1. Systems Linkages and Access to Care for Populations at High Risk for HIV Infection in New York State WELCOME Mid and Lower Hudson Regional Group April 14 th, 2015

2. Steven Sawicki Welcome and Opening Remarks

3. NY Links addresses community needs and statewide priorities through enhanced collaboration and integration of quality improvement methodology among agencies and programs that provide HIV services to decrease gaps in the HIV care cascade as part of the New York State initiative to end AIDS. 3 Mission of NYLinks

4. NY Links Regional Groups will reduce the transmission of HIV across New York State by: Implementing a community-based response to the HIV epidemic by mobilizing networks of clinical and non-clinical providers, community leaders, and community members living with or affected by HIV/AIDS. Aligning programs, providers and the community to address the goals of New York State to end the HIV epidemic through shared, local leadership and with technical support from state and local health departments. Building capacity for quality improvement in the region, identifying and disseminating successful interventions within the continuum of HIV services and sustaining the achieved regional results. Using community level data to link public health strategies with clinic and service level improvement initiatives. 4 Major strategies of NYLinks

5. Introductions

6. Family Services of Westchester

7. Monitoring Client Labs Across Ryan White Programs For Progressive Health Outcomes

8. Family Services of Westchester Monitoring Client Labs Across Ryan White Programs For Progressive Health Outcomes Director HIV Service Programs (Partnership for Care) Ryan White Non-Medical Case Managers Ryan White Mental Health Clinicians Ryan White Psychosocial Support Coordinator Goal of monitoring client labs across programs is to be able to identify individuals who may be struggling with adherence issues and/or other barriers (e.g. substance use, SMI) and provide increased services and with a primary emphasis on medication and treatment adherence for those clients who are not virally suppressed.

9. Family Services of Westchester Monitoring Client Labs Across Ryan White Programs For Progressive Health Outcomes Process for implementation of project: In an effort to identify and streamline services to those who may require less or minimal assistance with ARV TX and place increased Adherence Education Services to those who seemingly require such direction, the QM team thought to develop a way to identify those individuals while monitoring the total aggregate of clients enrolled in the Ryan White programs. 1)It was identified that the easiest and most efficient way to track and monitor client labs was through the use of excel tracking forms 2) The program looked at several template forms from previous QM projects the FSW had participated in through the Ryan White Case Management QI Learning Network. 3) After reviewing several different tracking tools Family Services of Westchester developed a tracking grid that would allow to reviewer to identify one’s VL status based on a color code system that would include the clients most updated viral load and CD 4 count.

10. Family Services of Westchester Monitoring Client Labs Across Ryan White Programs For Progressive Health Outcomes 4) Color code system would identify those with undetectable VL’s: Blue Those with suppressed VL’s: Green Those with viral loads above 200: Red for danger zone. 5) Tracking Time Frames: Since all 3 Ryan White programs under this project are required to utilize the eSHARE data system, the most streamlined way to document client VL’s and CD 4 counts is with their quarterly PCSM update (every 4 months per eSAHRE requirements) 6) For clients who have undetectable VL’s (<20), and attend PCP appointments every 6 months, a No Change can be entered in the secondary/subsequent update column, utilizing the previous quarters reported lab values.

11. Family Services of Westchester Monitoring Client Labs Across Ryan White Programs For Progressive Health Outcomes Implementation: 1)Each Ryan White program submitted a listing of clients in alphabetical order that included client viral load count and CD 4 count. 2)The program Director cross-reviewed each client list to screen out duplicate clients in order to determine the total amount of clients combined (rather then the total amount of clients by program as a number of clients overlap programs) 3)Once duplicate client data had been cleaned, the program Director entered all date by program category (CMNM, MHT, PSS) and then color coded the information based on client VL count. 4)Once all data had been entered the project showed the total number of clients enrolled in the RW programs across the board and allowed the program Director to determine the actual number of total clients who are virally suppressed and more importantly, the number who are not.

12. Family Services of Westchester Monitoring Client Labs Across Ryan White Programs For Progressive Health Outcomes Challenges: The biggest challenge was being able to obtain client labs from outside providers. The team initially assumed to obtain lab reports from clients. We felt that this approach would act to increase clients ability to become more responsible and become better “keepers” of their health information. However this method was not too successful. As a result staff became responsible to obtain the required lab data from clients medical providers. Next Steps: To obtain and document client labs and record during the completion of the next 3 month reporting period. It is our expectation that through increased treatment adherence and ongoing ARV education that clients will continue to work to decrease their VL’s and increase their CD 4 counts in an ongoing effort to live healthier lives.

13. A Tree Grows Along the Hudson Dan Belanger & Hazel Lever

14. A TREE GROWS ALONG THE HUDSON: USING TREE DIAGRAMS FOR CONSUMER-ORIENTED VIRAL LOAD SUPPRESSION QI PROJECTS April 14, 2015 NY Links Mid- and Lower-Hudson Regional Group Facilitators: Hazel Lever Steve Sawicki Dan Belanger

15. Agenda Explore various viral load suppression QI projects Review the purpose and usefulness of a tree diagram Develop a tree diagram Use a tree diagram to analyze a problem Use the System of Profound Knowledge with a tree diagram

16. CHCQLN Viral Load Suppression Quality Improvement Project Boriken Neighborhood Health Center Miguel Bustos, Special Projects Assistant November 22, 2013

17. Improvement Project Background Rationale for Project: Viral load suppression is a key indicator of HIV healthcare, and an important indicator as to how Boriken’s viral load intervention is impacting the patients’ viral load status. In January 2013, began project with a total of 34 eligible patients from 2012. There were 16 patients virally suppressed and 14 unsuppressed. Four individuals are no longer apart of the project.

18. Baseline Data 3434 161818 144 4 January 2013

19. 4 0 0 0 0

20. Improvement Project Goals To increase the overall viral load suppression rate by 10% over a 12 month period and help patients sustain viral load suppression.

21. Plan/Do The test of change/improvement activity, selected was a continuation of the one used in 2012, it involved a tailor-made educational approach to educate the patient on the importance of medical adherence, identifying barriers that could prevent adherence, and ultimately suggesting potential solutions. The case manager includes teach back in her sessions. This year case conference bi-weekly meetings were added which included the Medical Director and HIV Specialist, the HIV Coordinator, Case Manager, a Physician, and Physician’s Assistant. At these meetings the status of the patient’s most recent viral load test, suppression status, and medical adherence are discussed and addressed.

22. Educational Check List

23. Do/Study October 2013 3434 1616 1616 1616 1616 1818 1717 8

24. Do/Study Virally Suppressed Patients: Sustained suppressed status in 2013: Current: 100% (16 out of 16 patients) October 2013 Viral Load Tests For Suppressed Patients in 2013: Current: 100% (16 out of 16 patients) October 2013 Virally Unsuppressed Patients: Went from unsuppressed to suppressed: Current: 44.4% (8 out of 18 patients) October 2013 Viral Load Tests For Unsuppressed Patients in 2013: Current: 94.4% (17 out of 18 patients) October 2013

25. Study When reviewing the original process, it was observed that improvements needed to be made to get patients that were unsuppressed to be suppressed and those that were suppressed to stay suppressed. Measures used to evaluate the tests of change included the date of the patient’s last viral load test, their viral load, and whether the patient received the educational intervention with the Case Manager.

26. Act The educational sessions between the case manager and the patient have occurred since 2012. Case conference meetings have been implemented since July 2013 and medical providers have been added to this initiative as needed.

27. Next Steps Given the current results, we have implemented the education sessions and case conferencing as a regular clinic process. Improvements in the status of unsuppressed patients are to be made by outreaching more to the patient regarding their viral load status and their medical adherence.

28. Viral Load Suppression Program Updates Heather Kowalski- Data Analyst Katrina Balovlenkov-Program Director Community Prevention & Treatment Services

29. Viral Load Suppression Importance Core data element for Ryan White C, Ryan White D, and New York State AIDS Institute Multi-Services Agency Core Measure for WYH’s Performance Improvement Plan – Goal 90% VL Suppression (<200 copies) – 177 Active Patients – 136 Suppressed <200 (81%) New York State – 51% of PLWHA in NYS are virally suppressed <200

30. WYH Viral Load Suppression Project 2013 Cohort: – 33 patients; 22 active 2014 Cohort: – 39 patients; 34 active Cohort 1: 17 active patients Cohort 2: 7 active patients Cohort 3: 5 active patients Cohort 4: 5 active patients

31. 2013 Cohort

32. 2014 Cohort

33. Improvement Project Goal To increase the number of patients with a suppressed viral load (<200 copies) at their last test from 81% to 90% Sustain suppression in undetectable patients

34. Past & Current Success Treatment and Medication Adherence Discussion Care Coordination Case Conferences Peer Support

35. Challenges Cohort encompasses: – Newly diagnosed patients – Patients not on ARVs – Substance users – Medication Regimen Restart/Change Transient Patient Population New Patients Staff Retention

36. Steps to Improvement Anti-Retroviral Treatment and Access to Services (ARTAS) Simpler regimens Peer Support Improved Data

37. Thank you!

38. CHCQLN QI Activities/Tactics for VLS Increased adherence counseling Outreach phone calls Case conference without patient Teach back Adherence journal Visual aids Pillboxes Home and hospital visits Group education sessions Adherence groups Scripted messaging Checklist of interventions/VLS toolkit Adherence calendars Medication alarms Increased VL tests Letters encouraging appointment adherence Peer education Pre-visit labs Transport to clinic for DOT Pharmacy/medication tool to assess issues Medication reminder texts Motivational interviewing Personalized treatment plans for all unsuppressed patients Appointment within 2 weeks if change in medication QI Team meetings

39. Making a Tree Diagram

41. Learning Objectives Learn the purpose and usefulness of a tree diagram Learn how to develop a tree diagram Practice using a tree diagram to analyze a problem Use the System of Profound Knowledge to inform strategic tactics to attain objectives identified in the tree diagram

42. Tree Diagram Description A tree diagram is a quality instrument used to assist in the visualization of the structural elements of a plan, a problem or another area for investigation

43. Tree Diagram Usefulness Tree diagrams can be used to envision a desired outcome and the structures/processes necessary to achieve it Working up from the opportunity/desired outcome, we lay out strategic objectives and tactics (in increasing level of detail) to achieve the goal. Let’s look at some examples…

44. Tree Diagram Skeleton

45. A very simple example

46. A bit more complex…

48. Building a Mid and Lower Hudson tree diagram for involving consumers in VLS QI What four objectives need to be met to successfully involve consumers in improving rates of viral load suppression ? – Using the System of Profound Knowledge framework, bear in mind factors related to: – Psychology – Variation – knowledge – systems

49. Our Tree: A Skeleton Consumer and Provider driven VLS QI project

50. Small-group discussion: Tactics Split into four groups Each group will discuss one of the four objectives, using the discussion handout to develop tactics informed by the System of Profound Knowledge to reach the objectives necessary to achieve successful consumer involved viral load suppression quality improvement projects

51. Lunch

52. Regional Data

53. Regional Cascade Impact

54. BHAE/AI/NYDSOH 3/2014 1Artas 2Appointment Procedures 3Consistent Messaging 4Outreach/Return to Care 5Peer support 1,2,3,5 1,2,3,4,5

55. Exercise  The Care Continuum has been split into segments and posted on the side wall – one for Buffalo and one for Rochester  Participants catalogue improvement interventions along the care continuum  Match the intervention to the appropriate Care Continuum section based on measure used for testing  Discuss your observations

56. Color Coded Strategy Map  Use colored stickies to catalogue interventions – Blue – tested with data available – Yellow – tested anecdotally, no data available – Pink – in queue for testing, or other ideas  Write your agency (ies) initials  Write the intervention and the measure used for evidence- based testing, if you can remember it

57. Post Your Interventions on the Wall  Place each intervention on the wall near the relevant section of the care continuum  If intervention applies to several sections, match it based on the measure used for testing or make two

58. Wrap Up: Summation Steve Sawicki

59. UPCOMING STAKEHOLDER MEETINGS May—Upper Manhattan Late July/August, Mid and Lower Hudson—Newburgh August, Queens and Staten Island—Lower Manhattan August, Western New York—Batavia, NY

60. DATA DEADLINES April 1, 2015—NYLinks Bi-Monthly measures April 15, 2015—Intervention data for previous month May 15, 2015—Intervention data fro previous month June 1, 2015—NYLinks Bi-Monthly measures 60

61. NY Links Website www.NewYorkLinks.org

62. NY Links Blog http://linkandretain.wordpress.com/

63. Evaluation Sign in sheet

64. Contact Information Steven Sawicki, NYSDOH, SPNS Lead steven.sawicki@health.ny.gov, 518-474-3813 steven.sawicki@health.ny.gov Clemens Steinbock, NYS Director of Quality Initiatives clemens.steinbock@health.ny.govclemens.steinbock@health.ny.gov Bruce D. Agins, Medical Director, bda01@health.state.ny.us bda01@health.state.ny.us Blog at http://linkandretain.wordpress.com/http://linkandretain.wordpress.com/ Website at http://www.newyorklinks.orghttp://www.newyorklinks.org

65. Adjourn! Thank you!