Improving Viral Load Suppression Rates Easton Community HIV/AIDS Organization (ECHO) Quality Improvement Team Members Nurse Practitioner (& MD on prn basis) RN Office Manager Medical Assistant Case Managers

Background Information/Rationale for QI Project Of the more than 1 million people living with HIV/AIDS in the US, 4 in 5 are not viral load suppressed. The National AIDS Strategy acknowledges the role of HIV viral load suppression in both decreasing HIV transmission and in improving patient health outcomes. Easton Community HIV/AIDS Organization (ECHO) is a Ryan White Part C provider serving Northampton, Lehigh, Monroe, Carbon, & Pike counties in Pennsylvania and Warren county in New Jersey. Client base of approximately 100 patients. 100% of clients are either on Medicaid, Medicare, or are uninsured.

Performance Measure Percentage of patients with a viral load of <200 at last viral load testing of the measurement year

Baseline Data Percentage of patients with a suppressed viral load (<200) at the viral load test in the measurement year: Oct. 1, 2010 to Sept. 30, 2011 -- 66.7% Dec. 1, 2010 to Nov. 30, 2011 – 68.57%

Improvement Goal Increase percentage of patients with suppressed viral load (VL<200) at the last viral load measurement of the measurement year from 66% to 85% of patients.

Causal Analysis Workflow Process Analysis Identified the Following Problem Steps: No follow-up appointments scheduled for some patients with elevated viral load Need to develop and implement formal Adherence Program

Viral Load Suppression Performance Improvement Measure: Workflow Process Diagram Forwarded to Data Entry & to chart & flowsheet VL Received? Lab Slip Sent? Send LabSlip Reminder Call if no labs in 6 weeks Labs Done Reminder Letter PreClosure Letter (no Rx’s); CM Notified Reviewed By NP Appt. Kept? Appt Scheduled? Closure Letter at 9+ Months if no contact N Y Call to Schedule Or Resched. Discuss Next Steps –see Clinical Process Diagram Pt. Referred for VL Test

Formulate & Implement Adherence Plan Issues Identified? Formulate & Implement Adherence Plan 2nd VL >200 Consider /Do Genotype Consider/Do Tropism & HLAB5701 Evaluate for Drug-Drug Interactions Consider or Make Med  Evaluate for Drug- Adherence Assessment at Next Appointment Recheck VL in 3 months or less 2nd VL <200 Adherence Assessment by phone or appt. within 2 wks. Yes No Routine Monitoring Ongoing Monitoring of Adherence & VL Testing as indicated VL<200 VL>200

PDSA – Plan/Do Changes Planned for Process of Scheduling Patients for Follow-up Visits Appointments previously initiated by patient after labwork completed -> now will be initiated by staff after receipt of labwork Changes Planned for Adherence Program Initial Adherence assessment for patient with VL>200 to be done by phone or appointment within 2 weeks (previously at next scheduled appointment) of receipt of labwork Adherence Plan Assessment Form developed to track individual patient progress More aggressive adherence strategies: Weekly adherence evaluations of selected patients, including pill box fills and/or supervised pill box fills Involvement of case managers to supervise pill box fills and/or perform weekly evaluation of adherence Use of Adherence tools, such as pillbox with alarm, cell phone alarms, etc.

Action (Pill Box Fill, Supervison, or Check, etc.) ECHO Clinic Adherence Plan Assessment Form Patient Name: DOB: MR#: Date Action (Pill Box Fill, Supervison, or Check, etc.) Adherence Goal Assessment (Since Last Visit) Most Recent VL Result NEXT F/U DATE

PSDA - Study/Results Phase 2: Study/results

Repeated PDSAs

Overall Findings

Looking Ahead (next Steps)