Integration of Chronic Care Services: Making the HIV-NCD Connection Miriam Rabkin, MD, MPH Associate...

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Integration of Chronic Care Services:Making the HIV-NCD Connection

Miriam Rabkin, MD, MPHAssociate Clinical Professor of Medicine & Epidemiology

Director, Health Systems Strategies at ICAP ColumbiaColumbia University Mailman School of Public Health

27 July 2012

Integration of Chronic Care Services in Lower Income Countries

• Increasing prevalence of NCD in LMIC, amongst both PLWH and the general population;

• In many countries, however, health systems are best able to deliver episodic care for acute conditions. HIV programs are often the only exception to this rule;

• Unifying characteristics of chronic diseases – and their management – may provide insights into key programmatic questions;

• Many questions remain unanswered and a priority research agenda is evident…but lack of funding is a significant barrier to both implementation science and NCD services.

Outline

1. Chronic diseases – unifying characteristics

2. Chronic care services – implementation challenges in LMIC

3. Questions for NCD programs4. Questions for HIV programs5. Integration: unanswered questions

ICAP Columbia & Health Systems

Characteristics/priorities of chronic disease from the individual’s perspective:

• Interacting with the health care system on a regular basis over time and for life

• Incorporating responsibility for managing health and self-care into daily behavior

• Sustaining healthy behaviors (adherence, nutrition, smoking cessation, etc.)

• Accessing psychosocial support services to assist with the emotional and social impact of chronic illness

Adapted from Stuart 2008

Diagnosis and enrollment Identification of risk factors, early diagnosis, opportunistic case-finding, point-of-service diagnostics , standardized diagnostic protocols

Retention and adherence Appointment systems, defaulter tracking, patient counseling, expert patients, secure medication supply chains, pharmacy support

Multidisciplinary family-focused care

A multidisciplinary team of healthcare providers and community members delivers care in partnership with the patient

Longitudinal monitoring Health information systems have standardized and easily retrievable data

Linkages and referrals Links within the health facility (to lab, pharmacy, others), between facilities, and between facility & community

Self management An informed, motivated patient is an effective manager of his/her own health

Community linkages and partnerships

Need functional partnerships between health facility-based providers and community-based groups that facilitate access to services across the care continuum

Characteristics/priorities of chronic disease from the health system’s perspective:

Outline

Implementing Chronic Care in LMIC: ChallengesHIV/AIDS Diabetes CVD Chronic Lung

DiseaseCancers Mental

Health

Demand-side barriers + + + + + +

Inequitable availability + + + + + +

Health worker shortages ++ ++ ++ ++ ++ ++

Lack of adherence support ++ ++ + + + +

Inadequate infrastructure and equipment

+ + ++ ++ ++ +

Inconstant supplies of drugs and diagnostics

+ + + + + +

Missing linkage and referral systems

+ + + + + +

Need for client and community engagement

+ + + + + +

Stigma and discrimination ++ + + ++

Adapted from Rabkin and El-Sadr, Global Public Health, 2011

ICAP-Swaziland NCD Situational Analysis

Structured assessment of 15 health care facilities (3 hospitals, 3 health centers, 9 health clinics). All had HIV/AIDS clinics providing continuity care services:

• 0/15 sites surveyed had appointment systems for HTN or DM

• 4/15 sites had on-site medical records of any kind for HTN or DM

• 2/15 sites used any structured charting tool for HTN or DM• 3/15 sites had individuals or teams specifically responsible

for DM or HTN program

Rabkin, Koler, Kamiru et al. Global Health Council Annual Meeting, 2011

Availability of Basic Medical Equipment

0 10 20 30 40 50 60 70 80 90 100

Blood glucose

Creatinine

Full chemistry panel

Liver function tests

Urine protein

Urine glucose

Total cholesterol

Lipid panel

% of sites with on-site access to diagnostic tests

Access to On-site Diagnostics

Medical Records / Documentation

Chart review of 100 randomly-selected diabetic charts at national hospital diabetes clinic– 100% recorded at least one FBSG– 100% recorded at least one BP measurement– 7% documented a foot exam– 4% documented lab tests ordered– 1% documented a fundoscopic exam– 1% documented medications– 0% documented smoking status, adherence

assessment, diabetes-related complicationsRabkin, Koler, Kamiru et al. Global Health Council Annual Meeting, 2011

ICAP-Ethiopia NCD Situational Analysis

For all 261 “active” DM patients with on-site medical records:

• No standardized charting tools in place• 80% had documented blood pressure• 9% had documented foot exam• 8% had documented neurologic exam• 7% had documented eye exam (fundoscopy)• < 1% had documented weight• < 1% had documented cigarette/smoking status

Chart review at regional referral hospital

Outline

Selected Questions for NCD Programs

• Can NCD programs leverage the successes (and learn from the challenges) of HIV scale up to provide NCD prevention, care and treatment services to patients without HIV?

• What strategies, systems and tools are locally available?

• Where will the funding come from?

Lessons from HIV Scale-up

• The “Public Health Approach”– strategies, systems and tools

• Coverage targets (based on prevalence) at global, national, regional, and facility levels

• Engagement of civil society • Rights-based approach to prevention, care

and treatment services (universal coverage)

Illustrative Strategies / Policies

• The “three ones” – one national framework, one national coordinating authority, one national M&E system

• Simplified, standardized protocols (not just guidelines) for diagnosis, referral, care, and treatment

• Task-shifting and ↑↑ use of non-physician clinicians• A “minimum package” of clinical, laboratory and pharmacy

services and equipment• Simple powerful programmatic indicators (enrollment,

retention, adherence, outcomes)• Enhanced linkages and referrals

Illustrative Systems• Point-of-service diagnostics with real-time linkages to care

• Adherence support, expert clients

• Appointment systems, defaulter tracking

• Links between clinical, lab, and pharmacy services

• Task-shifting, multidisciplinary teams, decentralization

• Supportive supervision, clinical mentoring

• Routine use of data at the site level to guide program improvement

• Longitudinal / cohort M&E systems

Illustrative Tools

• Appointment logs, referral forms, outreach forms

• On-site medical records with structured charting tools

• Flowsheets, algorithms, SOPs

• Clinical support tools

• M & E systems, databases, training tools

• Pharmacy support tools

• Lab support tools

Leveraging HIV Programs to Support Diabetes Services in Ethiopia

Blood pressure Fundoscopic exam

Foot exam Neurologic exam

Oral/dental exam

Assessment of visual acuity

0%10%20%30%40%50%60%70%80%90%

1% 3% 3% 6% 4%

Services documented at least once in the 3 most recent visits

Baseline Follow up

Melaku, Reja & Rabkin. IAS 2011, Abstract WEPDD0104

Outline

1. Chronic diseases – unifying characteristics2. Chronic care services – implementation

challenges in LMIC3. Questions for NCD programs4. Questions for HIV programs5. Integration: unanswered questions and

research agenda

NCD amongst PLWH

• Mwangemi et al. 2010 (VCT platform in Kenya): 38% of 4,307 newly-diagnosed PLWH had HTN; 30% had elevated BMI

• Dave et al. 2011 (HIV clinic in South Africa): 26% of 406 ART-naïve patients had dysglycemia

• Gwarzo et al. 2012 (HIV clinic in Nigeria): 15% of 1,033 patients had HTN; 22% had elevated BMI

Selected Questions for HIV Programs• Can NCD (and risk factor) prevention, care and

treatment for PLWH be added to existing HIV programs without compromising coverage, quality and efficiency?

• What are the optimal models with which to provide these services?– Where: In HIV clinics or in OPD or NCD clinics? – Who: With the same clinical staff? Taskshifting? – When: At what level of program maturity? – How: ??

• What is the incremental cost?

EACS Guidelines

Lessons from NCD Programs

Lessons from NCD ProgramsScreening for gestational DM in Cameroon:Dr. Eugene Sobngwi, 2010

Lessons from Immunization Programs

• Vaccine programs are a sought-out platform for additional interventions (vitamin A, deworming, ITNs) but outcomes data are mixed

• “In an attempt to do more with less, it is possible to achieve less with more”– Schuchat & De Cock 2012

• Rigorous assessment of integration strategies is needed

Outline

Integration: Unanswered Questions

“As with many passionately debated subjects, data on risks and benefits of integration are scarcer than might be expected.”

– Schuchat & De Cock 2012

What are the tradeoffs? What is the impact on:• Coverage?• Quality?• Equity?• Efficiency?

Scenario 1: Parallel Services

Scenario 2: Coordinated Services

Scenario 3: Integrated Services

HIV services NCD services

Chronic Disease Services

From: Rabkin, Kruk and El-Sadr, AIDS 2012

Integration: Unanswered Questions

• Which elements of chronic disease programs should be integrated in a given context? – “Upstream” vs. “downstream”

• How can systems be integrated if there are no funds for NCD services?– Are we willing to provide free NCD services only to

PLWH?• What is the priority research agenda?

Thank You

• CDC, USAID, PEPFAR• The Rockefeller

Foundation• Ministries of Health• The Ethiopian

Diabetes Association• ICAP colleagues and

partners

No conflict of interest to declare

Integration of Chronic Care Services: Making the HIV-NCD Connection Miriam Rabkin, MD, MPH Associate...

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