1. Improving Viral Load Suppression Rates Easton Community HIV/AIDS Organization (ECHO)
Quality Improvement Team Members
Nurse Practitioner (& MD on prn basis) RN
Office Manager
Medical Assistant
Case Managers

2. Background Information/Rationale for QI Project
Of the more than 1 million people living with HIV/AIDS in the US, 4 in 5 are not viral load suppressed.
The National AIDS Strategy acknowledges the role of HIV viral load suppression in both decreasing HIV transmission and in improving patient health outcomes.
Easton Community HIV/AIDS Organization (ECHO) is a Ryan White Part C provider serving Northampton, Lehigh, Monroe, Carbon, & Pike counties in Pennsylvania and Warren county in New Jersey.
Client base of approximately 100 patients.
100% of clients are either on Medicaid, Medicare, or are uninsured.

3. Performance Measure
Percentage of patients with a viral load of <200 at last viral load testing of the measurement year

4. Baseline Data
Percentage of patients with a suppressed viral load (<200) at the viral load test in the measurement year:
Oct. 1, 2010 to Sept. 30, %
Dec. 1, 2010 to Nov. 30, 2011 – 68.57%

5. Improvement Goal
Increase percentage of patients with suppressed viral load (VL<200) at the last viral load measurement of the measurement year from 66% to 85% of patients.

6. Causal Analysis
Workflow Process Analysis Identified the Following Problem Steps:
No follow-up appointments scheduled for some patients with elevated viral load
Need to develop and implement formal Adherence Program

7. Viral Load Suppression Performance Improvement Measure:
Workflow Process Diagram
Forwarded to Data Entry & to chart & flowsheet
VL Received?
Lab Slip Sent?
Send
LabSlip
Reminder Call if no labs in 6 weeks
Labs
Done
Reminder Letter
PreClosure
Letter (no Rx’s); CM Notified
Reviewed
By NP
Appt. Kept?
Appt
Scheduled?
Closure Letter at 9+ Months if no contact N Y
Call to Schedule
Or Resched.
Discuss Next Steps –see Clinical Process Diagram
Pt. Referred for VL Test

8. Formulate & Implement Adherence Plan
Issues
Identified?
Formulate & Implement Adherence Plan
2nd VL >200
Consider /Do Genotype
Consider/Do Tropism & HLAB5701
Evaluate for Drug-Drug Interactions
Consider or Make Med 
Evaluate for Drug-
Adherence Assessment at Next Appointment
Recheck VL in 3 months or less
2nd VL <200
Adherence Assessment by phone or appt. within 2 wks.
Yes No
Routine
Monitoring
Ongoing Monitoring of Adherence & VL Testing as indicated
VL<200
VL>200

9. PDSA – Plan/Do
Changes Planned for Process of Scheduling Patients for Follow-up Visits
Appointments previously initiated by patient after labwork completed -> now will be initiated by staff after receipt of labwork
Changes Planned for Adherence Program
Initial Adherence assessment for patient with VL>200 to be done by phone or appointment within 2 weeks (previously at next scheduled appointment) of receipt of labwork
Adherence Plan Assessment Form developed to track individual patient progress
More aggressive adherence strategies:
Weekly adherence evaluations of selected patients, including pill box fills and/or supervised pill box fills
Involvement of case managers to supervise pill box fills and/or perform weekly evaluation of adherence
Use of Adherence tools, such as pillbox with alarm, cell phone alarms, etc.

10. Action (Pill Box Fill, Supervison, or Check, etc.)
ECHO Clinic
Adherence Plan Assessment Form
Patient Name:
DOB:
MR#:
Date
Action (Pill Box Fill, Supervison, or Check, etc.)
Adherence
Goal
Assessment
(Since Last Visit)
Most Recent VL
Result
NEXT F/U
DATE

11. PSDA - Study/Results
Phase 2: Study/results

12. Repeated PDSAs

13. Overall Findings

14. Looking Ahead (next Steps)