Care Management Tools
Questions? Thank you! Emily Lupo Director of Population Health emilylupo@lawndale.org Alyssa Sianghio Director of Development & Communications alyssasianghio@lawndale.org
ADHERENCE TO MEDICAL CARE AN OVERVIEW South Shore Hospital Wellness Ctr 2525 east 83 rd street, Chicago, Illinois
SouthShore Hospital Wellness Ctr Acknowledgements Program Director – Leslie Rogers, FACHE Medical Director – Clarence Parks, M.D. Office Coordinator – Rena Riggins Outreach/EIS – Keefe Powell
SouthShore Hospital Wellness Ctr Background It has been published that at least one-third of persons with known HIV infection in the United States are not engaged in care ( Clin Inf Dis; 2007 ). The problem continues to exist today. Our Agency is no different in that we face this challenge. To address this issue, will take a multimodal approach that is flexible and adaptable.
SouthShore Hospital Wellness Ctr Understanding Social Determinants that affect Client adherence. 1. Lack of trust in the Health system 2. Social support 3. Denial 4. Insurance 5. Transportation 6. Lack of reliable contact information 7. Unstable home situation
SouthShore Hospital Wellness Ctr Our agency has evaluated industry standard ways to reduce the “ no show phenom” and Improve client engagement 1. Automated Reminders 4. Use Multiple Reminders 2. Reducing wait times & time to appt. 5. Thanking Clients for keeping appt. 3. Incentives for appts kept. 6. Developing strong Relationships It has been clear that to improve client engagement will and have taken a multilevel Approach with some innovation.
SouthShore Hospital Wellness Ctr Traditional approaches 1. Phone calls 2. Letters 3. Reminder appointment cards 4. Utilizing community partners 5. Home visits
SouthShore Hospital Wellness Ctr Phone calls * Making multiple calls to ensure accurate contact information and developing a strong relationship * Barrier to this route is the lack of reliable phone for clients Letters * Confirms the appt & reminds the patient especially of upcoming appt. * Barrier to this is unstable home situation. A significant client population is transient and do not have stable home situations
SouthShore Hospital Wellness Ctr Reminder cards * We began to hand out reminder cards with the month of the appt. to schedule * Barrier to this is that clients often misplace or lose or discard the cards Community partners * utilizing pharmacy & case managers to remind and engage clients * Barrier to this is that the partners often have contact information that is no longer functional as well Home Visits
SouthShore Hospital Wellness Ctr Innovative ideas(future) secure email reminders secure social media direct messaging MOST PROMISING AS CLIENTS TEND TO MAINTAIN SOCIAL MEDIA “ PLEASE CONTACT US ” GENERIC MESSAGE secure text messaging reminders “ PLEASE CALL OUR OFFICE ” GENERIC MESSAGE
Managing Viral Load Suppression in Adolescents in Long-Term Care Justine Legbedze, MPH Clinical Research Coordinator III Barbara Bellg Academic & Research Manager Department of Pediatrics, Special Infectious Diseases (SID) January 24, 2019
Lurie Children’s Hospital Overview • Largest pediatric provider in Chicago and only freestanding, pediatric acute care hospital in Illinois • Pediatric teaching facility of Northwestern University Feinberg School of Medicine • Providing care in 70 pediatric specialties for >200,000 patients across 14 Chicago-area locations • Dedicated to leading pediatric healthcare delivery, innovative research, education for healthcare professionals, and advocacy for the general well- being of all children 61
Special Infectious Diseases Program • Multidisciplinary HIV program established at Lurie Children’s Hospital in 1987 • Mission to provide outstanding holistic multidisciplinary medical care to HIV impacted children, adolescents, and caregivers, and support HIV education, research, and advocacy for the well being of individuals living with HIV • SID population (>200 clients annually) – Ages: Birth to age 25 (or transition to adult care, if earlier) – HIV status • HIV-infected • HIV-affected born to HIV+ mothers and/or with HIV+ sibling(s) • HIV-indeterminate infants <2 years of age with perinatal exposure 62
SID Care Team SID Services • Physicians – PCP, infectious disease, HIV/AIDS • Primary & specialist care specialists • HIV/AIDS medical services • Nurses – pediatric & adolescent specialists • Psychosocial support • Clinical Nutritionist • Medical nutrition counseling • Pharmacist • Pharmacy services • Psychologists – neurodevelopmental, adolescent & • Neuropsychological & developmental assessments adherence specialists • Surveillance & counseling • Neurologist • Referrals • Social Worker • Laboratory services • Child Life Specialist • Transportation services • SID Specialty Laboratory • CAB • Phlebotomist • Mentoring program • Point of Service • Van Driver 63
Goals and Challenges • Monitoring health outcomes in an ages 13-24 HIV infected priority population – 68% of SID clients are ages 13-24, ~85% perinatally infected, in long-term care aging into adolescence and adulthood with a high incidence of viremia associated with: • Psychosocial challenges of diagnosis or disclosure, adolescence, transition to adult care • Complex medication management, successive ARV regimens, risks of drug resistance • Non-compliance with medication or medical visits • Data collection and reporting – Reliance on manual data entry/reporting – Reporting and monitoring of data from multiple data sources 64
Implementing Solutions • Tools for data reporting and health outcomes assessment – Quarterly reports reviewed by SID QM Committee • Retention and engagement in care among SID clients • Health outcomes, with viral load (VL) suppression as a priority • Factors associated with viremia in disproportionate populations served by SID (youth, MSM of color, transgender individuals, African-American and Latina women) – Development of focused, individual interventions based on identified factors impacting viremia • Ongoing projects – Developing a comprehensive database in SID Specialty Laboratory to maintain all viral load data – Creating a visualization dashboard relevant to SID clinical care team 65
2018 Ryan White SID Client Demographics No. (N=77) (%) Age <13 years 25 32 13 years and older 52 68 Gender Female 34 44 Male 42 55 Transgender (F-to-M) 1 1 Ethnicity Hispanic 15 19 Non-Hispanic 62 81 Race White 19 25 Black or African-American 53 69 Asian 3 4 More than one race 2 2 66 *Data collected between January 1 – December 31, 2018.
2018 Ryan White SID Client Demographics No. (N=77) (%) Insurance Medicaid/Medicare 44 57 Private/Other 29 38 No insurance 4 5 Income Level ≤100% FPL 33 43 101%-200% FPL 27 35 201% - 250% FPL 4 5 251%-400% FPL 9 12 >400% FPL 4 5 67 *Data collected between January 1 – December 31, 2018.
2018 Ryan White SID Continuum of Care (100%) 68 *As defined by the HIV/AIDS Bureau Core Performance Measures (percentage of patients, regardless of age, with a diagnosis of HIV and with a HIV viral load of less than 200 copies/ml at last HIV viral load test during measurement year).
VL Suppression in SID Clients by Age Group <13 years 13 years & older (n=25) (n=52) Undetectable VL at last medical 25 40 visit (VL suppressed) Detectable VL at last medical visit 0 12 (Viremic) VL Suppression Rate* 100% 77% • Clients ages 13 years and older were approximately 7 times more likely to have a detectable VL (≥200 copies/ml) than those younger than 13 years at their last medical visit (p<0.01). 69 *As defined by the HIV/AIDS Bureau Core Performance Measures (percentage of patients, regardless of age, with a diagnosis of HIV and with a HIV viral load of less than 200 copies/ml at last HIV viral load test during measurement year).
Retention in Care & VL Suppression by Number of Medical Visits in 2018 VL suppression rate: 100% 25 clients, 72 medical visits 70
Retention in Care & VL Suppression by Number of Medical Visits in 2018 VL suppression rate: 77% 52 clients, 151 medical visits 71
Retention in Care & VL Suppression in Adolescent Subgroups 86% VL suppressed 85% viremic at 1 at all medical visits or all medical visits 72
Socio-economic & Behavioral Factors Associated with Viremia in Adolescents Unadjusted 95% CI Odds Ratio Insurance Uninsured 9.36 (1.23, 71.34) Insured - Public, Private, or Other ref HIV Risk Factor Heterosexual 8.34 (1.53, 45.48) MSM or PHIV ref 73
Demographic Factors Associated with VL Suppression in Adolescent Subgroups VL Suppressed at Last Viremic at Visit Last Visit (n=40) (%) (n=12) (%) p-value Gender Female 15 (38) 6 (50) 0.63 Male 24 (60) 6 (50) Transgender (F-to-M) 1 (2) - Race Black or African-American 16 (40) 2 (17) 0.10 Other races 24 (60) 10 (83) Ethnicity Hispanic 12 (30) - 0.05 Non-Hispanic 28 (70) 12 (100) 74
Next Steps • Identify pathways to address challenges with VL suppression in adolescent population by: – Looking at success in VL suppression in pediatric population – Understanding retention in care and other socio-demographic factors associated with risk of viremia – Identifying clinical practices to re-engage adolescents into care and obtain access to medical insurance • Utilize data reporting to develop screening tools to assist SID clinical care team in identifying at risk adolescents for prevention of viremia 75
Questions? Contact Information Justine Legbedze Email: jlegbedze@luriechildrens.org Barbara Bellg Email: bbellg@luriechildrens.org
Learning Collaborative Quality Improvement Projects Nina Clark: Loyola University John Parisot: Michael Reese Karen Lee: University of Chicago
VIRAL SUPPRESSION AND DEPRESSION AMONG WOMEN OF COLOR Loyola University Medical Center Nina Clark, MD
RACIAL/ETHNIC DISPARITIES IN VIRAL SUPPRESSION IN US • Medical Monitoring Project 2009-2013 • HIV surveillance system to assess characteristics of those with HIV receiving care in US • 22,081 adults, 44% black, 23% Hispanic, 34% white • Viral suppression defined as VL < 200 copies/mL Beer, J Acquir Immune Defic Syndr. 2016 73(4): 446
RACIAL/ETHNIC HIV DISPARITIES IN US ART PRESCRIPTIONS • VIRAL SUPPRESSION • Beer, J Acquir Immune Defic Syndr. 2016 73(4): 446
RACIAL/ETHNIC DISPARITIES IN VIRAL SUPPRESSION IN US • Many potential reasons for disparities in outcomes • Differing social determinants of health: poverty, insurance, education, incarceration, homelessness • Level of engagement with providers • Depression Beer, J Acquir Immune Defic Syndr 2016 73(4): 446
DEPRESSION AND HIV • Affects up to 47% of HIV-infected adults; most commonly reported mental health condition among adults with HIV • Only half receive treatment • Associated with: • Lower quality of life • Reduced ART adherence • Reduced viral suppression Bengtson, PLoS One 2016 11(8):e0160738
GENDER/RACE/ETHNICITY AND DEPRESSION IN HIV • 31,000 HIV-infected adults, depression level measured with Patient Health Questionnaire-9 (PHQ-9) • 11% female • 49% white, 21% black, 24% Hispanic • Women more likely to have an indication for antidepressive treatment (score >=10), even after adjusting for race/ethnicity • Blacks and Hispanics were less likely to start antidepressant treatment, compared to whites Bengtson, PLoS One 2016 11(8):e0160738
LUMC VIRAL SUPPRESSION PROJECT GOAL • Study population: African American and Latina women • To assess whether there are gender and racial/ethnic disparities in viral suppression in the Loyola University Medical Center (LUMC) HIV Program • To assess PHQ-9 depression scores among African American and Latina women • To assess whether there is a relationship between depression scores and viral suppression among our population
METHODS • Implementation of PHQ-9 depression screening at LUMC HIV clinics from September 2017 to November 2018 • Score of >=10 has 88% sensitivity and 88% specificity for major depression • Manual data extraction from HIV clinic database maintained by HIV nurses
PHQ-9 QUESTIONNAIRE
LOYOLA UNIVERSITY MEDICAL CENTER HIV PROGRAM DEMOGRAPHICS Women Men Total Age, yrs (median, range) 48 (23-76) 51 (18-88) 50 (18-88) Race Black 56 (70%) 130 (41%) 186 (47%) Hispanic 10 (13%) 59 (19%) 69 (18%) White 7 (9%) 108 (34%) 115 (29%) Asian 6 (8%) 11 (4%) 17 (4%) Other 1 (1%) 6 (2%) 7 (2%) Total 80 (20%) 314 (80%) 394
LUMC HIV PROGRAM DEMOGRAPHICS Women Men Total Insurance Grant 5 (6%) 28 (9%) 33 (8%) Medicaid 30 (38%) 67 (21%) 97 (25%) Medicare 14 (18%) 61 (19%) 75 (19%) Private/Marketplace 31 (39%) 157 (50%) 188 (48%) Missing 0 1 (0.3%) 1 (0.3%) Total 80 314 394
LUMC HIV PROGRAM VIRAL SUPPRESSION Women Men Total Prescribed ART 78 (98%) 308 (98%) 386 (98%) VL ND 56 (70%) 218 (69%) 274 (70%) VL < 200 68 (85%) 285 (91%)* 353 (90%) Total 80 (20%) 314 (80%) 394 *N S
LUMC HIV PROGRAM VIRAL SUPPRESSION WOMEN BY RACE/ETHNICITY N=8 0 Black (56) 95% Hispanic (10) 90% White (7)100% Asian (6) 83% Other (1) 0% Ave (80) 93%
PHQ-9 SCORES • 205 of 394 assessed (52%) • 50 women (63% of female clinic population) • 36 African American • 6 Hispanic • 5 White • 3 Asian • 155 men (49% of male clinic population)
PHQ-9 SCORES • 24 (12%) had PHQ-9 scores >=10 consistent with at least moderate depression • 8 women (16% of those surveyed) • 16 men (10% of those surveyed)
PHQ-9 SCORES Women Men Total Median (range) 4.5 (0-15) 2 (0-26) 3 (0-26) Race Black (N=36) 4 (0-13) 2 (0-26) 3 (0-26) Hispanic (N=6) 10.5 (0-15) 2 (0-11) 3 (0-15) White (N=5) 4 (0-9) 2 (0-22) 2.5 (0-22) Asian (N=3) 4 (3-14) 1 (1-2) 2.5 (1-13) Total surveyed 50 155 205
CONCLUSIONS • High rate of ART prescription in both genders and all racial/ethnic groups • High rate of viral suppression (VL < 200 copies/mL) in both genders (>=85%) but slightly higher in men • High rate of viral suppression in all racial/ethnic groups (>=83%), lowest in Hispanic and Asian women • Rate of moderate depression low, similar in women/men with highest median score in Hispanic women • Correlations limited by small samples sizes
NEXT STEPS • Hispanic and Asian women could be a focus of future assessments • Lower viral suppression rates • Higher median scores for Hispanic women on PHQ-9 • Difficult to optimally study subgroups of women at LUMC given relatively small patient population
Promoting Viral Suppression in Gay and Bisexual Men of Color John Parisot, PhD, MSN, RN Nurse Educator Michael Reese Mercy Care Program CDPH Leaning Collaborative
Project Rationale ● Gay and Bisexual Men of Color was by far our highest demographic of patients ● If this model were to be successful in this population, we could possibly implement it with our other focused populations ● Youth and Trans Women are our least numerous patients ● We have more Gay and Bisexual Men of Color than Black and Latino women
Project Design ● Use of data to drive the focus on our priority population ● Intensive monitoring of those Gay and Bisexual Men of Color who were not virally suppressed during the timeframe (viral load > 200) ● Administration of short survey about knowledge of HIV viral load, challenges to becoming undetectable, and U = U (Undetectable Equals Untransmittable) ● Compare those who were not virally suppressed at the beginning of the data collection window period to those who became virally suppressed at the end of the data collection period
Data Collection ● Window of Data Collection: October 1, 2018-January 15, 2019 ● Revision of data collection markers and parameters: Initially looked at any detectable HIV viral load in 2018, then revised to anyone with a currently detectable HIV viral load ● Close review of whether or not data was actually representative of window of data collection (in some cases last detectable HIV viral load was in 2017 from one data query) ● Administer survey and analyze the results; compare pre and post test
U = U Survey ● 1. Do you know/can you explain what an HIV viral load is? ● a. Yes b. No c. Maybe/Sort of ● 2. Is getting an undetectable HIV viral load a personal goal for you? ● a. Yes b. No c. Maybe/Sort of ● 3. What have been your challenges to getting an undetectable HIV viral load? (qualitative narrative)
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