Transcript Document

in+care Campaign
Webinar
February 26, 2013
1
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2
Agenda
•
•
•
•
•
•
3
Welcome & Introductions
Robert Wood Johnson AIDS Program, 15min
Broward County EMA, 15min
Gurabo Community Health Center, 15min
Panel Dialogue and Q&A Session, 15min
Updates & Reminders
Submit Improvement Updates!
4
Robert Wood Johnson AIDS Program
New Brunswick, NJ
Roseann Marone, RN
OVERVIEW OF RWJAP –
• Located in central NJ—serving patients since 1983• Evolution of disease in NJ--- went from a very
acute to including lengthy hospital admissions to a
chronic disease
• Receives Part A and D and B funding
• Multidisclipinary Team
• Member of seven site statewide network
6
EARLY CONSUMER INVOLVEMENT
• Fifteen year process with foundation built from
‘early days’---• Parents met each other as in patients and at program
events
7
EVOLUTION OF CONSUMER
INVOVLEMENT FOR PART D
• FAMILY ADVISORY COUNCIL—identified
Family Representative
• Monthly Executive Committee meetings--Consumer
attendees—
• Annual Family Day—consumer driven
• Annual VOICES Conference-consumer advocacy
8
PEER MENTOR PROGRAM
• Purpose: To encourage women to return to care
• Program Coordinator obtains patient permission
for PM to contact patient. Release is signed
• Patient’s name and phone number shared with PM
• PM contacts patient and reviews special needs of
patient for returning to care
9
MAJOR BARRIERS FOR CARE
• Personal: family responsibilities, interpersonal
relationships, lack of disclosure, lack of acceptance
about disease , poor understanding for the need of
consistent care, inability to complete paperwork for
entitlements, relocation
• Medical: treatment fatigue ,untreated or under treated
mental illness, relapse, substance abuse
• Financial: disconnected phone service, work hours,
job loss, under-insured or uninsured , expired ADAP,
co-pays for all visits
10
PEER MENTOR CHECKLIST
• Discuss reason for missed appointments, missed
refills
• Need for blood test
• Need for Pap Screening
• Need for ancillary specialists--
11
CHALLENGES
• Women are unable to talk during work hours
• Concern about disclosing diagnosis
• Fear of other family members finding out about
their status and need for care
12
LESSONS LEARNED
• Able to reengage women who were not in care
• Provided peer to peer support that providers could
not do
• Shared status promotes greater understanding
• Ability to completely understand individual’s
situation
13
+
Broward County EMA
Utilizing Non-Medical Services to Improve Retention in Care
Presenters:
Shaundelyn Degraffenreidt
Quality Assurance Coordinator, Ryan White Part A Program Office
Ariela Eshel
Quality Improvement/Technical Assistance Manager, Broward Regional Health
Planning Council
+
Broward County EMA Snapshot

Over 17,000 People Living with HIV/AIDS in Broward County

Approximately 7,000 Clients Receive Ryan White Part A Program Services Annually

12 Part A Providers


6 Core Services
Outpatient/Ambulatory Medical Care
 Oral Health Care
 Pharmaceutical Assistance
 Medical Case Management
 Mental Health Services
Outpatient Substance Abuse Treatment

4 Support Services
Non-Medical Case Management
 Food Bank
 Legal Services
 Outreach
+

Clinical Quality Management
(CQM) Program
CQM Program Mission


Ensure high quality services are provided to HIV+ Broward
residents that meet or exceed HAB’s clinical and other performance
measures, through an inclusive structure that integrates consumer
and provider input
CQM Program Oversight
Grantee
CQM
Staff
• Oversight
• Evaluation
• Networks
CQM
Support
Staff
• Data
Analysis
• Training
HIVPC
QMC
• Advise
• Monitor
QI
Network
Activities
QI
Networks
• Review
CLD
• Develop
and
implement
QIPs
• Improve
Outcomes
+
In+Care Campaign Involvement

The campaign aims to ensure efforts are aligned with the NHAS to
improve access to, and retention in, quality care that will help lower
individual and community viral loads

The Broward County EMA elected to participate in the In+Care
Campaign in October 2011

Aligns with the EMA’s vision for delivery of high quality care

Kicked off during an All Networks’ meeting

Network activities are guided by the goal of timely engagement,
linkage, retention and coordination of care


Data-Driven, Collaborative Structure
Programmed In+Care retention measures in PE

System-wide aggregate data

Provider specific data

Client-level data
+
MCM QIP Development

In June 2012, the MCM Network received agency specific
client level data for the Gap Measure


04/01/2011 - 03/31/2012
Each provider was asked to document the following:

Last Attended Medical Appointment

Reasons for Missed Appointment

Next Scheduled Medical Appointment

Date and Result of Last CD4 Test

Date and Result of Last VL

Data Source for Each Element (e.g., PE, EMR, client self-report)
+
Gap Measure Definition

Definition: Percentage of patients, regardless of age, with a
diagnosis of HIV/AIDS who did not have a medical visit with
a provider with prescribing privileges in the last 180 days of
the measurement year

Numerator: Number of patients who had no medical visits in
the last 180 days of the measurement year

Denominator: Number of patients, regardless of age, with a
diagnosis of HIV/AIDS who had at least one medical visit with
a provider with prescribing privileges in the first 6 months of
the measurement year
+
Exclusions

Patients documented to be deceased at any time in the
measurement year

Patients who were incarcerated for greater than 90 days of
the measurement year

Patients who relocated out of the service area or transferred
medical care at any time in the measurement year
+
Last Attended Medical Appointment
Agency A
Agency B
Agency C
Agency D
Agency E
Agency F
12
35
45
8
10
25
Last
Attended
Medical
Appt.
Range:
9.11-4.12
Range:
5.11-4.12
Range:
7.11-5.12
Range:
12.11-5.12
Range:
8.11-4.12
Range:
2.11-7.12
Data
Source
PE, EMR
PE, Client,
Client’s
PCP,
Another
Agency
EMR
EMR
PE, Client’s
PCP
PE, EMR
N
+
Reasons for Missed Appointments
N
Reason for
Missed Appt.
Agency A
Agency B
Agency C
Agency D
Agency E
Agency F
12
35
45
8
10
25
None
None
Incarcerated
New Client
Incarcerated
Incarcerated
Too Busy
with Work
Case Closed
(Client
Transferred)
Unaware of
Appt.
Failed to
Recertify for
RW
Appt. Was
Attended
Client
Moved
Unknown
Private
Insurance/
Medicaid
Unable to
Contact Client
Private
Insurance/
Medicaid
Incarcerated
Appt. Was
Attended
Receives
Care through
Another RW
Provider
Moved
Unable to
Locate
Client
Medicare/
Medicaid
SA
Treatment
Fallen Out of
Care
Data Source
Client
PE, No Source
Listed
Client, BSO,
EMR
No Longer
Eligible
Client,
Client’s
Emergency
Contact
PE, PCP
PE, EMR,
DOC/BSO
Website
+
Next Scheduled Appointment
Agency A
Agency B
Agency C
Agency D
Agency E
Agency F
12
35
45
8
10
25
Next Sch.
Med Appt.
Range:
4.12-7.12
Range:
5.12-8.12
Range:
2.12-8.12
Range:
6.12
Range:
5.12-6.12
Range:
3.12-9.12
Data
Source
EMR, PE
PE, Client’s
PCP
EMR
EMR
MCM, PCP,
Client
EMR, PE
N
+
CD4 and VL Results


58% detectable, 33% CD4<200


Agency D:
100% detectable, 33% CD4<200


Agency C:
47% detectable, 20% CD4<200


Agency B:
21% detectable, 16% CD4<200


Agency A:
Agency E:
90% detectable, 40% CD4<200


Agency F:
No results submitted
+
Discussion

Data Entry




Case Closure




EMR indicates client attended appointment
Medical appointment not entered in PE
Client included in the Gap Measure
Incarceration, moving, transferring to another provider, Private
Insurance/Medicaid/Medicare
These cases should have been excluded
In some cases, the last documented medical appointment was in May
of 2011 with the case remaining open
Progress Note Documentation


Little to no indication that MCMs are tracking medical appointments
In some cases, no communication with client for six months
+
Questions

How are appointments scheduled and tracked in the MCM
Plan of Care to ensure compliance with medical care?

Detectable Viral Load and CD4<200 may indicate noncompliance with care as well as possible eligibility for nonRW funded services (e.g., PAC Waiver). How are MCMs
utilizing lab results?

How can MCMs proactively work to prevent clients from
falling out of care?
+
Gap Measure
35%
30%
25%
20%
15%
10%
5%
0%
All
MCM
12.1.11
30%
17%
2.1.12
28%
15%
4.1.12
22%
12%
6.1.12
23%
10%
8.1.12
23%
12%
10.1.12
23%
12%
12.1.12
22%
9%
2.1.13
20%
8%
+
Medical Visit Frequency
80%
70%
60%
50%
40%
30%
20%
10%
0%
All
MCM
12.1.11
49%
70%
2.1.12
47%
67%
4.1.12
48%
67%
6.1.12
49%
68%
8.1.12
49%
68%
10.1.12
51%
69%
12.1.12
51%
73%
2.1.13
52%
73%
+
Patients Newly Enrolled In Medical
Care
80%
70%
60%
50%
40%
30%
20%
10%
0%
All
MCM
12.1.11
35%
55%
2.1.12
44%
58%
4.1.12
46%
55%
6.1.12
41%
57%
8.1.12
40%
56%
10.1.12
47%
65%
12.1.12
50%
69%
2.1.13
53%
72%
+
Viral Load Suppression
72%
70%
68%
66%
64%
62%
60%
58%
56%
All
MCM
12.1.11
66%
61%
2.1.12
67%
62%
4.1.12
61%
64%
6.1.12
61%
66%
8.1.12
61%
67%
10.1.12
62%
68%
12.1.12
70%
68%
2.1.13
70%
68%
+
Improvement Plan
Accomplishments

Increased provider accountability of
client health outcomes

Data driven/collaborative structure

Ability to generate client-level data

Revised client-level outcomes and
indicators

Programming of measure per service
category
Challenges

Resolving data integrity issues

Implementing system-wide retention
strategies

Barriers and competing needs:

Low income

Housing instability

Lack of transportation

Standing agenda item for all Networks

MH/SA related barriers

Peer retention program

ADAP crisis and subsequent barriers
to accessing medications
+
Major Accomplishment
The EMA received the NQC’s 2012 Award for Performance
Measurement
The award honors grantees that have significantly
strengthened their ability to measure the quality of HIV care
and services. The EMA was recognized for its capacity to use
an integrated software system to collect data on over 7,000
Part A clients annually, ongoing data-driven QI activities, and
refining CQM infrastructure that enhances systemwide
performance.
+
Other Retention Activities

The EMA is the first to pilot the FC/AETC’s Operation HOPEFUL
(Healthy Objectives for People Enjoying Full, Uninterrupted Lives
with HIV/AIDS) with Medical and MCM providers

A three-year health literacy plan is being implemented

Local Client Level Outcomes and Indicators revised to include
retention measures in each service category

Mental Health/Substance Abuse Network QIP Development:

Among the themes identified as impeding retention (severe depression,
chronic and persistent mental illness, homelessness, cultural barriers),
depression was noted as the greatest indicator of non-retention

The Network is developing trainings for other providers on identifying and
addressing mental health barriers to retention
+
Our Goal
To transition clients along the treatment cascade to full
engagement in HIV care and viral load suppression
+
Next Steps

Routine Data Review and Validation

Monthly QI Data Calls with Providers

Data Findings


Planning Council Process
Implementing QI Projects at System and Provider Levels
Preperation by: Denise Vega Alvarado, RN, BSN
Clinical Coordinator
Lcda. María Elena López Ramos
Health Educator
Marlene Pérez, Program Director
Objectives
• Detail the initiatives performed by
Program SIVIF under the development
of the InCare campaign.
• To share methods and strategies
established to encourage participant
retention
• Present analysis and evaluation of the
project with the results obtained up to
September of the year 2012.
• Projections to the year 2013
Background
• Program SIVIF provides intergrated service to individuals
infected with HIV/AIDS as well as their families and
significant others. The population of patients in the clinic
currently are 278.
• Retention campaign was welcomed in our quality program
for the initiative to promote retention through the
measures established by the National Quality Center.
• This considerably is priority for our Center to provide and
maintain medical care for our patients.
• Under this approach we were able to maximize our efforts
in preventing the patient from being out of treatment for a
long period of time.
Project Initiation
• We initiated with the study and discussion of
the four indicators of the retention campaign
through a team meeting which forms part of
the quality improvement Committee.
• Strategies were developed and established to
be used in the plan for 2012.
• We identified the national measures and the
measures established by the AIDS Task Force
of San Juan (TGA).
Measures achieved in 2011
80%
70%
60%
50%
40%
30%
20%
10%
0%
73.73%
71.34%
60.00%
Dec-11
9.89%
Barrier to
care
Frequent
visits
New
Viral load
patients supression
<200
Goal
• The overall goal of the campaign's
retention in our program is to increase
15% retention of patients receiving
services in the SIVIF program and link
to treatments according to suggest
guidelines for treatments for HIV/AIDS
patients health care + by the
Department of health and human
service (HRSA).
Objectives
• Provide services of physicians and link treatment
every 3 months.
• Provide services of laboratory and in link
treatment every 4 months.
• Identify absent patients to medical visits and
laboratory.
• Link newly enrolled patients to treatment within
a 30 day period.
• Monitoring the viral load of the patient to
achieve to reaching levels of less than 200
copies/ml or not detectable.
Determined goals
•
•
•
•
Barrier to care (Gap Measure) Decrease to= 7%
Frequent visits(Medical Visit) Increase: 88%
New patients (Patients Newly) Increase: 75%
Viral load supression<200 (Load Supresión) Increase: 86%
88%
100%
75%
73.73%
80%
86%
71.34%
60.00%
60%
Dec-11
40%
20%
Goal
9.89% 7%
0%
Barrier to care
Frequent visits
New patients
Viral load
Supression
Work Team
María Elena Lopez,
Health Educator
Dra. Antonia Márquez, HIV Treater
Denise Vega
Dr. Jose Ortiz, HIV Treater
(Clinical Coordinator)
Ilka Sánchez (Case Manager)
Maria Velez (Pharmacy Assistant)
Laura Méndez (Pharmacy Assistant)
Joel González (Case Manager)
Joann Ross (Case Manager)
Brenda Vélez (Receptionist)
Nelida López (Nurse)
Dorileen Vélez (Nurse)
José Marrero, Outreacher
Work Assignments
•
•
•
Health Educator
1.
Maintains a laboratory registry
2.
Refers lost patients to treatment to Case Manager.
3.
Monitors absences of appointments weekly.
4.
Audit records
5.
Guides and educates the patient about Incare campaign and
adherence to treatment.
Clinical Coordinator1.
Monitors the compliance of clinical services / processes
facilitator / case discussions.
Case Manager1.
Search for case and link to treatment (letters, calls, home
visits).
2.
Refer to Outreacher patients lost to treatment.
3.
Discussion of cases (medical, nutrition, psychologist).
4.
Educates the participant using the compliance agreement.
5.
Audits of records weekly (last medical visit).
Work Assignments
•
Nurse1.
2.
3.
•
•
Outreacher1.
2.
3.
Receptionist1.
2.
3.
4.
Identifies absent patient from medical and laboratory
appointment.
Register laboratories carried out daily.
Educates participants on the importance of adherence to the
treatment and the side effects.
Case-finding / visits to the home.
Offers free transportation
Coordinates with partner agencies to detox or psychological
treatment.
Identifies the absent patient by using program Proclaim as 'No
Show' system.
Confirm appointments and the laboratories the day before their
appointment.
Coordinates medical visits every three months and laboratories
every four months.
Continuously updates patient demographic information
Work Assignments
• Pharmacy1. Submits monthly report of patients
with poor adherence to treatment.
• Medical Personnel
1. Takes part in the discussion of
cases and facilitate strategies for
adherence to treatment.
Weekly strategies / Health Educator
and Case Management
Auditory/
absences,
Thursday or
Fridays
Meeting C.
Manager and H.
Educator /Calls
/Appointment
Referred to Case
Management/
Internal Referral
Mailing of
Correspondence:
Follow up in two
weeks
Patient search system
Identifies the patient
/ Refers Case
Management
Addiction Problems /
coordinates with Detox, to
link treatment
Outreach/ Link to
treatment/Offers
free transportation
Case management
begins search / Refer
Outreach
Mental Health Problems
/Coordinated service with
psychologist in program or with
a collaborated agency
Absence Results/ Services
Provided
Measurement of absence in 2012
100
90
80
70
60
50
40
30
20
10
0
90
70
49
78
72
68 68
49
71
54
63
56
Absence
Progress of both services
100%
January to April
99%
98%
97%
96% 96%
96%
95%
May to August
97%
96%
95%
94%
94%
94%
94% 94%
93%
92%
91%
90%
Laboratory
Medical Service
Both
September to
December
Results obtained until
September 30, 2012 /
Comparative data (five years)
Results
INC01 - InCare 1: Visit gap
Neo Med Center/ Program SIVIF
09/30/2012 17 / 268 = 6.34%
10/01/2011 17 / 252 = 6.75%
10/01/2010 30 / 249 = 12.05%
10/01/2009 22 / 236 = 9.32%
10/01/2008 27 / 237 = 11.39%
7% an under
goal
Results
INC02 - InCare 2 :Medical visit frequency
7% to
reached
Goal
Neo Med Center/ Program SIVIF
09/30/2012 200 / 248 = 81%
10/01/2011 166 / 246 = 67.48%
10/01/2010 144 / 232 = 62.07%
10/01/2009 143 / 231 = 61.90%
10/01/2008 129 / 221 = 58.37%
Results
INC03 - InCare 3: Patients Newly
enrolled in Medical Care
Neo Med Center/ Program SIVIF
09/30/2012 6 / 9 = 66.67%
10/01/2011 3 / 7 = 42.86%
10/01/2010 1 / 5 = 20.00%
10/01/2009 6 /11 = 54.55%
10/01/2008 3 / 5 = 60.00%
8% to
reached Goal
Results
INC04 - InCare 4: Viral load suppression
Neo Med Center/ Program SIVIF
09/30/2012 220 / 318 = 70%
10/01/2011 215 / 304 =70 %
10/01/2010 229 / 296 =77%
10/01/2009 199 / 281 = 70%
10/01/2008 179 / 277 = 65%
16% to
reached Goal
Summary
•
•
•
According to the progress in each indicator found
we hoped to establish reached goals for 2012. The
data of "Careware" will be fully reported in the
system by March 2013. Therefore it is
contemplated that month to present the project
closing of 2012.
Because of the importance of patient retention in
health care, the project "In Care" will be a quality
improvement project in 2013.
This project will be strengthened with the
implementation of the Health Project 100, which
aims to use innovative strategies to achieve viral
load suppression of the patient.
Projections for 2013
1. Support the implementation of the project
"Health 100" which aims to achieve suppression
of viral load of the patient being a partnership to
improve our indicator # 4.
2. Continue efforts to coordinate group activities for
patients: focus group, support group and
educational activities.
3. Keep the strategies used in the collection of data
(records) and weekly monitoring InCare team
that facilitated patient retention to 94% .
Remember
Time for Questions
and Answers
61
Announcements
62
Upcoming Events
•
Partners in+care Webinar: How Social Services Work with
Medical Services To Keep Us in+care – to be announced!
•
Combined Journal Club and Partners in+care Webinar:
Our Experiences and Retention in+care – to be announced!
•
Campaign Webinar: Patient Experience Evaluation and Retention
To be announced!
March Topic – Patient Experience Evaluation
April Topic – Viral Suppression as the Ultimate Goal
May Topic – Youth, Transition, and Retention in+care
June Topic – Latinos and Retention
63
Upcoming Deadlines and Office Hours
•
Campaign Office Hours:
Mondays & Wednesdays 4-5pm ET
• Wednesday, February 27 – Successful Partnerships with Social Services Providers
• Monday, March 4 – Open Space, no set topic
• Wednesday, March 6 – Integration of Retention Dialogues into Community
Processes and Conversations
• Monday, March 11 – Open Space, no set topic
• Wednesday, March 13 – Tackling HIV Stigma
• Monday, March 18 – Open Space, no set topic
• Wednesday, March 20 – Patient Waiting Time and QI Opportunities
•
Data Collection Submission Deadline:
April 1, 2013
•
Improvement Update Submission Deadline:
March 15, 2013
64
MedScape Retention in HIV Care Series
• Technical Working Group working on articles for a new
Medscape Today News Series.
• We recommend that you subscribe to HIV/AIDS MedPlus to
be informed of new and exciting articles in this series!
• Published Pieces:
•
•
•
•
•
•
•
•
•
HIV Care Retention and the Goal of an AIDS-Free Generation
Improving Retention in HIV Care in Resource-Limited Settings
Implementing QI in HIV Clinics to Improve Retention in Care
Monitoring Rates of Retention in HIV Care Across the State
How Health Departments Promote Retention in HIV Care
Improving Retention in HIV Care: Which Interventions Work?
Engaging in HIV Care: What We Learned from AIDS 2012
How Should We Measure Retention in HIV Care?
Retention In HIV Care: The Scope of the Problem
http://www.medscape.com/index/section_10285_0
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Partners in+care
• Partners in+care Private Facebook Group is live!
• Share tips, stories and strategies
• Join a community of PLWH and those who love them
• Email [email protected] for more details
• Partners in+care website is live!
• http://www.incarecampaign.net/index.cfm/77453
• Join our mailing list (a list-serv version of the FB Group)
66
Campaign Headquarters:
National Quality Center (NQC)
90 Church Street, 13th floor
New York, NY 10007
Phone 212-417-4730
[email protected]
incareCampaign.org
youtube.com/incareCampaign
67