HHC Integration of HIV Testing Within Routine Care

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Integration of HIV Testing Within Routine Care in a Large Public Hospital System

Joanna OmiSenior Assistant Vice President

Corporate Planning and HIV ServicesNew York City Health and Hospitals Corporation

New York, NY

November 6, 2007

Copyright 2007, Joanna Omi, [email protected]

2

Topics covered

• Overview of HIV and the HIV Testing Expansion Initiative

• Corporatewide and facility results• Lessons learned


3

8.2 million peoplelive in NYC

100,000 of these are HIV positive and

25,000 do not

know it (est.)

HHC serves 1.3 million New Yorkers each year

It can be extrapolated that each year approximately 4,000

undiagnosed HIV positive New Yorkers access services

at an HHC facility

HHC is in the epicenter of the national HIV/AIDS epidemic


4

New York City Health and Hospitals Corporation (HHC)• Public benefit corporation created in 1969• Largest municipal healthcare delivery system in US

– 11 acute care hospitals with State Designated AIDS Centers

– 6 diagnostic and treatment centers (D&TCs)– 4 long-term care hospitals– 95 extension clinics– MetroPlus (health maintenance organization)– Partnership in Care (HIV-specific managed care plan)– Home care agency


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HHC, continued

• 1.3 million New Yorkers served• 224,300 discharges • 4,934,600 visits• $5.5B operating budget • Approximately 19,000 patients with

HIV/AIDS

Note: FY07 Data


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HIV Testing Expansion Initiative:Integrate HIV testing within routine medical care

• Increase the number of patients who know their HIV status

• Test 150,000 unique patients (increased from 100,000 in FY06)

• Increase the proportion of patients who enter care early

• Reduce the number of concurrent AIDS diagnoses

• Once in care, retain patients in care• >80% of patients will have 2 medical visits in the last 12

months, with at least one visit in the last 6 months


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HIV Testing Expansion Plan


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The percentage of unique patients tested at HHC hospitals steadily increased while overall volume remained stable

FY05 outpatient and ED Pilot S ites Only (Source: PLM and Pilot Project Sites Reports)FY06-FY07 outpatient, inpatient and ED (Source: PLM and Facility Reports)

3%

6%

7%

5%

7%

7%

5%

7%

10%

5%

4%

6%

5%

7%

9% 9%

9%

11%

11%

11%

10%

9%

7%

9%

8%

14%

13%

17%

12% 13

%

15%

18%

15%

16%

8%

13%

0%

2%

4%

6%

8%

1 0%

1 2%

1 4%

1 6%

1 8%

2 0%

B el l C I H E l m H ar l Jac K C H L i n c M e t N C B Q n s W o od A llA cu t es

% o

f vol

ume t

este

d

F Y 05 FY 0 6 F Y 07


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The percentage of unique patients tested at D&TCs steadily increased while overall volume remained stable

FY05 outpatient and ED Pilot S ites Only (Source: PLM and Pilot Project Sites Reports)FY06-FY07 outpatient, inpatient and ED (Source: PLM and Facility Reports)

14%

12%

10%

6%

10%

10%

9%

13%

11% 12

%

7%

12%

19%

11%

28%

13%

16%

10%

17%

23%

16%

0 %

5 %

1 0 %

1 5 %

2 0 %

2 5 %

3 0 %

B e lv C u m b E N Y G o u v M o rr R en A l l D & T C s

% o

f vol

ume

test

ed

FY 0 5 FY 0 6 F Y 0 7


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9 2 ,1 2 3

6 2 ,0 2 3

1 3 3 ,8 5 9

0

3 0 ,0 0 0

6 0 ,0 0 0

9 0 ,0 0 0

1 2 0 ,0 0 0

1 5 0 ,0 0 0

F Y 0 5 F Y 0 6 F Y 0 7

Num

ber o

f uni

que p

atien

ts te

sted

U n iq u e P re n a ta l T e st s A ll O th e r U n iq u e T es ts

The number of unique patients tested grew while prenatal testing remained relatively stable

FY05 All other unique tests outpatient and ED Pilot Sites Only (Source: PLM and Pilot Project S ites Reports)FY06-FY07 All other unique tests outpatient, inpatient and ED (Source: Facility Reports)FY05-FY07 Unique prenatal tests prenatal clinics only (Source: Siemens Data Warehouse)

45.3%

48.5%


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Rapid HIV testing comprised the majority of unique tests conducted in FY06 and FY07

FY05 outpatient and ED Pilot S ites Only (Source: PLM and Pilot Project Sites Reports)FY06-FY07 outpatient, inpatient and ED (Source: Facility Reports)

0

5 ,0 0 0

1 0 ,0 0 0

1 5 ,0 0 0

2 0 ,0 0 0

2 5 ,0 0 0

3 0 ,0 0 0

3 5 ,0 0 0

4 0 ,0 0 0

Q 1 Q 2 Q 3 Q 4 Q 1 Q 2 Q 3 Q 4 Q 1 Q 2 Q 3 Q 4

Num

ber

of

Uni

que

Pat

ient

s T

este

d

C on ve nti on al R H T

F Y 05 F Y 06 F Y 0 7


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But the use of rapid testing varied widely across facilities

FY07 outpatient, inpatient and ED (Source: Facility Reports)

74%

100%

96% 99

%

59%

100%

68%

100%

98%

35%

99%

90%

64%

99%

73%

95%

91%

26%

0% 4% 1%

41%

0%

32%

0% 2%

65%

1% 10%

36%

1%

27%

5% 9%

0%

20%

40%

60%

80%

1 00%

Bell Belv CIH Cumb Elm ENY G ouv H a rl Ja c K CH L inc M et M orr NC B Q ns R enn Wo od

% o

f tot

al te

sts b

y te

chno

logy

RH T Conv


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Patients in Care, Prevalence, Incidence and Venues


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People of color continue to represent the largest percentage of unique HIV positive patients in care…

FY06-FY07 All Venues (Source: PLM Database)

5 %5 %

3 5 %

5 3 %

1 %5 %4 %

3 5 %

5 4 %

1 %0

2 ,0 0 0

4 ,0 0 0

6 ,0 0 0

8 ,0 0 0

1 0 ,0 0 0

1 2 ,0 0 0

1 4 ,0 0 0

1 6 ,0 0 0

1 8 ,0 0 0

2 0 ,0 0 0

A S I A N B L A C K H I S P A N I C O T H E R W H I T E G r a n d T o ta l

HIV

pat

ient

s in

care

by

race

F Y 0 6 A ll V en u es F Y 0 7 A ll V en u es

1 0 0 %1 0 0 %


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While men continue to represent the largest number of unique HIV positive patients in care

FY06-FY07 All Venues (Source: PLM Database)

6 1 %

3 9 %

6 1 %

3 9 %

0

2 ,0 0 0

4 ,0 0 0

6 ,0 0 0

8 ,0 0 0

1 0 ,0 0 0

1 2 ,0 0 0

1 4 ,0 0 0

1 6 ,0 0 0

1 8 ,0 0 0

2 0 ,0 0 0

F E M A L E M A L E G ra n d T o ta l

HIV

pat

ient

s in

car

e by

sex

F Y 0 6 A ll V en u es F Y 0 7 A ll V en u es

1 0 0 %1 0 0 %


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Both the total number of unique patients who tested HIV positive and the subgroup newly diagnosed with HIV increased in FY07

FY06-FY07 outpatient, inpatient and ED (Source: Facility Reports)

1,514

774

1,630

8 64

0

20 0

40 0

60 0

80 0

1,00 0

1,20 0

1,40 0

1,60 0

1,80 0

All Pa tients w /HIV Po sitive R esults New ly Dia gnosed HIV Po sitiv e Pa tie nts

F Y06 F Y07

Tot

al H

IV p

ositi

ve a

nd n

ewly

dia

gnos

ed

8%

12%


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Most networks focused their expansion efforts in the outpatient and ED areas


87%

66%

74%

68%

54%

78%

71% 69%

9% 9%4%

8% 7%4%

12%8%

4%

25%21%

25%

39%

19% 18%

24%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

C. Bkln Gen + N. Brx N. Bkln Qns S. Bk ln S . Man . C orp.

% o

f tot

al te

sts

by v

enue

Outpatient Inpatien t ED


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Across all networks, prevalence was highest in inpatient units


1%

1%1 %

2%

1%0 %

2%

1%

6%

3%

6 %

4%

3%

4 %

5%

4%4 %

1% 1% 1 %

1% 1%

2 %

1%

0 %

1 %

2 %

3 %

4 %

5 %

6 %

7 %

C. Bkl n G en + N . B r x N. B kln Qns S. B kln S . M an. C or p.

HIV

pre

vale

nce

by v

enue

OP IP ED


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As was the percentage of newly diagnosed HIV positive patients


0 .6%0.4 %

0.3%

0 .6%0.4 %

0.3%

0 .6%0.5 %

4 %

1%

3%

2 %2%

4 %

2%2%

2.2%

0 .9% 0.8 %1.1%

0. 4% 0.5 %

0 .9%0. 8%

0%

1%

2%

3%

4%

5%

C. B kln G en + N . B r x N. B kln Qns S. B kln S . M an. C or p.

HIV

Pre

vale

nce

by v

enue

OP IP E D


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Preliminary utilization data suggest the proportion of newly HIV positive individuals may be greater in HHC than in the city as a whole

FY07 outpatient, inpatient and ED (Source: Facility Reports)NYC Incidence (Source: NYCDOHMH HIV Incidence Estimates Using STARHS – the serologic testing algorithm for recent HIV seroconversions. CROI poster 2/2007)NYC Prevalence (Source: NYC HIV/AIDS Annual Surveillance Statistics. 12/2006)

HHC Incidence

0.76%0.45%

2.02%

0%

1%

2%

3%

4%

Outpatient Inpatient ED

HHC Prevalence

3.78%

0.98% 1.08%

0%

1%

2%

3%

4%

Outpatient Inpatient ED

HHC Prevalence = 1.22%NYC Prevalence=1.2%

HHC Incidence = .65%NYC Incidence = .31%


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Patients newly diagnosed with HIV in outpatient areas aremore likely to be scheduled for and keep their first HIV primary care appointment


94 %

6 8%

85 % 86 %90 %

77% 7 9%84 %

0 %

20 %

40 %

60 %

80 %

1 00 %

O u tp atie n t I n p a t ien t ED To tal

% o

f new

ly d

x pa

tient

s sch

edul

ed a

nd k

eepi

ng a

ppoi

ntm

ent

A p p oin tm en t M a d e A p p o in tm e n t K e p t


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Of patients newly diagnosed with HIV who kept their first HIV appointment, fewer were concurrently diagnosed with AIDS in FY07 vs. FY06

FY06-FY07 outpatient, inpatient and ED (Source: Facility Reports)

2 5 %

5 4 %

3 6 %3 2 %

1 6 %

3 2 %

2 3 %2 1 %

0 %

1 0 %

2 0 %

3 0 %

4 0 %

5 0 %

6 0 %

O u t p a t ie n t I n p a t ien t E D T o t a l

F Y 0 6 F Y 0 7

Prop

ortio

n of

New

HIV

dx

conc

urre

ntly

dx

AID

S by

ven

ue


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Accomplishments• Large-scale implementation led to the identification of a

significant number of individuals who would not likely otherwise have taken the opportunity to test.

• Rapid HIV testing is now available at all HHC acute care hospitals and D&TCs (17 sites).

• All HHC acute care hospitals now offer HIV testing in multiple venues: ED, inpatient units and at least three outpatient clinics (including Dental, Medicine, Women’s Health Services, Adolescent Health Services and Chemical Dependency).


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Variables that impact the expansion of testing across HHCDrivers

– Widespread use of a rapid, easy-to-use HIV test– Consistent use of the streamlined HIV counseling model

with regular monitoring and evaluation– Clinical and executive level commitment to expand testing

within the facilitiesInhibitors

– Number of clinicians offering and conducting testing at some facilities

– Availability of interdisciplinary teams 24/7– Dedicated space for counseling HIV-positive patients in all

venues


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Data Caveats• FY05 testing data represents outpatient and ED Pilot Sites

only.• Data for FY06 and FY07 HIV-positive patients in care reflects

patients connected to care at the time of report and does not capture patients who may have entered care at a later date.

• The number of unique patients tested for HIV is based on patient self-report and facility medical records.

• Identification of ‘new diagnosis’ is based on patient self-report and facility medical records.

• Medical records are unique to each facility and in some cases, networks. It is possible in some instances that counts are not unduplicated between sites.


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Summary messages• Encouraging patients to know their HIV status is a

message that resonates with health care professionals.• The presence of clinician champions and well

functioning, interdisciplinary teams can significantly improve testing rates.

• Inpatient testing provides significant opportunities as well as challenges in complex teaching facilities.

• Best practices for successful expansion of HIV testing will look different at each facility – one size does not fit all.

• HHC - facilities and centrally - will continue to examine the data being generated to inform long-term direction and other service and policy implications.


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Acknowledgements and Appreciation

Terry Hamilton, Director of HIV Services, HHCDrew De Los Reyes, Senior Management Consultant, HHCJay Gabor, Senior Management Consultant, HHCJudy Aberg, MD, Medical Director of HIV Services, Bellevue Hospital Center and the HHC South Manhattan Network

The dedicated physicians, nurses, administrators, patient care associates, HIV counselors, phlebotomists, lab directors and many others throughout HHC who have contributed to the HIV testing expansion effort


Documents

HHC Integration of HIV Testing Within Routine Care