ART Clubs Managing large numbers of stable patients on ART - - PowerPoint PPT Presentation

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ART Clubs Managing large numbers of stable patients on ART - - PowerPoint PPT Presentation

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ART Clubs Managing large numbers of stable patients on ART Videoconference 26 February 2013 Welcome and Purpose 2012 Impumelelo Platinum Award Linking into resource material throughout the day Introduce yourself to your neighbour What

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ART Clubs Managing large numbers

  • f stable patients on ART

Videoconference 26 February 2013

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Welcome and Purpose

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2012 Impumelelo Platinum Award

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Linking into resource material throughout the day

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Introduce yourself to your neighbour What would you like to gain out of today?

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Introduction to clubs

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Why ART clubs ?

Health system perspective

  • Number of ART patients growing..........
  • Limited staff to manage...
  • Need capacity to initiate new & manage

unstable and at risk of failing

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Why ART clubs?

Patient perspective

  • Difficult to continue ART while carrying
  • n with the activities of life
  • Fatigue with ART collection system
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What are ART clubs in a nutshell?

  • Quick service option for groups of 30

stable ART patients

  • Facilitated by lay staff member
  • Limited support needed from clinician
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How do ART clubs work?

Every 2 months:

Quick clinical assessment Collection of 2 month ART supply Quick optimized group support

Once a year:

Blood taken for CD4 and viral load Clinical consultation with clinician

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Pilot outcomes

  • 97% (club) vs 85% (clinic) RIC of patients

who qualified for clubs over 40 months

  • 67% less virological rebound

Luque-Fernández M et al CROI 2012

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Where to next? Community ART clubs

  • Patient homes
  • Community venues
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The benefits

Patient

– Easier access – Group dynamic and peer support – Empowers through self management – Community network for tracing – Ensures access to clinical care – Improves retention in care and virological outcomes

Health system

– Reduces patient load

  • ptimizes clinician

– Optimizes capacity to initiate and manage unstable

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Adoption of club model

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Public Private Partnership for club roll out

  • Each partner's contribution
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IMPLEMENT FAILS PROBLEM

The traditional way

Evidence base published knowledge, experts, etc Plan

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Spreading the best practice

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GREAT IDEAS IDENTIFY BARRIERS IMPLEMENT SUCCEED/ SUSTAIN PROBLEM Test ideas in a small way before changing everything

Working together to overcome barriers to implementation at the frontline of care

Protocols guidelines

Plan Do Study Act

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Role of Steering Committee and Club Mentors

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Fitting Clubs in the to the existing ART programme

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Outcomes of scale up of ART club roll out in the Cape Metro

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A snapshot in time (Dec 2012) … ….. a sub-district perspective

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5000 10000 15000 20000 25000 30000 Eastern Khayelitsha Klipfontein M'Plain Northern Tygerberg Southern Western

ARV adult RIC patients: clinic / club care Dec 2012

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12.0% 20.9% 18.8% 13.7% 10.0% 8.3% 14.6% 13.9% 15.4% 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% Eastern Khayelitsha Klipfontein M'Plain Northern Tygerberg Southern Western Total

Percentage of adult patients who are in clubs - December 2012

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1000 2000 3000 4000 5000 6000 7000 8000 Eersterivier Hospital Helderberg Hospital Ikhwezi Clinic Ivan Toms Clinic Mfuleni CHC Westbank Clinic Gustrouw CHC Kleinvlei CHC Macassar CHC Kuyasa Clinic Luvuyo Clinic Mathew Goniwe Clinic Mayenzeke Clinic Michael M CHC Michael M MOU Nolungile CHC Site B Youth Centre Site B, Khayelitsha CHC Site C Youth Centre Town II Clinic Zakhele Clinic Site B MOU Eastern Khayelitsha

ARV adult RIC patients: clinic / club care Dec 2012

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21.0% 20.0% 11.6% 3.3% 7.3% 10.1% 15.8% 12.4% 21.9% 20.5% 18.9% 23.4% 26.7% 13.7% 17.1% 13.1% 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% Eersterivier Hospital Helderberg Hospital Ikhwezi Clinic Ivan Toms Clinic Mfuleni CHC Macassar CHC Kuyasa Clinic Luvuyo Clinic Mathew Goniwe Clinic Mayenzeke Clinic Michael M CHC Nolungile CHC Site B, Khayelitsha CHC Site C Youth Centre Town II Clinic Zakhele Clinic Eastern Khayelitsha

Percentage of adult patients who are in clubs - December 2012

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A look over time …… At patient flow in a clinic with clubs

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Club Basics

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Facility Club organogram: Roles and responsibilities

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Clubs Manager

Doctor/Senior Nurse responsible overall for the activities required to run successful ART clubs in the facility

  • ensuring facility clubs team in place
  • ensuring SOP being carried out – recruitment, club preparation,

club sessions, clinical governance, club follow up, club patients returning to mainstream care

  • scheduling annual TCB dates for club visits
  • ensuring 6 monthly CDU scripting of club
  • overview of clubs outcomes – new clubs, new enrolments, RIC
  • clinical oversight of clubs – review of VLs/CD4s/symptom checks
  • responsible for completing monthly Clubs stat sheet for

submission to facility manager

  • keeps facility manager updated on clubs progress in the facility
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Club Facilitator

Counsellor/Peer educator responsible for preparing for and running the club sessions

  • preparing for the club session including
  • collect club file with scripts
  • deliver to pharmacy for dispensing prepacks/CDu pre-packs
  • before scripting date – scripting book available
  • before blood taking day – complete blood forms
  • before clinical day – draw folders, ensure results in file
  • running club on club visit date:
  • registers members
  • conducts support/education group
  • conducts symptom screening
  • refers patients to Club nurse – sick/blood/clinical visit
  • distributes ARV supply
  • completing club registers
  • after club management:
  • returning uncollected ART pre-packs to pharmacy
  • Draws files of patients not attending
  • following up patients who missed session
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Club PN =

Responsible for clinical support on the day

  • f the club visit

Pharmacist =

Responsible for pre-packing ART for clubs/managing CDU script submission + receipt of pre-packs. Works with Clubs Manager to ensure 6 monthly CDU scripting done

Data Capturer =

Responsible for capturing patient visits to adherence club from club register after 5 day grace period

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Who qualifies for club?

  • Adult patient (>40kg)
  • On the same ART regimen for at least 12

months (regimen 1 or 2).

  • 2 most recent consecutive viral loads = LDL
  • No medical condition requiring regular clinical

consultations.

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Annual club session schedule

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Q & A

Questions so far? Shared experiences?

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Club Planning in a facility

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Where does the Clubs Mentor fit in?

  • Provides technical

support to Clubs Manager when facility starts clubs

  • Until Clubs Manager can
  • perate independently
  • Reduce technical support

in phased approach

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Obtain buy-in from all facility staff

  • Facility manager: reporting responsibility
  • Clinicians: retain responsibility to see club

patients outside of club visit dates

  • Pharmacy staff: retain responsibility for

supplying ART to club patients

  • Data capturer: retain responsibility for ART data

for club patients

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Club meeting space.... be creative

OPTIONS WITHIN FACILITIES:

– Support group room – Outside courtyard or NPO structure on clinic premises – General waiting area before main clinic opens or after it closes – Reduce size of club

OUT OF FACILITY OPTIONS:

Clinics have utilised public buildings close to the clinic incl: include:

– room at local public library – a church hall – a building used by clinic

  • utreach teams
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Tools for club scheduling

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Club recruitment

  • Patient empowerment
  • Clinician's role
  • Club allocation system
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Pre-packing, dispensing and distributing ART in clubs

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ART supply from facility

  • 2/3 month supply
  • 6 month script
  • Clinic pharmacy pre-packing/dispensing
  • Club facilitator distributes dispensed ART

pre-packs

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Use of central dispensing service

  • PGWC piloting central dispensing unit for

pre-packing/dispensing for clubs

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Running a club

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Club SOP: Annexure 4 on DVD

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Preparation first day of club

  • All club patients’ 1 x 2m scripts are taken

from the patient file into club file

  • Club file to pharmacy for pre-packing
  • Blank club register is available
  • 30 blank scripts available for 6m scripting
  • Patient files pulled ready for scripting
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Preparation for routine, blood, clinical and scripting club visits

  • Routine visit:

– 1-3 days before club: CF takes club file to pharmacy in time for pre- packing. – Morning of club: CF collects pre-packed ART from pharmacy – Club register ready for the club session

  • Blood visit:

– CF completed appropriate blood forms – Club nurse briefed need to be available to take bloods

  • Clinical/Scripting visit:

– Patient files drawn with blood result – blood results completed in club register – Blank scripts available – Club nurse briefed need to be available to see all 30 club patients

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Club session

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Club day: Clinical support

  • Blood visit – all club patients aligned

– Club nurse takes bloods for all club patients

  • Scripting visit:

– Patient files drawn – 6m scripts completed by club nurse (checked by NIMART authorised)

  • Clinical/Scripting visit:

– Patient files drawn – Club nurse sees all club patients for annual clinical visit (clinical SOP – annexure 11) and rescripting for 6m

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Buddies

  • Patient can send buddy if cant come
  • Except on first club visit, blood visit or clinical visit
  • Buddy can't attemd 2 club sessions in a row
  • If your buddy comes, counted as if patient came
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Grace Period & Defaulting

  • Determine appropriate grace period: 5 days
  • Who manages late patients: CM/CF
  • Provided within grace period, completed in club

register as attending

  • After grace period: CF contacts those who are late
  • CF marks as defaulter in club register
  • Defaulting club patient sees CM who returns

patient to clinic care

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Clinical exclusions from clubs

  • Club patient no longer eligible for the club where

club nurse/other clinician determines:

  • viral load is above 400
  • other safety blood results significantly abnormal
  • developed TB
  • changed ART regimen for clinical reasons
  • other clinical reasons requiring regular clinical follow up
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Clinical exclusions from clubs

  • Club nurse informs patient of clinical reason for

return to clinic care

  • Club nurse indicates on patient file & card
  • Club nurse informs CF who marks in club register

and removes script from club file

  • Clinicians are able to use clinical discretion for re-

enrolment in club care

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Q & A/shared experiences setting up clubs running clubs

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Monitoring and Evaluation

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The register reflects limited patient indicators for each club session, namely:

  • 1. Patient weight
  • 2. Where patient is asymptomatic – reflect ‘N – no symptoms’
  • 3. Where patient is symptomatic – reflect ‘RTC – refer to clinician’

Club register

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The register reflects limited patient indicators for each club session, namely:

  • 1. Patient weight
  • 2. Where patient is asymptomatic – reflect ‘N – no symptoms’
  • 3. Where patient is symptomatic – reflect ‘RTC – refer to clinician’

Club register

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  • Where the patient sends a buddy,

‘buddy is completed in the weight field’

Club register

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  • Club deregistration categories BTC, TFO, TFOC
  • r RIP
  • This will only be reflected next session when the

patient is not in your club

Club register

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Clubs Manager – what to check in register

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Club tally sheet

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Clubs Manager – what to check in tally sheet

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Monthly stats

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Clubs Manager to ensure:

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Club M&E capacity in eKapa/tier.net

  • Tier.net and eKapa now include capacity

for capturing club enrolment and retention

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Reflections of a Mentor

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The Beginning of the ART Journey – getting people onto treatment

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The Ongoing ART Journey – keeping people on treatment

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CONGESTION!!!

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Closing and thanks

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  • Resources available on DVD and www.

www.msf.org.za/publication/art-club-toolkit

  • Short evaluation
  • Request to be included on list serve

?

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Acknowledgements

  • Clubs Steering Committee

(PGWC/CoCT/MSF/IHI)

  • HAST Directorate Admin support team
  • Prof Rhoda Kadalie/Impulelelo
  • Mega Digital
  • Admin and technical support staff at each

site and each provincial HAST

  • Discovery
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