2017 HIV Care Cascade Submission Housing Works Leslie Pierce, MPH Quality Improvement Specialist Tempestt Perkins, LMSW Managing Director of Retention and Adherence

Data Source Housing Work’s EMR, eClinicalWorks (eCW) CHCANYS Center for Primary Care Informatics (CPCI) Platform that assists with ongoing monitoring of clinical quality measures Nightly extract from eCW Data extract used for eHIVQUAL indicator reporting Have been working with AZARA who manages CPCI to validate the data. Merged two reports to fill in missing data, particularly prescription data.

Methods HIV specific ICD 9 and 10 codes Defined PCP appointment defined by following visit types: Initial Comprehensive Primary Care Follow Up Primary Care Follow Up with Case Conference Acute Primary Care Active patients removed those who were deceased, reported receiving their primary care elsewhere or only had acute visits in 2017 Handful of clients deceased in 2016 Most patients who were not included attend our AIDS Adult Day Healthcare program and had an acute visit Their primary care services are documented in EMR as a non Housing Works

Methods Continued Also included: Primary Housing Works Service Location Downtown Brooklyn Cylar House (East Village) East New York Diagnosis Date Most recent viral load (vl) date with result Binary value for prescription for HIV treatment in 2017 Prescriptions were based on the approved list of prescriptions provided by AZARA on behalf of AI

Methods Continued Validation Proxies Primary service location was matched to the location of the provider Newly diagnosed patients and linkage to care were determined via: Chart review, Follow up with providers/testers, and Verification through other reporting platforms. Proxies Missing VL considered unsuppressed Null VL results were replaced with the second to the last lab Null results are due to insufficient blood samples or misreadings

Challenges and Lessons Learned Newly diagnosed patients Documentation Offsite testing Data verification Patients in care elsewhere Incarceration Data Newly diagnosed linkage to care data required some effort, as it is not always indicated in the chart. Many clients were diagnosed in 2016 but at another health care facility. Date of diagnosis often set as the first day of care at Housing Works. Offsite testing programs. Review and validate newly diagnosed data more frequently.

2017 Improvement Strategies, Goals and Outcomes Strategy 1: Targeted outreach for patients with VL<200 via retention adherence case managers (Jan – June) Goal: 25% of patients with unsuppressed HIV viral loads will be reached and reengaged. Outcomes: 225 patients outreached 70 reached (32%) 33 (15%) scheduled appointments

Strategy 1 Challenges Goal: 25% of patients with vl >200 copies/ml will be reengaged in care. Mass emails, text messages and previously recorded calls by the patient’s primary care provider were unsuccessful due to the high volume of out of date or inaccurate phone numbers and emails. While time consuming, attempting to contact patients on the phone is the most successful method of outreach. High effort, low impact.

2017 Improvement Strategies, Goals and Outcomes Strategy 2: Relaunch the (Jan-Feb 2017) Intervention elements include: Initial case conference - client, provider and case manager; Quarterly $100 gift card incentive for patients whose viral loads <200 copies/mL; CBT adherence support groups; Adherence toolkit methods (i.e., pill boxing, medication reminders and DOT); and Case conferences when there is an increase or rebound in viral load. Goal: 75 new patients will be newly enrolled in the Undetectables Outcome: 189 new patients enrolled in the Undetectables

2017 Analysis: What is our Data “Telling” Us? Categories Subcategories Open Active Prescribed ART Received Viral Load Test Virally Suppressed (<200) Age 0-12 (n=0) N/A 13-19 (n=0) 20-24 (n=30) 100% 97% 90% 60% 25-29 (n=127) 99% 98% 78% 30-39 (n=252) 79% 40-49 (n=192) 96% 50-59 (n=269) 83% 60+ (n=110) 91% Gender Male (n=597) 82% Female (n=235) 81% Transgender (n=78) 76% Unknown (n=70) 94% 70% Race / Ethnicity Non-Hispanic White (n=64) Non-Hispanic Black (n=653) 80% Hispanic (n=228) Asian/Pacific Islander (n=2) 50% Native American (n=2) Multi-Race (n=0) Unknown (n=31) Risk Category Men who have Sex with Men (MSM) (n=470) Intravenous Drug Users (IDU) (n=88) 95% 89% MSM/IDU (n=6) Heterosexual (n=312) Pediatric Risk (n=8) Unknown/Other (n=96) 93% 73% Housing Status Stable Permanent Housing (n=824) Temporary Housing (n=64) Unstable Housing (n=38) Unknown (n=54) 69%

Refining Our Goals and Strategies Strategy 1: Continue with the Strategy 2: At ENY site Youth and Prevention Services (YPS) launching a CBT group for all patients with viral load rates above 200 copies/ml (May 2018) E-CHATS model for CBT University of Pennsylvania Discussion of adherence challenges, feedback from peers and recommit to their personal goals Facilitated by Case Manager and/or Social Worker Meets weekly for 6 months Strategy 3: and YPS targeted outreach to individuals < 29 years-old and/or who identify as transgender Monthly report to identify population Outreach and engagement across all clinics Meeting patients in clinic during previously scheduled appointments to enroll in CM program

2018 Goals Goal 1: Increase the VLS rate of the population of patients between 20 to 29 years-old from 60% (2017) to 70% by end of 2018. Goal 2: Increase the VLS rate of the population of patients who identify as transgender from 76% (2017) to 80% by end of 2018. Goal 3: Improve agency-wide viral load suppression from 78% (2017) to 80% by end of 2018.

Anticipated Challenges Out of date or inaccurate phone numbers and emails. YPS services only offered at ENY location. Patients may not be eligible for case management programs based on funder requirements. Staff time and capacity to conduct outreach calls.

Questions? Contact: Leslie Pierce Quality Improvement Specialist l.pierce@housingworks.org Contact: Tempestt Perkins Managing Director of Retention and Adherence t.perkins@housingworks.org