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in+care CampaignWebinar

February 26, 2013

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(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• Robert Wood Johnson AIDS Program,

15min• Broward County EMA, 15min• Gurabo Community Health Center, 15min• Panel Dialogue and Q&A Session, 15min• Updates & Reminders

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Submit Improvement Updates!

Robert Wood Johnson AIDS ProgramNew Brunswick, NJ

Roseann Marone, RN

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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

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EARLY CONSUMER INVOLVEMENT

• Fifteen year process with foundation built from ‘early days’----

• Parents met each other as in patients and at program events

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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

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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

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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

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PEER MENTOR CHECKLIST

• Discuss reason for missed appointments, missed refills

• Need for blood test • Need for Pap Screening• Need for ancillary specialists--

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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

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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

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Broward County EMAUtilizing Non-Medical Services to Improve Retention in Care

Presenters: Shaundelyn Degraffenreidt

Quality Assurance Coordinator, Ryan White Part A Program OfficeAriela 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

• Oversight• Evaluation• Networks

Grantee CQM Staff

• Data Analysis• Training

CQM Support

Staff

• Advise • Monitor QI

Network Activities

HIVPC QMC

• Review CLD• Develop and

implement QIPs

• Improve Outcomes

QI Networ

ks

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

+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

N 12 35 45 8 10 25Last 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

+Reasons for Missed AppointmentsAgency A Agency B Agency C Agency D Agency E Agency F

N 12 35 45 8 10 25Reason for Missed Appt.

None

Too Busy with Work

None

Case Closed (Client

Transferred)

Private Insurance/ Medicaid

Unable to Contact Client

Incarcerated

Unaware of Appt.

Unknown

Appt. Was Attended

Receives Care

through Another RW

Provider

Fallen Out of Care

New Client

Failed to Recertify for RW

Incarcerated

Moved

Medicare/ Medicaid

Incarcerated

Appt. Was Attended

Incarcerated

Client Moved

Private Insurance/ Medicaid

Unable to Locate Client

SA Treatment

No Longer Eligible

Data Source

Client PE, No Source Listed

Client, BSO, EMR

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

N 12 35 45 8 10 25Next 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

+ CD4 and VL Results

Agency A: 58% detectable, 33% CD4<200

Agency B: 21% detectable, 16% CD4<200

Agency C: 47% detectable, 20% CD4<200

Agency D: 100% detectable, 33% CD4<200

Agency E: 90% detectable, 40% CD4<200

Agency F: No results submitted

+Discussion

Data Entry EMR indicates client attended appointment Medical appointment not entered in PE Client included in the Gap Measure

Case Closure 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 non-compliance with care as well as possible eligibility for non-RW 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

12.1.11 2.1.12 4.1.12 6.1.12 8.1.12 10.1.12 12.1.12 2.1.130%

5%

10%

15%

20%

25%

30%

35%

+Medical Visit Frequency

12.1.11 2.1.12 4.1.12 6.1.12 8.1.12 10.1.12 12.1.12 2.1.130%

10%

20%

30%

40%

50%

60%

70%

80%

+Patients Newly Enrolled In Medical Care

12.1.11 2.1.12 4.1.12 6.1.12 8.1.12 10.1.12 12.1.12 2.1.130%

10%

20%

30%

40%

50%

60%

70%

80%

+Viral Load Suppression

12.1.11 2.1.12 4.1.12 6.1.12 8.1.12 10.1.12 12.1.12 2.1.1356%

58%

60%

62%

64%

66%

68%

70%

72%

+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 Standing agenda item for all Networks Peer retention program

Challenges Resolving data integrity issues Implementing system-wide retention

strategies Barriers and competing needs:

Low income Housing instability Lack of transportation MH/SA related barriers 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

Quality Project“In Care Campaign”

Preperation by: Denise Vega Alvarado, RN, BSNClinical Coordinator

Lcda. María Elena López RamosHealth 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

Barrier to care

Frequent visits

New patients

Viral load supression

<200

0%10%20%30%40%50%60%70%80%

9.89%

73.73%

60.00%71.34%

Dec-11

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%

Barrier to care Frequent visits New patients Viral load Supression0%

10%20%30%40%50%60%70%80%90%

9.89%

73.73%

60.00%

71.34%

7%

88%

75%86%

Dec-11Goal

Work TeamMaría Elena Lopez,

Health Educator

Denise Vega (Clinical Coordinator)

Ilka Sánchez (Case Manager)Joel González (Case Manager)

Joann Ross (Case Manager)

Nelida López (Nurse)Dorileen Vélez (Nurse)

José Marrero, Outreacher

Brenda Vélez (Receptionist)

Maria Velez (Pharmacy Assistant)Laura Méndez (Pharmacy

Assistant)

Dra. Antonia Márquez, HIV Treater

Dr. Jose Ortiz, HIV Treater

Work Assignments• Health Educator

1. Maintains a laboratory registry2. Refers lost patients to treatment to Case Manager.3. Monitors absences of appointments weekly. 4. Audit records5. Guides and educates the patient about Incare campaign and

adherence to treatment.• Clinical Coordinator-

1. Monitors the compliance of clinical services / processes facilitator / case discussions.

• Case Manager- 1. 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• Nurse-

1. Identifies absent patient from medical and laboratory appointment. 2. Register laboratories carried out daily. 3. Educates participants on the importance of adherence to the treatment

and the side effects. • Outreacher-

1. Case-finding / visits to the home. 2. Offers free transportation3. Coordinates with partner agencies to detox or psychological treatment.

• Receptionist- 1. Identifies the absent patient by using program Proclaim as 'No Show'

system. 2. Confirm appointments and the laboratories the day before their

appointment. 3. Coordinates medical visits every three months and laboratories every

four months.4. Continuously updates patient demographic information

Work Assignments

• Pharmacy- 1. 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

Mailing of Correspon

dence: Follow up

in two weeks

Referred to Case Management/ Internal

Referral

Meeting C. Manager and H. Educator /Calls

/AppointmentAuditory/ absences, Thursday or FridaysStep # 1

Step # 2

Step # 3

Step # 4

Addiction Problems / coordinates with Detox, to

link treatment

Mental Health Problems /Coordinated service with

psychologist in program or with a collaborated agency

Patient search system

Identifies the

patient /

Refers

Case Management

Case management

begins search /

Refer Outreach

Outreach/ Link to

treatment/Offers free transporta

tion

Absence Results/ Services Provided

Measurement of absence in 2012

January

February

March

AprilMay

JuneJuly

August

September

October

November

December

0102030405060708090

100

49

7078

90

68 68

49

72

54

7163

56

Absence

Progress of both services

Laboratory Medical Service Both90%

91%

92%

93%

94%

95%

96%

97%

98%

99%

100%

94% 94%

96%

97%

96%

94%

95%96%

94%

January to April

May to August

September to December

Results obtained until September 30, 2012 /

Comparative data (five years)

Results INC01 - InCare 1: Visit gap

Neo Med Center/ Program SIVIF09/30/2012 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%

National HIVQUAL –US

Average = 17.72%

7% an under goal

Results INC02 - InCare 2 :Medical visit frequency

Neo Med Center/ Program SIVIF09/30/2012 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%

National HIVQUAL –US

Average = 64.70 %

7% to reached

Goal

Results INC03 - InCare 3: Patients Newly

enrolled in Medical Care

Neo Med Center/ Program SIVIF09/30/2012 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%

National HIVQUAL –US

Average = 57.33 %

8% to reached Goal

Results INC04 - InCare 4: Viral load suppression

Neo Med Center/ Program SIVIF09/30/2012 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%

National HIVQUAL –US

Average = 72 %

16% to reached Goal

• 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.

Summary

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

Together we can do great Things!!

Madre Teresa de Calcuta

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Time for Questions and Answers

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Announcements

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• 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 RetentionTo be announced!

March Topic – Patient Experience EvaluationApril Topic – Viral Suppression as the Ultimate GoalMay Topic – Youth, Transition, and Retention in+careJune Topic – Latinos and Retention

Upcoming Events

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• 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

Upcoming Deadlines and Office Hours

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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 michael@nationalqualitycenter.org 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)

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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