1. 1 Case Study Claire Biever, RN Morton Home Care Taunton, MA Linda Lebreux, RN, ACRN Medical Manager Infectious Disease Associates Taunton, MA Programs funded in part by the Massachusetts Department of Public Health HIV AIDS Bureau

2. 2 BACKGROUND  G.F. is a 44 year old white male diagnosed with HIV in 1994  Baseline CD4 of 394  Referred to HIV specialty care by his PCP in 2/95  15 year history of IVDU – heroin  Methadone maintenance 3/95 - present  Started antiviral monotherapy 4/95

3. 3 TREATMENT CONCERNS  July 2005 resistance analysis revealed: –Reduced response or total resistance to all NRTI’s –Reduced response or total resistance to all PI’s except Tipranivir –Full susceptibility to NNRTI’s –CD4 = 285/Viral Load = 28543 –Regimen: Reyataz 300mg qd, Norvir 100mg qd, Videx ED 250mg qd, Viread 300mg, qd, and Epivir 300mg qd

4. 4 COMPLICATING FACTORS  Chronic peripheral neuropathy requiring narcotics  Chronic Hepatitis C  Anemia due to medication side-effects and disease process  Lipodystrophy  Dyslipidemia  Depression/Anger issues  Family dysfunction  Allergies or intolerance to medications (AZT, Sustiva, Nevirapine, Zerit, Saquinavir)

5. 5 HOME HEALTH REFERRAL  Patient referred to comprehensive home-based care on 10/17/05 for assistance with initiation and maintenance of new HAART regimen. –Aptivus, Norvir, Delavirdine, Videx EC, Epivir, Viread –Other meds: ASA, Diflucan, OxyIR, Oxycontin, Colace, Valium  Observe potential interactions with Aptivus and Valium  Observe potential methadone interactions (i.e. excessive drowsiness or withdrawal symptoms)  Assess for side effects and intolerance  Monitor adherence

6. 6 HOME HEALTH ASSESSMENT  Conduct home assessment –Assess family support (wife incorrectly pre- filling meds, not able to provide support with basic ADL’s such as meal prep, laundry, housekeeping) –Review of systems at each visit (see nursing assessment form) –Assess need for LSA services to promote independence

7. 7 HOME HEALTH INTERVENTIONS  Initial nurse visit conducted jointly with LSA and twice weekly thereafter; currently weekly or as needed  Notification to HIV MD of clinical issues requiring medical assessment by MD  Patient hospitalized twice following nursing assessment of symptoms related to anemia; MD was notified  Assumed medication pre-fill responsibilities and medication refill ordering, and educated mother to assist with med pre-fills

8. 8 HOME HEALTH INTERVENTIONS  Administer Procrit injections for management of chronic anemia  LSA visits twice weekly for total 3 hours to assist with housing, support, adherence and teaching re: how to perform own ADL’s, as well as provide transportation as needed  Education of family members and identification of new support systems for appointments and ADL’s

9. 9 EMMS AND HOME HEALTH COLLABORATION  Communication is key to ensuring seamless care and an efficient referral process  Seamless Care: –Immediate contact between Home Care and HIV Primary Care as problems or needs were identified (daily phone calls, case conferences) –LSA notified of scheduled appointments in order to assist with transportation needs and to ensure attendance, particularly MD appointments scheduled monthly –Arrangements made for medication delivery from Specialty Script pharmacy to MD office where home care nurse picks up meds and delivers to patient  Referrals: –Primary Care facilitated emergency referrals to MD –Coordination of care with local case management via phone calls and case conferencing –LSA facilitated dental appointments

10. 10 PSYCHOSOCIAL OUTCOMES  Patient remains drug free in methadone program  Increased independence for ADL’s  Independent housing  Improved mental health with supports (home health, family)  Reduced stress - no longer living with addicted wife

11. 11 MEDICAL OUTCOMES  Viral load undetectable within 1 month of home health intervention  CD4 count has remained stable  Current status as of 6/6/07: CD4 = 359/Viral Load = <75  20lb weight gain with nutritional support since home health intervention  Anemia stabilized (Hematocrit increased from 25.8 to 40)  No missed appointments