Health at Home – The AMPATH Evolution Sonak Pastakia, PharmD, MPH, BCPS Assistant Professor Purdue University College of Pharmacy Collaborator, Chronic Disease Management Program

Objectives Provide a brief overview of AMPATH Discuss AMPATH’s transition Describe the structure and design of comprehensive care in Western Kenya Analyze key early results from the diabetes care program Describe areas of care focused research

Development of the Program IU Kenya partnership was started with an initial goal of training healthcare providers but this could not be achieved without treating the thousands of patients infected with HIV. This led to the creation of AMPATH with the help of funding from USAID and PEPFAR. Following the success of the HIV program, in 2008, the acronym changed and the program has now changed its focus to all of primary healthcare and particularly maternal and child health as well as chronic disease management. Academic Model Providing Access To Healthcare Academic Model for Prevention And Treatment of HIV/AIDS

Academic Model Providing Access To Healthcare Initiated in November 2001 55 care sites in western Kenya Catchment population ~ 2.2 million HIV prevalence 2 – 30% >130,000 patients enrolled; 75,000 active patients with 40,000 on cART

Cumulative Patients Enrolled: Nov ’01 – Mar ’08

80% of Chronic Disease Deaths Occur in Low & Middle Income Countries

Targeted Diagnostic Testing AMPATH Approach to Screening Community Screening Home Based Screening Village based screening at innovation sites Perpetual door to door screening for chronic diseases Targeted Diagnostic Testing Referral to clinic for enhanced care Linked to care by community worker

Health at Home Adults Children Total Pregnant Women Number Tested 317,172 38,376 355,548 8,977 Number and Percent Positive 9,731 (3.1%) 702 (1.8%) 10,433 (2.9%) 396 (4.4%) Number Newly Identified HIV positive 8039 (83%) 1028 (83.3%) 8641 (83%) 310 (78%) Number of Orphaned and Vulnerable Dependents Identified 36,593 51,066 87,659

Preliminary Screening Data from Webuye Parameter Result Number Screened 350 Number with random blood sugar > 7.0 mmol/L (128 mg/dL) 47 Total number returning for a confirmatory testing/diagnosis at the health center 19 Total number confirmed with diabetes 4 Estimated prevalence of diabetes 1.1* *60% of patients did not return for follow-up

Primary Health Care and Chronic Disease Innovation Sites Webuye MTRH Center of Excellence Port Victoria Mosoriot Turbo Chulaimbo Teso

CHRONIC DISEASE MANAGEMENT Patient can be admitted or treated and referred down for follow up at lower levels PATIENT CARE AND REFERRAL SYSTEM AMPATH-MTRH Centers of Excellence CVPD Onc DM Psych Others REGIONAL/DISTRICT REFERRAL CENTERS HEALTH CENTER/AMPATH CHRONIC DISEASE CLINIC Patient received and initiated to care using CDM protocols CASE FINDING (EARLY DIAGNOSIS) & LINKAGE TO CARE: PHCT: HIV, BP & RBS Patient referred up based on defined thresholds Patient sent home for dispensary/community/self care DISPENSARY (RN): Triage, prevention, monitoring (BP and RBS rechecks; foot exam etc.) and dispensing role through decision support COMMUNITY CARE AND SELF MANAGEMENT: CHEWS, CHWS, AND COUNSELORS Decision support/training on referral protocols Patient referred to dispensary

Electronic Medical Record Based On Handheld Android Phones A. Community health workers (CHWs) make home visits or client visits local dispensary Web –based Network Server Eventually connectivity to all areas within our catchment area B. CHW Scans Patients Medical ID card E. Data from previous visits available for decision support C. CHW performs basic assessment based on decision support in the phone based EMR D. Data entered directly into the phone

Preliminary Descriptive Data from the Clinics Number of Active Patients at Each Site Site Number of Active Patients Eldoret – Moi Teaching and Referral Hospital On insulin On oral agents or diet control 1343 604 (45%) 739(55%) Kitale – Kitale District Hospital 1122 359 (32%) 763(68%) Webuye – Webuye District Hospital 383 76(20%) 307 (80%)

Demographic Data (N=1348) Characteristic Average or Frequency Range 52 1-92 % With Food Insecurity 35% % With Outpatient Health Insurance <1% % With History of Smoking 2% % With a History of Alcohol Use 7% % With Caretaker Assistance 68%

Frequency of Exercise Per Week (N=637)

BMI of the Diabetes Population (N=637)

Preliminary Results from Home Glucose Monitoring Home Glucose Monitoring Program Results Patients with at least 3 months of follow up HbA1c data 101 Active patients 135 Mean HbA1c at enrolment 13.2 95%CI (12.8-13.6) Mean HbA1c after at least 3 months 10.2 95%CI (9.7-10.9)* Mean HbA1c after at least 6 months 9.8 95% CI (9.2-10.5)* % of patients with an improvement in HbA1c after at least 3 months 95% HbA1c’s of patients have shown dramatic improvement within 3 months of being in the program. *P<0.01 via t-test comparison with Mean HbA1c at enrollment

Preliminary Results from Home Glucometer Pilot-Webuye 14 13 12 11 10 9 8 7 6 5 Months of enrollment 0 3 6 9 12 15 18 21 HbA1c 20

Future Steps Innovative Partnerships Price Reductions on Supplies Development of Sustainable Models of Care Incorporation of co-pays Greater dependency on patients Integrated Partnership with Kenyan Government/ Ministry of Health