1. 2017 HIV Care Cascade Submission
Housing Works
Leslie Pierce, MPH
Quality Improvement Specialist
Tempestt Perkins, LMSW
Managing Director of Retention and Adherence

2. Data Source Housing Work’s EMR, eClinicalWorks (eCW)
CHCANYS Center for Primary Care Informatics (CPCI)
Platform that assists with ongoing monitoring of clinical quality measures
Nightly extract from eCW
Data extract used for eHIVQUAL indicator reporting
Have been working with AZARA who manages CPCI to validate the data. Merged two reports to fill in missing data, particularly prescription data.

3. Methods HIV specific ICD 9 and 10 codes
Defined PCP appointment defined by following visit types:
Initial
Comprehensive
Primary Care Follow Up
Primary Care Follow Up with Case Conference
Acute Primary Care
Active patients removed those who were deceased, reported receiving their primary care elsewhere or only had acute visits in 2017
Handful of clients deceased in 2016
Most patients who were not included attend our AIDS Adult Day Healthcare program and had an acute visit
Their primary care services are documented in EMR as a non Housing Works

4. Methods Continued Also included:
Primary Housing Works Service Location
Downtown Brooklyn
Cylar House (East Village)
East New York
Diagnosis Date
Most recent viral load (vl) date with result
Binary value for prescription for HIV treatment in 2017
Prescriptions were based on the approved list of prescriptions provided by AZARA on behalf of AI

5. Methods Continued Validation Proxies
Primary service location was matched to the location of the provider
Newly diagnosed patients and linkage to care were determined via:
Chart review,
Follow up with providers/testers, and
Verification through other reporting platforms.
Proxies
Missing VL considered unsuppressed
Null VL results were replaced with the second to the last lab
Null results are due to insufficient blood samples or misreadings

6. Challenges and Lessons Learned
Newly diagnosed patients
Documentation
Offsite testing
Data verification
Patients in care elsewhere
Incarceration Data
Newly diagnosed linkage to care data required some effort, as it is not always indicated in the chart. Many clients were diagnosed in 2016 but at another health care facility. Date of diagnosis often set as the first day of care at Housing Works. Offsite testing programs.
Review and validate newly diagnosed data more frequently.

8. 2017 Improvement Strategies, Goals and Outcomes
Strategy 1: Targeted outreach for patients with VL<200 via retention adherence case managers (Jan – June)
Goal: 25% of patients with unsuppressed HIV viral loads will be reached and reengaged.
Outcomes:
225 patients outreached
70 reached (32%)
33 (15%) scheduled appointments

9. Strategy 1 Challenges
Goal: 25% of patients with vl >200 copies/ml will be reengaged in care.
Mass s, text messages and previously recorded calls by the patient’s primary care provider were unsuccessful due to the high volume of out of date or inaccurate phone numbers and s.
While time consuming, attempting to contact patients on the phone is the most successful method of outreach.
High effort, low impact.

10. 2017 Improvement Strategies, Goals and Outcomes
Strategy 2: Relaunch the (Jan-Feb 2017)
Intervention elements include:
Initial case conference - client, provider and case manager;
Quarterly $100 gift card incentive for patients whose viral loads <200 copies/mL;
CBT adherence support groups;
Adherence toolkit methods (i.e., pill boxing, medication reminders and DOT); and
Case conferences when there is an increase or rebound in viral load.
Goal: 75 new patients will be newly enrolled in the Undetectables
Outcome: 189 new patients enrolled in the Undetectables

12. 2017 Analysis: What is our Data “Telling” Us?
Categories
Subcategories
Open
Active
Prescribed ART
Received Viral Load Test
Virally Suppressed (<200)
Age
0-12 (n=0)
N/A
13-19 (n=0)
20-24 (n=30)
100%
97%
90%
60%
25-29 (n=127)
99%
98%
78%
30-39 (n=252)
79%
40-49 (n=192)
96%
50-59 (n=269)
83%
60+ (n=110)
91%
Gender
Male (n=597)
82%
Female (n=235)
81%
Transgender (n=78)
76%
Unknown (n=70)
94%
70%
Race / Ethnicity
Non-Hispanic White (n=64)
Non-Hispanic Black (n=653)
80%
Hispanic (n=228)
Asian/Pacific Islander (n=2)
50%
Native American (n=2)
Multi-Race (n=0)
Unknown (n=31)
Risk Category
Men who have Sex with Men (MSM) (n=470)
Intravenous Drug Users (IDU) (n=88)
95%
89%
MSM/IDU (n=6)
Heterosexual (n=312)
Pediatric Risk (n=8)
Unknown/Other (n=96)
93%
73%
Housing Status
Stable Permanent Housing (n=824)
Temporary Housing (n=64)
Unstable Housing (n=38)
Unknown (n=54)
69%

13. Refining Our Goals and Strategies
Strategy 1: Continue with the
Strategy 2: At ENY site Youth and Prevention Services (YPS) launching a CBT group for all patients with viral load rates above 200 copies/ml (May 2018)
E-CHATS model for CBT University of Pennsylvania
Discussion of adherence challenges, feedback from peers and recommit to their personal goals
Facilitated by Case Manager and/or Social Worker
Meets weekly for 6 months
Strategy 3: and YPS targeted outreach to individuals < 29 years-old and/or who identify as transgender
Monthly report to identify population
Outreach and engagement across all clinics
Meeting patients in clinic during previously scheduled appointments to enroll in CM program

14. 2018 Goals
Goal 1: Increase the VLS rate of the population of patients between 20 to 29 years-old from 60% (2017) to 70% by end of Goal 2: Increase the VLS rate of the population of patients who identify as transgender from 76% (2017) to 80% by end of Goal 3: Improve agency-wide viral load suppression from 78% (2017) to 80% by end of 2018.

15. Anticipated Challenges
Out of date or inaccurate phone numbers and s.
YPS services only offered at ENY location.
Patients may not be eligible for case management programs based on funder requirements.
Staff time and capacity to conduct outreach calls.

16. Questions?
Contact: Leslie Pierce Quality Improvement Specialist Contact: Tempestt Perkins Managing Director of Retention and Adherence