The HotspottersRetention and VL Supression Monitoring Project

Ivy Clinic, Arnot Ogden Medical Center

DRAFT

Quality Improvement Team Clinical 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

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

5

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.

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 bi-sexual 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

Patients on HAART with HIV viroload over 100 Patients not seen in 6 months

CM follows up with CBOCM follows up with the patient

□ Schedule medical appointment with the provider □ Schedule case management review with CM (if needed, to follow up on patient’s issues)

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

Collection of Data by QI Coordinator(based on Excell spreadsheets, eMD and AIRS reporting)

□ 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.

Meeting of the Team (second Friday of the month), review of the data

Treatment Adherence for people with VL

Self-AssessmentDo they know which meds to take, how many, and

when?

Review Missed DosesAre they missing doses of their medication?

Medication Education

Provide medication and treatment education.

Identify BarriersFigure out how many doses missing and why?

Review Medication GuidelinesAre they taking it appropriately (i.e., with food,

without splitting, with other meds)?

Develop Care PlanSet client-focused goals to overcome adherence

barriers (if client is agreeable).

Resistance TestingDetermine if resistance has occurred and if a med

change needs to happen.

Reassess for ReadinessDetermine if client is ready to take medications

(confidence and importance).

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).