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

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

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Integrated Part A Outpatient Ambulatory Health Services and PrEP Learning Collaborative Session 4 Chicago Department of Public Health Public Health Institute of Metropolitan Chicago January 24, 2019 House Keeping Sign-in and binder

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Integrated Part A Outpatient Ambulatory Health Services and PrEP Learning Collaborative Session 4

Chicago Department of Public Health Public Health Institute of Metropolitan Chicago January 24, 2019

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House Keeping

  • Sign-in and binder materials
  • Refreshments
  • Restrooms
  • Please silence phones
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Ice Breaker Introduction

  • Name
  • Agency
  • PrIDE/OAHS or Both
  • Favorite comfort food
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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.

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How PHIMC Works

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

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

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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
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Goals for LC4

  • Share final instructions for the OAHS and PrEP Learning Collaborative
  • Promote a peer learning environment
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Agenda

Agenda Item Presenters

LC Wrap-up Instructions Audra Tobin: PHIMC Power BI Jennifer Catrambone: CORE Eduardo Mendoza: SSHARC Discussion of Client Tools Melissa Bordenave: AIDS Healthcare Foundation Erin Hantke: Heartland Alliance Health Alyssa Sianghio and Emily Lupo: Lawndale Leslie Rogers: South Shore Hospital Break LC QI Projects Barbara Bellg and Justine Legbedze: Lurie Children’s Hospital Nina Clark: Loyola University John Parisot: Michael Reese Karen Lee: University of Chicago Closing Audra Tobin: PHIMC

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Learning Collaborative Wrap-up

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LC Wrap-up: Participant Expectations

✓ Attend 4 in-person meetings ✓ Share your expertise through presenting during the LC ❑Conduct QI Activities and Document Progress:

  • Collected via survey monkey and Due January 31, 2019
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Power BI

at Cook County HIV/CORE Integrated Programs (CCHIP)

AUSTIN CBC – Javier lopez CORE CENTER – Jennifer Catrambone, Elexis Wright, & Ladonna Spencer SSHARC – Eduardo Mendoza

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CCHIP Data Process

Involves the following data systems, among others: ❖ CARP ❖ Power BI

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CCHIP Data Process

PDI = Provider Data Import ETL = Extract, Transform, Load *Graphic provided by CCH CRU

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Data Infrastructure as Quality Improvement

❖ Basic effort to minimize manual anything

❖ Performance Measures ❖ Medications in EMR ❖ Patient Satisfaction Surveys ❖ Pre-Clinic Prep!

❖ Power BI specifically…

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Power BI as a Tool to Improve Patient Care

❖Improves clinic flow ❖Assists Clinic Team Leads/Nurses/Medical Assistants:

❖ High risk patient identification ❖ Identifies most recent STD data ❖ Identifies most recent Hepatitis data

❖Provides Comorbidity Assessment ❖Future Appointment Information

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Power BI

❖MRN ❖Name ❖Gender ❖Birth date ❖High risk ❖Last VL ❖Last VL Date ❖Last CD4

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Power Bi High Risk Data

Last Viral Load

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Power Bi STD Data

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Power Bi Hepatitis / A1C / Comorbidity Data

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Next steps

CORE Pilot was a success, so now…

❖ Roll out Power BI to SSHARC & Austin! ❖ Streamline our sites data processes

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Client Tools Melissa Bordenave: AIDS Healthcare Foundation Barbara Bellg and Justine Legbedze: Lurie Children’s Hospital Erin Hantke: Heartland Alliance Health Alyssa Sianghio and Emily Lupo: Lawndale Christian Health Center Leslie Rogers: South Shore Hospital

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Melissa Bordenave: AIDS Healthcare Foundation

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AIDS Healthcare Foundation Background

  • The AIDS Healthcare Foundation (AHF) operates in 17 States (includes Washington D.C. &

Puerto Rico) and 43 countries.

  • 1,072,988 patients are in care globally.
  • There are 64 healthcare centers in the U.S.; 2 in Chicago (Hyde Park & South Loop)
  • 48 AHF Pharmacies and 19 Out of the Closet Stores
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Retention Efforts

  • Poor retention is a barrier to all providers treating HIV/AIDS.
  • To decrease viral suppression and overall health outcomes for patients, routine follow up care

is pertinent.

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AHF’s 104 Report

  • The 104 Report was created to reflect a list of patients on a provider’s patient panel that have

not been seen in 104 days.

  • The Lead Client Retention Coordinator formulates a spreadsheet for each provider.
  • On a monthly basis the report is placed on AHF’s system drive for each provider to access at

their convenience.

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AHF’s 104 Report Continued

Page 1 of Report

  • Gives patient summary of

medical information and contact information

  • Prior to internal deadline,

providers are to call each patient on the spreadsheet.

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AHF’s 104 Report Continued

Page 2 of Report Gives list of patients with basic labs, phone number(s), and outcome of contact.

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Goal of 104 Report

  • The goal of the 104 report is to place patients on the schedule for an upcoming appointment

aiding in the effort to decrease gaps in care.

  • Rationale for the report is based on the patient/provider relationship.
  • Hopefully with the provider reaching out to a patient, they get the feeling the provider cares

enough to check on them and personally schedule their next office visit.

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HEARTLAND HEALTH OUTREACH, INC.

Good Morning

Heartland Alliance Health January 24, 2019

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HEARTLAND HEALTH OUTREACH, INC.

Heartland Alliance Health works to eliminate HIV in Chicago by optimizing care across the continuum for our most vulnerable HIV+ and HIV- participants – particularly people who live with HIV, experience homelessness, are trans and/or gender non-conforming, or inject drugs – through universal testing, compassionate care coordination, meaningful utilization of data, and collaborative partnerships.

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HEARTLAND HEALTH OUTREACH, INC.

Heartland Alliance Health

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HEARTLAND HEALTH OUTREACH, INC.

Multiple funding streams enable breadth of services:

  • Primary Care
  • Psychiatry
  • Street and Shelter based Outreach
  • HIV Care
  • Oral Health
  • Case Management
  • Mental Health and Substance Use
  • Medication Assisted Treatment
  • Outpatient Behavioral Health – CSI and ACT
  • TB / Direct Observational Therapy
  • Benefits and Entitlement
  • Residential Programs
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HEARTLAND HEALTH OUTREACH, INC. HIV Measure FY2019 - YTD Gap in HIV Medical Visits: Percentage of patients, regardless of age, with a diagnosis of HIV who did not have a medical visit in the last 6 months of the measurement year 39% Viral load suppression: Percentage of participants with a diagnosis of HIV with a viral load less than 200 copies/mL at last HIV viral load test during the measurement year. 58%

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HEARTLAND HEALTH OUTREACH, INC.

Client Tool

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HEARTLAND HEALTH OUTREACH, INC.

Client Tool

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HEARTLAND HEALTH OUTREACH, INC.

Client Tool

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Alyssa Sianghio and Emily Lupo: Lawndale Christian Health Center

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6 West Side Clinic Locations

  • Main Campus: 3860 West Ogden Ave.
  • Health & Fitness: 3750 West Ogden Ave.
  • Breakthrough Clinic: 3219 West Carroll Ave.
  • Farragut Academy: 3256 West 24th. St.
  • Homan Square: 3517 West Arthington St.
  • Archer Avenue: 5122 South Archer Ave.

LCHC Today

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Health Services

  • Family Medicine
  • Internal Medicine
  • Pediatrics
  • Obstetrics/Gynecology
  • Nursing
  • Dental
  • Optometry
  • Pharmacy
  • Behavioral Health
  • Homeless Healthcare
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Population Health & a Patient Centered Medical Home

  • How do we reduce healthcare disparities?
  • Provide access to care – especially relational care – with a primary

care provider

  • Improve the quality of care
  • Preventive care
  • Chronic disease care
  • Improve care at the visit and between visits
  • Improve transitions of care and communication
  • Strategically bring needed resources around

those most in need

  • Risk Stratification – goal to complete for all HIV pts.
  • Care Plans & Care Management
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Population Health & a Patient Centered Medical Home

Inte tegr grated ated Care e Mana nagem gement ent

  • Generalist staff on each care team
  • Broad use of HRAs to assess risk
  • Collaboration with other care team

members to ensure effective CM services

  • Documentation in shared system
  • Address CM needs at the point-of-care
  • Consistency in CM across care teams
  • Staff receive training specific to

concerns of care team including disease-specific topics (HIV)

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Care Management Tools

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Care Management Tools

HIV Care Team Huddle Report (in development) with the goal of providing multi-disciplinary team with data to ensure:

  • Clinical services completion and quality care
  • Collaboration at the point-of-care to address unique needs of

patient

  • Appropriate risk re-assessment based on change in status
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Care Management Tools

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Care Management Tools

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Questions? Thank you!

Emily Lupo Director of Population Health emilylupo@lawndale.org Alyssa Sianghio Director of Development & Communications alyssasianghio@lawndale.org

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ADHERENCE TO MEDICAL CARE AN OVERVIEW

South Shore Hospital Wellness Ctr 2525 east 83rd street, Chicago, Illinois

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SouthShore Hospital Wellness Ctr

Acknowledgements Program Director – Leslie Rogers, FACHE Medical Director – Clarence Parks, M.D. Office Coordinator – Rena Riggins Outreach/EIS – Keefe Powell

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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.

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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
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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.

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SouthShore Hospital Wellness Ctr

Traditional approaches

  • 1. Phone calls
  • 2. Letters
  • 3. Reminder appointment cards
  • 4. Utilizing community partners
  • 5. Home visits
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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

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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

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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

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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

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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

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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

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SID Services

  • Primary & specialist care
  • HIV/AIDS medical services
  • Psychosocial support
  • Medical nutrition counseling
  • Pharmacy services
  • Neuropsychological & developmental assessments
  • Surveillance & counseling
  • Referrals
  • Laboratory services
  • Transportation services
  • CAB
  • Mentoring program
  • Physicians – PCP, infectious disease, HIV/AIDS

specialists

  • Nurses – pediatric & adolescent specialists
  • Clinical Nutritionist
  • Pharmacist
  • Psychologists – neurodevelopmental, adolescent &

adherence specialists

  • Neurologist
  • Social Worker
  • Child Life Specialist
  • SID Specialty Laboratory
  • Phlebotomist
  • Point of Service
  • Van Driver

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SID Care Team

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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

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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

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2018 Ryan White SID Client Demographics

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  • 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

*Data collected between January 1 – December 31, 2018.

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2018 Ryan White SID Client Demographics

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  • 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

*Data collected between January 1 – December 31, 2018.

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2018 Ryan White SID Continuum of Care

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(100%)

*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).

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VL Suppression in SID Clients by Age Group

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<13 years (n=25) 13 years & older (n=52) Undetectable VL at last medical visit (VL suppressed) 25 40 Detectable VL at last medical visit (Viremic) 12 VL Suppression Rate* 100% 77%

*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).

  • 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).

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Retention in Care & VL Suppression by Number of Medical Visits in 2018

25 clients, 72 medical visits

VL suppression rate: 100%

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Retention in Care & VL Suppression by Number of Medical Visits in 2018

VL suppression rate: 77%

52 clients, 151 medical visits

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Retention in Care & VL Suppression in Adolescent Subgroups

85% viremic at 1

  • r all medical visits

86% VL suppressed at all medical visits

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Socio-economic & Behavioral Factors Associated with Viremia in Adolescents

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Unadjusted Odds Ratio 95% CI 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

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Demographic Factors Associated with VL Suppression in Adolescent Subgroups

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VL Suppressed at Last Visit (n=40) (%) Viremic at Last Visit (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)

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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

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Questions?

Contact Information Justine Legbedze Email: jlegbedze@luriechildrens.org

Barbara Bellg Email: bbellg@luriechildrens.org

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Learning Collaborative Quality Improvement Projects

Nina Clark: Loyola University John Parisot: Michael Reese Karen Lee: University of Chicago

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VIRAL SUPPRESSION AND DEPRESSION AMONG WOMEN OF COLOR

Loyola University Medical Center Nina Clark, MD

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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

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RACIAL/ETHNIC HIV DISPARITIES IN US

Beer, J Acquir Immune Defic Syndr. 2016 73(4): 446

  • ART PRESCRIPTIONS
  • VIRAL SUPPRESSION
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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

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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

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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

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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

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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

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PHQ-9 QUESTIONNAIRE

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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

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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 1 (0.3%) 1 (0.3%) Total 80 314 394

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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

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LUMC HIV PROGRAM VIRAL SUPPRESSION WOMEN BY RACE/ETHNICITY

N=8 Black (56) 95% Hispanic (10) 90% White (7)100% Asian (6) 83% Other (1) 0% Ave (80) 93%

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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)
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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)
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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

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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
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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

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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

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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
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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

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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
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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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SLIDE 101

U = U Survey

  • 4. Have you ever heard of U = U?
  • a. Yes
  • b. No
  • c. Maybe/Sort of
  • 5. Would knowing that Undetectable = Untransmittable be an additional motivation

for you to get an undetectable HIV viral load?

  • a. Yes
  • b. No
  • c. Maybe/Sort of
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SLIDE 102

Results (N = 16)

Yes No Maybe/Sort Of Do You Know What an HIV Viral Load Is ? 11 (69%) 2 (12.5%) 3 (19%) Is an Undetectable HIV Viral Load a Personal Goal of Yours? 15 (94%) 0 (0%) 1 (6%) Have You Ever Heard

  • f

U = U? 0 (0%) 16 (100%) 0 (0%) Would U = U Be an Additional Motivation for You to Get an UD HIV VL? 15 (94%) 1 (6%) 0 (0%)

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SLIDE 103

Results

  • Correlation is not causation
  • Difficult to prove knowing U = U led to viral suppression, although the majority of respondents stated

that it would

  • Small sample size and timeframe of implementation of the model makes results less reliable
  • More than a quarter of respondents were not able to define an HIV viral load
  • The majority of the respondents stated that becoming undetectable was a personal goal and that being

untransmittable would be an additional motivation

  • Intensive monitoring of those who are not virally suppressed was useful
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SLIDE 104

Results

  • Challenges to An Undetectable HIV Viral Load
  • “substance abuse, Rx drug coverage;” "life;” no insurance;” “don’t take my

health serious enough;” “mental health/depression;” “being young;” “consistency;” “mistrust of the medical system;” “low level viral load;” “taking meds the same time of day;” “transportation”

  • During the window period, 5/20 gay and bisexual men of color became

undetectable, difficult to prove that it was as a result of the knowledge of U = U, but presumably would promote this as 100% of respondents reported that knowledge of U = U would be an additional motivation to becoming undetectable.

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SLIDE 105

Limitations, Lessons Learned

  • Structured monitoring of patients who are not virally suppressed is very effective
  • Using data to track this outcome is very useful
  • Repeated attempts to contact and intensive outreach of patients who are not virally

suppressed seems to be helpful (not always successful)

  • Knowledge about U = U appears to promote viral suppression, based on self report
  • f respondents
  • Unable to test the hypothesis as effectively as would have liked given timeframe,

difficulty in showing that knowledge of U = U led directly to an UD HIV VL

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SLIDE 106

Next Steps

  • Sustainability
  • Test behavior changes based on knowledge of U = U (will patients use condoms less,
  • r is the benefit more psychosocial?)
  • Implement intensive monitoring of all patients who are not currently virally

suppressed, and then continue to follow them until they are virally suppressed

  • Continue to provide education about U = U in the hope that it will promote viral

suppression in all populations

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SLIDE 107

Questions?

john@careprogram.care

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SLIDE 108

Karen Lee, MS, Data Manager Jessica Schmitt, LCSW, Adult Social Worker David Pitrak, MD, Adult Ambulatory Provider Julia Rosebush, DO, Pediatric Ambulatory Provider Elaine Seaton, MS, Manager of Care Coordination

University of Chicago

South Side of Chicago

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SLIDE 109

QI Project Goal

▪ Reduce/eliminate disparities in viral load suppression among our client population

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SLIDE 110

Priority Population

Focus on African American and Latina women Baseline 75.6% viral suppression rate ~ 52 clients not virally suppressed

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SLIDE 111
  • 1. Better and more formally track which clients are not

virally suppressed

  • 2. Tailor messaging about adherence to specific barriers

that women living with HIV experience

  • 3. Leverage the know-how of women living with HIV that

have successfully achieved virally suppression

Improvement Strategy Goals

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SLIDE 112

Strategy 1: Improve tracking and response

▪ Formally and regularly generate a list of clients that are not virally suppressed ▪ Identify their next subsequent appointment ▪ If client misses their appointment, activate the outreach team right away to make contact and get them in for a medical visit

112

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SLIDE 113

Strategy 2: Peer Mentor Program

113

Pilot program to pair women struggling with viral suppression with a peer mentor that has achieved viral suppression

  • 6 weeks
  • 7 pairs
  • Contract
  • Weekly contact & log
  • Paid outing incentive
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SLIDE 114

Strategy 3: Adherence Messaging & Tips from Peers

Desire to LIVE Thinking of loved ones, e.g. children, family, friends, and parents Creating goals – what would I like to accomplish before I check out? Developing an easy schedule – first thing in the morning

  • r right before bed

Setting alarms on clocks

  • r other technology for

reminders Having the appreciation for adherence in that, it helps me stay healthy

When you have struggled with adherence to medications, what have you thought about or done to get you through it?

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SLIDE 115

Data and Lessons Learned (so far)

▪ Improve tracking and response

  • Baseline data: 37 clients with VL 20-49,999 and 12 clients with VL

> 50,000, still collecting outcomes data

  • Initial outreach is complete
  • Assessing follow-up outcomes

▪ Peer Mentor Program

  • Baseline VL among mentees ranged from 31 – 213,000, still

collecting outcomes data

  • More structure is needed – group meeting with mentors at the

beginning and a midpoint check-in

  • Track contact attempts and simplify tracking tool
  • Offer certificate and recognition during long-term survivor’s event

to celebrate success

115

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SLIDE 116

Next Steps

▪ Finish collecting outcomes data on tracking and peer mentorship pilots ▪ Present data to the ambulatory teams to brainstorm ▪ Continued integration of case management, outreach, and clinic staff ▪ Integrate adherence messaging/tips from peers into materials and provider conversations with clients

116

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SLIDE 117

Questions?

Contact Us 773-702-4981 karenlee@uchicago.edu

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SLIDE 118

Closing

  • QI Worksheet
  • Final Submission Due January 31, 2019
  • Meeting Evaluation
  • Visit QM Resource Hub - www.chicagoryanwhiteresourcehub.org/

Thank you!!