1. Introduction to Cascades
New York Links
Introduction to Cascades
Welcome to the Webinar
Introduction
Chat Room Question
What improvement ideas to you have to advance linkages and retention across agencies and providers?
Steven Sawicki, MHSA Program Manager, AIDS Institute SPNS Lead, NY-LINKS August, 2016 1

2. Agenda What is NYLinks? Quick history of Cascades Benefits of cascades
Cascade Elements
Examples of Cascades using New York State Cascades
Cascade refinements using New York Links Cascades
Variations in Cascades illustrated by cascades from other states
Organizational Cascades
Prevention Cascades
How to build a cascade
Using the Cascade to inform improvement
Final thoughts
Contact info

3. NYLinks Mission
Bridge systemic gaps between HIV related services and achieve better outcomes for PLWHA through improving systems for monitoring, recording, accessing, and sharing information about linkage to care, retention in care, and viral load suppression in New York State.

4. NYLinks History
Created as a HRSA Special Projects of National Significance
One of six states funded through “Systems Linkages and Access to Care for Populations at High Risk of HIV Infection Initiative”
Currently part of Governor Cuomo’s Ending the Epidemic Initiative
Statewide Project that focuses on improving linkage to care, retention in care, and viral load suppression for PLWHA
Focus on using data to drive improvement

5. Cascades

6. HIV Care Continuum
Adapted from Eldred et al AIDS Patient Care STDs 2007;21(Suppl1):S1-S2 Cheever LW Clin Infect Dis 2007;44:1500-2

7. CDC Cascade
MMWR December 2, 2011 / 60(47);

8. Why A Cascade?

9. HIV Cascades…
Show the “number of individuals living with HIV infection who are impacted buy each point Along the Continuum”
Are a visual tool of HIV care and outcome at a point in time
Assess key parameters of care for persons living with HIV infection
Identify gaps in care
Prompt discussion on steps to improve HIV care outcomes

10. Cascade Elements

11. Considerations When Building an
HIV Care “Cascade”
What is the purpose?
Who is your target audience?
Can you manage the analytic requirements?
What is already being done?
How will you define your denominator?
E.g. number of active patients
Sub-populations

12. Considerations for Building an
HIV Care “Cascade” cont
Data
What data are available to you
Feasibility of data extraction from your system
Limitations of available data
How are your measures defined
Will your results be comparable to those used by others

13. Remember
Cascades progress from large to small usually with each subsequent measure a subset of the previous measure Sometimes Cascade progression is measured solely against the largest measure In order for cascades to be comparable all measures must be equitable Everything should be defined and labeled When possible use both % and number

14. As we look at Cascades…
Consider the choices that were made in terms of structure and data
Think about what is missing and what you might do different
Note aspects you might wish to borrow
Contemplate the cascade as a tool and how it could be used to inform improvement
Ponder what comes after

15. Cascades of New York

16. New York State Cascade of HIV Care, 2014 Persons Residing in NYS† at End of 2014 (6.7% NYC)

18. Cascade of HIV Care: Albany Ryan White Region Persons Residing in the Albany Ryan White Region†, at End of 2014 (excludes prisoner cases)

19. Cascade of HIV Care among Men who Have Sex with Men§ Persons Residing in NYS† at End of 2014

20. NYLinks Cascades

21. 1 As reported to the New York City HIV Surveillance Registry (NYC HSR) by June 30, 2014.
2 Timely linkage to care is defined as ≥1 CD4/VL reported to the NYC HSR days post diagnosis.
3 Retention in care is defined as ≥ 1 CD4/VL test reported to the NYC HSR during each 4 month period in the 12 months immediately following diagnosis.
4 Suppressed viral load is defined as a patient's most recent viral load quantity reported to the NYC HSR within 6 or 12 months of diagnosis was ≤200 copies/mL.

22. Cascades From Other States

25. San Antonio, TX

26. NC HIV Cascade, overall population Diagnosed 2007-2010 and living through 2008-2011
Cases
30%
Communicable Disease Surveillance Unit

28. Organization Cascades

29. Treatment cascade comparison of Mt Sinai1, NYC, & USA
Data shown for Mount Sinai Hospital’s Jack Martin & Greenwich Village Clinics
Quality Indicator #1 is Viral Load Suppression
To increase the total percentage of HIV+ patients on ART
To increase the total percentage of HIV+ patients with a controlled and/or undetectable HIV Viral Load

32. Prevention/Neutral Cascades

33. HIV CARE AND PREVENTION ARE THE SAME = GETTING TO HIV NEUTRAL
March 2016
The New HIV Neutral
Continuum of Care (Theoretical)
Undiagnosed
Diagnosed
At epidemiologic risk
So, we have been playing around and came up with this conjoined pyramid.
HIV CARE AND PREVENTION ARE THE SAME = GETTING TO HIV NEUTRAL
NYC DOHMH

34. How to Build a Cascade

35. Construct the Cascade Descriptive title1
HIV care, among Persons with One or More Visits in 2013: Fictitious Data from Agency A 5
Descriptive title
76% of in care 4
73% of in care
Clearly label the HIV measures presented 6
71% of in care
Clearly define the HIV measures presented
Show counts of persons at each bar
Show percent of persons in each bar (denominator) 2
Clearly label the axis 3
1HIV positive clients with at least one clinic visit in 2013
2HIV positive clients with at least 2 visits, at least 3 months apart
3HIV viral load of <200/mL (detectable or non-detectable) at last test during the measurement year

36. Describing Your “Cascade”
HIV care, among Persons with One or More Visits in 2013: Fictitious Data from Agency A
State results in the context of:
Definitions used
Denominator(s)
E.g., of 790 persons who were in care in 2013, 600 (76%) were retained in care (i.e., ≥2 visits, ≥3 months apart )
76% of in care
73% of in care
71% of in care
Stating the results in this manner will provide guidance when comparisons are made to other jurisdictions
1HIV positive clients with at least one clinic visit in 2013
2HIV positive clients with at least 2 visits, at least 3 months apart
3HIV viral load of <200/mL (detectable or non-detectable) at last test during the measurement year

37. Remember - Direct Comparisons with Other Jurisdictions’ Results may be MisleadingX

38. Utilizing Cascades to Inform Improvement

39. Setting Goals Based on HIV Care Outcomes
HIV Care, among Persons with One or More Visits in 2013: Fictitious Data from Agency A
Internal Goals
Address the greatest gaps
Target specific outcome e.g., viral suppression
“All persons who are prescribe ART are virally suppressed”
External Targets
Achieve specific targets such as the NHAS goals
1HIV positive clients with at least one clinic visit in 2013
2HIV positive clients with at least 2 visits, at least 3 months apart
3HIV viral load of <200/mL (detectable or non-detectable) at last test during the measurement year

42. Example
ECMC Measure 2A: Global Retention 85% How do we track Progress? How is this process connected to QI?

43. ECMC #
Excluded-118
957 pts
Retained:
86.4% (827)
Not Retained:
130

44. Final Thoughts About Cascades

45. The Aesthetics is up to You

46. Contact Information
Steven Sawicki, NYLinks Lead,