Know Your Status Project: HIV Case Management as a Model of Improvement of Quality of Care


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Improvement Story session at the 2013 Saskatchewan Health Care Quality Summit. For more information about the summit, visit Follow @QualitySummit on Twitter.

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Know Your Status Project: HIV Case Management as a Model of Improvement of Quality of Care

  1. 1. Know Your Status Project: HIV Case Management asa Model of Improvement of Quality of CareLeslie Ann Smith and Jocelyn AndrewsThis Session is sponsored by:
  2. 2. Presenters:Jocelyn Andrews, Regional Director of Primary Health Care and Population HealthLeslie-Ann Smith, Nurse in ChargeFirst Nations and Inuit Health Branch - Saskatchewan (FNIHB-SK)April 2013Know Your Status Project: HIV Case Managementas Model of Improvement of Quality of Care
  3. 3. Introduction• HIV/AIDS remains an issue of concern for Canada.• In Canada, the number of new infections in 2011 was estimatedat 3,175 (PHAC).• Saskatchewan has the highest incidence of HIV in Canada, withthe highest burden among First Nations/Métis people(Figures 1 & 2).
  4. 4. 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011SK 2.5 3.9 5.4 7.6 10.2 12.6 16.7 19.3 16.2 17.2Canada 7.9 7.8 7.9 7.7 7.8 7.5 7.9 7.2 6.8 6.40510152025Cruderateper100,000Year of diagnosisFigure 1: Rate of HIV cases by year, Saskatchewan and Canada,2002 to 2011 (sources: SK Ministry of Health, PHAC)
  5. 5. 03060901201501802002 2003 2004 2005 2006 2007 2008 2009 2010 2011NumberofcasesYear of diagnosisFigure 2: HIV Cases by self-reported ethnicity, Saskatchewan,2002 to 2011 (source: SK Ministry of Health)Aboriginal Non-Aboriginal/Unspecified
  6. 6. Background and ContextFirst Nations and Inuit Health Quality Improvement Framework• Articulate First Nations and Inuit Health Branch’s commitment toimproving continuously the quality of First Nations and Inuit(FNI) health services• Provide common vision, language and understanding of QualityImprovement for First Nations and Inuit Health Services• Prepare a foundation for quality improvement action planningBUILD PEOPLE CAPABILITIESBUILD SYSTEM CAPACITY
  7. 7. Background and Context• High rates of Chlamydia and Gonorrhea• Increase Hepatitis C• Sporadic cases of HIV• IDU population identified and growing• Initial testing in for the Know Your Status (KYS) project began inJanuary 2011.• Mobile Infectious Diseases clinic with physician services heldquarterly since July 2011.
  8. 8. This is a first of its kind client focused,mobile, community-based, multi-disciplinaryHIV /STI project delivered in First Nationscommunity.
  9. 9. ObjectivesKey objectives are:1. Decrease the number of new cases of HIV and STIs incommunity;2. Decrease stigma and increase understanding of HIV andSTIs; and3. Develop community and professional capacity to manageHIV and STIs.
  10. 10. Method Approach for case management: Client Focused Care Culturally competent care is provided by a multi-disciplinaryteam with ID specialist, pharmacist, mental health worker andcommunity health nurses in the health clinic or directly inpatients’ homes.• Client focused culturally sensitive care is being provided one-to-one care by community health nurses, including assisting in thedelivery of ARV and other supportive care.
  11. 11. Health IndicatorsMaximum Time to Care:• Maximum time to care, from testing to treatment, is threemonths. The time varies depending on the blood work. In manycases the time to care is less than three months.Access to appropriate care:• Clinics are provided by Infectious Diseases Doctor quarterly, onregular basis.Cultural Safety:• Case management occurs within the community. The specificneeds of each client are respected (e.g. meeting times andlocations).
  12. 12. Approach• Access to testing to clients and contacts by CHNsworking in rural First Nation settings• If positive for Chlamydia and Gonorrhea, expandtesting to all those with risky behavior for:• Hepatitis• Syphilis• HIV• Pregnancy testing for high risk
  13. 13. Approach• Referrals to PA Sexual Health - relationship buildingfor team (nurse to nurse), better understanding ofprogram.• Referrals to family physicians/NPs limited.• Numerous home visits to same client (challenging).• We needed one nurse to run CDC program.• Requisition in hand-MHO needed to be on board.
  14. 14. • Approach was not working.• Most clients would not go to PA-Positive livingprogram.• Transportation issue to lab-even with requisition inhand.• Poor access to care.
  15. 15. • We needed to develop a community based, but alsoculturally responsive program that would meet theneeds of our high risk clients.• We needed to start testing in the community-Veni-puncture, POCT, urinalysis.New Ideas
  16. 16. Action Plan• We advocated for change to our community health program.• Involved Nursing Office-RNO, ZNO and NIC and met with theChief.• HPPH-MHO/CDC coordinator was briefed on what we wouldlike to do to improve service delivery.• ARNO-was involved in the collaboration with SDCL.• Lab licensing - Quality Assurance testing for Tests: POCT,Pregnancy.• Forms for project
  17. 17. Action Plan• Community Meetings with Chief and Council andHealth Director.• Community Information Sessions - Nursing and HIVCoordinator.
  18. 18. Training• Pre and post-test counseling• Veni-puncture training• SDCL tour• PA positive living program - Marlene Allen• PA South Hill Lab
  19. 19. Testing and Referrals• Testing open to everyone• High school testing• Treat positive Chlamydia / Gonorrhea clients• Refer all clients with Hep C and HIV to PA PositiveLiving Program• Dr. Lanoie for methadone program
  20. 20. Concerns with Testing and Referrals• Clients would not go to PA for most referrals-stigma• Many wanting treatment but unable to do follow-upthat was needed• Poor access to physicians and NPs• We have an obligation to ensure clients are followedup• No relationship
  21. 21. Solutions for Testing and Referral Concerns• Clients already had relationship with nurses andtrusted them• Needed to develop relationships with doctors andother health care professionals• Very sensitive issue• ID doctor willing to come into community for clientassessment-VIP-relationship building
  22. 22. Client Case Management• Appointments• AV Treatment• Methadone• Medication delivery/follow up• Frequent testing-case management• Social networking ongoing
  23. 23. Program Concerns• POCT testing-immediate result• CD4 & CD8 & VL• Strict guidelines for quality specimens• Follow-up blood work and appointments (numerous)• Workload• Paper overload• Confidentiality-protecting client, community concerns
  24. 24. Lessons Learned and LimitationsThere are three crucial elements for success of a community-centered multi-disciplinary care model:1. Community readiness, ownership and mobilization to ensure thedevelopment of culturally appropriate strategies to deal with HIVrelated issues and harm reduction;2. Continuous alignment of resources, internal and external to meetthe needs of HIV clients; and3. Creation of effective, on-going partnerships.
  25. 25. Conclusion and Recommendations• Applied Quality Improvement principles & outcomes: STEEP(Safe; Timely; Equitable; Effective and Efficient; Patient-Centered)• The first year evaluation of the project has been finalized in2012 and recommendations approved and endorsed by the FirstNations community• Use of available and existing resources and tools• Continued partnership-building• Continuum in care and social support to clients• Evidence-based approach
  26. 26. References• Public Health Agency of Canada (2012) Estimates of HIV prevalenceand incidence in Canada• Saskatchewan Ministry of Health (2012): HIV/AIDS Annual ReportSaskatchewan• Saskatchewan Ministry of Health (2010): The Saskatchewan HIVStrategy 2010-14• Health Canada/FNIHB Project Evaluation (2012): Know Your Status. AComprehensive Review of HIV testing, Case Management andTreatment in a Saskatchewan First Nation.• Reif F, Golon SE, Smith SR (2005): Barriers to accessing HIV/AIDScare in North Carolina: Rural and urban differences. AIDS Care, 17(5),558-565.
  27. 27. AcknowledgementsTo…• Chief Morin and all key stakeholders from Big River First Nations fortheir engagement in this project• Community Health Nurses and clients involved in this project• The Ministry of Health and Regional Health Authorities involved• All the multidisciplinary team for their dedicated contribution andparticipation in this project…THANK YOU!
  28. 28. Questions?