Integration of HIV Testing Within Routine Care in a Large Public Hospital System

1
Integration of HIV Testing Within
Routine Care in a Large Public Hospital
System
Joanna Omi
Senior Assistant Vice President
Corporate Planning and HIV Services
New York City Health and Hospitals Corporation
New York, NY
November 6, 2007
Copyright 2007, Joanna Omi, Joanna.Omi@nychhc.org

2
Topics covered
• Overview of HIV and the HIV Testing
Expansion Initiative
• Corporatewide and facility results
• Lessons learned

3
8.2 million people
live in NYC
100,000 of these are
HIV positive and
25,000 do
not
know it
(est.)
HHC serves 1.3 million
New Yorkers each year
It can be extrapolated that
each year approximately 4,000
undiagnosed HIV positive
New Yorkers access services
at an HHC facility
HHC is in the epicenter of the national
HIV/AIDS epidemic

4
New York City Health and Hospitals
Corporation (HHC)
• Public benefit corporation created in 1969
• Largest municipal healthcare delivery system in US
– 11 acute care hospitals with State Designated AIDS
Centers
– 6 diagnostic and treatment centers (D&TCs)
– 4 long-term care hospitals
– 95 extension clinics
– MetroPlus (health maintenance organization)
– Partnership in Care (HIV-specific managed care plan)
– Home care agency

5
HHC, continued
• 1.3 million New Yorkers served
• 224,300 discharges
• 4,934,600 visits
• $5.5B operating budget
• Approximately 19,000 patients with
HIV/AIDS
Note: FY07 Data

6

7
HIV Testing Expansion Initiative:
Integrate HIV testing within routine medical care
• Increase the number of patients who know
their HIV status
• Test 150,000 unique patients (increased from 100,000
in FY06)
• Increase the proportion of patients who enter
care early
• Reduce the number of concurrent AIDS diagnoses
• Once in care, retain patients in care
• >80% of patients will have 2 medical visits in the last 12
months, with at least one visit in the last 6 months

8
HIV Testing Expansion Plan

9
The percentage of unique patients tested at
HHC hospitals steadily increased while
overall volume remained stable
FY05 outpatient and ED Pilot Sites Only (Source: PLM and Pilot Project Sites Reports)
FY06-FY07 outpatient, inpatient and ED (Source: PLM and Facility Reports)
3%
6%
7%
5%
7%
7%
5%
7%
10%
5%
4%
6%
5%
7%
9%
9%
9%
11%
11%
11%
10%
9%
7%
9%
8%
14%
13%
17%
12%
13%
15%
18%
15%
16%
8%
13%
0%
2%
4%
6%
8%
1 0%
1 2%
1 4%
1 6%
1 8%
2 0%
B ell C IH E lm H ar l Jac K C H L in c M e t N C B Q n s W o od A ll
A cu t es
%ofvolumetested
F Y 05 FY 0 6 F Y 07

10
The percentage of unique patients tested at
D&TCs steadily increased while overall
volume remained stable
FY06-FY07 outpatient, inpatient and ED (Source: PLM and Facility Reports)
14%
12%
10%
6%
10%
10%
9%
13%
11%
12%
7%
12%
19%
11%
28%
13%
16%
10%
17%
23%
16%
0%
5%
10%
15%
20%
25%
30%
B e lv C u m b E N Y G ou v M o rr R en A ll D & T C s
%ofvolumetested
FY 05 FY 0 6 F Y 07

11
9 2,12 3
62 ,023
13 3,8 59
0
30,0 00
60,0 00
90,0 00
1 20,0 00
1 50,0 00
F Y 05 F Y 06 F Y 07
Numberofuniquepatientstested
U n iq u e P re n ata l T e st s A ll O th e r U n iq u e T ests
The number of unique patients tested grew
while prenatal testing remained relatively
stable
FY05 All other unique tests outpatient and ED Pilot Sites Only (Source: PLM and Pilot Project Sites Reports)
FY06-FY07 All other unique tests outpatient, inpatient and ED (Source: Facility Reports)
FY05-FY07 Unique prenatal tests prenatal clinics only (Source: Siemens Data Warehouse)
45.3%
48.5%

12
Rapid HIV testing comprised the majority of
unique tests conducted in FY06 and FY07
FY06-FY07 outpatient, inpatient and ED (Source: Facility Reports)
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
Q1 Q 2 Q 3 Q 4 Q 1 Q2 Q 3 Q 4 Q 1 Q2 Q3 Q 4
NumberofUniquePatientsTested
C on vention al R H T
FY 05 FY 06 FY 0 7

13
But the use of rapid testing varied widely
across facilities
FY07 outpatient, inpatient and ED (Source: Facility Reports)
74%
100%
96%
99%
59%
100%
68%
100%
98%
35%
99%
90%
64%
99%
73%
95%
91%
26%
0%
4%
1%
41%
0%
32%
0%
2%
65%
1%
10%
36%
1%
27%
5%
9%
0%
20%
40%
60%
80%
100%
Bell Belv CIH Cumb Elm ENY Gouv Harl Jac KCH L inc M et M orr NC B Qns R enn Wood
%oftotaltestsbytechnology
RHT Conv

14
Patients in Care, Prevalence,
Incidence and Venues

15
People of color continue to represent the
largest percentage of unique HIV positive
patients in care…
FY06-FY07 All Venues (Source: PLM Database)
5%5 %
3 5%
53 %
1 %
5%4%
35%
54 %
1%
0
2,00 0
4,00 0
6,00 0
8,00 0
1 0,00 0
1 2,00 0
1 4,00 0
1 6,00 0
1 8,00 0
2 0,00 0
A S IA N B L A C K H IS P A N IC O T H E R W H IT E G r an d T ota l
HIVpatientsincarebyrace
FY 06 A ll V en u es FY 07 A ll V en u es
100 %10 0%

16
While men continue to represent the largest
number of unique HIV positive patients in
care
FY06-FY07 All Venues (Source: PLM Database)
6 1 %
3 9 %
6 1 %
3 9 %
0
2 ,0 0 0
4 ,0 0 0
6 ,0 0 0
8 ,0 0 0
1 0 ,0 0 0
1 2 ,0 0 0
1 4 ,0 0 0
1 6 ,0 0 0
1 8 ,0 0 0
2 0 ,0 0 0
F E M A L E M A L E G ra n d T o ta l
HIVpatientsincarebysex
F Y 0 6 A ll V en u es F Y 0 7 A ll V en u es
1 0 0 %1 0 0 %

17
Both the total number of unique patients who
tested HIV positive and the subgroup newly
diagnosed with HIV increased in FY07
1,514
774
1,630
8 64
0
20 0
40 0
60 0
80 0
1,00 0
1,20 0
1,40 0
1,60 0
1,80 0
All Pa tients w /HIV Po sitive R esults New ly Dia gnosed HIV Po sitiv e Pa tients
FY06 FY07
TotalHIVpositiveandnewlydiagnosed
8%
12%

18
Most networks focused their expansion efforts in
the outpatient and ED areas
87%
66%
74%
68%
54%
78%
71%
69%
9% 9%
4%
8% 7%
4%
12%
8%
4%
25%
21%
25%
39%
19% 18%
24%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
C. Bkln Gen + N. Brx N. Bkln Qns S. Bkln S. Man. Corp.
%oftotaltestsbyvenue
Outpatient Inpatient ED

19
Across all networks, prevalence was highest
in inpatient units
1%
1%
1 %
2%
1%
0 %
2%
1%
6%
3%
6 %
4%
3%
4 %
5%
4%
4 %
1%
1%
1 %
1% 1%
2 %
1%
0 %
1 %
2 %
3 %
4 %
5 %
6 %
7 %
C. Bkln G en + N . Brx N. Bkln Qns S. Bkln S . M an. C orp.
HIVprevalencebyvenue
OP IP ED

20
As was the percentage of newly diagnosed HIV
positive patients
0 .6%
0.4 %
0.3%
0 .6%
0.4 %
0.3%
0 .6%
0.5 %
4 %
1%
3%
2 %
2%
4 %
2%
2%
2.2%
0 .9% 0.8 %
1.1%
0.4%
0.5 %
0 .9%
0.8%
0%
1%
2%
3%
4%
5%
C. Bkln G en + N . Brx N. Bkln Qns S. Bkln S . M an. C orp.
HIVPrevalencebyvenue
OP IP ED

21
Preliminary utilization data suggest the proportion of
newly HIV positive individuals may be greater in HHC
than in the city as a whole
NYC Incidence (Source: NYCDOHMH HIV Incidence Estimates Using STARHS – the serologic testing algorithm for recent
HIV seroconversions. CROI poster 2/2007)
NYC Prevalence (Source: NYC HIV/AIDS Annual Surveillance Statistics. 12/2006)
HHC Incidence
0.76%0.45%
2.02%
0%
1%
2%
3%
4%
HHC Prevalence
3.78%
0.98% 1.08%
0%
1%
2%
3%
4%
HHC Prevalence = 1.22%
NYC Prevalence=1.2%
HHC Incidence = .65%
NYC Incidence = .31%

22
Patients newly diagnosed with HIV in outpatient areas are
more likely to be scheduled for and keep their first HIV
primary care appointment
94 %
6 8%
85 % 86 %
90 %
77%
7 9%
84 %
0 %
20 %
40 %
60 %
80 %
1 00 %
O utpatie nt Inpa tien t ED To tal
%ofnewlydxpatientsscheduledandkeepingappointment
A p poin tm en t M a de A ppo intm e nt K e pt

23
Of patients newly diagnosed with HIV who kept their
first HIV appointment, fewer were concurrently
diagnosed with AIDS in FY07 vs. FY06
25 %
54 %
3 6%
32 %
1 6%
32 %
2 3%
21 %
0%
1 0%
2 0%
3 0%
4 0%
5 0%
6 0%
O u tp atie n t I n p a tien t E D T o tal
F Y 06 F Y 07
ProportionofNewHIVdxconcurrentlydxAIDSbyvenue

24
Accomplishments
• Large-scale implementation led to the identification of a
significant number of individuals who would not likely
otherwise have taken the opportunity to test.
• Rapid HIV testing is now available at all HHC acute care
hospitals and D&TCs (17 sites).
• All HHC acute care hospitals now offer HIV testing in
multiple venues: ED, inpatient units and at least three
outpatient clinics (including Dental, Medicine, Women’s
Health Services, Adolescent Health Services and Chemical
Dependency).

25
Variables that impact the expansion of
testing across HHC
Drivers
– Widespread use of a rapid, easy-to-use HIV test
– Consistent use of the streamlined HIV counseling model
with regular monitoring and evaluation
– Clinical and executive level commitment to expand testing
within the facilities
Inhibitors
– Number of clinicians offering and conducting testing at
some facilities
– Availability of interdisciplinary teams 24/7
– Dedicated space for counseling HIV-positive patients in all
venues

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Data Caveats
• FY05 testing data represents outpatient and ED Pilot Sites
only.
• Data for FY06 and FY07 HIV-positive patients in care reflects
patients connected to care at the time of report and does not
capture patients who may have entered care at a later date.
• The number of unique patients tested for HIV is based on
patient self-report and facility medical records.
• Identification of ‘new diagnosis’ is based on patient self-report
and facility medical records.
• Medical records are unique to each facility and in some cases,
networks. It is possible in some instances that counts are not
unduplicated between sites.

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Summary messages
• Encouraging patients to know their HIV status is a
message that resonates with health care professionals.
• The presence of clinician champions and well
functioning, interdisciplinary teams can significantly
improve testing rates.
• Inpatient testing provides significant opportunities as well
as challenges in complex teaching facilities.
• Best practices for successful expansion of HIV testing
will look different at each facility – one size does not fit
all.
• HHC - facilities and centrally - will continue to examine
the data being generated to inform long-term direction
and other service and policy implications.

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Acknowledgements and Appreciation
Terry Hamilton, Director of HIV Services, HHC
Drew De Los Reyes, Senior Management Consultant, HHC
Jay Gabor, Senior Management Consultant, HHC
Judy Aberg, MD, Medical Director of HIV Services, Bellevue
Hospital Center and the HHC South Manhattan Network
The dedicated physicians, nurses, administrators,
patient care associates, HIV counselors,
phlebotomists, lab directors and many others
throughout HHC who have contributed to the HIV
testing expansion effort

Integration of HIV Testing Within Routine Care in a Large Public Hospital System

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