1. 1 in+care Campaign Webinar November 9, 2011

2. 2 Agenda Welcome & Introductions, 5min Story from the Field - Retention for HIV-infected Youth, 10min in+care Campaign Measures, 15min Review of Campaign Pre-Work, 15min Story from the Field - Retention in Care on Release from Corrections, 10min Q & A Session, 5min

3. 3 Retention in Care for HIV-infected Youth Thomas P. Giordano, MD, MPH Associate Professor of Medicine Sections of Infectious Diseases and Health Services Research Baylor College of Medicine

4. 4 Eras of Service for Youth at Thomas Street Health Center Decentralized care – 1/1/2002 to 2/28/2004 No youth specific services available Centralized care – 3/1/2004 to 3/31/2007 Multidisciplinary youth clinic Adolescent care providers Youth-specific case manager Centralized care plus enhanced supportive services– 4/1/2007 to 8/31/2008 Youth support groups and educational activities Motivational interviewing training for case managers Focus on teaching healthcare navigation skills

5. 5 Objective and Methods  Objective: To examine differences in retention in HIV care among African American and Hispanic youth who presented for primary HIV care during three distinct eras of youth services  Retrospective cohort study of African American and Hispanic youth (13-23 years old) who entered TSHC care during those eras. Visit constancy = 2/4 quarters (50%); Gap = yes  Good constancy = Medical visit during 3 or more quarter years (>75% visit constancy) during the 12-month follow-up period  Gap in care = > 6 months between any two consecutive visits during the 12-month follow-up period

6. 6 Proportion of Patients with Good Constancy in Care, by Era (n=174) Overall, 42% with good constancy in care Overall p-value: p=0.01 Decentralized vs. centralized: p<0.01 Centralized vs. enhanced: p<0.01

7. 7 Proportion of Patients with No Gaps in Care, by Era (n=174)

8. 8 Logistic Regression Models of Retention in Care, by Era Unadjusted odds ratio (95% CI) p-valueAdjusted* odds ratio (95% CI) p-value Adequate visit constancy Decentralized0.34 (0.15, 0.77)<0.010.42 (0.17, 1.03)0.06 CentralizedReferent Centralized + Enhanced1.40 (0.68, 2.88)0.371.18 (0.55, 2.53)0.68 No gap in care Decentralized1.25 (0.45, 3.45)0.671.37 (0.46, 4.17)0.57 CentralizedReferent Centralized + Enhanced5.88 (1.27, 25.0)0.025.66 (1.20, 25.0)0.03

9. 9 Opportunities for Increasing Retention in Care Targeted at Sub-populations  Centralize clinical and social services  Increase cultural competency  Target case management  Organize targeted support groups, educational opportunities, and networking activities  Teach skills to navigate healthcare system

10. 10 Acknowledgements Funded in part by the Special Projects of National Significance (SPNS) Young MSM of Color Initiative, HRSA Supported in part by facilities and resources of the Harris County Hospital District and the Houston VA Medical Center Presented in part as: Davila JA, Miertschin N, Sansgiry S, Mitts B, Parkinson- Windross D, Henley C, and Giordano TP. “Centralization of HIV services in HIV+ African American and Hispanic youth improves retention in care.” Fifth International Conference on HIV Treatment Adherence in Miami, FL, May 23-25, 2010 (Oral Presentation)

11. 11 in+care Campaign Measures and Data Collection Details

12. 12 Measurement Framework Performance data submissions on up to 4 Campaign measures every other month – Dec 1, Feb 1, Apr 1, Jul 1 Four Campaign retention measures have been developed in coordination with our TWG with detailed definitions Submit performance data to online Campaign database at incareCampaign.org/database Encouraged to use your entire caseload; sampling is allowed using the HIVQUAL sampling methodology Dec 1 – initial submission deadline; measurement period: 10/01/2010 – 09/30/2011

13. 13 1) Gaps in Care

14. 14 1) Gaps in Care Patient A Patient B = Medical Visit = Meets Numerator Definition (Gap in Care) = Does Not Meet Numerator Definition Month 1Month 6Month 12 Month 1Month 6Month 12

15. 15 2) Medical Visit Frequency

16. 16 2) Medical Visit Frequency Patient A Patient B = Medical Visit = Meets Numerator Definition = Does Not Meet Numerator Definition Month 1Month 12Month 24 Month 1Month 12Month 24 Month 6Month 18 Month 6Month 18 Patient C Month 1Month 12Month 24 Month 6Month 18 Patient D Month 1Month 12Month 24 Month 6Month 18

17. 17 3) Patients Newly Enrolled in Medical Care

18. 18 3) Patients Newly Enrolled in Medical Care Patient A Patient B = Medical Visit = Meets Numerator Definition = Does Not Meet Numerator Definition Month 1Month 12 Month 1Month 12 Month 4Month 8 Month 4Month 8

19. 19 4) Viral Load Suppression

20. 20 4) Viral Load Suppression Patient A Patient B = Viral Load Test Result = Meets Numerator Definition = Does Not Meet Numerator Definition Month 1Month 12 Month 1Month 12 Month 6 250 Patient C Month 1Month 12 Month 6 250150 Patient D Month 1Month 12 Month 6 250150

21. 21 Campaign Measures Gaps in Care (no visit in the last 180 days) Medical Visit Frequency (every 6 months over 24 months) Patients Newly Enrolled in Medical Care (every 4 months) Viral Load Suppression (last VL, <200 copies/ml, all pts in care)

22. 22

23. 23 Campaign Database Allows participating agencies to track their performance data over time and have immediate access to regional/national benchmarking reports to reports based on common search criteria to group scores of established groupings Form a group of grantees, which would allow them to generate group reports, such as HIVQUAL regional groups, collaboratives, networks Next Steps: Register one person to use the in+care database at incarecampaign.org/database Become familiar with the Campaign measures and definitions Enter your in+care Campaign data in the online database Review and validate your retention measure data Review your own data and benchmark against those of others

24. 24 Construct your Sample 1. Identify Eligible Patients Review all records for eligibility 2. Determine the minimum number of records to be reviewed Determine the minimum number of records needed from the Sample Table 3. Select Charts Randomly for Review Obtain a random number set equal to the number of records needed Apply the random number sets to the lists of eligible records using the sequence you created when numbering your lists

25. 25 Reviewing Campaign Pre-Work

26. 26 Campaign Pre-Work Assignments 1.Retention Follow-up Pool Tool - developed to help participating agencies to determine the Retention Follow-up Pool - the group of patients who should be targeted by retention follow-up activities 2.Lessons Learned Form – provide opportunity to share your retention experiences, best practices and lessons learned with retention with the Campaign peer learning community

27. 27 28,424 23,6354,789 1,124 84 243 789 2,493 683 3,680

28. 28 Retention Follow-Up Pool What were the Retention Follow-Up Pool results? 41 providers submitted data representing 28,424 HIV patients with a visit in the first six months of 2010 Of these patients 4,789 were out of care Of the 4,789 who were out of care, 3,680 were determined to need follow-up 87% of HIV patients served by these providers were retained in 2010 1 in 8 HIV patients were not retained

29. 29 Retention Lessons Learned Form Follow-up Contacts with Consumer Follow-up calls and letters after a missed appointment Follow-up home visits after missed appointment Periodic queries through EMR of patients who have not had visit in last 6 months, and who have not had CD4 in last 6 months Consumer Access to Medical Services Provide transportation cards/passes (Metro Card, Smart Card, etc…) or tokens in urban setting Pick-up patient with program vehicle

30. 30 Inter-agency Communication Using centralized source of data to see if patient is in care somewhere else (role for Part A and Part B grantees) Case managers notified when patients miss medical appointments Provider communication with designated ADAP pharmacy to ensure patient accessing medications Retention Lessons Learned Form

31. 31 Preventative Approaches Close contact through case manager or patient navigator until patient is fully engaged (i.e., two visits) ‘Red Carpet Treatment’ with walk-in appointments available for new patients Motivational interviewing training for all staff Performance measure results in or near waiting room so that information is readily available to patients Focus groups and key informant interviews each year Case manager notifies patient of appointment two days in advance of appointment Retention Lessons Learned Form

32. 32 Corrections and Retention: Supporting Retention in Care on Release from Corrections in RI Brian Montague, DO MS MPH Assistant Professor of Medicine in the Division of Infectious Diseases at Brown University and the Miriam Hospital

33. 33 Problem of Correction for Retention Short (Jails) vs Long-Term Stays (Prison) Maintaining continuity of care requires continuity of data from corrections to community (and at times back) Recognizing need to retain patients in care through their incarceration

34. 34 Rhode Island Model Miriam Hospital Immunology Center Ryan White Part B and Part C provider Serves 75% of patients with HIV in RI Adult Corrections Institute Combination Jail and Prison for RI in single facility Physicians from Miriam Hospital Immunology Center provide HIV care services to persons in ACI

35. 35 Retention Projects Projects Bridge (Prison) and Compass (Jails) Intensive case management model Connect with patients in corrections Accompany patients to visit and facilitate access to needed services Started as special projects, sustaining support through Ryan White Part B from RI DOH (Project Bridge)

36. 36 Project Bridge Jan-June 2011 Active caseload of 30 individuals (7 individuals newly released during the reporting period). 3/7 were released to the community-living with family 2/7 released to an intensive dual diagnosis unit 1/7 released to a sober housing environment 1/7 to a homeless shelter. All had an HIV primary visit scheduled prior to release and were seen within the first 30 days of release. 23/30 (77%) had at least one primary care visit within the reporting period. Of the remaining 7 23% no pcp visit. Of these 2/7 case was closed 2/7 lost-to-follow-up 2/7 re-incarcerated 1/7 deceased

37. 37 Integrating Corrections Projects into Retention For jails (short-term stays), standard indicators may be useful, programs are a model for supporting retention For prisons, pool of persons to be released needs to be included in retention pool as they will drop out using standard indicators Assumes patients are in care during time of incarceration If not in pool, the recently released may need to be considered as New to Care

38. 38 Challenges Developing communications protocols between community and corrections providers Assuring standard of care for treatment within corrections Accommodating uncertainty in release date Building relationship prior to release to support outreach in community Leveraging community resources where funding for special projects not available

39. 39 Time for Questions and Answers

40. 40 Meet the Author – Dr. Edward Gardner: November 16, 2011 at 12pm ET Data Collection Submission Deadline: December 1, 2011 Next Webinar: December 7, 2011 at 1pm ET Improvement Update Submission Deadline: December 15, 2011 Next Steps

41. 41 Campaign Headquarters: National Quality Center (NQC) 90 Church Street, 13 th floor New York, NY 10007 Phone 212-417-4730 incare@NationalQualityCenter.org incareCampaign.org youtube.com/incareCampaign