Campaign Webinar Viral Suppression is the Ultimate Goal April 30, 2013

1

Campaign WebinarViral Suppression is the Ultimate Goal

April 30, 2013

2

Ground Rules for Webinar Participation

• Actively participate and write your questions into the chat area during the presentation(s)

• Do not put us on hold• Mute your line if you are not speaking

(press *6, to unmute your line press #6)• Slides and other resources are available

on our website at incareCampaign.org• All webinars are being recorded

3

Agenda1. Welcome & Introductions, 5min2. Campaign Data Review, 10min3. Washington, DC Part A EMA, 10min4. Commonwealth of Virginia Part B, 10min5. University of Kansas Part C, 10min6. Question & Answer, 10min7. Updates & Reminders, 5min

In the chat room, Enter

your: 1. name, 2. agency, 3. city/state, and 4. professional role at agency

4

Viral Suppression by RW Part Funding

5

Viral Suppression by Caseload

6

Viral Suppression by Facility Type

7

Viral Suppression by Ambulatory Care Type

8

Interventions Related to Viral Suppression

Operational Activities• Process Mapping• Fishbone MappingClient Activities• Adherence Counseling• Health Education / Health Literacy

Improvement• Journaling or verbal description of how

patient takes meds

9

Interventions Related to Viral Suppression

Provider Activities• Motivational Interviewing Training• Cultural Competence Training• Utilization of Patient Portals / Electronic

Communications• Pharmacokinetic Assessment• Absorption Analyses

10

Submit Improvement Updates!

VIRAL SUPPRESSION:

THE ULTIMATE GOALJustin BritanikDistrict of ColumbiaHIV/AIDS, Hepatitis, STD, and TB Administration

Background• HAHSTA (HIV/AIDS, Hepatitis, STD, and Tuberculosis Administration)

is the Part A grantee for the DC EMA.• The EMA is uniquely diverse, comprised of 3 states, 18 counties, and

the District of Columbia.• Sub-recipients include providers of all types and sizes, from county

health departments, large hospital systems, Federally Qualified Health Centers (FQHCs), specialized HIV/AIDS clinics, to small community based organizations.

• HAHSTA also administers DC ADAP and Part B services for the District of Columbia.

Death Surveillance

HAHSTA Programs and Activities

Peri-incarcerated MCM

Targeted Treatment Adherence

Lab Surveillance

National HIV Behavioral Surveillance (NHBS)

Case Management Operating Committee

DC EMA Cross-Part Quality Collaborative

Program Coordination and Service IntegrationComprehensive

HIV Care Plan

Recapture Blitz

Strategic Planning for Target Populations

Enhanced Comprehensive HIV Prevention Planning

HIV Implementation Plan “Ending the Epidemic”

Priorities throughout the Continuum of Care

• HAHSTA recognizes the relevance of measurable outcomes to evaluate programs• Using program data and surveillance data together to increase

linkage and retention to care• The administration envisions that providers will

coordinate, and collaborate to maximize client access, enrollment and retention in outpatient/ambulatory medical care.

• Durable Viral Suppression is the goal, and the Administration understands that retention and adherence activities are the means to achieving this.

•

DC Treatment CascadeHIV Continuum of Care for HIV Cases Diagnosed in the District of Columbia, 2005-2009

Ryan White Cascade, 2011

Latest Request for ApplicationsPurpose of the Retention for Results: Towards Durable Viral Suppression in the District of Columbia RFA is to create a system of services that serves individuals with HIV as they achieve durable viral suppression• Prepare client for HIV-related care services• Increase the extent to which clients are retained in a

system of HIV-related care services• Improve the ability of clients to access and consume

services by increasing the coordination of services• Assist clients to achieve durable viral suppression

Outcomes of Viral Load Suppression• Fewer new infections from reduced community viral load• Avoiding drug resistance• Fewer adverse health outcomes (i.e. opportunistic

infections, immune system damage)• Savings to healthcare system (i.e. avoiding

hospitalization, decreased ED visits)

Healthier and happier patients!

Durable Viral load suppression is the goal, but in order to achieve this goal, patients have to be tested, linked to care, placed on ART, and retained in care…

So QI efforts around Viral Load suppression need to address all these

factors!

QI Projects to Address VL Suppression

• DC Collaborative• In+Care Measures

• Recapture Blitz• A city-wide outreach initiative to support all Ryan White funded

outpatient ambulatory medical care providers in identifying the clients that have truly fallen out of care to focus intensive “blitz” activities to re-engage clients that are no longer accessing care

• ADAP Project• Using ADAP data to look at trends in enrollment in the AIDS Drug

Assistance Program in Washington DC and quantify virologic response to antiretroviral therapy.

DC EMA Collaborative• Providers have been submitting data on Viral Load

Monitoring and Viral Load suppression since 2011.• Focusing on small steps in the right direction, getting full

participation

Viral Load Monitoring (#2) Viral Load Suppression (#3)68%

70%

72%

74%

76%

78%

80%

82%

84%

86%

88%

May-11Jul-11Sep-11Nov-11Jan-12Mar-1212-May12-Aug12-Dec

DC Collaborative Project 2013:Viral Suppression• In+Care Campaign Measure: Retention Measure 4: Viral

Load Suppression• Percentage of patients, regardless of age, with a diagnosis of

HIV/AIDS with a viral load less than 200 copies/mL at last viral load test during the measurement period

• Why look at this for retention?• Critical link between early linkage to medical care and healthy

patient survival.• Recent indication of viral suppression as means of preventing

transmission.• This is the ultimate goal, it gives us an overview of the big picture

of the continuum of care.

2013 Project Continued• Beginning this Grant Year Grantees will report quarterly

on In+Care viral load suppression measure.• Providers will conduct and share PDSA cycles via online

workspace.• Quarterly in-person meetings about joint quality

improvement training activity.• Regional approach: each agency works to reduce it’s own

viral load among patient population, the outcome will be profound from over 30+ agencies working in unison to reduce community viral load.

Recapture Blitz• During Spring of 2013, HAHSTA will redouble outreach

efforts to re-engage clients in care through a “Recapture Blitz.”

• Conducting evidence-based interventions and outreach activities to improve retention in care and treatment on an ongoing basis are standing expectations of the grant agreement.

• By coordinating a city-wide outreach initiative, HAHSTA can support providers in identifying the clients that have fallen out of care to focus intensive “blitz” activities and re-engage clients in care.

Recapture Blitz• Providers submit lists of patient believed to be out of care• Matching against HAHSTA datasets:

• Ryan White Services Report• AIDS Drug Assistance Program (ADAP)• Surveillance• Labs data

• Matching Process - Time since last contact with health care system will be calculated by comparing dates of last: • Ryan White-funded service at another facility across EMA• prescription fill date• lab test

• Lists of Clients actually out of care returned to providers• Providers conduct recapture activities to focus on this narrowed list of

patients

Assessment of Factors that Influence Care

Challenges to retention, adherence, and VL suppression • Language barrier• Discrimination• Stigma• Difficulties finding out where to go for care• Difficulties making an appointment • Difficulties getting to the appointment• Difficulties keeping appointment • Difficulties paying for care – transitioning from RW to Medicaid, etc.

ADAP Project• The DC ADAP absorbed a large increase in clients and

prescription volume. • Most clients achieved a desirable clinical benefit, as

measured by viral load.• Among patients who are on ART from ADAP Percentage of VL

Suppression (<400 copies/mL) 74.0% in 2007 to 90.4% in 2010• During the same span, from 44.0% in 2007 to 71.0% in 2010

among patients who are not on ART from ADAP

Questions and Contact InfoJustin BritanikQuality Management SpecialistHIV/AIDS, Hepatitis, STD, and TB AdministrationDistrict of Columbia Department of Health (DOH)Government of the District of Columbia899 North Capitol Street, NE, 4th [email protected]

mailto:[email protected]

VIRGINIA: VIRAL SUPPRESSION

INTERVENTIONS

Anne RhodesVirginia Department of Health

Background

Cross-Parts

NHASSPNS/CAPUS

Past Collaboratives Cross-State Collaborative (5 States) –

focused on improvements in data collection/service provision for Ryan White clients, including medical care and labs

DC Collaborative – involved 3 states and District of Columbia, focused on improved collaboration among the jurisdictions and reporting quality measures

Unaware of HIV Status(never tested or never

received results)Know HIV Status

(not referred to care or didn’t keep referral)

May Be Receiving Other Medical Care But Not HIV Care

Entered HIV Primary Medical Care but Dropped Out

(lost to follow-up)

In and Out of HIV Care or Infrequent User

Fully Engaged in HIV Primary Medical Care (linked to care)

• DIS Partner Elicitation

• PN Testing/Referrals

Unaware

• Active referral• Care Coordination • Patient Navigation

Known Status (not in

HIV care)

• Patient Navigation• Care Coordination • Mental Health

Lost to Care (Not Fully

Engaged)

SPNS Systems Linkages

SPNS Patient Navigation

Measuring Care Markers

Evidence of HIV

Care

Medical

Visit

CD4 count

ART Rx

Viral Load Test

Treatment Cascade Data: Virginia

Linkage• Care Marker within

90 days of HIV diagnosis

• Denominator is those newly diagnosed in time period

Retention• 2 or more care

markers in 12 months at least 3 months apart

• 1 care marker in each 6 month period of 24 month period

Viral Suppression• Last Viral Load <

200 in time period being measured

• Denominator is those with at least one care marker in time period

Baseline Data: Linkage to Care*

White

Black

Hispanic

Other Race

State

0 10 20 30 40 50 60 70 80 90 10077.5

64.3

63.9

61.5

67.8

76.8

68

72.6

64

70.8

Linked 2012 (Preliminary) Linked 2011

% of All Clients Diagnosed in Year

**Source: Surveillance, VACRS, ADAP data, Division of Disease Prevention, Virginia Department of Health, April 2013

Baseline Data: Retention in Care (2 Care Markers in 12 month period)*

Black White Hispanic Other State0

102030405060708090

69.4 73.6 75.8 71.2 71.269.9 73.382.5

71.5 71.8

Retained 2011 Retained 2012 (Preliminary)Total N for 2011 =11,187Total N for 2012=12,310

*% of those with 2 care markers in 12 months of those with at least 1 markerSource: Surveillance, VACRS, ADAP data, Division of Disease Prevention,Virginia Department of Health, April 2013

Ryan White Data: Retention in Care (2 Care Markers in 12 month period)*


102030405060708090

79.1 83.5 87.6

73.780.782.1 85

91.9

75.683.2

Retained 2011 Retained 2012 (Preliminary)

91.9

*% of those with 2 care markers in 12 months of those with at least 1 markerSource: Surveillance, VACRS, ADAP data, Division of Disease Prevention,Virginia Department of Health, April 2013

Total N for 2011 = 7,284Total N for 2012=7,496

Baseline Data: Viral Suppression (<200 C/ML)*


102030405060708090

68.279.3

74.269 72.267.8

79.385.6

71.8 72.7

Suppressed 2011 Suppressed 2012 (Preliminary)

*% of those with at least 1 care marker in yearSource: Surveillance, VACRS, ADAP data, Division of Disease Prevention,Virginia Department of Health, April 2013

Ryan White Data: Viral Suppression (<200 C/ML)*


102030405060708090

100

70.781.3 78.4

55.5

73.373.480.8

87.2

60.5

76.1

Suppressed 2011 Suppressed 2012 (Preliminary)

*% of those with at least 1 care marker in yearSource: Surveillance, VACRS, ADAP data, Division of Disease Prevention,Virginia Department of Health, April 2013

Treatment Cascade: Thoughts

2012 data is still preliminary – CDC recommends 15-18 months after end of year before finalizing surveillance data

Data reporting issues will impact numbers – electronic lab reporting may affect timeliness and completeness, as will other data system improvements

Future Directions: Viral Suppression

CAPUS: Lost to care

lists/Follow up by DIS

SPNS/CAPUS: Evaluation of

PN to determine

effectiveness of

components

Ryan White: Insurance

Implementation effects on

viral suppression

Data systems:

Integration of surveillance,

care, prevention

University of Kansas School of Medicine-Wichita

Viral Suppression ProjectPaulette Phipps


• 3500 patient Internal Medicine Clinic with approximately 1100 HIV+ patients

• 4 of our 5 medical providers are AAHIVM certified

• Main clinic located in Wichita, KS with 3 satellite clinics to cover 100 of the 105 Kansas counties

• UKSM-W is a Part B medical and medical case management provider and Part C & D grantee/provider

University of Kansas School of Medicine-

Wichita


• Our clinic currently uses Allscripts EHR with a bi-directional interface for laboratory resultso Integration of bi-directional interface made it

feasible to track lab data o Starting in 2011 viral load suppression and

clinic viral load for those in care were calculated

o In 2012 Quality Management Team created a project to increase the number of patients with undetectable viral load by 5% to 750 patients


• 2012 Viral Load Suppression Projecto Included all 1106 patients seen for on

outpatient ambulatory medical care (OPAMC)visit in 2012

o Suppression was defined as the most recent viral load lab value was <200copies/mL

o Only those prescribed HAART were assessed and counseled but clinicians and case managers were advised regarding viral load counts


• Where we started and what we dido At the beginning of January 2012 had 658 of

our 1056 current patients who were virally suppressed

o Identified clients who had viral loads above 100,000copies/mL to receive immediate counseling

o Identified Medical Case Managers (MCM) and medical providers assigned to patients

o Clinicians were asked to delve deeper with these patients during OPAMC visits


• UKSM-W MCM staff took on a greater role with struggling clientsoMCM’s were asked to arrange visits or calls

with client’s routinely to discuss and assess adherence

oClients struggling with barriers such as mental health, substance abuse, transportation or costs of medication were offered additional services through Part C or D or a concurrent retention in care project


• Patients with no case management contact or case managed outside of the UKSM-W system posed a particular challengeo MCM’s from satellite clinics and Aids Service

Organizations (ASO’s) were contacted by QM staff to alert them to the current adherence concerns and lab values

o Part C case management staffers, QM staff and clinic nursing staff tried to engage those clients who did not receive CM services to address adherence issues


• Tracking our progressRed = all HIV+ clinic patients Blue = viral suppression

December-11 March-12 June-12 September-12 December-120

100200300400500600700800900

100011001200

Virally Suppressed

# o

f Pa

tien

ts


• Looking to the futureo Working to develop an education program for

medical case management staff to assist them to assess, problem solve and educate clients regarding adherence

o Expanding the counseling program to those clients with viral loads >10,000 copies/mL

o Developing education and resources for clients that include commercially available tools and reminders as well as tips from successful current patients

53

Announcements

54

• Partners in+care Webinar: What is Viral Suppression – May 21, 12pm ET

• Campaign Webinar: Transitions in+care, Adolescent to Adult Care – May 22, 3pm ET

• Partners in+care Webinar: Linkages Between Mental Health and Medical Services – May 29, 12pm ET

• Journal Club Webinar: Timothy Minniear: “Delayed Entry Into and Failure to Remain in HIV Care Among HIV-Infected Adolescents” – May 30, 2pm ET

• NQC TA Webinar: Jose Montaner, Canadian Treatment CascadeMay 16, 4pm ET

Upcoming Events

55

• Campaign Monthly Topics: ― May Topic – Youth, Transition, and Retention

in+care― June Topic – Latinos and Retention― July Topic – Patient Navigation― August Topic – Refugees, Migrants and

Retention• Data Collection Submission Deadline:

June 3, 2013• Improvement Update Submission Deadline:

May 15, 2013

Upcoming Deadlines and Office Hours

56

Time for Questions and Answers

57

Campaign Headquarters:National Quality Center (NQC)90 Church Street, 13th floorNew York, NY 10007Phone [email protected]

incareCampaign.orgyoutube.com/incareCampaign

Documents

Campaign Webinar Viral Suppression is the Ultimate Goal April 30, 2013