV Primary Medical Care but Dropped Out
(lost to follow-up)
In and Out of HIV Care or Infrequent User
Fully Engaged in HIV Primary Medical Care (linked to care)
• DIS Partner Elicitation
• PN Testing/Referrals
Unaware
• Active referral• Care Coordination • Patient Navigation
Known Status (not in
HIV care)
• Patient Navigation• Care Coordination • Mental Health
Lost to Care (Not Fully
Engaged)
SPNS Systems Linkages
SPNS Patient Navigation
Measuring Care Markers
Evidence of HIV
Care
Medical
Visit
CD4 count
ART Rx
Viral Load Test
Treatment Cascade Data: Virginia
Linkage• Care Marker within
90 days of HIV diagnosis
• Denominator is those newly diagnosed in time period
Retention• 2 or more care
markers in 12 months at least 3 months apart
• 1 care marker in each 6 month period of 24 month period
Viral Suppression• Last Viral Load <
200 in time period being measured
• Denominator is those with at least one care marker in time period
Baseline Data: Linkage to Care*
White
Black
Hispanic
Other Race
State
0 10 20 30 40 50 60 70 80 90 10077.5
64.3
63.9
61.5
67.8
76.8
68
72.6
64
70.8
Linked 2012 (Preliminary) Linked 2011
% of All Clients Diagnosed in Year
**Source: Surveillance, VACRS, ADAP data, Division of Disease Prevention, Virginia Department of Health, April 2013
Baseline Data: Retention in Care (2 Care Markers in 12 month period)*
Black White Hispanic Other State0
102030405060708090
69.4 73.6 75.8 71.2 71.269.9 73.382.5
71.5 71.8
Retained 2011 Retained 2012 (Preliminary)Total N for 2011 =11,187Total N for 2012=12,310
*% of those with 2 care markers in 12 months of those with at least 1 markerSource: Surveillance, VACRS, ADAP data, Division of Disease Prevention,Virginia Department of Health, April 2013
Ryan White Data: Retention in Care (2 Care Markers in 12 month period)*
Black White Hispanic Other State0
102030405060708090
79.1 83.5 87.6
73.780.782.1 85
91.9
75.683.2
Retained 2011 Retained 2012 (Preliminary)
91.9
*% of those with 2 care markers in 12 months of those with at least 1 markerSource: Surveillance, VACRS, ADAP data, Division of Disease Prevention,Virginia Department of Health, April 2013
Total N for 2011 = 7,284Total N for 2012=7,496
Baseline Data: Viral Suppression (<200 C/ML)*
Black White Hispanic Other State0
102030405060708090
68.279.3
74.269 72.267.8
79.385.6
71.8 72.7
Suppressed 2011 Suppressed 2012 (Preliminary)
*% of those with at least 1 care marker in yearSource: Surveillance, VACRS, ADAP data, Division of Disease Prevention,Virginia Department of Health, April 2013
Ryan White Data: Viral Suppression (<200 C/ML)*
Black White Hispanic Other State0
102030405060708090
100
70.781.3 78.4
55.5
73.373.480.8
87.2
60.5
76.1
Suppressed 2011 Suppressed 2012 (Preliminary)
*% of those with at least 1 care marker in yearSource: Surveillance, VACRS, ADAP data, Division of Disease Prevention,Virginia Department of Health, April 2013
Treatment Cascade: Thoughts
2012 data is still preliminary – CDC recommends 15-18 months after end of year before finalizing surveillance data
Data reporting issues will impact numbers – electronic lab reporting may affect timeliness and completeness, as will other data system improvements
Future Directions: Viral Suppression
CAPUS: Lost to care
lists/Follow up by DIS
SPNS/CAPUS: Evaluation of
PN to determine
effectiveness of
components
Ryan White: Insurance
Implementation effects on
viral suppression
Data systems:
Integration of surveillance,
care, prevention
University of Kansas School of Medicine-Wichita
Viral Suppression ProjectPaulette Phipps
University of Kansas School of Medicine-Wichita
• 3500 patient Internal Medicine Clinic with approximately 1100 HIV+ patients
• 4 of our 5 medical providers are AAHIVM certified
• Main clinic located in Wichita, KS with 3 satellite clinics to cover 100 of the 105 Kansas counties
• UKSM-W is a Part B medical and medical case management provider and Part C & D grantee/provider
University of Kansas School of Medicine-
Wichita
University of Kansas School of Medicine-Wichita
• Our clinic currently uses Allscripts EHR with a bi-directional interface for laboratory resultso Integration of bi-directional interface made it
feasible to track lab data o Starting in 2011 viral load suppression and
clinic viral load for those in care were calculated
o In 2012 Quality Management Team created a project to increase the number of patients with undetectable viral load by 5% to 750 patients
University of Kansas School of Medicine-Wichita
• 2012 Viral Load Suppression Projecto Included all 1106 patients seen for on
outpatient ambulatory medical care (OPAMC)visit in 2012
o Suppression was defined as the most recent viral load lab value was <200copies/mL
o Only those prescribed HAART were assessed and counseled but clinicians and case managers were advised regarding viral load counts
University of Kansas School of Medicine-Wichita
• Where we started and what we dido At the beginning of January 2012 had 658 of
our 1056 current patients who were virally suppressed
o Identified clients who had viral loads above 100,000copies/mL to receive immediate counseling
o Identified Medical Case Managers (MCM) and medical providers assigned to patients
o Clinicians were asked to delve deeper with these patients during OPAMC visits
University of Kansas School of Medicine-Wichita
• UKSM-W MCM staff took on a greater role with struggling clientsoMCM’s were asked to arrange visits or calls
with client’s routinely to discuss and assess adherence
oClients struggling with barriers such as mental health, substance abuse, transportation or costs of medication were offered additional services through Part C or D or a concurrent retention in care project
University of Kansas School of Medicine-Wichita
• Patients with no case management contact or case managed outside of the UKSM-W system posed a particular challengeo MCM’s from satellite clinics and Aids Service
Organizations (ASO’s) were contacted by QM staff to alert them to the current adherence concerns and lab values
o Part C case management staffers, QM staff and clinic nursing staff tried to engage those clients who did not receive CM services to address adherence issues
University of Kansas School of Medicine-Wichita
• Tracking our progressRed = all HIV+ clinic patients Blue = viral suppression
December-11 March-12 June-12 September-12 December-120
100200300400500600700800900
100011001200
Virally Suppressed
# o
f Pa
tien
ts
University of Kansas School of Medicine-Wichita
• Looking to the futureo Working to develop an education program for
medical case management staff to assist them to assess, problem solve and educate clients regarding adherence
o Expanding the counseling program to those clients with viral loads >10,000 copies/mL
o Developing education and resources for clients that include commercially available tools and reminders as well as tips from successful current patients
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Announcements
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• Partners in+care Webinar: What is Viral Suppression – May 21, 12pm ET
• Campaign Webinar: Transitions in+care, Adolescent to Adult Care – May 22, 3pm ET
• Partners in+care Webinar: Linkages Between Mental Health and Medical Services – May 29, 12pm ET
• Journal Club Webinar: Timothy Minniear: “Delayed Entry Into and Failure to Remain in HIV Care Among HIV-Infected Adolescents” – May 30, 2pm ET
• NQC TA Webinar: Jose Montaner, Canadian Treatment CascadeMay 16, 4pm ET
Upcoming Events
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• Campaign Monthly Topics: ― May Topic – Youth, Transition, and Retention
in+care― June Topic – Latinos and Retention― July Topic – Patient Navigation― August Topic – Refugees, Migrants and
Retention• Data Collection Submission Deadline:
June 3, 2013• Improvement Update Submission Deadline:
May 15, 2013
Upcoming Deadlines and Office Hours
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Time for Questions and Answers
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Campaign Headquarters:National Quality Center (NQC)90 Church Street, 13th floorNew York, NY 10007Phone [email protected]
incareCampaign.orgyoutube.com/incareCampaign