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in+care CampaignWebinar

June 27, 2012

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Ground Rules for Webinar Participation

• Actively participate and write your questions into the chat area during the presentation(s)

• Do not put us on hold• Mute your line if you are not speaking

(press *6, to unmute your line press #6)• Slides and other resources are available

on our website at incareCampaign.org• All webinars are being recorded

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Agenda

• Welcome & Introductions, 5min• TLC+ Initiative in Los Angeles County,

30min• The Seattle and Washington State

Story, 10min• Data Review and Discussion of Best

Practices Collected Through the Campaign, 15min

• Q & A Session, 5min• Updates & Reminders, 5min

TLC+ Initiative in Los Angeles County

Sonali P. Kulkarni, MD, MPHActing HIV Medical DirectorLos Angeles County Department of Public HealthDivision of HIV and STD Programs (DHSP)

InCare CampaignJune 27, 2012

Overview

• Overview of HIV Epidemic in LAC• HIV Spectrum of Engagement in Care in LAC• LAC DPH’s Testing, Linkage to Care, and Treatment (TLC+) Framework

• Re-engagement and Retention Efforts

Overview of LAC Epidemic

California

2.6%

97.4%

Land Area (Square Miles)

Los Angeles County

Other California Counties

26.6%

73.4%

Population

Los Angeles County

Other California Counties

Los Angeles County

Los Angeles County California

9,848,011 36,961,664

Los Angeles County California

4,060 sq mi 155,959 sq mi

Los Angeles County California

Estimated living HIV/AIDS Cases 59,500 136,123*

Reported HIV/AIDS Cases 46,700 112,550

Estimated Undiagnosed

HIV/AIDS Cases12,800 23,573*

Data Source: U.S. Census , 2010

Data Source: Los Angeles County Department of Public Health, HIV Surveillance, 2012 California State Department of Public Health, State Surveillance Data, 2012

*134,401 calculated assuming 21% of HIV positive Californians are unaware of their status.

46.1%53.9%

HIV/AIDS Cases, 2010

Los Angeles County

Other California Counties

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Los Angeles County

Data Source: U.S. Census Bureau, Topologically Integrated Geographic Encoding and Referencing system, 2009. Maps Drawn at 1:750,000 scale.

Chicago

Houston

New York City

San Francisco

Philadelphia

District of Columbia

21.0%

40.0%

35.0%

3.0% 1.0%

HIV/AIDS Cases

Black

Latino

White

Asian/PI

NA/AI

8.8%

47.3%30.1%

13.3% 0.5%

Overall, Race/Ethnicity

Population Estimated HIV/AIDS Cases

9,848,011 59,500

Data Source: U.S. Department of Commerce, 2010; Los Angeles County Department of Public Health, HIV Surveillance, 2011

Proportion of LAC PLWH/A Cases by Race/Ethnicity* & Diagnosis Year, 2001-10

0%5%

10%15%20%25%30%35%40%45%50%

01 02 03 04 05 06 07 08 09 10

Year of HIV or AIDS Diagnosis

*American Indian and Alaska Native are not presented here but consistently comprise <1% of cases, including 0.4% in 2010. *Data are provisional due to reporting delay.Source: HIV Epidemiology Program, LAC-DPH; data as of December 31, 2010

WhiteLatino

Black Asian/PI

21%

39%

4%

35%

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LA COUNTY HIV EPIDEMIOLOGY PROGRAM

* Persons with an undetermined transmission category are assigned a risk factor using multiple imputation (MI) methods (see technical notes in HIV/AIDS Surveillance Summary). Other risks include hemophilia or coagulation disorder, transfusion recipient, perinatal exposure, and confirmed other risk. ** Data are provisional due to reporting delay.

Source: HIV/AIDS Surveillance Summary, data as of December 2010

Pe

rcen

tPercent of HIV/AIDS Diagnoses Among

Adults/Adolescents, by Transmission Category* and Year of HIV Diagnosis, Los Angeles County, 1992-2010

Source: HIRS, Calendar Year 2007

Data Source: eHARS as of September 30, 2011

Palmdale

Santa Clarita

Calabasas

Burbank

Pasadena

Pomona

Inglewood

Santa Monica

Whittier

Long Beach

North

East

South

Central

Northwest

West Hollywood

Downtown

Compton

PLWHA by Resdience Zip Code

No PLWHA Reported

Spectrum of Engagement in HIV Care in LAC

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Spectrum of Engagement in Care in the United States

Gardner et al. Clinical Infectious Diseases 2011;52(6):793-800 15

Spectrum of Engagement in Care in Los Angeles County

16Los Angeles County HIV Surveillance Data 2009-2010

Note: Using Gardner et al. (CID 2011) treatment cascade criteria

Los Angeles County Treatment Cascade among PLWH in Care, 2009

17Los Angeles County HIV Surveillance Data 2009-2010

Ryan White “in Care” Treatment Cascade, 2009

18Ryan White Casewatch Data, January – December 2009 (CY2009)

Ryan White “in Care” Treatment Cascade, 2010

19Ryan White Casewatch Data, March 2010 – February 2011 (Year 20)

Among RW clients in medical care and on ART, 83% have an undetectable VL.

Question

• How do the LAC data compare to your local data regarding retention and viral load suppression?

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Predictors of Retention in Care in LAC

Source: Casewatch YR 19 (Feb. ‘09 – Mar. ‘10): Limited to RW clients w/ 1 or more MOP visit

• Multivariate regression model on data from Ryan White Care clients who accessed medical outpatient services during Feb. ‘09 – Mar. ‘10.

• Used falling out of care (defined as < 2 medical outpatient visits in a span of one year) as the outcome.

• Those who were not retained in care were more likely to be: African American YouthHomelessRecently incarcerated

Not on ARTAdvanced Disease (CD4<200)Detectable VL

Retention in Care* by Resident Zip CodeRetention in Care

<= 60

%

61-7

2%

73-7

9%

80-8

6%> 8

6%

<= 10 RW Clients

Medical Outpatient Sites

Source: Casewatch YR 19 (Feb. ‘09 – Mar. ‘10): Limited to Zip-Codes w/ > 10 RW clients.* Defined as 2 MOP visits at least 90 days apart in a span of one year.

SPA 1: Antelope Valley

SPA 2: San Fernando

SPA 3: San Gabriel

SPA 7: East

SPA 5: West

SPA 8: South Bay

SPA 4: Metro

SPA 6: South

SPA 280%-87%

Range by Provider:

58% – 92%

SPA 458%-88%

SPA 678%-86%

SPA 887%-92%

Reasons Not In Care For Those Who Left and Returned to Care

Data Source: Los Angeles Coordinated HIV Needs Assessment, 2007-2008.

Why They Left Why They Returned

Substance abuse;Unstable housing;Good/improved health;Incarceration.

Illness;Substance abuse treatment;Overcoming depression;Ready to deal with HIV;Housing situation stabilized;Heard about a new doctor or clinic;Discovered different meds or treatments are availableEncouraged by family and friends.

N = 14,799

CD4 Levelsn =14,097

ART Utilization in RW System

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• Multivariate logistic regression with dependent variable: detectable VL (>200 copies)

• Those with detectable VL are more likely to be:

Multivariate Model for Detectable* HIV Viral Load in RW (N=11,397)

* Detectable VL is ≥ 200 copies/mL

• Female • Uninsured • CD4 <200

• African American • Substance user • Not retained

• Youth (18-24) • Hx incarceration • Dx in last year

• <133 FPL • Not on ART

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LAC’s TLC+ Framework

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Los Angeles County TLC+ Framework

High Risk Individuals

HIV Positive

Linked to Care

Engaged/

Re-Engaged in Care

Retained in HIV Care

Adherent to ART

Medication

Suppressed VL and Reduced Transmission

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HIV Negative

Customized Prevention Program:

• Behavioral Risk Reduction• Linkage to SA/MH Service• Additional Prevention Service• STI Diagnosis/Treatment• Biomedical Prevention (nPEP, PrEP)

HIV Testing

HTS LinkageARTAS LCM

Youth Linkage Specialist

Project EngageNavigation ProgramEIP/Bridge Worker

Medical Home:• Medical Care Coordination• Youth Case Management

Jails:• Transitional Case Management• Peer NAV• HIV Nurse Liaison

Project Engage

Goal: Identify HIV+ persons who are out of care and link them to care

Current status: To begin in July 2012

Key elements:

Snowball sampling using HIV+ persons who are in care to recruit HIV+ social network members who are out of care

Incentivize seeds and referrals when referral completes first care visit

Project Engage Target Population: Newly-diagnosed or out of care with

no care visits in 6 months or more

Cross match with RW care database (Casewatch) and HIV surveillance data to validate out of care

Staff: One clinic-based coordinator

Key outcomes:

Number of HIV+ people out of care identified

Completion of 1 care visit

% suppressed VL at 6 & 12 mos

Navigation Program Goal: Re-engage lost HIV clinic patients in care

Current status: To begin November 2012

Target Population: HIV clinic patients with no care visits in 6 months or longer

Key elements:

Review clinic records to identify lost to care patients

Cross match with Ryan White data and HIV Surveillance data to determine which patients are truly out of care

Navigation Program Key elements:

Use PHI investigative techniques to locate lost patients

After locating patient, administer 90-day ARTAS-like linkage intervention

Staff: 4 navigators (NAVs); 1 social work supervisor; 1 program coordinator

Roll out at 5 public HIV clinics

Eventually create team that rotates to all DHSP funded clinics

Navigation Program Key outcomes:

Proportion of those lost to care at the clinic who are successfully re-engaged

Completion of 1 medical visit

Suppressed VL at 6 and 12 months

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• Goal: Promote retention in medical care, remove barriers to care, and improve health outcomes for PLWH through care coordination

• Current Status: 5 pilot sites in progress, widespread implementation in all RW funded sites by October 2012

• Staff: 3 person multi-disciplinary team • Registered Nurse, • Master’s level Social Worker• Case Worker or LVN

Medical Care Coordination (MCC)

Medical Care Coordination (MCC)• Target Population

• Newly diagnosed (< 6 months)• Recently re-engaged in care• Meets criteria for ART but not on• On ART but with detectable viral load• Multiple poorly controlled co-morbidities

Key outcomes:• Proportion successfully retained in care• Suppressed VL at 6 and 12 months

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MCC Key Services

Non-Medical– Risk Reduction Counseling– Mental Health

Evaluations/Referrals– Linkage to Substance

Abuse Treatment– Disclosure Assistance– Housing Referrals– Legal Assistance Referrals– Assistance with Public

Benefits

Medical – Adherence intervention– Readiness for ART intervention– Manage Co Infections, Side

Effects– HIV Health Literacy/Education– Consultation with other care

providers– Monitor missed appointments to

detect those falling out of care – Health Care Maintenance

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Population Health Registry

• Goal: Implement “i2i Tracks” health registry system in 7 LAC public HIV clinics

• Status: To begin January 2013• Key elements: HIV performance measures will

enhance panel management– Ex: Prompt for health care maintenance (TB

screening, STI screening)– Ex: Query list of patients who have detectable

viral load or have no visit in > 6 months

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Thank You!

Sonali Kulkarni, MD, MPH

Acting HIV Medical Director

Division of HIV and STD Programs

600 S. Commonwealth Ave

Los Angeles, CA 90005

(213) 351-8189

skulkarni@ph.lacounty.gov

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Regional Retention Efforts: Seattle & Washington State

Julie Dombrowski, MD, MPHHIV/STD Program, Public Health – Seattle & King County

Department of Medicine, University of Washington

Population-Based Linkage and Re-linkage to HIV Care in King County

• Linkage assistance for all newly diagnosed persons through HIV partner services

• Assessment of ongoing HIV care engagement – HIV surveillance – STD case investigations– STD Clinic

• Care and Antiretroviral Promotion Program

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Impetus for the Project• King County

– Despite high rates of linkage to HIV care within 3 months of diagnosis (94% in 2011), attrition from care is common

– Most medical providers do not have a way to systematically identify who has fallen out of care

– Majority of PLWHA receive care outside Ryan White Part C clinics

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• Identify persons who appear not to be engaged in continuous HIV care

• HIV surveillance data– CD4 and viral load reports from labs

• Contact medical providers regarding eligible patients

• Call eligible persons to offer entry into CAPP

The Care and ART Promotion Program (CAPP)

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• Structured one-on-one interview to identify barriers to care and ART use – Develop concrete plan with participant– 45 minutes, $50 compensation

• Referral to services as appropriate– Summary to medical provider & case manager (if

participant consents)• Follow-up call in 1 month • Refer to high needs outreach worker if needed

The CAPP Intervention

Formative work with stakeholders

Calls to PLWHA identified through surveillance to survey acceptability

In-depth, qualitative individual interviews with PLWHA (N=20) & medical providers (N=15)

Pilot testing and vetting of educational materials

Meetings with large medical practices, case management organizations, ADAP leadership, Ryan White Planning Council, community action board

Group meeting with Seattle HIV medical providers

Year

2009

2010

2011

2012

Program launch in King County

Preparation for statewide expansion

Internal coordination

Summary of stakeholder interactions

• Dramatic change in support over time• Medical providers – spectrum of opinions• PLWHA and community groups generally very

supportive of idea• Case manager reaction• Internal program issues

– Integration of QM and surveillance activities– “Clean up” of surveillance data: major investment– Use of surveillance for outreach

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Experience to Date• Biggest challenge is establishing contact with

eligible persons– High rates of acceptance once contact successful

• Diverse barriers to care and ART use• Analysis of uptake, barriers, and program

outcomes in progress

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Lessons Learned• Broad support was due to formative work with

stakeholders• Providers’ perceptions of privacy issues may

differ substantially from those of patients.• Surveillance-based activities require an

investment in data clean-up• Integration of program activities internally is

key (care/prevention; surveillance/QM)

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Improvement Strategies Exercise

Michael Hager, MPH MANQC Manager

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in+care Campaign National Data Snapshot

December – June Data as of 06/26/2012

Dec Average

(Patients)Dec

SitesFeb

Average (Patients)

Feb Sites

Apr Average

(Patients)Apr

SitesJun

Average (Patients)

Jun Sites

Measure 1: Gap Measure 16.06% (120,625) 198 15.85%

(124,396) 191 14.71% (121,916) 195 15.44%

(96,318) 149

Measure 2: Visit Frequency Measure

64.06% (81,928) 147 65.45%

(83,652) 145 62.33% (95,061) 168 62.85%

(74,692) 136

Measure 3: New Patient Measure

56.29% (7,564) 188 58.02%

(8,607) 182 58.78% (8,186) 186 59.29%

(6,477) 147

Measure 4: Viral Suppression Measure

68.97% (130,326) 188 69.37%

(143,130) 183 70.49% (142,230) 186 71.21%

(115,525) 150

Coming Soon – new analyses!

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New Way to Submit Improvement Updates!

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Improvement Update Discussion

A) Regional-Level Interventions• Recapture Blitzes (state or local level)• Regional peer navigator programs• Regional Health Information Organizations

(RHIOs), as they mature• Form Community Working Groups (similar to

HIVQUAL and Local Retention Groups led by Local Quality Champions)

• Centralized training on retention by funders – an educational meet and greet

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Improvement Update Discussion

B) Barriers to Regional-Level Initiatives• HIPAA concerns – patients, providers, funders• Data cleaning projects can be resource-intensive

(highly detail-oriented work) if a central reporting database is not used

• Needs strong central leadership: interest and commitment

• Provider unwillingness to work together within communities

• Consumers using false names, addresses or other critical identifying information

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Improvement Update Discussion

C) Lessons Learned on Regional-Level Initiatives

• Centralized, high quality data systems make a major difference

• Community education on HIPAA alleviates patient fears

• Provider education on HIPAA alleviates concerns with regard to litigation risk

• Consumer education on the use of consistent aliases can help keep records straight

• Don’t forget to include private providers, Medicaid and other service systems!

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Time for Questions and Answers

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Partners in+care

• Partners in+care Secret Facebook Group is live! • Share tips, stories and strategies• Join a community of PLWH and those who love

them• Email michael@nationalqualitycenter.org for

more details• Partners in+care website is live!

• http://www.incarecampaign.net/index.cfm/77453 • Join our mailing list (a list-serv version of the FB

Group)

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• Campaign Office Hours: Mondays & Wednesdays 4-5pm ET

• Model Policy on Using Social Media&Texting to Contact PtsJuly 9, 2012 4pm ET

• Improvement Update Submission Deadline: July 16, 2012

• Data Collection Submission Deadline: August 1, 2012

• Next Campaign Webinar: Substance Abuse and RetentionTo be announced

• Next Meet-the-Author Webinar: S. Nikki Cockern To be announced

Upcoming Events and Deadlines

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Campaign Headquarters:National Quality Center (NQC)90 Church Street, 13th floorNew York, NY 10007Phone 212-417-4730incare@NationalQualityCenter.org

incareCampaign.orgyoutube.com/incareCampaign