Data to Care: An International Approach to Improving ......o Mobile app: CHWs use hand held tablets to securely enter data during patient home visits. o Web-based interface: Site and

Data to Care: An International Approach to Improving Health Outcomes

Lucy Slater

Senior Director, Global Program

#NASTAD17UNITED TO END THE EPIDEMICS

Funded by PEPFAR (CDC) since 2001

Focus on responding to identified program and organizational capacity needs of public health agency directors

Draw upon NASTAD members to develop peer relationships and provide technical support

Globally, we co-locate field staff with public health agencies for mentoring, guidance, and support

NASTAD Global: What We Do


Uses HIV surveillance data to identify HIV-diagnosed individuals not in care, link them to care, and support the HIV care continuum

Approaches frequently used in the U.S.:

o Health Department Model - Health department-initiated linkage and re-engagement outreach

o Healthcare Provider Model - Healthcare provider-initiated linkage and re-engagement outreach

o Combination Health Department/Healthcare Provider Model - A combination of both approaches

What is Data to Care (DTC)?

https://effectiveinterventions.cdc.gov/en/HighImpactPrevention/PublicHealthStrategies/DatatoCare.aspx


PEPFAR 1.0 – Emergency response. Focused on getting treatment and care to individuals (2004 – 2007)

PEPFAR 2.0 – Focused on country capacity, sustainability, country ownership and leadership (2008 – 2012)

PEPFAR 3.0 –”Right things, in the right place, at the right time”

Global Relevance of DTC


Ten global indicators, six collected by HIV CBS*

*WHO. Consolidated Strategic Information Guidelines for HIV in the Health Sector. May 2015


CBS system development and support Haiti, Ethiopia, Guyana, Trinidad and

Tobago, Guatemala, Nicaragua, Panama, South Africa

Regional CBS Workshops (42 countries)

Partner Services Ethiopia, Uganda, Haiti

Patient care linkage and ART adherence Haiti, South Africa

Global Contributions to DTC


Lead authors of the Case-Based Surveillance Toolkit, a comprehensive guide for development of HIV CBS systems in resource-constrained settings

Toolkit will be included as an attachment in pending WHO CBS Guidelines, anticipated later in 2017

NASTAD Global Contributions to DTC


Dr. Ermane Robin, Senior Technical Advisor, National AIDS Program, Ministère de la Santé Publique et de la Population (MSPP)

Jude Eddy Louis, NASTAD Haiti Country Director

Dr. Daniella Myriam Pierre, Patient Linkage & Retention Project Manager

Mark Griswold, NASTAD Global Senior Manager

Our Presenters

Completing the Puzzle:Data to Care

Initiatives in Haiti


NASTAD Haiti Overview


• First case of HIV was reported in Haiti in 1982

• HIV prevalence was estimated at 5% in the 1990s; now at 2%

• NASTAD has been working in Haiti since 2003

Background


1. HIV case based surveillance (SALVH)

2. Enhanced perinatal HIV surveillance (SAFE)

3. Patient care linkage and retention (PLR)

4. Partner services

5. Capacity building for MoH

Project areas


Our key partnersDirector General

DELR

LNSP

UPEDeptm’lDirectors UCC

PNLS

UGP DSF

NASTAD

Implementer

SOLUTIONS

IT platform

I-TECH

MoH EMR

GHESKIO

EMR

PIH

EMR

Health provider networks

1. Ministry of Health

2. NGOs

3. CDC Haiti and Atlanta


NASTAD Haiti Staffing

Country DirectorJude Eddy Louis

Drivers(3 staff) SALVH Technical

Support(2 staff)

Data Manager

Office maintenance and security

(3 staff)PLR Technical

Support(2 staff)

National HIV & PMTCT

Surveillance Manager

Nadjy Joseph

Patient Linkage & Retention Project

ManagerDaniella Myriam Pierre

Finance and Admin Manager

Christine Durosier

SAFE Technical Support(1 staff)

Partner Services Coordinator


• U.S. TA providers have always played a critical role in Haiti projects

• Haiti TA team has existed since 2003, when CDC and MoH asked NASTAD to conduct a Haiti CBS SWOT assessment

• Provides ongoing assistance

• Current TA providers:o Jami Stockdale (MD)

o Amy Robbins (NY)

o Jen Gunderman (University of New England)

o Kristiana Dhillon

• Past Haiti TA providers have come from VA, ME, FL, SF, LA, MN

TA Providers


SALVH: HIV case-based Surveillance


• SALVH defined: Surveillance Active et Longitudinale du VIH en Haïti)o In English: HeALTH (Haitian Active Longitudinal Tracking of HIV)

• SALVH serves to:o Use existing data sources to create a national dataset that is cleaned and de-

duplicatedo Facilitates data analysis for epidemiologic profiling and production of care

cascadeso Provide functional data linkages to both SAFE and PLR (more on this later in

the presentation)

• SALVH development has spanned 10+ years from piloting, to national implementation, to expansion of care variables.

Overview


System Evolution

2005-2007 Planning and Pilots

2008-2009

National training and system implementation

2012-2014

EMR integration c. SAFE developed

2015 PLR developed

2016

System streamlined . Clinical variables expanded

2017Fingerprint added to dedup process

Data visualization platform implemented

TA for better site use of data


• Name-based reporting of HIV is mandated by MoH

• Cases reported include:o New HIV diagnoses

o Previous diagnoses not yet reported

o Clinical data from people living with HIV who are in care

Case Reporting


Summary of SALVH Data Elements

Case ID and demographics(name, sex, DOB, address, phone)

Transmission risk

Case matching and dedup

(Mother’s first name, town of birth, fingerprint)

Laboratory tests

(VL, CD4, STI, HBV, etc.)

All hospital visit data

Pregnancy

Medical record number(s)

HIV test data

TB testing, dx, tx

Disease stage

ART referral, receipt, regimen, adherence

Death


SALVH Data Flow

iSanté GHESKIO PIHEMR EMR EMR

MESI(site interface)

SALVH

DASHBOARD (SISENSE)New HIV diagnoses

Patients enrolled in carePLR

Re-linkage of LTFU patients

SAFE

Perinatal HIV surveillance

• SALVH data feeds include• Electronic notification of

new cases from sites• Longitudinal clinical data

from EMRs

• SALVH exchanges date with both SAFE and PLR systems

• System captures an estimated 92% of cases


• Data are available down to the community (commune) and institution levels

• Variety of epi and M&E reports available

• Longitudinal data can be used to

o Track clinical outcomes

o Analyze linkage to care

o Create care cascades at the national, regional, and facility levels

Data Use


Data Visualization Dashboard (sample data)


Data Visualization Dashboard (sample data)


SAFE Project


• MoH and its partners began implementing PMTCT programs in 1999

• 139 prevention of mother-to-child transmission (PMTCT) sites in place throughout Haiti

• Estimated that >75% of pregnant women are HIV tested

• Despite this, challenges remain

o Some estimates of vertical transmission in Haiti are as high as 9%

o An estimated 14.5k children under age 14 are HIV-infected

Background


• In 2012, NASTAD worked MoH and the U.S. CDC to develop and implement a system of enhanced perinatal HIV case-based surveillance

• “SAFE” (Surveillance Active de Femmes Enceintes Seropositives), was implemented nationally in 2014

• Objectives:o Improve disease surveillance of HIV among mothers and infants, o Promote linkage and adherence to HIV care and treatment

Development


• MoH requires that 10 “sentinel events” be reported related to HIV infection among pregnant women

• SAFE leverages existing PMTCT case management and data collection processes.

Development


• PMTC Case Manager obtains demographic and clinical information from ANC registry

• CM logs onto SAFE platform by using an unique ID and confidential password

• HIV CBS Report Form is entered on the interface and populates core data in the online SAFE platformo SAFE cases are directly linked with HIV CBS

Process


• During antenatal and postnatal care, key benchmarks are tracked and recorded

• System provides timed reminders to PMTCT case managers about patient care visits

• Case managers initiate outreach efforts as needed for the lost to follow-up patientso Using a checkbox on the electronic interface, SAFE links to

PLR System for LTFU patients

Process


MOH Patient Registers

34


• There are typically ~2,000 pregnant women actively followed by SAFE

• Data are compiled and analyzed to track epidemic progress and to monitor use and effectiveness of Haiti’s PMTCT system

• SAFE has improved reporting of HIV among pregnant women, but challenges remaino Initial diagnoses among pregnant women are well-reported (>90%), BUT

- Follow up visits are less well-reported- ~50% of women give birth at home

o Electricity, internet and high staff turnover contribute to reporting issueso Electronic PCR data from the national lab are now being integrated into SAFE,

but data quality issues need to be overcome

Outcomes


PLR Project


• MoH Clinical Goals:o Universal access to HIV care and treatment and the prevention of new

HIV cases

o Retention in care >= 80-85% of patients

o 90 90 90 UNAIDS goals for HIV program

• Gaps in the HIV Clinical Cascade:o Attrition rate is 46% after 5 years

o 36% diagnosed cases not linked to care

o 25% of the patients initiated on ART are lost to follow-up

Background


• Health care sites use community health workers (CHW) for patient follow up in the field

• NASTAD was asked by MoH and CDC to create CHW tools and processes

• NASTAD developed the “PLR Toolkit” to help CHW reach out to HIV patients

• Project began enrolling sites in March 2015

Background


• Improve patient linkage retention in HIV care and treatment through:

o Provision of effective, consistent community outreach tools and processes

o Access to real-time data about PLR to drive policy and practices

o Better tracking of CHW outputs and outcomes

o Improved tracking of community ART distribution

Goals of PLR


• Tools and processes leverage existing data from EMRs and CBS

• Uses a secure online platform accessed through: o Mobile app: CHWs use hand held tablets to

securely enter data during patient home visits.

o Web-based interface: Site and national administrators monitor program performance

• Data are synchronized through the web app when connected, or via secure cellular data feed

Methodology


Mobile App


Mobile app


PC Interface


PC Interface


• NASTAD produces reports that are shared with key partners to monitor site-level performance, including:o inactive patients to be contacted

o patients who have returned to care

o Patients receiving community ART from CHW (30 day and 60 day scripts)

Program Monitoring


Summary of Tracking Activities

41,075

14,603

31,457

Total Phone calls Home visits

Tracking Reached

58%

60%

47%


Reason Given for Missing Appointments2,721

2,190

1,547 1,483 1,454

1,134

571 543 423 409

Lacked moneyfor transport

Died Work conflict In careelsewhere

Forgotappointment

Too sick Usingalternativetreatment

Stigma Poor clinicexperience

Missedappointmentdue to travel


PLR Cascade

51,061

41,042

19,915

12,448

LTFU patients targeted for PLR Patients contacted (calls and/orvisits)

Patients who returned to clinic Patients who returned andremained active in care

80%of total LTFU

49%of LTFU contacted

42%(of LTFU contacted)

62%of patients who returned to care


Outcomes through April 2017

Unable to locate22%

Outcome in process9%

In care at another site4%

Refused to return

8%

Returned to clinc52%

Died5%


• Monitor patient outcomes in conjunction with CBS clinical datao Better understanding of how ART retention impacts health outcomes

• PLR platform provides a chance to conduct other outreach activitieso Partner notification (beginning pilot phase)

o Key population outreach: MSM , CSW (MSM pilot in process)

Future Opportunities


Summary:Fitting the pieces together


• EMRs feed case report and clinic visit data to SALVH and PLR

• SAFE f/u is initiated by a SALVHcase report

• Mother-baby pairs identified by SAFE are reported to SALVH

Interconnected systems for DTC

SALVH

SAFEPLR

EMRs


• LTFU cases in SAFE are electronically linked to PLR

• SALVH helps identify PLRpatients who migrate to other sites

• EMRs are updated using PLRdata (and soon, SALVH data as well)

Interconnected systems for DTC

SALVH

SAFEPLR

EMRs


Mèsiampil !

Documents

Data to Care: An International Approach to Improving ......o Mobile app: CHWs use hand held tablets to securely enter data during patient home visits. o Web-based interface: Site and