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in+care CampaignWebinar

March 14, 2012

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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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Agenda

• Welcome & Introductions, 5min• Strategies to Maintain Retention in

Care Over Periods of Incarceration, 30min

• Review of Best Practices Collected, 20min

• Q & A Session, 5min

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Strategies to Maintain Retention in Care Across Periods of Incarceration

Brian Montague, DO MS MPHDivision of Infectious DiseasesWarren Alpert School of Medicine at Brown University

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HIV in Corrections

• Since the early years of the HIV epidemic, HIV has disproportionately impacted prisoners.

• In 2008, the HIV prevalence was 1.6% among the state prisoners, representing 20,449 people.3 

• Approximately 150,000 HIV-infected persons, 14% of all Americans with HIV, pass through corrections each year.4, 5

• The prevalence of HIV within correctional settings ranges from 2.5 to more than 3 times that of the general population with prevalence in high prevalence communities such as Baltimore and Washington D.C. as high as 6.6%.3, 5, 6

• Minority disparities in HIV care are amplified in corrections

1. Montaner JS, Lima VD, Barrios R, et al. Lancet. Aug 14 2010;376(9740):532-539.2. Conway B, Tossonian H. Current Infectious Disease Reports. 2011;13(1):68-74.3. BJS. Bulletin HIV in Prisons 2007-2008. In: Justice, ed. Washington, DC: Department of Justice; 2009.4. Spaulding AC, Seals RM, Page MJ, Brzozowski AK, Rhodes W, Hammett TM. PLoS One. 2009;4(11):e7558.5. Boutwell A, Rich JD. Clin Infect Dis. Jun 15 2004;38(12):1761-1763.6. Solomon L, Flynn C, Muck K, Vertefeuille J. J Urban Health. Mar 2004;81(1):25-37.

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Disproportionate Impact on Minorities

• African Americans are incarcerated at 6 times the rate of whites1

• HIV disproportionately impacts African Americans• 7 times the rate of HIV infection• constitute 45% of new HIV

infections nationwide2

• Nearly twice as likely to lack health insurance3

• Nearly 50% of Ryan White program clients are African American41. Sabol WW, West HC, Cooper M. Prisoners in 2008. BJS Bulletin. Washington, DC: US DOJ Bureau of Justice Statistics, 2010; NCJ 228417.2. Hall HI, Song R, Rhodes P, et al. Estimation of HIV incidence in the United States. JAMA 2008; 300:520–9.3. KFF. The uninsured: a primer. Washington DC: Kaiser Family Foundation, 2010.4. http://hab.hrsa.gov/data/files/2010progressrpt.pdf

http://irishgreeneyes-welcometomyworld.blogspot.com/2011/06/infographic-not-guilty-program-seeks-to.html

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Risks on Reentry

― CD4 declines, viral load increases at reincarceration and return to care1,2

― Texas experience: 5.8% fill ARV prescription in time to avoid gap in treatment3

1. Springer et al. Clin Infect Dis. Jun 15 2004;38(12):1754-1760. 2. Stephenson et al. Public Health Rep. Jan-Feb 2005;120(1):84-88.3. Baillargeon J, et al. JAMA. Feb 25 2009;301(8):848-857.

http://www.mlive.com/news/muskegon/index.ssf/2010/01/mentoring_program_focused_on_c_1.html

• Health gains during the stay in corrections are often lost at the time of reentry

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Patterns of Incarceration

• Jails• Typically short term stays• Often unpredictable time of release• Less likely to result in interruption in

services

• Prisons• Generally long-term stays• Incarceration may lead to termination of

Medicaid or other insurance benefits

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Common Risks

• Incarcerated persons may lose housing or other social supports during incarceration

• High rates of substance abuse and other transmission risk events both leading up to incarceration and on reentry

• Treatment Interruption

• Incarcerated persons often experience at least short term interruptions in treatment on entry

• Gaps in treatment frequently occur on release

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Challenges

• Lack of communication between community and correctional care systems• Difficulty determining who is incarcerated

and when release is planned• Limited coordination regarding care plan

• Homelessness or lack of reliable contacts for persons on reentry limits outreach

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Retention Pool

• Standard definition is those in care who are at risk of falling out

• Distinguished from reengagement in which those who are out of care are encouraged to return

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Are the Incarcerated In Care?

• May not be seen in clinic during period of incarceration, but:• Often intend to return to clinic on release• May have access to and continuity of

treatment while incarcerated• Are high risk for loss to care on release if

transitions are not managed well

• Analogous to those transitioning care to another practice from point of view of retention

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Models for Supporting Retention

• Case management• BRIDGE/Compass

• Active review of incarceration rolls for known patients

• Recruitment while incarcerated for intensive case management on release

• Case manager facilitates access to services and may transport or accompany patient to care visits

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Compass

• Intervention Group: Jails • 71 individuals completed intervention

• 78% male, 65% African American• ⅔from RI and ⅓ from MA• 89% reported some insurance benefit available• 7 moved out of catchment area on release, 2 were

reincarcerated, 1 refused services, 1 died

• 60 completed follow-up

• Outcomes• 60% made it to first scheduled PCP

appointment

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Bridge

• Intervention Group: Prison (Sentenced)• 230 clients enrolled since inception

• 67% male, 40% African American, 13% Hispanic (60% minority or multiracial)

• At baseline on release, 49% had no health insurance• At completion of the program 18% remained

uninsured with pending applications

• Outcomes 2010-2011:• 2010-2011: 31 active patients, 25 seen by case

manager and attended 1 or more appointments• 7 (24%) lost to follow-up of which 2/7 refused

services or were reincarcerated prior to outpatient follow-up

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Evaluating the Success of Your Program

• Cannot measure it only by those who link to care

• Requires linkage of corrections data and clinical data set

• Outcomes both keeping follow-up appointment and maintaining treatment

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Model Evaluation Strategy

• Link client level data from Ryan White reporting to corrections release data to create metrics for adequacy of linkage to care• In many jurisdictions, Ryan White likely the

first payer on reentry• CLD reporting includes both dates of service

and clinical status measures (CD4 and VL)• eUCI identification provides confidential

means of linking data sets

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Model Evaluation Strategy:Validation in RI

Sentenced Data (6815)

Un-sentenced Data (36061)

Complete Data (42876)

10307 Inmates

ACI Data(n=10555)

De-duplication

Matching with HIV Clinic Data (n=1431)

188 Possible Matches

Prison HIV Database Verification

Released back tothe community

102 HIV-infected inmates and 79 linkages

44 True Matches

Paper-based Chart Verification

58 HIV-infected Inmates

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Validation in RICharacteristic Prison Clinic  10307 1432Average age (SD) 34.67(10.81) 45.76(10.51)Gender        

Male 8810 85.5% 992 69.3%

Female 1492 14.5% 438 30.6%

Transgender 1 0.01% 2 0.1%

Unknown 4 0.04% -- --

Race/ethnicity        

White 5781 56.1% 658 45.9%

Black 2394 23.2% 395 27.6%

More than 1 race -- -- 8 0.6%

Hispanic 1894 18.4% 325 22.7%

Asian 98 1.0% 24 1.7%American Indian 62 0.6% 12 0.8%Other Race -- -- 7 0.5%Native Hawaiian/Pacific 53 0.5% 2 0.1%Unknown 28 0.3% 1 0.1%

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Match Results

Matching Methods

Deterministic

Match by name related eUCI

Match by alias related eUCI

Match by names

Match by names, gender

Match by names, DOB , gender

Match by names, DOB

eUCI matching

Match by alias

Match by alias , gender

Match by alias, DOB , gender

Match by alias, DOB

Name related

Alias related

Name related

Alias related

Match:86, Linkage:77

Match:91, Linkage:82

Match:157, Linkage:117

Match:154, Linkage:114

Match:74, Linkage:68

Match:74, Linkage:68

Match:177, Linkage:133

Match:173, Linkage:129

Match:81, Linkage:74

Match:81, Linkage:74

True Match = 102; True Linkage = 79

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Next Steps

• Assessment of linkage adequacy• Time to linkage• Clinical status at linkage

• Once metrics are developed, the goal of these is to inform ongoing efforts towards program improvement

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Action Steps• Define your population: what is the real scope of the problem?

• Develop communication protocols with local correctional facilities for continuity of care while incarcerated and discharge planning

• Notification on incarceration and release (similar to hospital best practices)

• Track incarcerated patients

• Develop procedures for rapid reintake for persons on release (same day visits)

• Restore patients to retention pool on release treating them as in care during prior 6 months

• Case managers if engaged can provide invaluable support.

• Develop partnerships between clinical providers and ASO’s to support smooth transitions of care

• Develop strategies to address barriers to retention in this population

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Best Practices Exercise

Michael Hager, MPH MANQC Manager

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in+care Campaign National Data Snapshot

December and February Data as of 03/14/2012

Dec Average

Feb Average

Dec Patients

Feb Patients

Dec Sites

Feb Sites

Measure 1: Gap Measure 15.97% 15.89% 106,680 103,205 182 162

Measure 2: Visit Frequency Measure 62.39% 67.13% 63,811 58,248 107 95

Measure 3: New Patient Measure 58.23% 59.71% 7,223 8,628 171 156

Measure 4: Viral Suppression Measure 67.93% 69.32% 112,782 119,388 171 156

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Improvement Update Discussion

A) Interventions•↑ communication (internal and external)•↑ staff/volunteer/intern presence in waiting room•↑ staff/volunteer/intern presence in call center/reception•↑ data integrity maintenance•↑ reliance on performance measure reports appropriate for your service setting

•↑ consumer engagement by convening a joint-CAB between agencies that have struggled establishing CABs individually

•Use more/new data sources to find patients who are ‘lost’•Patient navigation programs

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Improvement Update Discussion

B) Barriers • Housing Status forces patients to focus on other

things• Homeless patients are difficult to contact/track• Transportation unavailability makes care inaccessible• MH/SA comorbidities force providers and patients to

focus on those issues first• Childcare unavailability makes care inaccessible• Challenging to navigate payer changes• Lengthy/challenging applications for charity care• Varying interpretations of HIPAA

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Improvement Update DiscussionC) Lessons Learned• Senior leadership at quality meetings ↑ likelihood for success• High patient satisfaction is a strong predictor for high

retention• Decreased wait times are strongly correlated with patient

satisfaction results• Screen for and address issues not related to HIV• Build trust with patients and then take advantage of that

trust• Patient orientation offerings help patients feel more

comfortable (or at least that your agency is looking out for them)

• Exit interviews for patients transferring away can provide very clear direction on opportunities for improvement

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Time for Questions and Answers

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Announcements

• Partners in+care website is live! (check Partners tab)

• New CAREWare build is available for all 4 Campaign Measures – go to www.incarecampaign.org

• Visit www.nationalqualitycenter.org to learn more about NQC Awards Program or to apply• Award for Performance Measurement• Award for Quality Improvement Activities• Award for Quality Management Infrastructure

Development• Award for Leadership in Quality• Award for Consumer Involvement in Quality

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• Campaign Office Hours: Every Monday and Wednesday, 4pm ET

• Improvement Update Submission Deadline: TOMORROW March 15, 2012, 5pm ET

• Data Submission Deadline: April 2, 2012, 5pm ET

• Meet the Author: Dr. Michael Mugavero TOMORROW March 15, 2012 at 12:00pm ET

• April Webinar: Homelessness and RetentionApril 26, 2012, 2pm ET

Next Steps

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Campaign Headquarters:National Quality Center (NQC)90 Church Street, 13th floorNew York, NY 10007Phone 212-417-4730incare@NationalQualityCenter.org

incareCampaign.orgyoutube.com/incareCampaign