2. Bronx Regional Group June 30th, 2016
WELCOME
Chat Room Question
What improvement ideas to you have to advance linkages and retention across agencies and providers? 2

3. Bronx Regional Group Meeting Agenda
830am Breakfast/Networking
9:00am Welcome
9:30am Bronx Regional Data
9:45 Introductions
10:00am The Living Cascade, Part 1
11:00am BREAK
11:15am The Living Cascade, Part 2
11:30 Viral Load Suppression (VLS Quality Improvement (QI) Projects
12:00pm Involving Consumers in Improving VLS
12:15pm Challenging VLS Stories
12:30pm Q&A, Next Steps
1:00pm Wrap Up

4. Bronx Regional Group Meeting objectives
Introduce Bronx NY Links Mission and Objectives
Understand the synergy between ETE, Bronx Knows and NY Links
Review Bronx Regional Cascade Data
Peer Learning focused on improving processes for linkage, retention and viral load suppression in The Bronx
Sharing Improvement projects and ideas
Learn how to involve consumers as equal partners in improving quality of care outcomes
Sharing challenges to viral load suppression in the Bronx
Discuss next steps

6. State and City ETE Structure
in the Bronx
State and City ETE Structure
So, we have been playing around and came up with this conjoined pyramid.

7. 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

9. Ending the Epidemic Mission
Reduce the number of new HIV infections in New York State to just 750 [from an estimated 3,000] by 2020

10. ETE Key Components
Regional forums held throughout the state Needs and gaps related to ETE assessed by community members Development of regional specific Meeting Summary and Action Plan documents ETE Steering Committee Implementation  

11. Blueprint Recommendations (BPs)
Identify persons with HIV who remain undiagnosed and link them to health care.
Link and retain persons diagnosed with HIV in care to maximize virus suppression so they remain healthy and prevent further transmission
Provide access to PrEP for high-risk persons to keep them HIV- negative

12. Visit the ETE Dashboard at
Contact Information
Deborah Dewey, Assistant Director Office of Planning & Community Affairs AIDS Institute
Visit the ETE Dashboard at

14. New York Knows Mission
New York Knows is a collaboration between New York City Department of Health and Mental Hygiene and community organizations, clinics, hospitals, colleges/universities, faith-based organizations and businesses, which aims to coordinate efforts to encourage all NYC residents to learn their HIV status and facilitate access to the city’s HIV prevention and treatment services.

16. The Bronx Knows Initiative
The first community-led HIV testing initiative – kick-off June 27, 2008
There are over 70 partners, many of who are in the BPHC PPS
“Bronx Serving Realness”– the youth initiative, launched in 2014
Data will reflect that nearly 2 million tests have been done since its inception, with thousands diagnosed and thousands linked to care
In 2015, Bronx partners reported 218,836 tests (39% of NYC total), 1505 confirmed positives, 1031 positives linked to care, 438 newly diagnosed positives, 353 newly diagnosed linked to care – leading NYC in all categories

18. DSRIP Overview
What is DSRIP (Delivery System Reform Incentive Payment) Program?
CMS has negotiated with individual states to reinvest Medicaid savings into delivery system reform (MRT waiver)
Incentive program to transform the healthcare delivery system for Medicaid and uninsured populations
Goal of improving health of populations and their experience with the clinical environment, while reducing high cost care, specifically in ED and Hospital settings (Triple Aim)
At the end of 5 years, NYS must demonstrate 25% reduction in avoidable ED visits, admissions and readmissions
How do Providers participate in the DSRIP program?
Providers need to join regional coalitions called a PPS (Performing Provider System)
A PPS selects 10 projects from a list defined by NYS
Each project has metrics/deliverables that trigger payments
Project selection guided by a community needs assessment
May want to add language about PQI,PPR,PPV, PDI

19. 357,424 total attributed patients
BPHC Profile
Our largest 7 partners
357,424 total attributed patients

20. BPHC: Who We Are
BPHC’s network includes a wide array of organizations and services:
Hospitals
Primary and specialty care services
Behavioral health and substance abuse services
Long term care and assisted living facilities
Home care agencies
Health homes
IPAs
Community-based organizations (e.g., services for the developmentally disabled, housing, adult day care centers, advocacy, foster care, meal delivery, food banks, legal aid, counseling, youth development)
Educational institutions
Pharmacies
Unions
Health plans
Central Services Organization (CSO) leads and coordinates the work of BPHC

21. System Transformation
BPHC’s DSRIP Projects
Create Integrated Delivery Systems
Health Home At-Risk Intervention Program
Emergency Department Care Triage
Care Transitions to Reduce 30-Day Readmissions
Integration of Primary Care Services and Behavioral Health
Evidence-Based Strategies for Managing Adult Population with Cardiovascular Disease
Evidence-Based Strategies for Managing Adult Population with Diabetes
Expansion of Asthma Home‐Based Self‐Management Program
Strengthen Mental Health and Substance Abuse Infrastructure Across Systems
Increase Early Access to, and Retention in, HIV Care
Domain 2
System Transformation
Domain 3
Clinical Improvement
Domain 4
Population-wide

22. Welcome to the Webinar
Introduction
Chat Room Question
What improvement ideas to you have to advance linkages and retention across agencies and providers? 22

23. 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.

24. Overall Objectives of NY Links
Improve Linkage to Care in NYS
Improve Retention in Care in NYS
Improve Viral Load Suppression in NYS

25. NYLINKS Key Components
Develop regional networks that would bridge the gap between individual health and public health Voluntary Nature of involvement would stabilize and sustain work over time Involve providers and consumers in planning and implementing regional networks that improve outcomes along the cascade of care (continuum) Make NYS surveillance data accessible to frontline providers for QI efforts and to compare against facility level reports    Enhance understanding of how facility and local quality outcomes have regional and statewide impact   Strengthen partnerships and peer learning

27. HIV Care Continuum in The Bronx
Qiang Xia, MD, MPH
HIV Epidemiology and Field Services Program
New York City Department of Health and Mental Hygiene
June 30, 2016

28. Presentation Overview
HIV surveillance in NYC
HIV Care Continuum in The Bronx
Surveillance data are used to:

29. Objectives of HIV surveillance
To monitor and characterize the complex and evolving HIV epidemic
To detect changing patterns of HIV transmission
To inform public health planning, including testing, prevention and treatment strategies
To guide the allocation of funding for prevention and care services
Surveillance data are used to:

30. HIV surveillance in NYC
HIV case reporting
HIV-related laboratory reporting
HIV incidence surveillance
HIV drug resistance surveillance
HIV behavioral surveillance
Many more …
Surveillance data are used to:

31. HIV surveillance in NYC
HIV case reporting
HIV-related laboratory reporting
HIV incidence surveillance
HIV drug resistance surveillance
HIV behavioral surveillance
Many more …
Surveillance data are used to:

32. HIV Case Reporting Passive surveillance Active surveillance
Healthcare facilities report newly diagnosed HIV cases to NYC DOHMH
Name
date of birth
date of HIV diagnosis
etc.
Active surveillance
NYC DOHMH staff conduct field investigations and registry data matches to identify and confirm HIV cases
~3,000 cases a year
Surveillance data are used to:

33. HIV-related laboratory reporting
Passive surveillance
Healthcare facilities report HIV-related laboratory test results to NYS DOH, and then NYS DOH sends NYC test results to NYC DOHMH
Diagnostic tests: Western Blot, 3rd or 4th gen EIA, HIV 1/2 differentiation assay, and qualitative RNA test
CD4 counts and percents
Viral loads
nucleoside sequence results
Active surveillance
NYC DOHMH staff conduct field investigations to identify and confirm HIV-related test results
~800,000 test results a year
Surveillance data are used to:

34. The Evolution of HIV/AIDS Surveillance in NYC
1981
1983
1993
1998
2000
2005
2010
2014
First cases of PCP, KS
AIDS reporting expanded to include HIV cases
Amended NYS HIV law: oral notification of test; expanded data sharing
HIV surveillance expanded to include incidence and resistance testing
AIDS case reporting mandated
1981: MMWR reports cases of OIs (PCP and KS) from Los Angeles and NYC. AIDS surveillance begins
1983: NYS mandates named AIDS case reporting through an emergency amendment to section 24.1 of the state sanitary code
1998: NYS expanded AIDS case reporting to include HIV through Public Health Law Article 21 Title III (the law took effect on June 1, 2000)
Law was amended on June 1, 2005 to expand HIV-related laboratory reporting (all viral load and CD4 values).
Addition of HIV Incidence and resistance surveillance in 2005.
In 2010 and this year, the NYS HIV law has been amended -
AIDS case definition expanded; includes additional OI’s and CD4<200
Amended NYS HIV law: routine offer of HIV test, streamlined consenting; limited data sharing
HIV reporting and partner services law implemented

35. NYC HIV Surveillance Registry
HIV case registry
Over 230,000 individuals
~50% have died
Variables (name, sex, race/ethnicity, date of birth, date of diagnosis, date of death, etc.)
HIV-related laboratory test registry
~10 million tests
CD4: ~6 million
VL: ~3 million
Other: ~1 million
Variables (name, test date, test type, result, etc.)

36. HIV Care Continuum
Monitor HIV-infected persons at the population level along the steps from infection to viral suppression
Infected
Diagnosed
Retained in care
Prescribed antiretroviral therapy (ART)
Virally suppressed

37. HIV Care Continuum

38. HIV Care Continuum – Methods (1)
HIV-infected
Number of people living with HIV (PLWH) by the end of 2014
Calculated as “HIV-diagnosed” divided by the estimated proportion of PLWH who had been diagnosed (93.3%), based on a back-calculation method
Hall HI, et al. MMWR 2015;64(24):
HIV-diagnosed
Number of PLWH who had been diagnosed by the end of 2014
Calculated as PLWH “retained in care” plus the estimated number of PLWH who were out of care, based on a statistical weighting method.
Xia Q, et al. JAIDS 2015;68(3):

39. HIV Care Continuum – Methods (2)
Retained in care
Number of PLWH with ≥1 CD4/viral load test in NYC in 2014
Prescribed ART
Number of PLWH who were prescribed ART in 2014
Calculated as PLWH “retained in care” multiplied by the estimated proportion of PLWH who were prescribed ART (96.1%), based on NYC Medical Monitoring Project data.

40. HIV Care Continuum – Methods (3)
Virally suppressed
Number of PLWH with a suppressed viral load (≤200 copies/mL) by the end of 2014
Calculated as PLWH in care with a most recent viral load measurement in 2014 of ≤200 copies/mL, plus the estimated number of out-of-care 2014 PLWHA with a viral load ≤200 copies/mL, based on a statistical weighting method.
Xia Q, et al. JAIDS 2015;68(3):

41. HIV Care Continuum in The Bronx, 2014
Viral suppression is defined as viral load ≤200 copies/mL.
As reported to the New York City Department of Health and Mental Hygiene by June 30, 2015.

42. HIV Care Continuum in NYC and The Bronx, 2014
Viral suppression is defined as viral load ≤200 copies/mL.
As reported to the New York City Department of Health and Mental Hygiene by June 30, 2015.

43. HIV Care Continuum in The Bronx in 2014, by Sex
Viral suppression is defined as viral load ≤200 copies/mL.
As reported to the New York City Department of Health and Mental Hygiene by June 30, 2015.

44. HIV Care Continuum in The Bronx in 2014, by Age
PLWH younger than 13 (N = 44) were excluded from the analysis.
Viral suppression is defined as viral load ≤200 copies/mL.
As reported to the New York City Department of Health and Mental Hygiene by June 30, 2015.

45. HIV Care Continuum in The Bronx in 2014, by Race/ethnicity
Viral suppression is defined as viral load ≤200 copies/mL.
As reported to the New York City Department of Health and Mental Hygiene by June 30, 2015.

46. HIV Care Continuum in The Bronx in 2014, by Transmission Risk
Viral suppression is defined as viral load ≤200 copies/mL.
As reported to the New York City Department of Health and Mental Hygiene by June 30, 2015.

47. HIV Care Continuum in The Bronx in 2014, by Area-based Poverty
Viral suppression is defined as viral load ≤200 copies/mL.
As reported to the New York City Department of Health and Mental Hygiene by June 30, 2015.

48. THANK YOU!

49. “The Living Cascade” Focusing on the Care in the Care continuum
Improving Health Outcomes in the Bronx
June 30, 2016
Bronx Meeting

50. What Is an “Upstreamist” in Health Care? -Richi Manchanda, MD, MPH

51. “If you can’t describe what you are doing as a process, you don’t know what you are doing.” ~ W. Edwards Deming

52. The Living Cascade: Focusing on the Care in the Care Continuum
Questions-
If you improve the steps along the continuum, will there be an increased chance that patients will achieve better sustained health outcomes?
Each process step along the continuum involves a human interaction. All of the steps together are a journey the consumer takes. Working together, can we improve the consumer journey and help the consumer to arrive at a place of sustained health?
How can we partner with the community beyond our clinic walls to improve outcomes along the treatment cascade?

54. The Living Cascade Exercise Part 1: 60 minutes Part 2: 30 minutes
Linkage
Engagement and Retention
Viral Load Suppressed

55. Part One (60 minutes)

56. Cascade
Each team selects a Cascade Captain who will assist the group in navigating the discussion of the consumer’s cascade journey.
The Cascade Captain will report back to the larger group on the journey and aspects to consider for improvement.
Each team will designate an artist to draw a process flow map for each step in the cascade.

57. Teams review the current process steps for linkage, retention, and viral load suppression, the team artist drawing a process flow map for each of these areas.
Each team identifies ways that these processes can be improved, streamlined or strengthened by eliminating unnecessary steps, adding steps or improving steps.
Team artist draws the new process steps using a different color for the team’s suggested improvements in each area of the cascade.
The team puts the improved processes together into a single process flow that begins with linkage and culminates with suppression.

58. Most Commonly Used Flowchart Symbols
Activity
Connecting lines
Terminator
Decision A
Page connector
Wait symbol

59. Flow Chart: Is This an Efficient Process?
Staff asks name,
searches data-
base for file
Patient in
system?
Patient arrives
at front desk
Staff asks
patient to
be seated
Yes No
Patient
waits
Staff asks
patient to
provide
information
Nurse takes
patient to
exam room

60. QI Flow Chart – Pap

61. Part Two: The “Cascades” Spring to Life!!! (30 minutes)

62. Report Back
Each team will report back or, for extra points, act out the step by step process of their care continuum, pointing out where steps have been eliminated, added or improved (10 minutes).
The “Cascade Committee” will announce winners of Niagara Awards for the following categories:
Best Picture (of your Cascade Flow)
Most original cascade process improvements to support VLS
Best proposed collaboration between all service providers
Best acting

63. Best Picture

64. Most original cascade process improvements to support VLS

65. Best proposed collaboration between all service providers

66. Best Acting

67. Next Steps Develop your own clinic level cascade
Analyze data of your clinic level cascade
Identify areas for improvement
Work on improving care in the care continuum
Redo your cascade to reflect changes and improvements

68. ENGAGING MORRISANIA HIV PATIENT IN HEALTHY CARE
Increasing HIV Suppression Rates
Presented by:
Dr. David H.A. John
Medical Director Morrisania Health + Hospitals

69. Improvement Project Background
Viral load counts provides important information related to the HIV/AIDS patients health status, and how well they are responding to antiretroviral therapy (ART)
In 2013 (Ehivqual):
63% Virally Suppressed
53% Always Suppressed

70. Improvement Project Goal
To increase the number of patients with suppression from 63% - 90%
To increase the continuous suppression from 53% - 70%

71. Plan/Do
There was not a dedicated Case Manager (CM) assigned to work with providers to ensure that patient were scheduled and kept their appointments; as well as retention in care

72. Do/Study
CM prepared daily reports on HIV patients scheduled and informed providers of any outstanding labs etc.
CM made reminder calls to patients with regards to their appointments as well as follow-up
CM presented monthly updates on patients as well as identified any fall-outs at the monthly HIV meeting
The Systems Analyst prepared provider specific reports focusing on viral load suppression

73. Do/Study Viral Load Suppression: 81% (85 of 95 patients)
Always Suppressed:
75% (78 of 95 patients)
Presented by: Dr. David H.A John - Medical Director Morrisania Health + Hospitals

74. New Patient Retention – 75%
Study
Patients visited more frequently:
12- Month Retention – 83%
24 – Month Retention – 63 %
New Patient Retention – 75%

75. Act
Further investigation is required as to the loss of the 24 month retention.
Indications suggests that the fall-out maybe attributed due to a gap in available appointment dates
A segment of the population are not US residents as such they miss scheduled appointments and follow-up
Check Care Systems Report (CSR) to ascertain whether patients are visiting other H+H facilities

76. Next Steps
Look at other PDSA cycles that will improve patient outcomes
Daily huddles with CM and providers:
- Provide updates on non-compliant HIV patients
- Identify missing services on existing patients

77. TA and Coaching is available
Please contact:
Dan Belanger Director, NYS Quality of Care Program (212)

78. Bronx Next Steps VLS QI Project- VLS hubs VLS Reporting Form
Webinar to go over
New Reporting database
First reporting of data in September
Cascade Webinar
Next Meeting in September

79. Thank you!!!

80. Greater Hudson Valley Family Health Center
Positive Choices Center
Viral Load Suppression Update 2015

81. Entire Caseload Viral Load Suppression 2015
Suppressed - 84%
113 clients
Unsuppressed – 15%
21 clients
No test – 1%
1 client
Undetectable – 82%
93/113 suppressed clients

82. Improvement Project Goal
Goal: Sustain a Viral Load Suppression rate of 84% for 2015.
During 2014 clients received incentives for:
Obtaining Viral Load Suppression - $50
Attending all required medical visits/completing labs - $25
Specific Case Management visits, e.g. Reassessments, Tx. Adherence, Tx. Adherence Group - $15

84. Study
We reviewed the list of all unsuppressed clients on our Viral Load Suppression Project and we “drilled down the data”.
We looked at what factors could potentially cause barriers to obtaining suppression such as:
Behavioral Health Issues
Substance Abuse Issues
Age
Sexual Orientation
We found that most of our unsuppressed clients have a combination of Mental Health and Substance Abuse issues. A separate PDSA was created to increase Behavioral Health engagement and treatment.

87. Act
Case Management efforts were discussed on a monthly basis at CQI Meetings to gain input from all HIV CQI Sub-Committee members, which includes all levels of staff from Providers to Program Assistants. Ideas and techniques were shared.
At the bi-monthly CAB meeting clients were asked for input on these efforts. The CAB committee spoke highly of the need for visual aids.
PCC and CAB collaborated in developing a visual aid that would help low-literacy clients understand viral load and CD4 in a simple, graphic format. This visual was coupled with laboratory graphs generated from our EMR software to help clients fully understand their results.

90. Next Steps Continue with PDSA cycles
Behavioral Health
Viral Load Suppression
Increase goal to end 2016 with an 89% Viral Load Suppression Rate

91. TA and Coaching is available
Please contact:
Dan Belanger Director, NYS Quality of Care Program (212)

92. Bronx Next Steps VLS QI Project- VLS hubs VLS Reporting Form
Webinar to go over
New Reporting database
First reporting of data in September
Cascade Webinar
Next Meeting in September

93. Thank you!!!

94. Bronx Next Steps VLS QI Project- VLS hubs VLS Reporting Form
Webinar to go over
New Reporting database
First reporting of data in September
Cascade Webinar
Next Meeting in September

95. Thank You Dr. Bruce Agins Dr. Peter Gordon
Stephen Crowe, Steve Sawicki, Susan Weigl and the OA team

96. Thank You Bruce Agins, MD Demetre Daskalakis Edward Telzak, MD
Ralph Belloise
Patrick Padgen
Stephen Crowe
Steve Sawicki
Susan Weigl
Debbie Quinones

97. Thank you!!!