1 Campaign Webinar Viral 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 Agenda 1.Welcome & Introductions, 5min 2.Campaign Data Review, 10min 3.Washington, DC Part A EMA, 10min 4.Commonwealth of Virginia Part B, 10min 5.University of Kansas Part C, 10min 6.Question & Answer, 10min 7.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 Mapping Client 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: VIRAL SUPPRESSION: THE ULTIMATE GOAL Justin Britanik District of Columbia HIV/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 Integration Comprehensive 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 Cascade HIV Continuum of Care for HIV Cases Diagnosed in the District of Columbia,

Ryan White Cascade, 2011

Latest Request for Applications Purpose 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 Focusing on small steps in the right direction, getting full participation

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 Info Justin Britanik Quality Management Specialist HIV/AIDS, Hepatitis, STD, and TB Administration District of Columbia Department of Health (DOH) Government of the District of Columbia 899 North Capitol Street, NE, 4 th Floor

Anne Rhodes Virginia Department of Health

Cross- Parts NHAS SPNS/ CAPUS

 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)

Evidence of HIV Care Medical Visit CD4 count ART Rx Viral Load Test

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

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

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

*% of those with 2 care markers in 12 months of those with at least 1 marker Source: Surveillance, VACRS, ADAP data, Division of Disease Prevention, Virginia Department of Health, April 2013 Total N for 2011 = 7,284 Total N for 2012=7,496

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

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

 2012 data is still preliminary – CDC recommends 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

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 Project Paulette Phipps

University of Kansas School of Medicine-Wichita 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 results o 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

University of Kansas School of Medicine-Wichita 2012 Viral Load Suppression Project o 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

University of Kansas School of Medicine-Wichita Where we started and what we did o 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

University of Kansas School of Medicine-Wichita UKSM-W MCM staff took on a greater role with struggling clients o MCM’s were asked to arrange visits or calls with client’s routinely to discuss and assess adherence o Clients 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

University of Kansas School of Medicine-Wichita Patients with no case management contact or case managed outside of the UKSM-W system posed a particular challenge o 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

University of Kansas School of Medicine-Wichita Tracking our progress Red = all HIV+ clinic patients Blue = viral suppression

University of Kansas School of Medicine-Wichita Looking to the future o 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 Cascade May 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, 13 th floor New York, NY Phone incareCampaign.org youtube.com/incareCampaign