1. SMARTEE Howard Brown Health, Chicago
James Zuniga, Kristin Keglovitz Baker, George J. Greene, Reynaldo Cordova, Sarah Shulbank-Smith
June 15, 2017

2. Implementation
IRB Approval on Jan. 16th with start date of Feb. 7, 2017
Number of participants enrolled to date: 57
Monthly enrollment target:11-14 participants
Participants create an account after survey administration.
Engaging through the app:
Participants receive 3 standard messages once a month.
Each participant is contacted every 30 days to check in.
Refining segments of the app with the developer
Identifying if clients read messages.
Identifying charts with missing results.
Deciding which results are auto-populated and when.
A participant receives 3 messages, one inspiring, general support, medication adherence, HIV facts and sexual health 3 weeks out of the month. HBH SOP calls for clients receiving case management have contact with clients at least once every 30 days. Advocates contact clients through the app and ask how the client is doing, if they need anything or have any questions. We have worked with HV to decipher if clients are reading messages we have sent, and we now have a client read stamp. HV has made it significantly easier to identify accounts with missing results, allowing us to enter results before the client needs to contact us. One concern is HIV confirmatory results are automatically pushed through, however this may impact the LTC process. For ex. while we don’t post a new reactive rapid results we still enter their gc/ct orders, but their HIV confirmatory results were being pushed through anyway. We are working closely together to see if this is steady trend or something we should monitor in the future.

3. Tools and Estimates HAB Measures Internal referrals
Gap in HIV Medical Visits
Numerator
HIV Viral Load Suppression
VL Noncompliance Report
(Den – Num = VL NC Report)
Internal referrals
Table 1
Month
VL NC Total
Elig.
Gap Total
Feb
312
227
464
177
March
233
459
189
April
305
215
458
188
May
289
209
185
VL Suppression report includes all clients living with HIV who have had a medical appointment within the measurement year as the denominator, the numerator is the number of those clients who have a VL less than 200. The noncompliance report subtracts the numerator from the denominator of the VL suppression report. Gap in care reports are released on the 1st of the month for the previous month, (We will not have May’s report until June 1st). VL NC reports are released on the 15th. Elig numbers are the initial number after filtering before chart auditing. Factors like new dx, clients on both lists, clients lost to care, clients that only receive gender affirming services but not HIV care, and clients already virally suppressed are not yet taken into account.

4. Data at a Glance Criteria Total Newly Dx. 5 Gap in Care 43 Viral Load
Table 2
Table 3
Criteria
Total
Newly Dx. 5
Gap in Care 43
Viral Load 18
Multiple 9
Population
Total
MSM 53
TWOC 4
Mean Age 28
Demographics %
Black/African American 44
Hispanic/Latino 22
White/Caucasian 28
Asian 3
American Indian/Alaska Native 2
Recruitment did not begin until Feb with IRB approval, but clients in need of a medical appt were contacted. All clients on the gap in HIV medical visits report are contacted regardless of study eligibility. We call these efforts and processes Retention in Care. Different orders are used for tracking clients who do not fit study criteria.
Table 4

5. Implementation Successes
Working processes
Protocols
Schedules
Team Communication
Assisting the LTC team
Over 1609 contact attempts made to re-engage clients into care.
Over 215 HIV medical appointments were scheduled.
Most clients contacted:
Not in need/want of case management
Not eligible for LTC services
Have lower needs
Very receptive
Table 5
Outreach Attempts
(12/01/16 to 06/09/2017)
Unique Pts
Attempts
Retention
540
980
SPNS
287
629
Total
1609
Table 6
HIV Medical Appts. Scheduled
(12/01/16 to 06/09/2017)
Unique Pts
Sched. Appts.
Retention
134
146
SPNS 63 69
Total
197
215
While the LTC program does retention work, they do not have the capacity to work with both new clients, and follow up with clients who are no longer in need of LTC services. The SPNS teams assists with contacting clients before they are lost to follow up and considered in need of LTC. Its important to note we make a distinction between those who qualify for the study, SPNS, and those who do not, Retention.
Most clients who were contacted were at greater risk of being lost to follow up because they were not in case management, have lower medical needs, and were no longer eligible for LTC services. However, these clients still struggled with make or keeping an HIV medical appointment every 6 months. By contacting these clients, we are able to prevent many from being lost to follow up and experiencing breaks in their ART. While some clients are not interested in the program, over 92% accept assistance with scheduling an appointment.

6. Challenges
Next Steps
Old contact information
Other departments conducting research with similar client pool
Youth Advisory Board
Check In Process
Improved protocols to avoid client confusion
Updating EHR information
Reforming the Youth Advisory Board
Examining our system integrations
Monitoring our marketing.
A more structured protocol for contacting clients will be helpful when navigating clients who are working with other staff. While we want avoid confusing clients by having many different staff contact them, its also difficult to monitor if clients are given information about the program or following up with appointments. Activing updating client contact information within the EHR will reduce repeat contact attempts. Reforming the YAB to an focus group to provide direct feedback from actual users. A greater systems integration would allow for easier use for clients and staff.
While the check in process for clients has improved since first launching, we are still working to remind clients to check in every time, and working with Healthvana to fine tune which tests are automatically pushed through and which are not.

7. Recruitment Successes and Challenges
As of now, we have reach 1/3rd of our recruitment goal.
Direct outreach and staff referrals have worked the best.
What are the challenges in recruiting?
Clients not attending appointments.
Clients confusing the role of the Advocate.
Little meeting space.
Next steps for overcoming challenges?
Being proactive – more appointment reminders
Clearer boundaries with clients and existing case mangers.
Using alternative work times more often.
Our marketing is being edited and will be available to clients. As of now, nearly ½ of the clients who agree to participate do not complete enrollment. We anticipated this struggle given we are working with clients who struggle to remain in care. One challenge is clients who have existing case managers confusing the Advocate with an additional cm. This has led to some clients believing their needs will get met faster and confusion between case managers and clients. Not having space to conduct the survey means fewer options for the client to come in when its convenient for them, especially if space cannot be found on the same day of their medical appt.

8. Additional Updates: Focus Groups
Challenges in assembling a focus group required revision
Revised age, number of participants, attendance and HIV status.
The invite was sent in Healthvana to 180 clients, 50 replied, the first 5 were selected and 3 attended.
Feedback on marketing
Participant messages
App Features
Next meeting will be in September
We hope to recruit from enrolled participants to get direct feedback.
Focus on marketing, messages, and the app features.
Increase incentives offered.
The age of participants was increased to 34, the number of participants decreased to 5, participants no longer had to be living with HIV, and each meeting can have different members. The first focus group met on April 12th and lasted roughly 90 minutes.

9. Additional Updates: Recruitment materials
Feedback from the focus group is being incorporated into the design. A comparison of the original flyers on top, and the edited version on the bottom.

11. The Howard Brownies!!

12. Contact
James Zuniga Kristin Keglovitz Baker George Greene