Karen McCraw Chief Program Officer Family First Health

Karen McCrawChief Program Officer

Family First Health

Goals: Reducing New HIV Infections Increasing Access to Care and Improving

Health Outcomes for People Living with HIV Reducing HIV-Related Health Disparities and

Health Inequities Achieving a More Coordinated National

Response to the HIV Epidemic

The number of patients with a first time diagnosis of HIV ◦Rationale: HIV positivity is a HHS data

reporting priority that is not currently in the UDS.

Quality of Care Measures◦ Adding a measure for new HIV cases with timely

follow up

HIV screening must be included as a covered Preventive Service by private insurance plans under the Affordable Care Act*◦ Screening for ages 15-65; other ages at increased

risk What does “at increased risk” mean? No deductible or copayment can be applied

to HIV screening

In April 2013, the U.S. Preventive Services Task Force (USPSTF) updated its previous recommendations for HIV screening as follows:◦ The USPSTF recommends that clinicians

screen adolescents and adults aged 15 to 65 years for HIV infection.  Younger adolescents and older adults who are at increased risk should also be screened.  (Grade A recommendation)

Early diagnosis of HIV infection leads to better outcomes◦ 33% of the newly diagnosed are “late testers”

with an AIDS diagnosis within one year People in treatment are less likely to

transmit HIV to others There are ~50,000 new HIV infections a

year; half of those new infections originate from the 18-20% of people with HIV who are unaware of their status

So we know we need to do it. But

how???????

Plan around your existing processes

Management and staff buy-in The law Choosing the right HIV test Developing a framework Training Reactive tests Linkage to care Financial issues Record keeping/data management Ongoing monitoring

What is the selling point for routine screening for your audience?◦ Public health?◦ Medical?◦ Ethical?◦ Funder expectations?◦ Insurance regulations?◦ PI issue?

PA no longer requires pre- and post-test counseling

Documentation of informed consent required

Positive results must be reported via NEDSS as with all other reportable diseases

Cannot use the word “positive” in the absence of a confirmatory result

Opt-out testing allowed

One of the most important variables Considerations:

◦ Processing time!!◦ Storage◦ Ease of use◦ Reliability◦ CLIA status◦ Shelf life◦ Cost

Who will obtain consent? Who will answer patient questions? Informational handouts Who will perform tests? Who will deliver results? How will a reactive result be handled? How to keep track of multiple tests

concurrently? EHR documentation How to handle minors? Parent in room?

HIV 101 for support staff Training on performing test How to answer patient questions How to offer a routine HIV test How to deliver a reactive test result

◦ Reassurance◦ Confirmatory

Assessing immediate patient needs

Develop a protocol in the event of a reactive test

Forget the conventional wisdom about not testing on a Friday—”routine” means whenever you are seeing patients

Consider performing a second rapid test to rule out a defective test

Always get confirmatory lab work done before patient leaves

Resources for patient

People who are engaged in care soon after diagnosis have a higher rate of remaining engaged in care

Do you do in-house HIV care? Are you interested in developing the

capacity to provide HIV care? Referral agreements with Ryan White-

funded entities Clarify who is responsible for tracking a

patient once the referral is made Document linkage to care

Negotiate lower test cost Some tests available through 340B pricing Public grant funding Uninsured patients and those covered by

PPS rate may be majority of patients Pharmaceutical company grant funding Increased reimbursement from private

payers under ACA

Incorporation into EHR EHR reporting capacity What do you want to track? What would potential funders want to see? Offered tests/accepted tests/linkage to care

at minimum Do you need a separate database?

Just like everything else, routine HIV screening can fall off the radar

Family First Health has included routine HIV screening in monthly PI chart audits

Share outcomes to reinvigorate staff Family First Health includes testing in set of

core competencies for clinical support staff

Routine HIV screening did not disrupt the clinic flow

Routine HIV screening is helping reduce stigma around HIV testing

Routine screening is philosophically provider driven but operationally support staff driven

Clinical staff buy-in increased dramatically after the first positive test

The first people newly diagnosed as HIV positive through this program were existing health center patients

We were terrible at assessing “risk” Patients like the rapid test and the absence

of risk assessment Staff members were initially upset when

tests were reactive—had to recalibrate their perspective

There is still a role for testing outside the primary care setting

Approximately 82% of HIV positive individuals in York County have been linked to care

77% of HIV positive clients have been retained in HIV care

100% of clients retained in care are receiving Antiretroviral Treatment

Out of the clients who are retained in care and receiving treatment, 93% have an undetectable viral load

Across all Caring Together clients, 83% have an undetectable viral load

Karen McCrawFamily First Health(717) 845-7244kmccraw@familyfirsthealth.org