Transcript Slide 1

in+care Campaign
Webinar
November 9, 2011
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Agenda
• Welcome & Introductions, 5min
• Story from the Field - Retention for HIV-infected
Youth, 10min
• in+care Campaign Measures, 15min
• Review of Campaign Pre-Work, 15min
• Story from the Field - Retention in Care on Release
from Corrections, 10min
• Q & A Session, 5min
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Retention in Care for
HIV-infected Youth
Thomas P. Giordano, MD, MPH
Associate Professor of Medicine
Sections of Infectious Diseases and
Health Services Research
Baylor College of Medicine
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Eras of Service for Youth at Thomas Street
Health Center
• Decentralized care – 1/1/2002 to 2/28/2004
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No youth specific services available
• Centralized care – 3/1/2004 to 3/31/2007
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•
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Multidisciplinary youth clinic
Adolescent care providers
Youth-specific case manager
• Centralized care plus enhanced supportive services– 4/1/2007 to
8/31/2008
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Youth support groups and educational activities
Motivational interviewing training for case managers
Focus on teaching healthcare navigation skills
Objective and Methods
 Objective: To examine differences in retention in HIV care among African
American and Hispanic youth who presented for primary HIV care during
three distinct eras of youth services
 Retrospective cohort study of African American and Hispanic youth (13-23
years old) who entered TSHC care during those eras.
Visit constancy = 2/4 quarters (50%); Gap = yes
 Good constancy = Medical visit during 3 or more quarter years (>75% visit
constancy) during the 12-month follow-up period
 Gap in care = > 6 months between any two consecutive visits during the
12-month follow-up period
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Proportion of Patients with Good Constancy in
Care, by Era (n=174)
Overall, 42% with good constancy in care
80
70
Overall p-value: p=0.01
Decentralized vs. centralized: p<0.01
Centralized vs. enhanced: p<0.01
69.4
56.7
60
50
40
64.6
43.3
35.4
30.6
30
20
10
0
Decentralized
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Centralized
Centralized +
Enhanced
Poor
constancy
Good
constancy
Proportion of Patients with No Gaps in Care,
by Era (n=174)
Overall, 85% with no gaps in care
Overall p-value: p=0.04
Decentralized vs. centralized: p=0.67
Centralized vs. enhanced: p=0.01
120
100
83.3
95.8
80
Gap in
care
80
No gap in
care
60
40
20
16.7
20
4.2
0
Decentralized
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Centralized
Centralized +
Enhanced
Logistic Regression Models of Retention in
Care, by Era
Unadjusted odds
ratio
(95% CI)
p-value
Adjusted* odds ratio
(95% CI)
p-value
0.34 (0.15, 0.77)
<0.01
0.42 (0.17, 1.03)
0.06
Adequate visit constancy
Decentralized
Centralized
Centralized + Enhanced
Referent
Referent
1.40 (0.68, 2.88)
0.37
1.18 (0.55, 2.53)
0.68
1.25 (0.45, 3.45)
0.67
1.37 (0.46, 4.17)
0.57
No gap in care
Decentralized
Centralized
Centralized + Enhanced
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Referent
5.88 (1.27, 25.0)
Referent
0.02
5.66 (1.20, 25.0)
0.03
Opportunities for Increasing Retention in Care
Targeted at Sub-populations
 Centralize clinical and social services
 Increase cultural competency
 Target case management
 Organize targeted support groups, educational
opportunities, and networking activities
 Teach skills to navigate healthcare system
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Acknowledgements
• Funded in part by the Special Projects of National Significance
(SPNS) Young MSM of Color Initiative, HRSA
• Supported in part by facilities and resources of the Harris
County Hospital District and the Houston VA Medical Center
• Presented in part as:
Davila JA, Miertschin N, Sansgiry S, Mitts B, ParkinsonWindross D, Henley C, and Giordano TP. “Centralization of
HIV services in HIV+ African American and Hispanic youth
improves retention in care.” Fifth International Conference on
HIV Treatment Adherence in Miami, FL, May 23-25, 2010
(Oral Presentation)
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in+care Campaign
Measures and Data
Collection Details
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Measurement Framework
• Performance data submissions on up to 4 Campaign
measures every other month – Dec 1, Feb 1, Apr 1, Jul 1
• Four Campaign retention measures have been developed
in coordination with our TWG with detailed definitions
• Submit performance data to online Campaign database
at incareCampaign.org/database
• Encouraged to use your entire caseload; sampling is
allowed using the HIVQUAL sampling methodology
• Dec 1 – initial submission deadline; measurement
period: 10/01/2010 – 09/30/2011
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1) Gaps in Care
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1) Gaps in Care
Patient A
Month 1
Month 6
Month 12
Month 6
Month 12
Patient B
Month 1
= Medical Visit
= Meets Numerator Definition (Gap in Care)
= Does Not Meet Numerator Definition
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2) Medical Visit Frequency
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2) Medical Visit Frequency
Patient A
Month 1
Month 6
Month 12
Month 18
Month 24
Month 6
Month 12
Month 18
Month 24
Month 6
Month 12
Month 18
Month 24
Month 6
Month 12
Month 18
Month 24
Patient B
Month 1
Patient C
Month 1
Patient D
Month 1
= Medical Visit
= Meets Numerator Definition
= Does Not Meet Numerator Definition
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3) Patients Newly Enrolled in Medical Care
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3) Patients Newly Enrolled in Medical Care
Patient A
Month 1
Month 4
Month 8
Month 12
Month 4
Month 8
Month 12
Patient B
Month 1
= Medical Visit
= Meets Numerator Definition
= Does Not Meet Numerator Definition
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4) Viral Load Suppression
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4) Viral Load Suppression
250
Patient A
Month 1
Month 6
Month 12
Month 6
Month 12
Patient B
Month 1
150
Patient C
Month 6
Month 1
Patient D
150
Month 6
= Viral Load Test Result
= Meets Numerator Definition
= Does Not Meet Numerator Definition
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Month 12
150
250
Month 1
250
Month 12
Campaign Measures
• Gaps in Care (no visit in the last 180 days)
• Medical Visit Frequency (every 6 months over 24
months)
• Patients Newly Enrolled in Medical Care (every 4
months)
• Viral Load Suppression (last VL, <200 copies/ml,
all pts in care)
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Campaign Database
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Allows participating agencies to track their
performance data over time and have immediate
access
• to regional/national benchmarking reports
• to reports based on common search criteria
• to group scores of established groupings
Form a group of grantees, which would allow them
to generate group reports, such as HIVQUAL
regional groups, collaboratives, networks
Next Steps:
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Register one person to use the in+care database at
incarecampaign.org/database
Become familiar with the Campaign measures and
definitions
Enter your in+care Campaign data in the online
database
Review and validate your retention measure data
Review your own data and benchmark against those
of others
Construct your Sample
1. Identify Eligible Patients
• Review all records for eligibility
2. Determine the minimum number of
records to be reviewed
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Determine the minimum number of records needed
from the Sample Table
3. Select Charts Randomly for Review
• Obtain a random number set equal to the
number of records needed
• Apply the random number sets to the lists of
eligible records using the sequence you
created when numbering your lists
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Reviewing Campaign
Pre-Work
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Campaign Pre-Work Assignments
1. Retention Follow-up Pool Tool - developed to help
participating agencies to determine the Retention
Follow-up Pool - the group of patients who should be
targeted by retention follow-up activities
2. Lessons Learned Form – provide opportunity to
share your retention experiences, best practices and
lessons learned with retention with the Campaign peer
learning community
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28,424
23,635
4,789
3,680
1,124
84
27
243
789
2,493
683
Retention Follow-Up Pool
What were the Retention Follow-Up Pool results?
• 41 providers submitted data representing 28,424 HIV
patients with a visit in the first six months of 2010
• Of these patients 4,789 were out of care
• Of the 4,789 who were out of care, 3,680 were
determined to need follow-up
• 87% of HIV patients served by these providers were
retained in 2010
• 1 in 8 HIV patients were not retained
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Retention Lessons Learned Form
Follow-up Contacts with Consumer
• Follow-up calls and letters after a missed appointment
• Follow-up home visits after missed appointment
• Periodic queries through EMR of patients who have
not had visit in last 6 months, and who have not had
CD4 in last 6 months
Consumer Access to Medical Services
• Provide transportation cards/passes (Metro Card,
Smart Card, etc…) or tokens in urban setting
• Pick-up patient with program vehicle
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Retention Lessons Learned Form
Inter-agency Communication
• Using centralized source of data to see if patient is in
care somewhere else (role for Part A and Part B
grantees)
• Case managers notified when patients miss medical
appointments
• Provider communication with designated ADAP
pharmacy to ensure patient accessing medications
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Retention Lessons Learned Form
Preventative Approaches
• Close contact through case manager or patient
navigator until patient is fully engaged (i.e., two visits)
• ‘Red Carpet Treatment’ with walk-in appointments
available for new patients
• Motivational interviewing training for all staff
• Performance measure results in or near waiting room
so that information is readily available to patients
• Focus groups and key informant interviews each year
• Case manager notifies patient of appointment two days
in advance of appointment
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Corrections and Retention:
Supporting Retention in Care
on Release from Corrections in
RI
Brian Montague, DO MS MPH
Assistant Professor of Medicine in the
Division of Infectious Diseases at Brown
University and the Miriam Hospital
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Problem of Correction for Retention
• Short (Jails) vs Long-Term Stays (Prison)
• Maintaining continuity of care requires continuity of
data from corrections to community (and at times
back)
• Recognizing need to retain patients in care through
their incarceration
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Rhode Island Model
• Miriam Hospital Immunology Center
• Ryan White Part B and Part C provider
• Serves 75% of patients with HIV in RI
• Adult Corrections Institute
• Combination Jail and Prison for RI in single facility
• Physicians from Miriam Hospital Immunology Center
provide HIV care services to persons in ACI
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Retention Projects
• Projects Bridge (Prison) and Compass (Jails)
• Intensive case management model
• Connect with patients in corrections
• Accompany patients to visit and facilitate access to
needed services
• Started as special projects, sustaining support
through Ryan White Part B from RI DOH (Project
Bridge)
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Project Bridge Jan-June 2011
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Active caseload of 30 individuals (7 individuals newly released during the
reporting period).
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3/7 were released to the community-living with family
2/7 released to an intensive dual diagnosis unit
1/7 released to a sober housing environment
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1/7 to a homeless shelter.
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All had an HIV primary visit scheduled prior to release and were seen within the
first 30 days of release.
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23/30 (77%) had at least one primary care visit within the reporting period.
Of the remaining 7 23% no pcp visit. Of these
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2/7 case was closed
2/7 lost-to-follow-up
2/7 re-incarcerated
1/7 deceased
Integrating Corrections Projects into Retention
• For jails (short-term stays), standard indicators may
be useful, programs are a model for supporting
retention
• For prisons, pool of persons to be released needs to
be included in retention pool as they will drop out
using standard indicators
• Assumes patients are in care during time of incarceration
• If not in pool, the recently released may need to be
considered as New to Care
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Challenges
• Developing communications protocols between
community and corrections providers
• Assuring standard of care for treatment within
corrections
• Accommodating uncertainty in release date
• Building relationship prior to release to support
outreach in community
• Leveraging community resources where funding for
special projects not available
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Time for Questions
and Answers
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Next Steps
• Meet the Author – Dr. Edward Gardner:
November 16, 2011 at 12pm ET
• Data Collection Submission Deadline: December
1, 2011
• Next Webinar: December 7, 2011 at 1pm ET
• Improvement Update Submission Deadline:
December 15, 2011
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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
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