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in+care CampaignWebinar
February 26, 2013
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(press *6, to unmute your line press #6)• Slides and other resources are available
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Agenda• Welcome & Introductions• Robert Wood Johnson AIDS Program,
15min• Broward County EMA, 15min• Gurabo Community Health Center, 15min• Panel Dialogue and Q&A Session, 15min• Updates & Reminders
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Submit Improvement Updates!
Robert Wood Johnson AIDS ProgramNew Brunswick, NJ
Roseann Marone, RN
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OVERVIEW OF RWJAP –
• Located in central NJ—serving patients since 1983-
• Evolution of disease in NJ--- went from a very acute to including lengthy hospital admissions to a chronic disease
• Receives Part A and D and B funding• Multidisclipinary Team • Member of seven site statewide network
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EARLY CONSUMER INVOLVEMENT
• Fifteen year process with foundation built from ‘early days’----
• Parents met each other as in patients and at program events
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EVOLUTION OF CONSUMER INVOVLEMENT FOR PART D
• FAMILY ADVISORY COUNCIL—identified Family Representative
• Monthly Executive Committee meetings--Consumer attendees—
• Annual Family Day—consumer driven• Annual VOICES Conference-consumer
advocacy
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PEER MENTOR PROGRAM
• Purpose: To encourage women to return to care
• Program Coordinator obtains patient permission for PM to contact patient. Release is signed
• Patient’s name and phone number shared with PM
• PM contacts patient and reviews special needs of patient for returning to care
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MAJOR BARRIERS FOR CARE
• Personal: family responsibilities, interpersonal relationships, lack of disclosure, lack of acceptance about disease , poor understanding for the need of consistent care, inability to complete paperwork for entitlements, relocation
• Medical: treatment fatigue ,untreated or under treated mental illness, relapse, substance abuse
• Financial: disconnected phone service, work hours, job loss, under-insured or uninsured , expired ADAP, co-pays for all visits
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PEER MENTOR CHECKLIST
• Discuss reason for missed appointments, missed refills
• Need for blood test • Need for Pap Screening• Need for ancillary specialists--
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CHALLENGES
• Women are unable to talk during work hours
• Concern about disclosing diagnosis• Fear of other family members finding
out about their status and need for care
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LESSONS LEARNED
• Able to reengage women who were not in care
• Provided peer to peer support that providers could not do
• Shared status promotes greater understanding
• Ability to completely understand individual’s situation
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Broward County EMAUtilizing Non-Medical Services to Improve Retention in Care
Presenters: Shaundelyn Degraffenreidt
Quality Assurance Coordinator, Ryan White Part A Program OfficeAriela Eshel
Quality Improvement/Technical Assistance Manager, Broward Regional Health Planning Council
+Broward County EMA Snapshot Over 17,000 People Living with HIV/AIDS in Broward County Approximately 7,000 Clients Receive Ryan White Part A Program Services
Annually 12 Part A Providers
6 Core Services Outpatient/Ambulatory Medical Care
Oral Health Care Pharmaceutical Assistance Medical Case Management
Mental Health Services Outpatient Substance Abuse Treatment
4 Support Services Non-Medical Case Management
Food Bank Legal Services
Outreach
+Clinical Quality Management (CQM) Program
• Oversight• Evaluation• Networks
Grantee CQM Staff
• Data Analysis• Training
CQM Support
Staff
• Advise • Monitor QI
Network Activities
HIVPC QMC
• Review CLD• Develop and
implement QIPs
• Improve Outcomes
QI Networ
ks
CQM Program Mission Ensure high quality services are provided to HIV+ Broward
residents that meet or exceed HAB’s clinical and other performance measures, through an inclusive structure that integrates consumer and provider input
CQM Program Oversight
+In+Care Campaign Involvement The campaign aims to ensure efforts are aligned with the
NHAS to improve access to, and retention in, quality care that will help lower individual and community viral loads
The Broward County EMA elected to participate in the In+Care Campaign in October 2011 Aligns with the EMA’s vision for delivery of high quality care Kicked off during an All Networks’ meeting Network activities are guided by the goal of timely
engagement, linkage, retention and coordination of care Data-Driven, Collaborative Structure
Programmed In+Care retention measures in PE System-wide aggregate data Provider specific data Client-level data
+MCM QIP Development
In June 2012, the MCM Network received agency specific client level data for the Gap Measure 04/01/2011 - 03/31/2012
Each provider was asked to document the following: Last Attended Medical Appointment Reasons for Missed Appointment Next Scheduled Medical Appointment Date and Result of Last CD4 Test Date and Result of Last VL Data Source for Each Element (e.g., PE, EMR, client self-
report)
+Gap Measure Definition
Definition: Percentage of patients, regardless of age, with a diagnosis of HIV/AIDS who did not have a medical visit with a provider with prescribing privileges in the last 180 days of the measurement year
Numerator: Number of patients who had no medical visits in the last 180 days of the measurement year
Denominator: Number of patients, regardless of age, with a diagnosis of HIV/AIDS who had at least one medical visit with a provider with prescribing privileges in the first 6 months of the measurement year
+Exclusions
Patients documented to be deceased at any time in the measurement year
Patients who were incarcerated for greater than 90 days of the measurement year
Patients who relocated out of the service area or transferred medical care at any time in the measurement year
+Last Attended Medical Appointment
Agency A Agency B
Agency C
Agency D
Agency E Agency F
N 12 35 45 8 10 25Last Attended Medical Appt.
Range:9.11-4.12
Range:5.11-4.12
Range:7.11-5.12
Range:12.11-5.12
Range:8.11-4.12
Range:2.11-7.12
Data Source
PE, EMR PE, Client, Client’s
PCP, Another Agency
EMR EMR PE, Client’s
PCP
PE, EMR
+Reasons for Missed AppointmentsAgency A Agency B Agency C Agency D Agency E Agency F
N 12 35 45 8 10 25Reason for Missed Appt.
None
Too Busy with Work
None
Case Closed (Client
Transferred)
Private Insurance/ Medicaid
Unable to Contact Client
Incarcerated
Unaware of Appt.
Unknown
Appt. Was Attended
Receives Care
through Another RW
Provider
Fallen Out of Care
New Client
Failed to Recertify for RW
Incarcerated
Moved
Medicare/ Medicaid
Incarcerated
Appt. Was Attended
Incarcerated
Client Moved
Private Insurance/ Medicaid
Unable to Locate Client
SA Treatment
No Longer Eligible
Data Source
Client PE, No Source Listed
Client, BSO, EMR
Client, Client’s
Emergency Contact
PE, PCP PE, EMR, DOC/BSO Website
+Next Scheduled Appointment
Agency A Agency B Agency C Agency D Agency E Agency F
N 12 35 45 8 10 25Next Sch. Med Appt.
Range: 4.12-7.12
Range: 5.12-8.12
Range: 2.12-8.12
Range: 6.12
Range: 5.12-6.12
Range: 3.12-9.12
Data Source
EMR, PE PE, Client’s
PCP
EMR EMR MCM, PCP, Client
EMR, PE
+ CD4 and VL Results
Agency A: 58% detectable, 33% CD4<200
Agency B: 21% detectable, 16% CD4<200
Agency C: 47% detectable, 20% CD4<200
Agency D: 100% detectable, 33% CD4<200
Agency E: 90% detectable, 40% CD4<200
Agency F: No results submitted
+Discussion
Data Entry EMR indicates client attended appointment Medical appointment not entered in PE Client included in the Gap Measure
Case Closure Incarceration, moving, transferring to another provider, Private
Insurance/Medicaid/Medicare These cases should have been excluded In some cases, the last documented medical appointment was in
May of 2011 with the case remaining open Progress Note Documentation
Little to no indication that MCMs are tracking medical appointments In some cases, no communication with client for six months
+Questions
How are appointments scheduled and tracked in the MCM Plan of Care to ensure compliance with medical care?
Detectable Viral Load and CD4<200 may indicate non-compliance with care as well as possible eligibility for non-RW funded services (e.g., PAC Waiver). How are MCMs utilizing lab results?
How can MCMs proactively work to prevent clients from falling out of care?
+Gap Measure
12.1.11 2.1.12 4.1.12 6.1.12 8.1.12 10.1.12 12.1.12 2.1.130%
5%
10%
15%
20%
25%
30%
35%
+Medical Visit Frequency
12.1.11 2.1.12 4.1.12 6.1.12 8.1.12 10.1.12 12.1.12 2.1.130%
10%
20%
30%
40%
50%
60%
70%
80%
+Patients Newly Enrolled In Medical Care
12.1.11 2.1.12 4.1.12 6.1.12 8.1.12 10.1.12 12.1.12 2.1.130%
10%
20%
30%
40%
50%
60%
70%
80%
+Viral Load Suppression
12.1.11 2.1.12 4.1.12 6.1.12 8.1.12 10.1.12 12.1.12 2.1.1356%
58%
60%
62%
64%
66%
68%
70%
72%
+Improvement Plan
Accomplishments Increased provider accountability of
client health outcomes Data driven/collaborative structure Ability to generate client-level data Revised client-level outcomes and
indicators Programming of measure per service
category Standing agenda item for all Networks Peer retention program
Challenges Resolving data integrity issues Implementing system-wide retention
strategies Barriers and competing needs:
Low income Housing instability Lack of transportation MH/SA related barriers ADAP crisis and subsequent barriers
to accessing medications
+Major Accomplishment
The EMA received the NQC’s 2012 Award for Performance Measurement
The award honors grantees that have significantly strengthened their ability to measure the quality of HIV
care and services. The EMA was recognized for its capacity to use an integrated software system to collect data on over 7,000 Part A clients annually,
ongoing data-driven QI activities, and refining CQM infrastructure that enhances systemwide performance.
+Other Retention Activities The EMA is the first to pilot the FC/AETC’s Operation HOPEFUL
(Healthy Objectives for People Enjoying Full, Uninterrupted Lives with HIV/AIDS) with Medical and MCM providers
A three-year health literacy plan is being implemented Local Client Level Outcomes and Indicators revised to include
retention measures in each service category Mental Health/Substance Abuse Network QIP Development:
Among the themes identified as impeding retention (severe depression, chronic and persistent mental illness, homelessness, cultural barriers), depression was noted as the greatest indicator of non-retention
The Network is developing trainings for other providers on identifying and addressing mental health barriers to retention
+Our Goal
To transition clients along the treatment cascade to full engagement in HIV care and viral load
suppression
+Next Steps
Routine Data Review and Validation Monthly QI Data Calls with Providers Data Findings
Planning Council Process
Implementing QI Projects at System and Provider Levels
Quality Project“In Care Campaign”
Preperation by: Denise Vega Alvarado, RN, BSNClinical Coordinator
Lcda. María Elena López RamosHealth Educator
Marlene Pérez, Program Director
Objectives• Detail the initiatives performed by
Program SIVIF under the development of the InCare campaign.
• To share methods and strategies established to encourage participant retention
• Present analysis and evaluation of the project with the results obtained up to September of the year 2012.
• Projections to the year 2013
Background
• Program SIVIF provides intergrated service to individuals infected with HIV/AIDS as well as their families and significant others. The population of patients in the clinic currently are 278.
• Retention campaign was welcomed in our quality program for the initiative to promote retention through the measures established by the National Quality Center.
• This considerably is priority for our Center to provide and maintain medical care for our patients.
• Under this approach we were able to maximize our efforts in preventing the patient from being out of treatment for a long period of time.
Project Initiation
• We initiated with the study and discussion of the four indicators of the retention campaign through a team meeting which forms part of the quality improvement Committee.
• Strategies were developed and established to be used in the plan for 2012.
• We identified the national measures and the measures established by the AIDS Task Force of San Juan (TGA).
Measures achieved in 2011
Barrier to care
Frequent visits
New patients
Viral load supression
<200
0%10%20%30%40%50%60%70%80%
9.89%
73.73%
60.00%71.34%
Dec-11
Goal
• The overall goal of the campaign's retention in our program is to increase 15% retention of patients receiving services in the SIVIF program and link to treatments according to suggest guidelines for treatments for HIV/AIDS patients health care + by the Department of health and human service (HRSA).
Objectives• Provide services of physicians and link treatment every 3
months. • Provide services of laboratory and in link treatment
every 4 months.• Identify absent patients to medical visits and laboratory. • Link newly enrolled patients to treatment within a 30
day period.• Monitoring the viral load of the patient to achieve to
reaching levels of less than 200 copies/ml or not detectable.
Determined goals
• Barrier to care (Gap Measure) Decrease to= 7%• Frequent visits(Medical Visit) Increase: 88%• New patients (Patients Newly) Increase: 75%• Viral load supression<200 (Load Supresión) Increase: 86%
Barrier to care Frequent visits New patients Viral load Supression0%
10%20%30%40%50%60%70%80%90%
9.89%
73.73%
60.00%
71.34%
7%
88%
75%86%
Dec-11Goal
Work TeamMaría Elena Lopez,
Health Educator
Denise Vega (Clinical Coordinator)
Ilka Sánchez (Case Manager)Joel González (Case Manager)
Joann Ross (Case Manager)
Nelida López (Nurse)Dorileen Vélez (Nurse)
José Marrero, Outreacher
Brenda Vélez (Receptionist)
Maria Velez (Pharmacy Assistant)Laura Méndez (Pharmacy
Assistant)
Dra. Antonia Márquez, HIV Treater
Dr. Jose Ortiz, HIV Treater
Work Assignments• Health Educator
1. Maintains a laboratory registry2. Refers lost patients to treatment to Case Manager.3. Monitors absences of appointments weekly. 4. Audit records5. Guides and educates the patient about Incare campaign and
adherence to treatment.• Clinical Coordinator-
1. Monitors the compliance of clinical services / processes facilitator / case discussions.
• Case Manager- 1. Search for case and link to treatment (letters, calls, home visits). 2. Refer to Outreacher patients lost to treatment.3. Discussion of cases (medical, nutrition, psychologist). 4. Educates the participant using the compliance agreement. 5. Audits of records weekly (last medical visit).
Work Assignments• Nurse-
1. Identifies absent patient from medical and laboratory appointment. 2. Register laboratories carried out daily. 3. Educates participants on the importance of adherence to the treatment
and the side effects. • Outreacher-
1. Case-finding / visits to the home. 2. Offers free transportation3. Coordinates with partner agencies to detox or psychological treatment.
• Receptionist- 1. Identifies the absent patient by using program Proclaim as 'No Show'
system. 2. Confirm appointments and the laboratories the day before their
appointment. 3. Coordinates medical visits every three months and laboratories every
four months.4. Continuously updates patient demographic information
Work Assignments
• Pharmacy- 1. Submits monthly report of patients
with poor adherence to treatment. • Medical Personnel
1. Takes part in the discussion of cases and facilitate strategies for adherence to treatment.
Weekly strategies / Health Educator and Case Management
Mailing of Correspon
dence: Follow up
in two weeks
Referred to Case Management/ Internal
Referral
Meeting C. Manager and H. Educator /Calls
/AppointmentAuditory/ absences, Thursday or FridaysStep # 1
Step # 2
Step # 3
Step # 4
Addiction Problems / coordinates with Detox, to
link treatment
Mental Health Problems /Coordinated service with
psychologist in program or with a collaborated agency
Patient search system
Identifies the
patient /
Refers
Case Management
Case management
begins search /
Refer Outreach
Outreach/ Link to
treatment/Offers free transporta
tion
Absence Results/ Services Provided
Measurement of absence in 2012
January
February
March
AprilMay
JuneJuly
August
September
October
November
December
0102030405060708090
100
49
7078
90
68 68
49
72
54
7163
56
Absence
Progress of both services
Laboratory Medical Service Both90%
91%
92%
93%
94%
95%
96%
97%
98%
99%
100%
94% 94%
96%
97%
96%
94%
95%96%
94%
January to April
May to August
September to December
Results obtained until September 30, 2012 /
Comparative data (five years)
Results INC01 - InCare 1: Visit gap
Neo Med Center/ Program SIVIF09/30/2012 17 / 268 = 6.34%
10/01/2011 17 / 252 = 6.75%10/01/2010 30 / 249 = 12.05%10/01/2009 22 / 236 = 9.32%
10/01/2008 27 / 237 = 11.39%
National HIVQUAL –US
Average = 17.72%
7% an under goal
Results INC02 - InCare 2 :Medical visit frequency
Neo Med Center/ Program SIVIF09/30/2012 200 / 248 = 81%
10/01/2011 166 / 246 = 67.48%10/01/2010 144 / 232 = 62.07%10/01/2009 143 / 231 = 61.90%10/01/2008 129 / 221 = 58.37%
National HIVQUAL –US
Average = 64.70 %
7% to reached
Goal
Results INC03 - InCare 3: Patients Newly
enrolled in Medical Care
Neo Med Center/ Program SIVIF09/30/2012 6 / 9 = 66.67%
10/01/2011 3 / 7 = 42.86%10/01/2010 1 / 5 = 20.00%10/01/2009 6 /11 = 54.55%10/01/2008 3 / 5 = 60.00%
National HIVQUAL –US
Average = 57.33 %
8% to reached Goal
Results INC04 - InCare 4: Viral load suppression
Neo Med Center/ Program SIVIF09/30/2012 220 / 318 = 70%
10/01/2011 215 / 304 =70 %10/01/2010 229 / 296 =77%10/01/2009 199 / 281 = 70%10/01/2008 179 / 277 = 65%
National HIVQUAL –US
Average = 72 %
16% to reached Goal
• According to the progress in each indicator found we hoped to establish reached goals for 2012. The data of "Careware" will be fully reported in the system by March 2013. Therefore it is contemplated that month to present the project closing of 2012.
• Because of the importance of patient retention in health care, the project "In Care" will be a quality improvement project in 2013.
• This project will be strengthened with the implementation of the Health Project 100, which aims to use innovative strategies to achieve viral load suppression of the patient.
Summary
Projections for 2013
1. Support the implementation of the project "Health 100" which aims to achieve suppression of viral load of the patient being a partnership to improve our indicator # 4.
2. Continue efforts to coordinate group activities for patients: focus group, support group and educational activities.
3. Keep the strategies used in the collection of data (records) and weekly monitoring InCare team that facilitated patient retention to 94% .
Remember
Together we can do great Things!!
Madre Teresa de Calcuta
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Time for Questions and Answers
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Announcements
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• Partners in+care Webinar: How Social Services Work with Medical Services To Keep Us in+care – to be announced!
• Combined Journal Club and Partners in+care Webinar: Our Experiences and Retention in+care – to be announced!
• Campaign Webinar: Patient Experience Evaluation and RetentionTo be announced!
March Topic – Patient Experience EvaluationApril Topic – Viral Suppression as the Ultimate GoalMay Topic – Youth, Transition, and Retention in+careJune Topic – Latinos and Retention
Upcoming Events
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• Campaign Office Hours: Mondays & Wednesdays 4-5pm ET
• Wednesday, February 27 – Successful Partnerships with Social Services Providers
• Monday, March 4 – Open Space, no set topic• Wednesday, March 6 – Integration of Retention Dialogues into
Community Processes and Conversations• Monday, March 11 – Open Space, no set topic• Wednesday, March 13 – Tackling HIV Stigma• Monday, March 18 – Open Space, no set topic• Wednesday, March 20 – Patient Waiting Time and QI
Opportunities
• Data Collection Submission Deadline: April 1, 2013
• Improvement Update Submission Deadline:March 15, 2013
Upcoming Deadlines and Office Hours
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MedScape Retention in HIV Care Series
• Technical Working Group working on articles for a new Medscape Today News Series.
• We recommend that you subscribe to HIV/AIDS MedPlus to be informed of new and exciting articles in this series!
• Published Pieces:• HIV Care Retention and the Goal of an AIDS-Free Generation• Improving Retention in HIV Care in Resource-Limited Settings• Implementing QI in HIV Clinics to Improve Retention in Care• Monitoring Rates of Retention in HIV Care Across the State• How Health Departments Promote Retention in HIV Care• Improving Retention in HIV Care: Which Interventions Work?• Engaging in HIV Care: What We Learned from AIDS 2012• How Should We Measure Retention in HIV Care? • Retention In HIV Care: The Scope of the Problem
http://www.medscape.com/index/section_10285_0
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Partners in+care
• Partners in+care Private Facebook Group is live! • Share tips, stories and strategies• Join a community of PLWH and those who love
them• Email [email protected] for
more details• Partners in+care website is live!
• http://www.incarecampaign.net/index.cfm/77453 • Join our mailing list (a list-serv version of the FB
Group)
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Campaign Headquarters:National Quality Center (NQC)90 Church Street, 13th floorNew York, NY 10007Phone [email protected]
incareCampaign.orgyoutube.com/incareCampaign