Integrated care for people with HIV OHTN HIV Endgame Claire - - PowerPoint PPT Presentation

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Integrated care for people with HIV OHTN HIV Endgame Claire - - PowerPoint PPT Presentation

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Integrated care for people with HIV OHTN HIV Endgame Claire Kendall Presenter disclosure I have no relationships with commercial interests to disclose. Success: Improvements in HIV care 4 Burchell et. al (2015) Problem: Fragmentation of

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Integrated care for people with HIV OHTN HIV Endgame

Claire Kendall

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Presenter disclosure

I have no relationships with commercial interests to disclose.

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Success: Improvements in HIV care

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Burchell et. al (2015)

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Problem: Fragmentation of HIV care delivery

1 2 3 4 5 6 Odds ratio (ref = Exclusively specialist care)

Colorectal cancer screening Cervical cancer screening Mammography Any receipt of ART

*

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Kendall et. al (2015)

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Problem: Fragmentation of HIV care delivery

1 2 3 4 5 6 Odds ratio (ref = Exclusively specialist care)

Colorectal cancer screening Cervical cancer screening Mammography Any receipt of ART

*

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Kendall et. al (2015)

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Problem: Fragmentation of HIV care delivery

1 2 3 4 5 6 Odds ratio (ref = Exclusively specialist care)

Colorectal cancer screening Cervical cancer screening Mammography Any receipt of ART

*

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Kendall et. al (2015)

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0% 20% 40% 60% 80% 100% <=5 6‐49 >=50 <=5 6‐49 >=50 <=5 6‐49 >=50 Exclusively primary care Family physician dominant co‐ management Specialist dominant co‐management Percentage of patients prescriebed ART (95% CI) Family physician HIV experience (number of HIV patients)

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Kendall et. al (2015)

Problem: Fragmentation of HIV care delivery

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8.6% 52.7% 10.1% 30.7% 5.3% 0% 10% 20% 30% 40% 50% 60%

Low engagement Exclusively primary care Co‐manager (FP principal HIV provider) Co‐manager (Specialist principal HIV provider) Exclusively HIV specialist care

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Forrest (2009), Kendall (2015)

Problem: Fragmentation of HIV care delivery

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8.6% 52.7% 10.1% 30.7% 5.3% 0% 10% 20% 30% 40% 50% 60%

Low engagement Exclusively primary care Co‐manager (FP principal HIV provider) Co‐manager (Specialist principal HIV provider) Exclusively HIV specialist care

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Forrest (2009), Kendall (2015)

Problem: Fragmentation of HIV care delivery

75% have <= 5 people with HIV in their practice

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50,000 100,000 150,000 200,000 250,000 number of visits/3 years

Kendall et. al (2015)

Problem: Fragmentation of HIV care delivery

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50,000 100,000 150,000 200,000 250,000 number of visits/3 years

Kendall et. al (2015)

5 visits/year

Problem: Fragmentation of HIV care delivery

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Barr et. al (2003)

Integrated care: Chronic Care Model

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Barr et. al (2003)

Integrated care: Chronic Care Model

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Barr et. al (2003)

Integrated care: Chronic Care Model

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Barr et. al (2003)

Integrated care: Chronic Care Model

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Barr et. al (2003)

Integrated care: Chronic Care Model

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Health Quality Ontario Recommendations

1.Smooth out transitions

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Health Quality Ontario Recommendations

1.Smooth out transitions 2.Improve access to care in the community

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Health Quality Ontario Recommendations

1.Smooth out transitions 2.Improve access to care in the community 3.Reduce inequities

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Health Quality Ontario Recommendations

1.Smooth out transitions 2.Improve access to care in the community 3.Reduce inequities 4.Enhance performance measurement

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HQO recommendation #1 Smooth out transitions

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Smooth out transitions between sectors – linkage to care within 90 days

Kendall and Antoniou

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Smooth out transitions between sectors – linkage to care within 90 days

Kendall and Antoniou

← 90% of those diagnosed in hospital ← 45% of those diagnosed in the emergency department

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Smooth out transitions between sectors – end of life

Kendall and Tanuseputro (2016)

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Smooth out transitions between sectors – end of life

Kendall and Tanuseputro (2016)

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Smooth out transitions between sectors – end of life

Kendall and Tanuseputro (2016)

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Smooth out transitions between sectors – end of life

Kendall and Tanuseputro (2016)

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Smooth out transitions – within sectors

10,000 20,000 30,000 40,000 50,000 number of visits/3 years

Kendall et. al (2015)

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Smooth out transitions – within sectors

10,000 20,000 30,000 40,000 50,000 number of visits/3 years

Kendall et. al (2015)

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Smooth out transitions – within sectors

10,000 20,000 30,000 40,000 50,000 number of visits/3 years

Kendall et. al (2015)

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Smooth out transitions – within sectors

10,000 20,000 30,000 40,000 50,000 number of visits/3 years

Kendall et. al (2015)

1000 visits/year

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Smooth out transitions – within sectors

Specialist MD Allied health Pharmacist

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Smooth out transitions – within sectors

Specialist MD Allied health Pharmacist

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Barr et. al (2003)

Smooth out transitions: Decision Support

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HQO recommendation #2: Improve access to care in the community

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Improve access to care in the community

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Improve access to primary care in the community: Consistent

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Improve access to primary care in the community: Consistent

  • People with HIV have greater use of

emergency department visits (adjusted rate ratio 1.58, 95% CI 1.51–1.65])

  • Results held when restricted to visits

for Ambulatory Care Sensitive Conditions

Ng and Antoniou et. al. (2016)

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Improve access to primary care in the community: Comprehensive

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Improve access to primary care in the community: Comprehensive

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Improve access to primary care in the community: Comprehensive

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Improve access to primary care in the community: Comprehensive

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Improve access to primary care in the community: Comprehensive

Lower colorectal cancer screening [41.4% (95% CI 41.3% to 41.5%) versus 49.1% (95% CI 46.5% to 51.7%)]

Antoniou (2015), Kendall (2016)

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Improve access to primary care in the community: Comprehensive

Lower colorectal cancer screening [41.4% (95% CI 41.3% to 41.5%) versus 49.1% (95% CI 46.5% to 51.7%)]

Antoniou (2015), Kendall (2016)

Lower breast cancer screening [50.1% versus 63.4%, p<0.001]

  • More likely if they have a

family physician

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Improve access to primary care in the community: Coordinated

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Improve access to primary care in the community: Coordinated

communication

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Specialist MD Allied health Pharmacist

Improve access to primary care in the community: Coordinated

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Specialist MD Allied health Pharmacist

Improve access to primary care in the community: Coordinated

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Improve access to primary care in the community: Coordinated

communication role definition

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HQO recommendation #3: Reduce inequities

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Reduce inequities ‐ geographic

  • 8% of people with HIV in Ontario live rurally
  • 5% of family physician practices
  • 0% of internal medicine and ID specialist practices
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Reduce inequities ‐ socioeconomic

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Recommendation #4: Enhance performance measurement

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Enhance performance measurement

Johnston, Kendall et al.

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Johnston, Kendall et al.

PROMS Enhance performance measurement

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Johnston, Kendall et al.

PROMS PREMS Enhance performance measurement

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Enhance performance measurement– Patient reported outcome

Kendall and MacPherson

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Barr et. al (2003)

Chronic Care Model: Self‐ management supports

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Enhance performance measurement – Patient reported experience measure

Rachlis, B. and Rourke, S.

Patient Assessment

  • f Chronic Illness

Care

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Barr et. al (2003)

Chronic Care Model: Self‐ management supports

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Enhance performance measurement

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Enhance performance measurement

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Barr et. al (2003)

Microcosm approach

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Barr et. al (2003)

Integrated population‐based system‐level approach

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Acknowledgements

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Integrated care for people with HIV OHTN HIV Endgame

Claire Kendall

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1 2 3 4

Mental health condition Myocardial infarction Congestive heart failure End stage renal disease Peripheral vascular disease Asthma Diabetes Hypertension Stroke Mental‐physical comorbidity Multimorbidty (>=2)

Standardized ON

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Smooth out transitions – within sectors

HIV Kendall et. al (2014)

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Multimorbidity patterns reflect ON population

20 40 60 80 100 18‐35y36‐50y51‐64y >65y 18‐35y36‐50y51‐64y >65y ≥1 chronic condition ≥2 chronic conditions Prevalence (%) Multimorbidity burden by age goup (Women) HIV ON

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Multimorbidity patterns reflect ON population

20 40 60 80 100 18‐35y36‐50y51‐64y >65y 18‐35y36‐50y51‐64y >65y ≥1 chronic condition ≥2 chronic conditions Prevalence (%) Multimorbidiy burden by age group (Men) HIV ON