Transcript Example Retention Monitoring Project (Arnot

The Hotspotters
Retention and VL Supression Monitoring Project
Ivy Clinic, Arnot Ogden Medical Center
DRAFT

Quality Improvement Team
Coordinator – Joan Cain, FNP-C, HIV
Specialist
 Treatment Adherence Counselor – Lynn Bassler
 Program Asst./QI Coordinator – Anna Lechowska
 Case Managers – Shannon Sprague and Lawanda
Robinson
 Clinical
Purpose

Purpose:
 To
test a care coordination process for managing
patients – “Hot Spotters” who fall out of care and
need targeted interventions and
 To
improve patient care for those patients who are
not retained and who do not have suppressed Viral
Loads <100 copies by testing targeted interventions
Performance Measures

HIVQUAL Retention measure:
Number of unique clients with at least 2 or more medical
visits during the past 12 months, one in each 6-month
period
_______________________________________________
Number of unique clients with at least 1 medical visit during
the past 12 months
HIVQUAL Viral Load Suppression
Guidelines

Value derived from the last viral load measurement of
the review period
 Not
Suppressed
 Detectable based on clinic lab definition
 No measurement in the last half of the review period
 Suppressed
 Undetectable based on clinic lab definition
 Most recent measure in the last half of the review period

Data reported by gender, race, ethnicity, risk/
transmission
Viral Load Measure
Viral Load Suppression measure:
All* patients with the most recent VL Test within
the last 6 months of the measurement year that
are considered undetectable based on clinic lab
definition - <100 copies
_______________________________________
All* eligible patients with at least one medical visit
in each of the 6 months in the measurement year
and at least on ART for 3 months.
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HIVQUAL Viral Load Suppression
Guidelines

Value derived from the last viral load measurement of
the review period
 Not
Suppressed
 Detectable based on clinic lab definition
 No measurement in the last half of the review period
 Suppressed
 Undetectable based on clinic lab definition
 Most recent measure in the last half of the review period

Data reported by gender, race, ethnicity, risk/
transmission
Viral Load Suppression Performance
Measure
Numerator: All* patients with a VL Test ((or
measure) within the last 6 months of the
measurement year that are considered
undetectable based on clinic lab definition
Denominator: All* eligible patients with at least
one medical visit in each of the 6 months in the
measurement year.
* Repeat measure replacing “All” with African
American patients, Latino patients, gay and bisexual male patients, male/female, by
risk/transmission
Background Information

Clinic’s Info:
- 246 active clients in March 2012, 96% of them on HAART.
Patients’ numbers doubled in last 8 years. (10 patients not on
HAART)
- Clinic’s goal is to see each patient every 3 months for primary care
visit with NP and bloodwork, and twice a year to follow up with
dietician, medical case manager and treatment adherence
counselor.
- 3 locations: Elmira (main), Ithaca and Bath (most recently
established), cover Chemung, Tompkins, Schuyler, Steuben, Tioga,
and growing into Cortland and Seneca counties.
Baseline Data – based on IPRO and
HIVQUAL reporting
2010 Data:


Retention rate – 91.6%
HIV viral load suppression – 77.6% undetectable (less
than 48)
2011 Data:


Retention – 94.6%
HIV viral load suppression:



57.6% undetectable (less than 20)
72.7% VL suppressed at less than 48
14% clients with VL over 100.
Improvement Goals

Increase percentage of clients with HIV
primary care visits every 3 months (or at
least one visit in each 6 month-period)

Increase percentage of clients with
undetectable HIV VL (less than 100).
Improvement steps

Identify clients most likely to miss appointments and
develop problems with treatment adherence.

Identify patterns in behavior that my lead to retention
problems and medication non-adherence, develop
prevention and care coordination plan and approach.
Model of Hotspotters team activities – test new process
Collection of Data by QI Coordinator
(based on Excell spreadsheets, eMD and AIRS reporting)
Meeting of the Team (second Friday of
the month), review of the data
Patients on HAART with HIV viroload
over 100
Patients not seen in 6 months
Review most recent clinic and adherence
data for the client
Identify individual retention problems
Contact the patient with lab results
(NP)
□ Schedule f/u bloodwork
□ Schedule visit with NP to discuss
the lab results
□ Schedule appointment with
Treatment Adherence Counselor
CM follows up with the patient
CM follows up with CBO
□ Schedule medical appointment with the provider
□ Schedule case management review with CM (if
needed, to follow up on patient’s issues)
□ Review outcome of interventions at the end of the month.
□ Update viroload information and follow up on scheduled appointments
□ Review client’s chart in eMD for possible coordination of care needs.
Treatment Adherence for people with VL
Self-Assessment
Do they know which meds to take, how many, and
when?
Review Missed Doses
Are they missing doses of their medication?
Identify Barriers
Figure out how many doses missing and why?
Medication Education
Provide medication and treatment education.
Review Medication Guidelines
Are they taking it appropriately (i.e., with food,
without splitting, with other meds)?
Reassess for Readiness
Determine if client is ready to take medications
(confidence and importance).
Develop Care Plan
Set client-focused goals to overcome adherence
barriers (if client is agreeable).
Resistance Testing
Determine if resistance has occurred and if a med
change needs to happen.
Overall Findings

Start of the project –
November 2011
- 60 clients on the list
- 25% no-shows
- 75% VL over 100
- 23% female/77% male

Current data March 2012
- 54 clients
- 13% no-shows
- 13% new clients
- 73% VL over 100
- 26% female/74%male
• 22 patient from November list remain on it in March
• 18%(4) no-shows/82%(18) VL over 100
• 32% female/68% male (note: higher number of women remaining on list for longer time)
• All of the clients remaining on the list were outreached to schedule an appointment,
repeat VL, run a resistance test and/or see Treatment Adherence Counselor.
• Patients with VL over 100: 61%(11) VL down, 28% (5) VL up, 2 – no change
• 2 clients restarted medications recently
• 5 clients with severe mental health problems – 4 enrolled in MH care
• 1 client refusing care, 1 about to be closed (MIA).