The Hotspotters Retention and VL Supression Monitoring Project Ivy Clinic, Arnot Ogden Medical Center DRAFT Quality Improvement Team  Clinical Coordinator – Joan Cain, FNP-C, HIV Specialist  Treatment Adherence Counselor – Lynn Bassler  Program Asst./QI Coordinator – Anna Lechowska  Case Managers – Shannon Sprague and Lawanda Robinson

Purpose Purpose:  To test a care coordination process for managing patients – “Hot Spotters” who fall out of care and need targeted interventions and  To improve patient care for those patients who are not retained and who do not have suppressed Viral Loads <100 copies by testing targeted interventions

Performance Measures HIVQUAL Retention measure: Number of unique clients with at least 2 or more medical visits during the past 12 months, one in each 6-month period _______________________________________________ Number of unique clients with at least 1 medical visit during the past 12 months

HIVQUAL Viral Load Suppression Guidelines Value derived from the last viral load measurement of the review period  Not Suppressed Detectable based on clinic lab definition No measurement in the last half of the review period  Suppressed Undetectable based on clinic lab definition Most recent measure in the last half of the review period Data reported by gender, race, ethnicity, risk/ transmission

5 Viral Load Measure Viral Load Suppression measure: All* patients with the most recent VL Test within the last 6 months of the measurement year that are considered undetectable based on clinic lab definition - <100 copies _______________________________________ All* eligible patients with at least one medical visit in each of the 6 months in the measurement year and at least on ART for 3 months.

HIVQUAL Viral Load Suppression Guidelines Value derived from the last viral load measurement of the review period  Not Suppressed Detectable based on clinic lab definition No measurement in the last half of the review period  Suppressed Undetectable based on clinic lab definition Most recent measure in the last half of the review period Data reported by gender, race, ethnicity, risk/ transmission

Viral Load Suppression Performance Measure Numerator: All* patients with a VL Test ((or measure) within the last 6 months of the measurement year that are considered undetectable based on clinic lab definition Denominator: All* eligible patients with at least one medical visit in each of the 6 months in the measurement year. * Repeat measure replacing “All” with African American patients, Latino patients, gay and bi- sexual male patients, male/female, by risk/transmission

Background Information Clinic’s Info : active clients in March 2012, 96% of them on HAART. Patients’ numbers doubled in last 8 years. (10 patients not on HAART) - Clinic’s goal is to see each patient every 3 months for primary care visit with NP and bloodwork, and twice a year to follow up with dietician, medical case manager and treatment adherence counselor. - 3 locations: Elmira (main), Ithaca and Bath (most recently established), cover Chemung, Tompkins, Schuyler, Steuben, Tioga, and growing into Cortland and Seneca counties.

Baseline Data – based on IPRO and HIVQUAL reporting 2010 Data: Retention rate – 91.6% HIV viral load suppression – 77.6% undetectable (less than 48) 2011 Data: Retention – 94.6% HIV viral load suppression:  57.6% undetectable (less than 20)  72.7% VL suppressed at less than 48  14% clients with VL over 100.

Improvement Goals Increase percentage of clients with HIV primary care visits every 3 months (or at least one visit in each 6 month-period) Increase percentage of clients with undetectable HIV VL (less than 100).

Improvement steps Identify clients most likely to miss appointments and develop problems with treatment adherence. Identify patterns in behavior that my lead to retention problems and medication non-adherence, develop prevention and care coordination plan and approach.

Model of Hotspotters team activities – test new process Patients on HAART with HIV viroload over 100 Patients not seen in 6 months CM follows up with CBOCM follows up with the patient □ Schedule medical appointment with the provider □ Schedule case management review with CM (if needed, to follow up on patient’s issues) Review most recent clinic and adherence data for the client Identify individual retention problems Contact the patient with lab results (NP) □ Schedule f/u bloodwork □ Schedule visit with NP to discuss the lab results □ Schedule appointment with Treatment Adherence Counselor Collection of Data by QI Coordinator (based on Excell spreadsheets, eMD and AIRS reporting) □ Review outcome of interventions at the end of the month. □ Update viroload information and follow up on scheduled appointments □ Review client’s chart in eMD for possible coordination of care needs. Meeting of the Team (second Friday of the month), review of the data

Treatment Adherence for people with VL Self-Assessment Do they know which meds to take, how many, and when? Review Missed Doses Are they missing doses of their medication? Medication Education Provide medication and treatment education. Identify Barriers Figure out how many doses missing and why? Review Medication Guidelines Are they taking it appropriately (i.e., with food, without splitting, with other meds)? Develop Care Plan Set client-focused goals to overcome adherence barriers (if client is agreeable). Resistance Testing Determine if resistance has occurred and if a med change needs to happen. Reassess for Readiness Determine if client is ready to take medications (confidence and importance).

Overall Findings Start of the project – November clients on the list - 25% no-shows - 75% VL over % female/77% male Current data - March clients - 13% no-shows - 13% new clients - 73% VL over % female/74%male 22 patient from November list remain on it in March 18%(4) no-shows/82%(18) VL over % female/68% male (note: higher number of women remaining on list for longer time) All of the clients remaining on the list were outreached to schedule an appointment, repeat VL, run a resistance test and/or see Treatment Adherence Counselor. Patients with VL over 100: 61%(11) VL down, 28% (5) VL up, 2 – no change 2 clients restarted medications recently 5 clients with severe mental health problems – 4 enrolled in MH care 1 client refusing care, 1 about to be closed (MIA).