1. Health at Home – The AMPATH Evolution
Sonak Pastakia, PharmD, MPH, BCPS Assistant Professor Purdue University College of Pharmacy
Collaborator, Chronic Disease Management Program

2. Objectives Provide a brief overview of AMPATH
Discuss AMPATH’s transition
Describe the structure and design of comprehensive care in Western Kenya
Analyze key early results from the diabetes care program
Describe areas of care focused research

3. Development of the Program
IU Kenya partnership was started with an initial goal of training healthcare providers but this could not be achieved without treating the thousands of patients infected with HIV. This led to the creation of AMPATH with the help of funding from USAID and PEPFAR. Following the success of the HIV program, in 2008, the acronym changed and the program has now changed its focus to all of primary healthcare and particularly maternal and child health as well as chronic disease management.
Academic Model Providing Access To Healthcare
Academic Model for Prevention And Treatment of HIV/AIDS

4. Academic Model Providing Access To Healthcare
Initiated in November 2001
55 care sites in western Kenya
Catchment population ~ 2.2 million
HIV prevalence 2 – 30%
>130,000 patients enrolled; 75,000 active patients with 40,000 on cART

5. Cumulative Patients Enrolled: Nov ’01 – Mar ’08

6. 80% of Chronic Disease Deaths Occur in Low & Middle Income Countries

7. Targeted Diagnostic Testing
AMPATH Approach to Screening
Community Screening
Home Based Screening
Village based screening at innovation sites
Perpetual door to door screening for chronic diseases
Targeted Diagnostic Testing
Referral to clinic for enhanced care
Linked to care by community worker

8. Health at Home Adults Children Total Pregnant Women Number Tested
317,172
38,376
355,548
8,977
Number and Percent Positive
9,731 (3.1%)
702 (1.8%)
10,433 (2.9%)
396 (4.4%)
Number Newly Identified HIV positive
8039 (83%)
1028 (83.3%)
8641 (83%)
310
(78%)
Number of Orphaned and Vulnerable Dependents Identified
36,593
51,066
87,659

9. Preliminary Screening Data from Webuye
Parameter
Result
Number Screened
350
Number with random blood sugar > 7.0 mmol/L (128 mg/dL) 47
Total number returning for a confirmatory testing/diagnosis at the health center 19
Total number confirmed with diabetes 4
Estimated prevalence of diabetes
1.1*
*60% of patients did not return for follow-up

12. Primary Health Care and Chronic Disease Innovation Sites
Webuye
MTRH Center
of Excellence
Port Victoria
Mosoriot
Turbo
Chulaimbo
Teso

13. CHRONIC DISEASE MANAGEMENT
Patient can be admitted or treated and referred down for follow up at lower levels
PATIENT CARE AND REFERRAL SYSTEM
AMPATH-MTRH Centers of Excellence
CVPD
Onc DM
Psych
Others
REGIONAL/DISTRICT REFERRAL CENTERS
HEALTH CENTER/AMPATH CHRONIC DISEASE CLINIC
Patient received and initiated to care using CDM protocols
CASE FINDING (EARLY DIAGNOSIS) & LINKAGE TO CARE:
PHCT: HIV, BP & RBS
Patient referred up based on defined thresholds
Patient sent home for dispensary/community/self care
DISPENSARY (RN): Triage, prevention, monitoring (BP and RBS rechecks; foot exam etc.) and dispensing role through decision support
COMMUNITY CARE AND SELF MANAGEMENT: CHEWS, CHWS, AND COUNSELORS Decision support/training on referral protocols
Patient referred to dispensary

14. Electronic Medical Record Based On Handheld Android Phones
A. Community health workers (CHWs) make home visits or client visits local dispensary
Web –based Network Server
Eventually connectivity to all areas within our catchment area
B. CHW Scans Patients Medical ID card
E. Data from previous visits available for decision support
C. CHW performs basic assessment based on decision support in the phone based EMR
D. Data entered directly into the phone

15. Preliminary Descriptive Data from the Clinics
Number of Active Patients at Each Site
Site
Number of Active Patients
Eldoret – Moi Teaching and Referral Hospital
On insulin
On oral agents or diet control
1343
604 (45%)
739(55%)
Kitale – Kitale District Hospital
1122
359 (32%)
763(68%)
Webuye – Webuye District Hospital
383
76(20%)
307 (80%)

16. Demographic Data (N=1348) Characteristic Average or Frequency Range52
1-92
% With Food Insecurity
35%
% With Outpatient Health Insurance
<1%
% With History of Smoking 2%
% With a History of Alcohol Use 7%
% With Caretaker Assistance
68%

17. Frequency of Exercise Per Week (N=637)

18. BMI of the Diabetes Population (N=637)

19. Preliminary Results from Home Glucose Monitoring
Home Glucose Monitoring Program Results
Patients with at least 3 months of follow up HbA1c data
101
Active patients
135
Mean HbA1c at enrolment
13.2
95%CI ( )
Mean HbA1c after at least 3 months
10.2
95%CI ( )*
Mean HbA1c after at least 6 months
9.8
95% CI ( )*
% of patients with an improvement in HbA1c after at least 3 months
95%
HbA1c’s of patients have shown dramatic improvement within 3 months of being in the program.
*P<0.01 via t-test comparison with Mean HbA1c at enrollment

20. Preliminary Results from Home Glucometer Pilot-Webuye14 13 12 11 10 9 8 7 6 5
Months of enrollment
HbA1c 20

21. Future Steps Innovative Partnerships Price Reductions on Supplies
Development of Sustainable Models of Care
Incorporation of co-pays
Greater dependency on patients
Integrated Partnership with Kenyan Government/ Ministry of Health