1. Brooklyn Regional Group
Meeting
Welcome to the Webinar
Introduction
Chat Room Question
What improvement ideas to you have to advance linkages and retention across agencies and providers?
April 2, 2019
9.30am to 2.00pm
Brooklyn 1

2. Opening Remarks 2 Bruce Agins, Medical Director, NYSDOH AIDS Institute
Gail Burstein, MD, Commissioner of Health Erie County 2

3. Overview 3 Bruce Agins, Medical Director, NYSDOH AIDS Institute
Gail Burstein, MD, Commissioner of Health Erie County 3

4. Meeting Overview
Introduction of Brooklyn Co-Chairs: Clemens Steinbock, Zeenath Rehana
Meeting Purpose
To strengthen the Brooklyn Regional Group as a platform for peer learning and regional improvements
To better understand Brooklyn Surveillance Data
To learn from presentations from the field

5. Agenda Registration and Working Breakfast 9:00 - 9:30
Welcome, Introductions & Meeting Overview
9:30 – 9:45
QI Exercise
9: :15
Presentations from the Field: Lessons Learned
10:15 – 10:55
Break
10:55 – 11:10
2019 QOC Guidance/HIV Cascades
11:10 – 11:30
Overview of Patient Self-Management Strategies
11:30 – 12:00
ETE Priority Selection Activity
12: :45
Next Steps & Evaluation
12:45 - 1:00
Networking
1:00
Adjourn
2:00

6. Traffice Jam

7. Traffic Jam Instructions
Steps:
Form 2 equal groups of participants, each group facing each other within the provided spaces
The goal is to move each group to the other site while adhering to the established rules
The group that is quicker wins 1 2 3 4 D C B A
Start:
End: 1 2 3 4 D C B A

8. Traffic Jam Rules   You can… You can not..
- Move into an empty space in front of you
- Move around a person who is facing you into an empty space
- The order of participants within their respective group must remain the same
You can not..
- Move backwards
- Move around a person who is facing the same direction
- Make a move with two people at the same time  2 1 A B 1 2 B A  1 2 B A 1 2 3 A
ALL other moves are illegal and will require each team to assume the original starting positions.

9. Activity De-brief
What behaviors helped the group complete the activity?
What behaviors hindered the group?
What could the group have done differently to improve their performance?
How does this experience relate to your work with QI teams? What can we learn?

10. Presentations from the Field

11. Presenters Presenters
Housing Works Community HealthCare: Leslie Pierce
Brightpoint Health: Darshna Dave
SUNY Downstate: Jameela Yusuff

14. BACKGROUND
Access to sustained medical care is critical to achieving HIV suppression (<200 copies/mL).
Rates of HIV viral suppression are not, however, evenly distributed and factors associated with achieving viral suppression vary at individual, social, organizational and financial levels.
In STAR Health Center, a Level 3 Patient Centered Medical Home located in Central Brooklyn, women under the age of 30 (N=47) were identified as having the lowest VL suppression rates.
This cohort was screened by a barrier assessment tool and participated in motivational interviewing to promote good adherence practices.

15. PURPOSE
Assess pervasive barriers impeding ART adherence among women under the age of 30 and develop an intervention providing tools to promote adherence and improve viral suppression rates over a 12-month period

16. METHODS (1)
A model for improvement and serial PDSA cycles was used to test modified practices to improve ART adherence and support higher rates of viral suppression.
Stage 1: Assessment, January to September 2016: An adherence assessment survey was developed to evaluate current rates of adherence to medications and barriers impeding consistent treatment adherence. Results from the assessments were analyzed to inform an intervention to follow-up with the patients and discuss the use of tools to promote treatment adherence and viral load suppression.

17. Adherence Assessment Tool

18. METHODS (2)
Stage 2: Intervention: Patients were given a choice of interventions to assist in improving adherence, including pill boxes, key chains, and alarm reminders.
Motivational interviewing sessions were conducted with patients to reflect on difficulties and benefits surrounding regular ART adherence and to support good practices to promote viral load suppression.
Viral load test results from the lab were monitored and analyzed to evaluate the impact of these interactions on rates of viral suppression.

19. Motivational Interviewing Tools
DARN-C
OARS
Desire: Why do you want to change?
Ability: Do you have the tools to make the change?
Reasons: Reasons or Motivators
Need: How important is it on a scale of 1 to 10?
Commitment: What action will you take to make this happen?
Open Ended: No short answers, yes-no, rhetorical
Affirm: Comment on positively on intentions
Reflect: on what is said, “active listening”
Summarize: Draw together the person’s perspectives on change

20. Motivational Interviewing Tools
SELF EVALUATION
CHANGE RULER
Engagement
Assessing Motivation
Addressing Ambivalence
Promoter internal motivation
Elicit change talk
Rolling with resistance
Supporting client strengths
How confident are you to make that change?
On a scale of 0 to 10, what number do you give yourself
0……………………..10
Not all Extremely
Why are you 5 and not 7?
What can I do to assist you in moving up to 7?

21. RESULTS 1st Quarter 2016 (began assessments)
Viral suppression (<200 copies/mL): 17 (53%)
2nd Quarter 2016
Viral suppression (<200 copies/mL): 20 (67%)
3rd Quarter 2016 (began intervention)
Viral suppression (<200 copies/mL): 21 (79%)
4th Quarter 2016
Viral suppression (<200 copies/mL):16(75%)

22. RESULTS
Overall, 71% of those who completed the intervention have exhibited a favorable response – either reduced viral load or maintenance of undetectable status.
Of those who completed the intervention and have follow-up labs on record (N=20), 55% remained virally suppressed, 19% achieved viral suppression throughout the intervention, and 30% remained unsuppressed.
In total, 85% of those who have participated in the intervention and completed follow-up lab analyses have shown a favorable response – either reduced viral load or maintenance of undetectable status.
Viral load suppression rates in the cohort increased from 53% in the first quarter (Jan-Mar 2016) to 75% in the fourth quarter of (Oct-Dec 2016).

23. CONCLUSIONS
The coupling of motivational interviewing and electronic reminders proved to be effective. This feasible and low cost intervention has the potential to be equally effective within similar populations.
The results suggest that different processes and social mechanisms may influence load suppression.
Incorporating formal adherence assessments with patients during clinic visits and providing detailed information surrounding particular personal barriers to treatment adherence are necessary.
However, despite the significant increase in viral load suppression rates from 53% to 75% within the 2016 calendar year, about 25% of this subpopulation are still not virally suppressed and may require further intervention.

24. Current Research
We have identified about 300 patients with unsuppressed viral loads (at any given time throughout 2018). (VL suppression 2018: 86%)
Many of these patients are currently receiving interventions from Harm Reduction (serving patients with substance use disorders), Care Coordination, Supportive Counseling Group (servicing patients with mental health conditions), Family Program (servicing youth and pregnant women) or Back to Brooklyn (focusing on the re-entry population).
However, we have identified a high rate of co-occurring social and medical conditions within this population that we intend to address.

25. Conditions and Co-occurrences

26. Medical and Behavioral Health Conditions
Mental Health: 7%
Mental Health and SUD: 45%
SUD: 48%

27. Current Research Goals
Identify internal and external barriers to care within this population
Stigma, disclosure, program linkages (CCR, HRM, etc.)
Utilize Patient Centered Evidence Based approaches to care
Devise Targeted Interventions to address co-occurring conditions of varying intensities, including qualitative assessment

28. Therapy readiness and support network assessments for Virally unsuppressed AYA Patients
The Brooklyn Hospital PATH Center
NYS DOH AI Brooklyn Regional Group Meeting
April 2, 2019

29. Overview Patient population QI Project description Outcomes
Lessons learned

30. QI Project Population Virally unsuppressed in last year N=26
Similar parental involvement, housing stability, education status as general AYA population
Higher proportion of perinatally infected youth and young adults

31. QI Project prep: Survey staff
PATH Family Program staff held a meeting and hypothesized factors leading to uncontrolled viral load for all patients in QI project
Top reasons identified:
Mental health
Poor adjustment to diagnosis (perinatal/behavioral infection)
Death/trauma in family, in last year
Lack of family/ support
Substance use
Poor health literacy

32. Medical Case Management goals were developed
to address specific resource needs.
ALL patients presented with a common theme of
needing more support and increased resilience.
Instead of assuming external supports are needed,
intervention should also incorporate amplifying existing supports.
Staff prioritized developing an intervention that was easily integrated into clinic flow.

33. QI Project: Assessment + Intervention
Support Person Assessment (Process Change 2)
Typically completed by provider
Informal conversation probing for supportive person(s) in patient’s life who are aware of status and care about patient getting medical care
If nobody, provide disclosure counseling
If support person(s) identified, offer HIPAA to bring person(s) into appointment/medication reminder conversations

34. QI Project: Assessment + Intervention
Therapy readiness script (Process Change 1)
Typically completed during medical case management or social work visit
Developed to ensure all patients received appropriate individualized intervention
Those interested in therapy referred for consultation/scheduling with LCSW
If not interested, provide brief review of availability of therapy as needed and intent to re-visit at next re-assessment

35. “Therapy is a full hour once a week to discuss whatever you want to discuss. You can express yourself and get support.”
In all instances, ask:
Have you had mental health care in the past?
If YES, ask 1) when MH services received; 2) for how long; 3) reason for getting MH care (required? School?) and 4) was it a positive or negative experience. Why?
Describe how mental health services work at PATH, being sure to emphasize any differences between PATH and negative experience patient may have shared about past MH care.
If NO, simply summarize mental health services at PATH.
“We have therapy available to you at no cost. We can also help refer you to therapy or psychiatry services at an outside agency, if you prefer. Mental health services are completely voluntary, and you can go for whatever amount of time you find helpful, whether it’s temporary or long term.”
Name Penny, Carolyn, and Adrienne as PATH therapists; offer in-person introduction.
Explain that psychiatry is more focused on medication management and review referral options based on insurance.
“Do you have any questions about mental health services?
Would you like to receive any of these services at this time, or talk to a therapist about it to help you decide?”

36. Patient Responsiveness
Support assessment:
Only 1 patient refused to involve support person
7 support persons had repeated contacts with PATH staff to discuss patient medication adherence and ways to support increased health self management
Therapy readiness:
2 patients completed consultation with LCSW but did not initiate therapy
6 patients initiated therapy at PATH
1 patient has transitioned to long term therapy at PATH
2 patients stated they would only accept at-home therapy, were not eligible for any known at- home service

37. Treatment Outcomes Viral loads Appointment adherence
52.3% of all eligible patients had become virally suppressed by end of 2018 (N=26)
Of those who received intervention, 60% were virally suppressed (N=20)
12mos clinic wide VLS rate = 85%
Appointment adherence
Marked improvement for nine participants as measured by frequency of completed medical visit and VL test
Most participants maintained or improved existing attendance patterns
Two patients lost to follow up, neither achieved VL suppression in 2018
Both patients known to go in and out of care over multiple years at clinic

38. Lessons learned
Unsuppressed population struggles to achieve clinic wide VLS rates with or without intervention
Barriers to retention in care are complex and often long-term
Patients are interested in therapy but struggle to attend regularly
Long term relationship in which mental health is re-visited regularly is important
Was there a “yes-ing the worker” factor?
Most patients have someone in their lives who knows their status and cares about their engagement in care
Patients seemed happy to involve loved ones
Having a support person aware of appointments increases appointment attendance but less clear effect on medication adherence

39. 121 Dekalb Ave Brooklyn 11201 @ Ashland pl
121 Dekalb Ave Brooklyn Ashland pl., across from LIU church ave Brooklyn btw Bedford Ave. & Flatbush AVE. primary care, specialty care, pharmacology, nutrition, GYN, medical case management, therapy, insurance navigation * Positive care * PEP/PrEP * at-risk *
Madelyn McNamara
Penny Buentello, LCSW
Family Program Director
Family Program Social Worker

40. Break

41. Introduction to NYS HIV Organizational Treatment Cascades
Quality of Care Program, NYSDOH AIDS Institute

42. Presentation Agenda Background Overview Requirements and Measurements
Reporting Methodology
Analysis and Improvement Plan
What’s Next?
Q&A

43. Organizational HIV Treatment Cascade Review…
Is a component of the annual Quality of Care Program Review.
Was created to bring attention to gaps along the continuum of care for people living with HIV (PLWH).
Was implemented in 2017 by the Office of the Medical Director in the NYSDOH AIDS Institute as part of the strategy to “End the Epidemic by 2020.”
Enables providers to visualize the quality of care being provided to PLWH at their own organization.

44. 2018 Organizational Treatment Cascade

45. Results of 2018 Cascade Review (2017 Data)
In 2018, we received 78 of the 79 requested submissions.
Of the 78, 64 organizations submitted cascade data that passed validation checks for all of the core cascades (new-to-care/newly diagnosed, open and active).
The magnitude of gaps in care varied greatly among organizations.
Organizations reported between 10% (10th percentile) and 100% (90th percentile) of patients newly diagnosed internally were linked within 3 days (or 30 days if inpatients).
Organizations reported between 100 (10th percentile) and 1,224 (90th percentile) open patients.

46. 2019 Organizational Cascade Overview
Retrospective review of care provided in 2018.
Organizations will register as needed for the NYS Health Commerce System.
An Excel template will be given to all organizations for data input.
Data validation checks are incorporated in the Excel template to ensure the integrity of the data.
The template will automatically construct visuals for each cascade (newly diagnosed/new-to-care, open and active patients).
Organizations will submit their finalized Excel documents via the Health Commerce System.
After final validation checks are passed, quality coaches and assistants will provide additional feedback via .
Final approval after review by quality coach and medical director.

47. Components of the Excel Template
Patient-level information previously reported through the eHIVQUAL application.
Data fields matched to Ryan White requirements where possible.
This will include the patient’s first and last name, date of birth, sex at birth, current gender, ethnicity, race, housing status, HIV exposure risk, primary insurance, and enrollment status.
Automated Cascade Visuals
Newly diagnosed/new-to-care (if applicable)
Previously diagnosed
- Open caseload
- Active caseload
Drill-down of previously diagnosed caseload
Methodology Section
Quality Improvement Plan
*Built in Features:
Data validation
Cascade chart generation
Export of non-confidential content for use in-house and within networks

48. Organizational Treatment Cascade Patient-level Data Fields
Patient Information
Applies To
Field Type
Allowed Values
Notes
First name
All patients
Text
Up to 50 characters
Last name
Up to 80 characters
Middle initial
Single character
Date of birth
Date
mm/dd/yyyy
MRN
Optional
Sex at birth
Single selection
M (= male), F (= female), I (= intersex), UK (= unknown)
Mark ‘UK’ if unknown, but sex at birth and current gender cannot both be unknown
Current gender
M (= male), F (= female), TGM (= transgender man), TGW (= transgender woman), OTH (= transgender other, non-binary, gender non-conforming, other), UK (= unknown)
Ethnicity
H (= Hispanic or Latino/Latina), NH (= non-Hispanic/Latino/Latina), UK (= unknown)
Mark ‘UK’ if unknown
Hispanic subgroup
Hispanic patients
Multiple selection (as needed, comma separated)
M (= Mexican, Mexican American or Chicano/Chicana), PR (= Puerto Rican), C (= Cuban), OH (= other Hispanic, Latino/Latina, Spanish Origin), UK (= unknown), NA (= not applicable)
Mark ‘NA’ if patient is not Hispanic, ‘UK’ if unknown
Race
W (= White), B (= Black or African American), A (= Asian), NHPI (= Native Hawaiian or Pacific Islander), AIAN (= American Indian or Alaska Native), UK (= unknown)

49. Clinic (where was the patient enrolled in care?)
Patient Information
Applies To
Field Type
Allowed Values
Notes
Asian subgroup
Asian patients
Multiple selection (as needed, comma separated)
AI (= Asian Indian), C (= Chinese), F (= Filipino), J (= Japanese), KOR (= Korean), V (= Vietnamese), OA (= Other Asian), UK (= unknown), NA (= not applicable)
Mark ‘NA’ if patient is not Asian, ‘UK’ if unknown
Housing
All patients
Single selection
S (= stable/permanent), T (= temporary), US (= unstable), UK (= unknown)
Mark ‘UK’ if unknown
HIV Risk
MSM = (= male who has sex with male(s)), IDU (= injecting drug use), HETERO (= heterosexual contact), HEMO (= hemophilia/coagulation disorder), BLOOD (= blood transfusion/blood products), PERI (= perinatal transmission), OTH (= other), UK (= unknown)
Insurance status
MEDICAID, MEDICARE, DUALELG (= Medicaid & Medicare), PRIVATE (= Individual or employer-based private insurance), VA (= Veteran's Administration), ADAP (= AIDS Drug Assistance Program (Primary Care)), OP (= other plan), NONE, UK (= unknown)
Primary insurance on last status check during the review period; mark ‘UK’ if unknown
Enrollment status (as of the end of the review period, was the patient established in care, new to care, deceased, incarcerated, relocated, in external care, or of other/unknown status?)
ACTNEW (= active, new to clinic during review period or returning after not being seen the previous two years, continuing in program), ACTEST (= active, seen prior to the review period, continuing in program), DEC (= died during review period), INC (= incarcerated as of end of review period), RELOC (= relocated out of New York State during the review period), EXTCARE (= confirmed to be receiving ongoing HIV care at another site as of end of the review period), OTH (= other status, not enrolled in care at your organization)
Mark ‘OTH’ if unknown
Clinic (where was the patient enrolled in care?)
New or established active patients
Must match one of the clinic codes we have defined for your organization
If seen at multiple sites, location where seen most often or, if tied, where seen last; leave blank if not applicable

50. Service line (where was the patient seen within your system?)
Patient Information
Applies To
Field Type
Allowed Values
Notes
Service line (where was the patient seen within your system?)
Unknown-status patients (enrollment = ‘OTH’)
Multiple selection (as needed, comma separated)
ED (= emergency department/urgent care), IP (= inpatient care, including ICU, surgery and psychiatric care), PC (= primary care provided outside of your HIV clinic(s)), FACHIV (= faculty practice HIV care outside HIV clinic(s)), NHSC (= non-HIV specialty care such as cardiology, pulmonology, neurology, ambulatory surgery, etc.), RHS (= reproductive health services)
MBHS (= outpatient mental and behavioral health services), DS (= dental services), SS (= supportive services), OTH (= other)
Leave blank if not applicable
Service line specifics
Unknown-status patients seen on “other” service
Text
Up to 200 characters
Diagnosis status (when was the patient diagnosed, and if during the review period, where?)
All patients
Single selection
NEWINTIP (= internally diagnosed during the review period while on an inpatient service), NEWINTAMB (= internally diagnosed during the review period while not on an inpatient service), NEWEXT (= externally diagnosed during the review period), PREV (= diagnosed prior to the review period), UK (= unknown)
Mark ‘UK’ if unknown
Was the patient on ARV therapy during the review period?
YES, NO, UK (= unknown)
Was a VL test obtained during the review period?
Diagnosis date
Newly diagnosed patients
Date
mm/dd/yyyy
During the review period; leave blank if patient was previously diagnosed or unknown when diagnosed

51. Patient Information
Applies To
Field Type
Allowed Values
Notes
Discharge date
Newly diagnosed as inpatient
Date
mm/dd/yyyy
On or after diagnosis date; leave blank if not applicable
Was the patient seen for HIV care during the review period?
Newly diagnosed patients
Single selection
YES, NO, UK (= unknown), NA (= not applicable)
Mark ‘UK’ if unknown, ‘NA’ if patient was previously diagnosed
If yes, date of first visit with an HIV provider
Leave blank if not applicable
Was a suppressed viral load obtained during the review period?
YES, NO, UK, NA (= not applicable)
Mark ‘UK’ if unknown, ‘NA’ if patient was previously diagnosed or not tested
Date of first VL test during review period
Must be within the review period, on or after date of diagnosis; leave blank if not applicable
Date of first suppressed VL
Was the patient suppressed on final VL test during the review period?
Previously diagnosed patients
Mark ‘UK’ if unknown, ‘NA’ if patient was newly diagnosed or not tested

52. 2018 Cascade Data - Why?
Provides robust quality of care data for providers and NY State.
Comprehensive look at HIV+ patients
Automates the indicator scoring
Facilitates optional additional analysis
Integrates data collection, analysis and QI planning.
Facilitates patient matching by the State, focusing provider attention on what they can control.
Lays the groundwork for next two annual reviews and submission of any other quality program data.
Registration of users in HCS
Reusable template
Extensible database

53. Timeline Health Commerce registration: Ongoing as needed
Distribution of data definitions: February 22nd
Introductory webinars:
Wednesday, February 27th, 3:30 pm - 5 pm
Tuesday, March 5th, 9 am - 10:30 am
Friday, March 8th, 12 pm - 1:30 pm
Additional webinars: TBD
Release of cascade data template, and instructions: March 29
April 30th Submissions due (may be extended based on release dates)

54. Newly Diagnosed/ New-to-care Cascade

55. Newly Diagnosed/New-to-care Cascade
Purpose: Automatic visualization of cascade data enables organizations to see the outcomes for a particularly vulnerable group of patients – those diagnosed within the measurement year (2018) and those new to care at an organization.
Terminology:
Newly Diagnosed/New-to-care Caseload: All patients diagnosed in 2018 and all patients who are new to an organization’s HIV program in 2018, regardless of the year in which they were diagnosed. Patients returning after an absence of two or more years are considered new to care.

56. Received Viral Load Test
Newly Diagnosed/New-to-care Cascade: Summary
Newly Diagnosed/New-to-care Caseload
All newly diagnosed patients and all patients who are new to an organization’s HIV program, regardless of the year in which they were diagnosed. Includes patients returning after 2+ years of absence.
Linked to Care
Percentage of people diagnosed with HIV at the organization in 2018 linked to HIV care within 3 days.
Prescribed ART
Percentage of newly diagnosed and new-to-care patients who were prescribed ART in Patients newly diagnosed at the organization who were linked externally will be excluded.
Received Viral Load Test
Percentage of newly diagnosed and new-to-care patients with a recorded viral load test in Patients newly diagnosed at the organization who were linked externally will be excluded.
Virally Suppressed
Percentage of newly diagnosed and new-to-care patients with viral load <200 copies/mL after 91 days in Patients newly diagnosed at the organization who were linked externally will be excluded.

57. Example: Newly Diagnosed/New-to-care Cascade
Newly diagnosed/new-to-care: # of pts newly diagnosed with HIV in 2018 and all patients new to care in the HIV program in 2018, regardless of HIV diagnosis date
Prescribed ART*: Percentage of newly diagnosed and new-to-care pts prescribed ART in 2018
Received Viral Load Test*: Percentage of newly diagnosed and new-to-care pts with a documented viral load test in 2018
Virally suppressed*: Percentage of newly diagnosed and new-to-care pts with viral load <200 copies/mL after 90 days of viral load test.
Data Source: Infinity EMR
*Denominator excludes 3 patients newly diagnosed with HIV at the organization who were linked to care externally.

58. Previously Diagnosed Cascades

59. Terminology Overview Previously diagnosed patients Deceased
All patients diagnosed with HIV before 2018, who received services from the organization during 2018.
Terminology
Overview
Open patients
Deceased
by end of 2018
Incarcerated
at end of 2018
Confirmed in HIV care elsewhere
at end of 2018
Established Active Patients
All open patients who received HIV primary care services within the organization in Excludes all new-to-care patients.
Open Non-Active Patients
All open patients who received services from the organization in 2018, but did not receive HIV primary care services.

60. Previously Diagnosed Cascade
Two cascades will automatically be generated for previously diagnosed patients.
One for all open patients (established active + open non-active)
One for established active patients (broken down by HIV care site, if multiple care sites)
NOTE: Excludes all active patients who are new-to-care from the previously diagnosed cascade. That is, the previously diagnosed and newly diagnosed/new-to-care cascades are mutually exclusive.

61. Received Viral Load Test
Open Caseload Cascade: Summary
Open Caseload
All previously diagnosed patients who received services from an organization within 2018, except those who were new to care or returning after 2+ years, were deceased by the end of the year, incarcerated at the end of the year, or were confirmed to be in care elsewhere by the end of the year.
Active Caseload
Percentage of open patients who received HIV primary care services within 2018.
Prescribed ART
Percentage of open patients who were prescribed ART in 2018.
Received Viral Load Test
Percentage of open patients with a recorded viral load test in 2018.
Virally Suppressed
Percentage of open patients with viral load <200 copies/mL at last test of 2018.

62. Example: Generated Open Caseload Cascade
Open – # of PLWH, diagnosed before measurement year, with any visit in 2018, except those confirmed to be in care elsewhere, deceased, or incarcerated*
Active – percentage of open patients with HIV visit in 2018
Prescribed ART – percentage of open patients with ART prescription in 2017
Received Viral Load Test – percentage of open patients with documented viral load test in 2018
Virally Suppressed – percentage of open patients with viral load <200 copies/mL at last viral load test in 2018
Data Source – Infinity EMR
Note: Excludes patients who were previously diagnosed and new to care at the organization

63. Received Viral Load Test
Active Caseload Cascade: Summary
Active Caseload
All open patients who received HIV primary care services within the organization in 2018, except those new-to-care in 2018 or returning after absence of 2+ years.
Prescribed ART
Percentage of active patients who were prescribed ART during 2018.
Received Viral Load Test
Percentage of active patients with a documented viral load test in 2018.
Virally Suppressed
Percentage of active patients with a viral load <200 copies/mL at last test of 2018.

64. Example: Generated Active Caseload Cascade
ACTIVE: # of open patients who received HIV primary care services at the organization in 2017
PRESCRIBED ART: Percentage of active patients who were prescribed ART in 2017
RECEIVED VIRAL LOAD TEST: Percentage of active patients with a documented viral load test in 2017
VIRALLY SUPPRESSED: Percentage of active patients who had <200 copies/mL at last viral load test of 2017

65. Drill Down Non-Active Caseload By Service Delivery Point

66. Previously diagnosed patients
All patients diagnosed with HIV before 2018, who received services from the organization during 2018
Open patients
Established Active Patients
All open patients who received HIV primary care services within the organization in Excludes all new-to-care patients.
Open Non-Active Patients
All open patients who received services from the organization in 2018, but did not receive HIV primary care services
Deceased
by end of 2018
Incarcerated
at end of 2018
Confirmed in HIV care elsewhere

67. Identify Service Delivery Points for Non-active Caseload
Purpose: To better target (re)engagement interventions to PLWH who may be out of care, find where they are touching the healthcare organization.
Required components: Report service delivery points for non-active patients; template will calculate how many non-active patients were seen at each delivery point.
Looking at all previously diagnosed patients who did NOT receive HIV primary care services from the organization.

68. Example: Identify Service Delivery Points for
Non-Active Patients
Service delivery point
Number of non-active patients who received services during CY 2018
Behavioral health services 88
Dental clinics 15
Emergency department
150
Inpatient units
123
OB/GYN 8
Faculty practice HIV care 64
Supportive housing services 35

69. Drill Down Active Caseload By Key Characteristics

70. Previously diagnosed patients
All patients diagnosed with HIV before 2018, who received services from the organization during 2018.
Open patients
Established active patients
All open patients who received HIV primary care services within the organization in Excludes all new-to-care patients.
Open non-active Patients
All open patients who received services from the organization in 2018, but did not receive HIV primary care services.
Deceased
by end of 2018
Incarcerated
at end of 2018
Confirmed in HIV care elsewhere

71. Drill Down by Key Characteristics
Purpose: To identify disparities in care among key populations, allowing for targeted improvement work
Required Components: Demographic data to enable disaggregation of the active caseload by each of the following key characteristics (demographic data also requested for non-active patients)
Date of birth
Sex at birth and/or current gender
Ethnicity (Hispanic or Latina/Latino, Non-Hispanic Latina/Latino, Unknown)
Race (White, Black or African American, Asian, Native Hawaiian or Pacific Islander, American Indian or Alaska Native, Unknown)
Risk Category
Housing status
Excel template automates calculation of active caseload, prescription of ART, receipt of a viral load test, and viral suppression.
Cascade format will also be generated in the template.

72. Definitions: Drill Down by Key Characteristics
Categories (adapted from Ryan White)
Age
0-12; 13-19; 20-24; 25-29; 30-39; 40-49; 50-59; 60+
Gender
Male; Female; Transgender Man; Transgender Woman; Transgender other, non-binary, gender non-conforming; Unknown
Race
White; Black or African American; Asian; Native Hawaiian or Pacific Islander; American Indian or Alaska Native; Unknown
Ethnicity
Hispanic or Latina/Latino; Non-Hispanic, Latina/Latino; Unknown
Risk Category
Men who have Sex with Men (MSM); Intravenous Drug Users (IDU); Hemophilia or coagulation disorder; Blood transfusion or blood products; Perinatal transmission; Other; Unknown  
Housing Status
Stable permanent housing; Temporary housing; Unstable housing; Unknown

73. Example: Drill Down Cascade
Active: # of patients diagnosed with HIV before 2018, who received HIV primary care services in 2018, by housing status
Prescribed ART: percentage of active patients receiving ART prescription in 2018
Received Viral Load Test: percentage of active patients with a documented VL test in 2018
Virally suppressed: percentage of active patients who had VL <200 copies/mL in last VL test of 2018

74. First Look at Data Reports in the Excel Template

75. Cascade Indicators

76. Linkage

77. Quality Improvement Plan
Methodology Analysis
&
Quality Improvement Plan

78. Methodology Section
Purpose: To allow internal and external stakeholders to understand how the cascade data were collected and reviewed.
Responses to all specific questions in the guidance, at a minimum
For each data point, describe the data source(s) used to collect it
Which data source(s)
Why the data sources were selected
What the limitations of the data sources were
Who was involved in extracting, analyzing, and presenting cascade data?

79. Consumer Involvement in Quality Improvement
Organizations will be asked to submit a Quality Improvement Plan that addresses specific gaps identified in the cascades.
Each organization describes how consumers were engaged in the process of developing the Quality Improvement Plan based on the data in the cascades.
Questions to consider…
What are the barriers to consumer involvement in QI?
What are the benefits of consumer involvement in QI?

80. Analysis and Improvement Plan
Report progress on 2018 cascade improvement plan
Analyze all gaps in care in 2018 data; compare to 2017 data
Develop specific, time-bound, measurable goals for each gap identified in 2018 and steps/activities planned to achieve goals
Explain how consumers were involved in development of improvement plan and improvement activities
List staff responsible for implementing each step of the improvement plan
Plan for dissemination of the cascades to stakeholders

81. Next Steps Webinars will be offered until the deadline:
Introductory webinars (2/27, 3/5, and 3/8)
Additional webinars on the reporting template and additional documents:
4/9/19, 11:30 to 1:00
4/10/19, 3 to 4:30
4/11/19, 12 to 1:30
Submissions due no later than April 30th (pending final release dates)
Contact your QI coach before submission for technical assistance and to make sure you are on track for approval. Do not the template!
Submit finalized Excel document via the NYS Health Commerce System.

82. Questions?

83. Patient Self-Management Strategies

84. Self Management Presentation
Presented by: Tempestt Perkins, LMSW
Managing Director, Retention and Adherence Department
Yvette Allen
Health Advocate
April 2, 2019
Housing Works Community Healthcare fosters good health and positive social change through empowerment, innovation and collaboration.
We provide high-quality integrated medical care and other essential services that improve individual and overall community well-being. 84

85. Self management
Management of or by oneself; the taking of responsibility for one's own behavior and well-being. (Oxford)
Self management Support
Care and encouragement for individuals living with chronic conditions to make informed decisions about their care, manage illness and engage in healthy behaviors.

86. Develop Improvement Strategies
Case conference with provider, patient and Case management
Outreach calls from team, adherence measurement (throughout enrollment), coordination of services

87. Yvette’s Story Peer to Peer ADHC Groups Harm Reduction
Medication Adherence

88. Meet the RAP Team

90. ETE Priority Selection Activity

91. Evaluation

92. Evaluation Please complete the session evaluation form
Complete our contact information sheet

93. Contact Information
Steve Sawicki, NYLinks Lead,
Regional Leads
Upper Manhattan—Susan Weigl,
Lower Manhattan—Susan Weigl
Western NY—Nanette Brey Magnani,
Long Island—Steven Sawicki
Central NY & Southern Tier—Steve Sawicki
Mid & Lower Hudson—Steve Sawicki
Queens—Nova West,
Brooklyn—Clemens Steinbock, and
Zeenath Rehana,
Bronx—Dan Belanger,
Northeastern NY—Steve Sawicki If not sure,