1 in+care Campaign Webinar June 27, 2012. 2 Ground Rules for Webinar Participation Actively...
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Transcript of 1 in+care Campaign Webinar June 27, 2012. 2 Ground Rules for Webinar Participation Actively...
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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%
10
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
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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
45
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)
46
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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 [email protected] 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 [email protected]
incareCampaign.orgyoutube.com/incareCampaign