1. Part A Treatment Adherence Site Visit reviews Kinga Cieloszyk, MD,MPH Deputy Medical Director of Clinical Care, NYCDOHMH, HIV Care, Treatment, and Housing Program Jacqueline P. Colon, MHA Part A Program Manager, NYSDOH, AIDS Institute Quality Management Program

2. Purpose of Site Visit  Joint effort by the NYC and NYS Department of Health in support of quality improvement efforts across all Part A programs  Unexpectedly low service performance scores in several quality indicators  Address questions related to program scores  Assessment of service provision and gaps that may have impacted program’s ability to meet each quality indicator  Address program's ongoing service performance needs through quality improvement activities

3. Part A Programs Reviewed Six Part A Treatment Adherence Programs reviewed:  Two Community Based Organizations (CBO’s)  Two clinic based programs  Two hospital based providers

4. Overview of Treatment Adherence Indicators Indicators are established with the involvement of various key stakeholders:  Part A service providers  Clinical consultants, educators  Treatment Adherence Quality Learning network committee members  NYSDOH Part A Quality Management staff  NYCDOHMH, HIV Care, Treatment, and Housing Program staff  other representatives as deemed appropriate.

5. Overview of Treatment Adherence Indicators  Once indicators are chosen, a statistician assists with developing a method for the sampling of records.  The sampling plan ensures that enough records are reviewed to provide reliable, meaningful data, without requiring the review of more records than necessary.

6. Barriers with Treatment Adherence Indicators  Program staff at the various facilities reviewed identified indicators were too rigid  Too many indicators for initial review  Difficulty to assess all indicators  Different standards addressed by AI and NYCDOHMH versus the program’s current contractor

7. Barriers with Treatment Adherence Indicators  Indicators are too clinical in nature for the various programs  Providers identified based on level of importance i.e. standard of care such as VL and CD 4 values) was most important to collect) and other support services were not relevant to integrating TAS

8. Barriers with Treatment Adherence Indicators  Documentation of the TA indicators was time consuming and did not occur at every intervention (i.e. due to the onset of client needs)  Unable to meet minimum requirements (i.e. adherence to ARV therapy has been quantified and documented every 4 months) versus various provider’s collecting information from PCP at 6 month intervals

9. Barriers with Treatment Adherence Indicators  Inability to obtain indicator information in a timely manner (CD 4 and VL values) since most programs are not co-located  Some indicators are not very important and do not accurately reflect what occurs at all facilities

10. Indicator Compliance  Not meeting initial documentation standards  Documentation activities do not reflect treatment adherence activities  Information was difficult to find  Staff retention issues affected some programs

11. Indicator Compliance  Counseling activities and other interventions offered did not support treatment adherence activities  The integration of treatment adherence services was not clear  Evidence does not suggest effective integration of care for some programs

12. Review of Program Models Elements of a Treatment Adherence Program  Target population/enrollment criteria/intake process  Barrier identification/treatment readiness assessment  How, when and how often services will be delivered  ART assessment & Quantification of adherence

13. Review of Program Models  Treatment adherence support tools (curriculum-based education, individual and/or group counseling, peer support, pillboxes, DOT, etc.)  Link to non-medical case management (includes advice and assistance in obtaining social, community, legal, financial, and other needed services)

14. Review of Program Models  Staff training/supervision  Multidisciplinary team communication/rounds  Strategies to engage, re-engage and maintain clients in care  Criteria for service intensity/step- down/program completion

15. Responses from Part A Treatment Adherence Questionnaire Barriers to Program Implementation  Frequently missed appointments/ lost-to-follow-up  Patient fails to obtained ordered labs  Patient barriers: mental health, substance use, legal issues, housing needs

16. Responses from Part A Treatment Adherence Questionnaire Barriers to Program Implementation  Lack of co-location with limited record access  Working with multiple providers  Limited staff (case managers, outreach workers, data entry)

17. Review of the Evaluation Process IndicatorsNYCHSRO average score 6 Site Evaluation Process CD4 & VL Assessed every 4 months Average = 21% 6 Reviewed Programs (Range) =20-56%  Scoring inconsistent at 2-3 sites 60-70% CD4/VL assessed every 4 mos. 80-90% CD4/VL assessed every 6 mos.  Barriers Lack of co-location Multiple charting/reporting systems Documentation ART Adherence Assessed & Quantified Average = 31-37% 6 Reviewed Programs (Range) =20-56%  Most scoring consistent, some discrepancy at 1-2 site Quantified is an important part of assessment Lack of an adherence record keeping Documentation Adherence Treatment Plan Average = 22.6 % 6 Reviewed Programs (Range) =0-56%  Most scoring consistent, some discrepancy at 1-2 site Sites asked to review own charts Lack of adherence treatment plan forms Documentation

18. Documentation Improvement  Proper documentation is critical  Chronological record of patient care that contributes to high quality  Allows treatment to be planned and monitored over time  Effective ‘communication’ between staff and improves hand-offs

19. Documentation Documentation Improvement  Appropriate utilization review and quality of care evaluations  Assists in the defense of staff in the event of legal cases  Service reimbursements  Collection of data that may be useful in data evaluation and research

20. Documentation Documentation Improvement Programs  Part of a site’s ‘Quality Improvement Project in HIV Care  Comprehensive and well-designed program focused at developing a well- documented adherence record system

21. Key components of documentation  Adherence record should be complete and legible (date and legible identity of staff)  Best practice:  Adherence section  Treatment Plan (date, reason for enrollment/referral, barrier assessment, ART treatment review, service intensity (e.g. frequency of follow-up), use of supportive tools (e.g. pillbox), assessment/service plan, follow- up/next appointment, communication with PCP/team)  Progress notes (date, reason for encounter, medication review, adherence quantification, labs, assessment/plan, next follow-up)  Flow sheet  Trend: labs, ART, adherence rate (quantified), etc. DateCD4/ % VL% of doses missed HAART (regimen & dose, start date, date end, reason for change) Treatment Plan Developed Barrier Assessment SAMPLE FLOW SHEET

22. Summary of Finding & Recommendations Identified ChallengesImproving the Process Indicators  Too many  Difficult to measure  Changing standards  Some not very relevant  Re-evaluate & re-consider some chosen indicators (relevance, measurability, accuracy, improvability)  Run an ‘indicator pilot test’ Treatment Adherence Program Models  Range of program models – from weak to strong  Lacking ‘Treatment Adherence Program’ elements  Present ‘Best Practice’ Program Models  Treatment Adherence Learning Networks – share experiences  Standardize ‘best practice’ program elements Documentation  Varied across programs – missing treatment adherence forms, plan updates, dedicated adherence sections, flow sheets  QI- Documentation Improvement Projects! Review process  Multiple reviewers (NYSDOH/ PHS/ DOHMH)  Weak collaboration and information sharing  Review findings to validate results  Feedback from providers –what worked well and what posed challenges  Analyze and share results  DOHMH/NYSDOH/PHS  improve measurement process & work together!

23. Questions & Comments

24. Thank you

25. Contact Information Kinga Cieloszyk, M.D., MPH Deputy Medical Director of Clinical Care, NYCDOHMH, HIV Care, Treatment, and Housing Program Tel: (212) - 788-4660 Email: kcielosz@health.nyc.govkcielosz@health.nyc.gov Jacqueline Colon, MHA Program Manager, Part A Quality Management Program Tel: (212) 417-4615 Email: jpc19@health.state.ny.usjpc19@health.state.ny.us