Integrated Part A Outpatient Ambulatory Health Services and PrEP - - PowerPoint PPT Presentation

Integrated Part A Outpatient Ambulatory Health Services and PrEP Learning Collaborative Session 2

Chicago Department of Public Health Public Health Institute of Metropolitan Chicago September 11, 2018

About PHIMC

Public Health Institute of Metropolitan Chicago (PHIMC) enhances the capacity of public health and health care systems to promote health equity and expand access to services.

How PHIMC Works

PHIMC leads efforts to strengthen the public health infrastructure in Illinois through:

• Organizational Development
• System Transformation
• Fiscal Management
• Program Implementation

The PHIMC RWQM Program is….

A partnership between PHIMC and the Chicago Department of Public Health’s Quality Management (QM) Unit to provide training, technical assistance, and capacity building support to Ryan White Part A funded agencies in an effort to maintain sustainable internal QM infrastructure across the Chicago EMA.

PHIMC RW Part A QM Program resources and activities

• Quality Management Infrastructure
• Manage QM Resource Hub
• Webinars
• Facilitate revision of Standards of Care
• Quality Improvement
• Facilitate the Learning Collaboratives
• Consumer Engagement
• Support the Grievance Hotline
• Evaluation
• Support the annual Evaluation of the Grantee
• Support the annual CAHISC Member Evaluation

Goals for LC2

• Review the learning collaborative and participant expectations
• Explore quality improvement, sharing tricks and tools
• Share tools for EMR and data extraction
• Share success in attaining viral load suppression
• Share success in attaining PrEP uptake

Agenda

Agenda Item Presenters

LC Refresher Audra Tobin: PHIMC Basics of Effective QI Barbara Schechtman Choosing a Good QI Project Daniel Pohl: Heartland Health Alliance Discussion of QI Tools Elizabeth Hamilton: Howard Brown Charlotte Detournay: AIDS Foundation of Chicago Break EMR and Data Extraction Bijou Hunt: Sinai Health Systems Success in Attaining Viral Load Suppression Katrina Barone: Erie Family Health Centers Success in Attaining PrEP Uptake Josh Brunsting: Open Door Clinics Group Activity Audra Tobin: PHIMC

Learning Collaborative Refresher

LC Refresher: Goal

GOAL

Utilize Quality Improvement (QI) methods to increase Pre- exposure Prophylactics (PrEP) uptake and viral load suppression rates among one of the four disproportionately affected populations: Youth 13-24 years. old, MSM of color, Transgender individuals, African American and Latina women.

LC Refresher: Purpose

PURPOSE

Assist PrEP and Outpatient Ambulatory Health Service (OAHS) providers in identifying effective methods to reduce the risk of new HIV infections and increase viral load suppression rates among disproportionately affected populations.

LC Refresher: Participant Expectations

• Attend In-Person Meetings
• November 15, 2018 and January 2019
• Conduct QI Activities and Document Progress
• OAHS: Viral Load Suppression
• PrIDE: Linked, Prescribed PrEP, Filled PrEP Prescription or Attended Follow-up

Visit

• Share your Expertise through Presenting during the LC
• Signup for November and January LC due 10/14/2018.

Quality Improvement

Basics of Effective QI Choosing Good QI Projects Discussion of QI Tools

Effective QI Barbara Schechtman

What is Quality Improvement? /

• A. A way to figure out if you are meeting standards
• B. A process for looking at what is and figuring out how

to make it better

• C. An internal agency culture
• D. A HRSA requirement

What’s the very first step?

• A. Figure out what you mean by “quality”
• B. Try some changes and see what happens
• C. Report improvements over the last year

Data is important to the QI process because…

• A. It tells our funder what we are doing
• B. It proves we are doing good work
• C. We can figure out if change is needed and if change

happens after we do something

Some key questions for doing QI work include…

• A. “How will we know if the change we make is an

improvement?”

• B. “What can we do by next Tuesday?”
• C. “Why is our service not at the quality level we

want?”

• D. “Why do I have to do this anyway?”

What resources can help us move ahead?

• A. PHIMC Quality Hub
• B. HRSA Target Center/CQII
• C. Our peers who have done this work before
• D. Robert Wood Johnson Foundation
• E. Institute for Healthcare Improvement
• F. Centers for Medicare and Medicaid Services

Questions? Barbara Schechtman barbaraschechtman@gmail.com

Quality Improvement Tools Charlotte Detournay: AIDS Foundation of Chicago

200 WEST JACKSON BLVD. | SUITE 2100 | CHICAGO IL 60606 | TEL 312-922-2322 | FAX 312-922-2916 | AIDSCHICAGO.ORG

Utilizing visualization tools to track and enhance health

• utcomes

Charlotte Detournay Senior, Ryan White Program Manager AIDS Foundation of Chicago

Learning Objectives

• To discuss limitations of databases and

underscore the importance of utilizing visualization tools

• To effectively use dashboards to pinpoint areas
• f concern related to subcontractor agency

performance as well as denote trends to inform programmatic decisions

• To demonstrate the use of a dashboard as a

visualization tool to monitor and track health

• utcomes

Background of AFC

• Founded in 1985
• Departments include: Housing, Care, Policy,

Research and Evaluation, Finance and Communications

• Braids multiple funding sources for Case

Management into one Collaborative System

• Lead agent for Case Management and Part B

services for Region 7/8

• Fund over 30 agencies and 100 CMs within our EMA

Limitations of Databases

• Reliance on manual data entry/reporting
• Inability to showcase trends in data
• Performance/Compliance
• Viral suppression and other health indicators
• Narrow scopes
• Reporting and monitoring of data from multiple databases
• Limited analysis of social determinants of health
• Inability to evaluate correlation between case

management and improved client health

AFC Programmatic Issues

• Annual site visits
• Feedback from last year’s data
• CMs evaluated on 43 performance measures
• Inability of finding software to combine

data from multiple databases

QM Project

• Revamped qualitative tool
• Established dashboards
• Data reviewed by Leadership Collaborative
• Developed qualitative tool to monitor

and track outcomes to barriers

• Provided quarterly feedback to agencies

Dashboards

• RW Performance Standards
• Tracks monthly performance results for core

CM standards

• Viral Suppression
• Filters viral suppression by demographic

information and social determinants of health

Performance Dashboard

Viral Load Suppression Dashboard

Special thanks to: Alanna Berdanier (dashboard analyst) Joel Ritsema (dashboard developer)

EMR and Data Extraction

Using the EMR & REDCap to track patient navigation and medical care

• utcomes for HIV+ patients

Bijou Hunt Sinai Infectious Disease Center Sinai Health System 9/11/2018

The Problem

• We need a good system for tracking navigation and

medical outcomes for both internal and external reporting and QI

• Sinai uses Meditech as our Electronic Medical Record

(EMR)

– Meditech is not easily modifiable – Creating reports in Meditech is not a simple process – Previous approach of using Excel to track outcomes is not ideal

• Only one person can be in the sheet
• Sheet gets confusing! And too many sheets!!
• Info is not easily shared across multiple users who may need

access to patient info

The Solution

The Solution

• REDCap database

– Data can be imported into REDCap and updated easily – REDCap fields are chosen by the architect and can be easily added/modified – REDCap is incredibly user-friendly and staff have been able to make a seamless transition from tracking outcomes in Excel spreadsheets to using REDCap

• Multiple staff can use at the same time
• Multiple staff can view patient info relevant to them
• Reporting capabilities are vast!
• Eliminates need for multiple confusing sheets maintained by multiple different users!

So how do we get from the EMR to REDCap?

UNITNUM NAME DOB COLLDTE TESTMNEMONI RACE SEX RESULT VERFYDTE LOCATIONNAME SUBMITDOCNAME SUBMITDOCADMSERVICENAME SUBMITDOCABSTRACTSERVNAME 9/17/1973 8/3/2018 HIVCOMBO AAB M NONREACT 8/3/2018 3 NORTH-OLIN SANG Shehata,Kerolus MD MEDICINE INTERNAL MEDICINE 1/6/1959 8/7/2018 HIVCOMBO OTHER M NONREACT 8/7/2018 3 NORTH-OLIN SANG Borges,Luis MD MEDICINE INTERNAL MEDICINE 9/21/1948 8/9/2018 HIVCOMBO AAB F NONREACT 8/9/2018 3 NORTH-OLIN SANG Suber Pablo,Berenice MD FAMILY PRACTICE - ADULT FAMILY PRACTICS - ADULT 1/7/1969 8/9/2018 HIVCOMBO AAB M NONREACT 8/9/2018 3 NORTH-OLIN SANG Borges,Luis MD MEDICINE INTERNAL MEDICINE 12/5/1948 8/4/2018 HIVCOMBO AAB F NONREACT 8/4/2018 5 NORTH-OLIN SANG Grewal,Revant MD MEDICINE INTERNAL MEDICINE 10/25/1981 8/5/2018 HIVCOMBO AAB F NONREACT 8/5/2018 5 NORTH-OLIN SANG Khan,Aysha MD MEDICINE INTERNAL MEDICINE 11/26/1953 8/8/2018 HIVCOMBO AAB M NONREACT 8/8/2018 5 NORTH-OLIN SANG Khan,Aysha MD MEDICINE INTERNAL MEDICINE 7/1/1979 8/4/2018 HIVCOMBO AAB M NONREACT 8/4/2018 6 EAST-KURTZON(PSYCH) Rattan,Pradeep MD PSYCHIATRY PSYCHIATRY 6/11/1995 8/4/2018 HIVCOMBO OTHER M NONREACT 8/5/2018 6 EAST-KURTZON(PSYCH) Rattan,Pradeep MD PSYCHIATRY PSYCHIATRY 1/6/1962 8/5/2018 HIVCOMBO CA F NONREACT 8/5/2018 6 EAST-KURTZON(PSYCH) Berkowitz,Paul MD PSYCHIATRY PSYCHIATRY 3/1/1991 8/10/2018 HIVCOMBO CA M NONREACT 8/10/2018 6 EAST-KURTZON(PSYCH) Grover,Michael B MD PSYCHIATRY PSYCHIATRY 2/8/1969 8/1/2018 HIVCOMBO AAB F NONREACT 8/1/2018 6 NORTH-OLIN SANG Khan,Aysha MD MEDICINE INTERNAL MEDICINE 10/31/1955 8/6/2018 HIVCOMBO AAB F NONREACT 8/6/2018 6 NORTH-OLIN SANG Sternberg,Evan MD MEDICINE INTERNAL MEDICINE 7/15/1966 8/1/2018 HIVCOMBO AAB F NONREACT 8/1/2018 8 KURTZON-ICU/CCU Phillip,Melby MEDICINE INTERNAL MEDICINE 9/23/1956 8/1/2018 HIVCOMBO AAB F NONREACT 8/1/2018 8 KURTZON-ICU/CCU Trivedi,Anand MD MEDICINE INTERNAL MEDICINE 12/15/1958 8/5/2018 HIVCOMBO OTHER M NONREACT 8/5/2018 8 KURTZON-ICU/CCU Yadullahi Mir,Wasey Ali MD MEDICINE INTERNAL MEDICINE 6/21/1943 8/7/2018 HIVCOMBO AAB F NONREACT 8/7/2018 8 KURTZON-ICU/CCU Manshaem,Aaron D PA SURGERY SURGERY 12/13/2001 8/2/2018 HIVCOMBO UNV F NONREACT 8/2/2018 ANTILLAS Sinai Medical Vera Daner,Dennys Omar MD FAMILY PRACTICE - ADULT MEDICINE 4/14/1976 8/2/2018 HIVCOMBO OTHER M NONREACT 8/2/2018 ANTILLAS Sinai Medical Vera Daner,Dennys Omar MD FAMILY PRACTICE - ADULT MEDICINE 11/6/1973 8/3/2018 HIVCOMBO CA F NONREACT 8/3/2018 ANTILLAS Sinai Medical Nunez,Josue NP MEDICINE FAMILY PRACTICS - ADULT 3/3/1998 8/6/2018 HIVCOMBO UNV F NONREACT 8/6/2018 ANTILLAS Sinai Medical Vera Daner,Dennys Omar MD FAMILY PRACTICE - ADULT MEDICINE 12/30/2002 8/6/2018 HIVCOMBO UNV F NONREACT 8/6/2018 ANTILLAS Sinai Medical Vera Daner,Dennys Omar MD FAMILY PRACTICE - ADULT MEDICINE 5/29/1996 8/7/2018 HIVCOMBO CA M NONREACT 8/7/2018 ANTILLAS Sinai Medical Vera Daner,Dennys Omar MD FAMILY PRACTICE - ADULT MEDICINE 5/13/1986 8/7/2018 HIVCOMBO CA F NONREACT 8/7/2018 ANTILLAS Sinai Medical Nunez,Josue NP MEDICINE FAMILY PRACTICS - ADULT 6/12/1994 8/8/2018 HIVCOMBO UNV F NONREACT 8/8/2018 ANTILLAS Sinai Medical Simon,Sherrone MD OBSTETRICS OBSTETRICS/GYNECOLOGY 9/6/1990 8/1/2018 HIVCOMBO AAB M NONREACT 8/1/2018 ASHLAND HEALTH CENTER - SMG Rupani,Prem H MD HCH MEDICAL INTERNAL MEDICINE 10/9/1968 8/3/2018 HIVCOMBO AAB M NONREACT 8/3/2018 ASHLAND HEALTH CENTER - SMG Pandit,Ananta MD MEDICINE INTERNAL MEDICINE 9/19/1966 8/7/2018 HIVCOMBO AAB M NONREACT 8/8/2018 ASHLAND HEALTH CENTER - SMG Rupani,Prem H MD HCH MEDICAL INTERNAL MEDICINE 2/15/1978 8/5/2018 HIVCOMBO AAB M NONREACT 8/5/2018 CATH LAB Jlasi,Ahmed MD MEDICINE INTERNAL MEDICINE 2/24/1996 8/1/2018 HIVCOMBO AAB F NONREACT 8/1/2018 CICERO HEALTH CENTER SMG DaFonseca,Carlos MD FAMILY PRACTICE - ADULT FAMILY PRACTICE 8/4/1967 8/1/2018 HIVCOMBO AAB M NONREACT 8/1/2018 CICERO HEALTH CENTER SMG DaFonseca,Carlos MD FAMILY PRACTICE - ADULT FAMILY PRACTICE 3/6/2001 8/9/2018 HIVCOMBO UNV M NONREACT 8/9/2018 CICERO HEALTH CENTER SMG DaFonseca,Carlos MD FAMILY PRACTICE - ADULT FAMILY PRACTICE 5/8/1969 8/9/2018 HIVCOMBO CA F NONREACT 8/9/2018 CICERO HEALTH CENTER SMG Barsky,Gary MD MEDICINE INTERNAL MEDICINE 12/21/1985 8/8/2018 HIVCOMBO OTHER F NONREACT 8/8/2018 CROWN 4TH LDR SUITES Chawla,Devyani MD OBSTETRICS OBSTETRICS/GYNECOLOGY 7/13/1982 8/9/2018 HIVCOMBO AAB F NONREACT 8/9/2018 CROWN 4TH LDR SUITES Uzonyi,Janos MD OBSTETRICS OBSTETRICS/GYNECOLOGY 8/8/1991 8/1/2018 RHIVPOC AAB F NONREACT 8/1/2018 CROWN 4TH OB TRIAGE AREA Cavens,Paula L MD OBSTETRICS OBSTETRICS/GYNECOLOGY 8/24/1994 8/5/2018 HIVCOMBO AAB F NONREACT 8/5/2018 CROWN 4TH OB TRIAGE AREA Araujo,Tatiana MD OBSTETRICS OBSTETRICS/GYNECOLOGY

HIV Screening Report – output from EMR

Use an Excel macro to format data for input into REDCap database

study_id hiv_nav_name hiv_screened_location hiv_agab_collect_date name_first name_last dob race___0 race___1 race___2 race___5 race___99 gender_birth address hiv_agab_result 10 HCH EMERGENCY DEPT TRIAGE 8/7/2018 7/17/1998 1 1 TOUHY HEALTH CENTER SMG 8/7/2018 8/3/1995 1 1

Now that the macro has identified HIV+ results, and recoded variable names and outcomes, the data on positives can be imported into REDCap

Benefits

• Customize data collection processes

– Ensure we collect all variables required by our multiple funders

• Customize data reporting process

– Allows us to run reports specific to each of our various funders

• Produce reports that are useful to the navigation team

Success in Attaining Viral Load Suppression and PrEP Uptake

Success in Attaining Viral Load Suppression Katrina Barone: Erie Family Health Centers

Viral Load Suppression

Katrina Barone Lending Hands for Life Erie Family Health Centers September 11, 2018

49

Agenda

• Overview: Lending Hands for Life program
• Continuous Quality Improvement (CQI)
• Viral Load Champion Project
• Data Review
• Lessons Learned
• Next Steps

50

Lending Hands for Life (LHL)

• HIV Primary Care
• Behavioral health
• Medical and non-medical

case management

• Hep C treatment
• Health education
• Nutrition counseling
• Offered at two sites!
• Erie Humboldt Park – HQ
• Erie Foster Avenue

51

Lending Hands for Life (LHL)

• 363 Active clients
• 72.5% Hispanic/Latino/a
• 37.2% Uninsured
• Gender:
• 22.6% Female
• 75.5% Male
• 1.9% Transgender
• Transmission Mode:
• 57.3% MSM
• 7.4% IDU
• 38.6% Hetero

52

Continuous Quality Improvement (CQI)

• LHL Quality Management Plan
• Regular monthly meeting to review data and perform QI

activities

• Weekly Case Conference with each provider and program staff
• MA, 3 medical case managers, 1 non-medical case manager, 1 care

coordinator, behavioral health consultant

53

Continuous Quality Improvement (CQI)

• Monitored indicators and improvement indicators
• FY18 improvement indicator: Viral Load Suppression
• Definition aligns with HAB: viral load less than 200 copies/ml at last

viral load test in measurement year

• Goal: 89%

54

Viral Load Champion Project

• Focus on clients with a detectable viral load
• Create outreach scripting for case managers
• Review Viral Load Dashboard every CQI meeting
• Assign champion for outreach
• Ensure all clients with detectable viral load are in medical case

management

• Track using CQI data and champion spreadsheets

55

Outreach Scripting

• Use motivational interviewing

techniques

• Help clients self-identify

barriers and strategize to improve adherence

• Importance of client preferred

language

56

Viral Load Data

57

89.78% 90.30% 90.49% 89.76% 89.73% 89.84% 89.84% 89.84% 91.92% 91.69% 91.69% 92.56% 93.39% 70% 80% 90% 100% Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18

Undetectable Viral Load

Undetectable Viral Load Internal Goal

What We Learned

• The 1 on 1 attention of the Viral Load Champion is powerful!
• It helped our clients to discuss barriers to adherence and

brainstorm strategies to reduce barriers

• Important to keep a list of clients who became undetectable
• Shows Champions that improvement efforts successful!
• Opportunity to monitor clients who were once detectable more closely

58

Next Steps

• Emphasis on U = U
• Helping yourself stay healthy and preventing infection of others

59

Success in Attaining PrEP Uptake Joshua Brunsting: Open Door Clinics

PrEP at Open Door

PRESENTED BY: JOSHUA BRUNSTING

The Numbers

 Current number of active PrEP users at Open Door:

 Approximately 75-80 patients

 Approx. 10% identify as female & 90% as male  Majority of patients are Caucasian and Hispanic/LatinX

 A small percentage of users are Indian, Asian and African American

 Large majority of identified male PrEP users identify as gay, bisexual, or MSM

 Estimate of patients retained in PrEP services: approx. 65-70%

Who does Open Door target for PrEP?

 Adults at risk of contracting HIV through sex

 Women of color (Black & Latina)  MSM  Sex workers  Transgender persons  IDU  H/O sexually transmitted infections  HIV positive person’s partner

 “U+U” unpacked

Where does Open Door get patients to start PrEP?

 Walk-in  Social Media, Website, Print  Word of mouth  Outreach  Partners of PLWH  Referral from outside agency  Social events

How does Open Door provide PrEP services?

 Takes walk-in patients or scheduled patients  Who do they meet with first?

 EIS/Retention: Carmen, Josh, Bryan

 PrEP Navigation, risk reduction, patient education, support & linkage

 Do labs either with Outreach or Health Lab  Schedules F/U visit with Provider 2 weeks after labs, 1 month after starting

medication, and then every 3 months for labs and F/U

 Financial re-certification every 6 months, or 1 year, depending on

program used to pay for medications

How can patients get financial support?

 Sliding scale for patients who are not insured, or who are not eligible for

insurance (Medicaid, Private, Medicare)

 Patient pays for labs and medical visit based on annual income

 Fee-for-service

 Patient who have insurance and choose not to bill will pay $25 for each lab

visit, and $75 for each medical visit with a provider

 Reasons why patients don’t use insurance:

 Privacy, i.e., spouse, job, stigma  Deductibles are too high

 Open Door accepts most private insurances, Medicaid & Medicare

How can patients get financial support?

 Patient Assistance:

 Patients who do not have insurance are eligible (based on income) for Patient

Assistance through Advancing Access who work with Gilead

 Paystubs  Proof of residency

 IDPH Co-Pay Assistance (PrEPDAP):

 Patients who have insurance (Private or Medicare) and want co-pay assistance

are eligible for assistance through IDPH who partners with CVS Specialty

 Verification of insurance  Verification of residency

How can patients get financial support?

 Co-pay Cards:

 Gilead provides patients with co-pay cards that provide patients with $4,800 on

a co-pay card that can be used towards their medication co-pays (annually)

 No income/residency verification required  Card can be obtained online or in the clinic (when available)  Patients with private insurance qualify (no Medicaid or Medicare)

 Medicaid:

 Patients with Medicaid do not qualify for co-pay assistance as Medicaid covers

the full cost of medication

 Only Meridian requires a prior-authorization for Truvada and is filled through

MeridianRx

Questions????

Thank You

Contact Information

E-mail: joshuab@odhcil.org Phone: 847-695-1093, x239

Closing

• QI Worksheet
• Updates Due October 31, 2018
• Presentation Sign-up
• Due October 14, 2018
• Next LC
• November 15, 2018
• Meeting Evaluation
• Visit QM Resource Hub - www.chicagoryanwhiteresourcehub.org/

Thank you!!