Engaging Hard-to-Reach Populations into HIV Care: Inreach
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This Webinar is the second of a three-part series synthesizing successful practices to engage hard-to-reach populations into HIV primary care. Lessons are drawn from SPNS population-specific initiatives, and speakers will offer insights relevant to a wide range of audiences, from clinicians to social workers. Presenters discussed the use of data to improve inreach. Jane Herwehe, DeAnn Gruber, Betsy Shepard, and Debbie Wendell; Louisiana Public Health Information Exchange (LaPHIE) Peter Gordon, MD; New York-Presbyterian Hospital/Columbia University Jesse Thomas; RDE Systems
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Engaging Hard-to-Reach Populations into HIV Care: Inreach
- 2. Agenda Introduction to SPNS Integrating HIV Innovative Practices (IHIP) project Sarah Cook-Raymond, Impact Marketing + Communications Presentations from SPNS grantees on using data to improve inreach Jane Herwehe & DeAnn Gruber, Louisiana Public Health Information Exchange (LaPHIE) Peter Gordon, New York-Presbyterian Hospital/Columbia University Jesse Thomas, RDE Systems Brief post-Webinar questionnaire Q&A
- 4. IHIP Resources: Innovative Approaches to Engaging Hard-to-Reach Populations Living with HIV/AIDS into Care IHIP Tools on Engaging Hard-to-Reach Populations Training Manual Curriculum Webinar Series Outreach – April 18; archive recording to be up soon! Inreach – May 1 Empowering the Patient - May 15
- 5. Engaging Hard to Reach Populations thru In reach HRSA Ryan W hite spns webinar May 1, 2013
- 6. A Collaborative Initiative funded in part by: HRSA HIV/AIDS Bureau Office of Science and Policy Special Projects of National Significance Grant # H9HA08476
- 7. A carefully designed two-way electronic information exchange Uses OPH surveillance data to generate point of care messages for providers in the LSU HCSD (public hospital) system in Louisiana Targets patients with HIV who have fallen out of care, or never received test results, as well as persons with TB or syphilis who are in need of treatment
- 8. HIV Surveillance Database Laboratory Database Filte r busi ed data ness s rule et after s ap plied Target populations: Persons considered “not in care” (no record of CD4/VL in 9* months) Persons who have not received test results and may be unaware of HIV status HIV-exposed infants in need of follow-up LaPHIE Server LaPHIE Database Communication system: MIRTH – open source (behind OPH firewall)
- 9. s io mis Ad Admission Information (ADT) Disease Alert (PPR) n Registration Dis eas eA lert Dis eas eA lert Res pon se Interface Engine Disease Alert Response (PRR) LaPHIE Server n atio o rm In f EMR Office of Public Health Firewall LSUHCSD Firewall
- 10. Physician follows onscreen steps to reengage patient into care and provide HIV treatment, as appropriate Patient comes to clinic, hospital, or ED for nonHIV service Real time communication with surveillance system alerts physician that patient needs attention for HIV/AIDS HIV clinic 10
- 11. Established partnership, governance and agreements Assessed and modified technical infrastructure Designed messaging with iterative prototype process Conducted consumer research Participated in an ethics review by national experts in biomedical ethics, public health ethics and AIDS privacy Requested a legal review of legislation related to sharing of public health information Raised community awareness and readiness Prioritized open dialogue and established feedback mechanisms
- 12. Essential questions: We have the information and the technical ability to inform clinicians about patients in need of care … BUT SHOULD WE? Would this be accepted by patients, providers, and the public? Do state laws and regulations allow the proposed information exchange? Is surveillance data reliable as a basis for clinical interventions? Can we adequately address security/privacy concerns?
- 13. Legitimate public health purposes Respect rights of individuals and communities Seek input from those to be impacted Minimize undue burden Privacy and security standards
- 15. 46% <35 years of age Mean age 37.8 years [sd 11.4], median age 36 years 87% black/African American 38% female 21% had no prior labs in OPH system 41% had no monitoring for > 18 months Mean time out of care 25 months (sd 21.0, range 0.2-109 months, median19 months)
- 16. Among 84% with a CD4 following alert Absolute CD4 mean 282 (sd 235) 42% < 200 Among 79% with a viral load following alert HIV RNA copies/mL mean167,488 (sd 467,160) 66% HIV RNA copies/mL > 10,000
- 17. Substantial formative and evaluative work with consumers demonstrated acceptability N=24 qualitative interviews of LaPHIE identified patients Acceptable Positive experience of LaPHIE communication Perception that it is a “good system” System helped re-engage in care No negative calls to OPH hotline Provider ease of use, acceptable Source: Qualitative data
- 18. Using LaPHIE, we were able to: Identify over 989 (thru 3/31/2013) HIV-infected individuals who had been out of care thereby reducing missed opportunities to intervene Offer clinical services to improve individual- and population-level health Determine that system is acceptable to both patients and providers through feedback processes Confirm that a well developed, stakeholder involved process promotes success in implementing novel approaches in addressing linkage and retention.
- 19. Patient and provider acceptance of the interventions Stakeholder engagement Management of public opinion Importance of data validity Importance of engaging legal experts early on Mission/scope/guiding principles and governance % of hits on persons known HIV+ in the LSU system already - and possibility to intervene in absence of HIE
- 20. Patients OPH HIV, STD and TB programs LSU/TU clinicians OPH Nurses UH Infection Control OPH Epidemiologists Delta Region AETC LSU SPH Medical Informatics & Telemedicine OPH Disease Intervention Specialists OPH Medical Directors DHH Legal Counsel LPHI HCSD CEO, CMO, CIO/CMIO LIS Core Group HCSD Programming Support
- 21. Louisiana DHH OPH STD/ HIV Program DeAnn Gruber, PhD Administrative Director deann.gruber@la.gov 504-568-7474 LSU Health Care Services Division Jane Herwehe, MPH Project Coordinator jherwe@lsuhsc.edu 504-903-3089
- 22. Using Data and Innovative HIT to In-Reach and Out-Reach to Difficult to Engage Populations Peter Gordon, MD Medical Director, CHP NYP/Columbia
- 23. Using Data and Innovative HIT to In-Reach and Out-Reach to Difficult to Engage Populations The Problem: The HIV care cascade illustrates the falloff that occurs between being ‘linked’ and retained in care, and between ‘receiving’ care and adequately suppressed viral loads. Why are we not doing better? We generally have poor tools to effect group or population management Multiple IT systems that: • Do not ‘talk’ to each other • Cannot ‘extract’ information easily • Result in ‘shadow’ processes that result in duplicative work Divert critical personnel manpower from service provision to data abstraction
- 24. The ACA and Health Homes • The Affordable Care Act of 2010 created an optional Medicaid State Plan benefit for states to establish Health Homes to coordinate care for people with Medicaid who have chronic conditions. CMS expects states health home providers to operate under a “whole-person” philosophy. Health Homes providers will integrate and coordinate all primary, acute, behavioral health, and long-term services and supports to treat the whole person. Health Home Services • Comprehensive care management • Care coordination • Health promotion • Comprehensive transitional care/follow-up • Patient & family support • Referral to community & social support services
- 25. So how can we use innovative IT tools to harvest, process, and better utilize all of this very important data that we already collect as part of care provision and care coordination activities?
- 26. How much data? NYP/Columbia must track and manage over 800,000 data elements annually for grant and regulatory reporting purposes: • HRSA, NYC DOHMH, AIDS Institute, CDC • RSR, AIRS, eSHARE • 95 ‘users’ who need to contribute, add, manage, and export data
- 27. So one approach is to ‘tap’ into the ‘Medical Record’ , which in many institutions is typically an amalgamation of multiple electronic systems, tied together by an IT network that exchanges information.
- 28. What is the data? Often duplicative and derived from common sources NYC DOHMH MCM Program RW Part D WICY Program
- 29. So one approach is to find a trusted IT partner, ‘think’ interoperability, and utilize IT tools made available by HRSA and others…
- 30. To develop an IT system and approach that utilizes the critical individual information already routinely collected and provides tools for group or population management
- 31. Once you have the data what can you do with it? Automated data transfer (HIE) 398,000 data elements updated/added via HIE since March 2012 (demographics, visits/services, staff assignment) PCP and Care Coordinator Assignment Calculated from HIE visit feeds, highly accurate, no evolutionary divergence Care Engagement and Population Management Calculated from HIE visit feeds, FORC and LTFU derived, enables care coordination team to generate population level care engagement work lists
- 40. How much is automated vs. manual?
- 41. System Adoption After Launch 8000 7000 d c a s i t f o r e b m u N 6000 5000 4000 3000 2000 1000 0 1 2 3 Week 4 5 6
- 42. Who uses NYP eCOMPAS? Viewonly 4% Admin 2% Clinical 7% DBA 8% Socialwork 35% Care Coordinator 41% Medical 3%
- 43. Data Feed 2 Data Feed 3 Data Feed 1 6.3 million HL7 Messages 1,000 est. hours saved 1,000 est. hours saved each year! each year! Automated Data Transformation Direct Data Integration 398,000 Data Elements Automated Data Automated Data Transformation Transformation Engine Engine Master Database Master Database PCP and Care Coordinator Assignment Care Engagement and Population Management
- 44. Summary Using innovative HIT tools and approaches can transform a program’s ability to practice group or population management Effective, sustainable program inreach or out-reach efforts require such tools The diffusion of effective HIT tools need to accelerate if the important goals of the NAS and ACA are to be met Find good partners, collaborate, innovate, share
- 45. And special thanks….. to SPNS! Especially, Adan Cajina Chief, Demonstration and Evaluation Branch
- 46. Two Stories of SPNS-Supported In- Reach Innovation 1. SPNS in Hawaii (Part B + Part C) 2. SPNS in New Jersey (Part A) (The very definition of SPNS replication and adaptation working in very different regions!)
- 48. Network Data Sharing Model
- 50. SPNS Helps State Part B via Part C Data Exchange Initiative
- 51. Data Sharing Combined with Web-Based Analytical Tools…
- 53. Outcomes
- 54. “Life Foundation case managers use e2 for in-reach and engaging hard to reach population by viewing client’s visits to doctors at Spencer Clinic or Waikiki Health Center and lab entry in the service entry sections.” --HIV Care Services Director
- 55. Hours Saved by eCOMPAS Per Year 2,000 1,800 1,600 1,400 1,200 1,000 800 600 400 200 - 1,792 1,260 331 ADAP Recertifications and New Applications 276 Monthly Reports Requests for RW Client Office Visits Assistance Total of 5,659 Hours Saved by e2Hawaii Each Year An additional 2,000 hours of savings is projected by the Waikiki Health Center based on the e2Hawaii Electronic Health Record Data Exchange Module developed by RDE Systems for a total of 5,659 hours saved per year.
- 56. Has e2Hawaii helped users view clients’ past treatment history before planning and providing services to consumers prior to each visit? 160% Improvement
- 57. “Also, the case managers can also see if clients are accessing Gregory House or Food Baskets in the service entries section. With that information, the case managers are aware that the client is accessing services and… we can follow-up with the providers. ”--HIV Care Services Director
- 58. City of Paterson Part A: A Case Study in SPNS Innovation Interactive Reports + Data Sharing + Proactive Alerts City of Paterson
- 60. “…we have used the Cross Collaborative reports and RSR to achieve same goal of gathering information in order to send letters/make calls and get persons back in care.” --Program Coordinator
- 61. eCOMPAS Retention Reporting “In regards to retention, we have used the retention tab as a guide to see which patients needed to be sent letters or make calls to remind them to come in for overdue labs, missed appointments.”– Program Coordinator
- 62. Outcomes
- 64. Comparative Benchmarks Spur Healthy Competition
- 67. Statewide Recognition of Bergen-Passaic Providers BergenBergenPassaic Passaic eCOMPAS eCOMPAS SPNS SPNS Agencies Agencies
- 69. Agency Alerts “We have used the QM tab - summary of current alerts (categories such as Active clients who have not received any services in the past 6 months, missing labs and missed appointment) in order to flag these patients and send reminder letters or make reminder phone calls. We have used the alerts emailed to us to also gather this information and improve retention”-- Program Coordinator
- 71. Email Alerts • Proactive, regular, push notification • Supervisors are more likely to read email
- 72. Outcomes
- 73. Usage of Alerts Makes a Difference Alerts Usage vs. Number of Alerts 2400 CD4 Past Due VL Past Due Alerts Usage 500 450 400 2350 350 300 2300 250 2250 200 150 2200 100 2150 2100 11/3/09 11/23/09 12/13/09 1/2/10 50 1/22/10 2/11/10 Date 3/3/10 3/23/10 4/12/10 0 5/2/10 Cumulative Number Of Times Accessed Cumulative Number Of Clients (not unduplicated) 2450
- 74. Data entry + charts SPNS QM + Alerts Undetectable VL improved 38.6% 2006-2007 prior to SPNS, all medical patients
- 75. International Journal of Medical Informatics, October 2012
- 76. Consumers who access their key care information personally… are by definition more engaged in their own healthcare…
- 77. With MyHealthProfile... …you can securel y access your heal th informa tion on-the-go …on any device, anywhere. © 2013 RDE Systems LLC. All rights reserved.
- 78. Care Information. All of your critical medical history is just one click away Comprehensive summary designed to help you understand your medical information without feeling overwhelmed © 2013 RDE Systems LLC. All rights reserved.
- 79. Alerts & Reminders. Never miss an appointment again, with the easy to use T oDo list. Alerts help you better manage your health © 2013 RDE Systems LLC. All rights reserved.
- 80. Emergency Cards. With MyHealthProfile, you can easily create and print temporary emergency cards, so that your …so that your information can be accessed when you need it Peter Gordon, MD the most. NewYorkPresbyterian / Columbia University © 2013 RDE Systems LLC. All rights reserved. Medical Center
- 81. Critical Success Factors Involvement Responsive and User-friendly Platform Organic process Collaboration The platform and culture facilitates continuous quality improvement through a direct relation between the system, the process and the people.
- 83. Thank you from all of us on the Paterson SPNS Team… (from left to right) Denise Coba, Pat Virga, Jesse Thomas, Millie Izquierdo, Jimease Green, Maria Cordova, Doug Mendez, Pricilla Moschella, Jerry Dillard, Ellen McNamara, Larry Rodgers, Blanca Roman, Anthony Fazzinga, Sandra Murillo, Maryann Collins, Irene Panagiotis, Serge Virodov, Chantia Douglas, Kathy Lebron.
- 84. Q&A To be informed when these upcoming IHIP resources are ready, keep an eye out for HRSA announcements or sign up for the IMC newsletter email scook@impactmc.net. Connect with Us Sarah Cook-Raymond, Managing Director |Impact Marketing + Communications | Twitter: @impactmc1| Facebook: ImpactMarCom |www.impactmc.net | 202-588-0300
Editor's Notes
- I recommend passing out the SPNS Part F fact sheet, the IHIP One-Pager, and a sign-up sheet for the IMC newsletter, along with your business cards of course, and any IHIP samples you want to provide.
- A carefully designed bi-directional electronic information exchange linking public health and the LSU HCSD (public hospital) system Uses OPH surveillance data to generate point of care alert messages in real time for providers in 7 hospitals and their affiliated ERs, inpatient units and ambulatory clinics. Targets patients with HIV, TB, syphilis who have fallen out of care, or never received test results, as well as perinatally HIV-exposed infants needing follow-up Briefly, OPH populates a dataset nightly with those out of care per LaPHIE criteria (figure on right). As a patient registers at a participating LSU facility (top left), his/her identifying information is immediately and securely transmitted to OPH and “bounced off” the dataset to see if there is a match. If so, a standardized message is immediately returned which will appear in the patient’s electronic medical record when it is accessed by an authorized clinician at the point of care.
- This slide has animation!!! Need to click through to get to next step. Provide concrete example here: person comes into ED with broken toe, identified as having been out of care (sans viral load & CD4 x 2 years) person re-engaged in-care, referred for treatment at HIV specialty clinic, then followed.
- Or the “change ‘don’t’ come easy” days… Cultivating the “invisible infrastructure” – this isn’t just an IT project Stewardship of information – what can and can’t be shared – better understanding of the laws as well as consideration of minimum necessary. Communication – among partners and with the community. Transparency and Readiness to go public with potentially controversial model Change management Mindfulness of patients and patient concerns from qualitative research “invasion of an individual’s right to privacy’ and you can’t do that… then well maybe you can legally, but it will be a public relations nightmare. Shifting the paradigm Openness around purpose, design and evaluation findings Cautious optimism, recognition of any partner’s concern – value of neutral convener. Recognizing people will need to fully understand the model and see the outcomes before supporting.
- In all past analyses, roughly 1/3 of those identified through LaPHIE had not been diagnosed or received HIV related care previously in the LSU system – would have been missed in the absence of LaPHIE. Mode of HIV acquisition 53% NIR, DK, unknown 25% heterosexual 14% MSM 9% IDU and other No prior labs in OPH could indicate – never entered care (unless they did in another state)
- You can also reference the 16 focus groups in formative stages.
- Since LaPHIE went “live”, nearly 800 persons living with HIV who had not received HIV-related medical care for the past 12 months have been identified. It was determined that 24% had no prior labs in the OPH surveillance system, meaning that they had not received any HIV-related medical care in Louisiana. Through the development and implementation of this process, we feel that LaPHIE is one tool to successfully offer clinical services to improve both individual- and population-level health. In addition, through the formative research activities, as well as the ongoing evaluation processes, we’ve determined that this system is a mechanism that is acceptable to both patients and providers. And finally, this process, which has been well thought-out, thorough, and collaborative including both consumers and key stakeholders, has resulted in high success. We look forward to continuing to utilize and expand this system to other medical facilities during the upcoming year and that this system demonstrates another tool that can promote “new hope for stopping HIV”. Replication and the SPNS grant at OLOL and HRSA initiative to 3 states to replicate LaPHIE type interventions. I’d like to acknowledge the many, many partners who have been a part of this process, who are listed here. Thank you very much.
- Through the development and implementation of this process, we feel that LaPHIE is one tool to successfully offer clinical services to improve both individual- and population-level health. In addition, through the formative research activities, as well as the ongoing evaluation processes, we’ve determined that this system is a mechanism that is acceptable to both patients and providers. And finally, this process, which has been well thought-out, thorough, and collaborative including both consumers and key stakeholders, has resulted in high success. We look forward to continuing to utilize and expand this system to other medical facilities during the upcoming year and that this system demonstrates another tool that can promote “new hope for stopping HIV”. Replication and the SPNS grant at OLOL and HRSA initiative to 3 states to replicate LaPHIE type interventions. I’d like to acknowledge the many, many partners who have been a part of this process, who are listed here. Thank you very much.
- So
- The ‘Medical Record’ is generally thought of as the repository of ‘all’ information, but actually as a single entity it often does not exist, rather it is a collection of IT systems linked together by an IT network. More on this later.
- Well, much of the data is duplicative and derived from the RSR – at least for our Part A, B, D, and F supported programs. Here is an example from our Medical Case Management grant from the NYC DOHMH – a Part A supported program – and our Part D WICY program.
- You can then use the data in new and innovative ways, saving time, vastly improving accuracy, moving to manage populations as well as individual clients
- System adoption is the best measure of ‘value’
- Especially by the most important individuals, those delivering the services
- Sincerely human-centered Strong emphasis on change management and stakeholder engagement Very iterative, dynamic, and organic Integrated tightly with quality improvement Focused on empowering users who were not “data people” Providers presenting PDSA’s to team with peer review Role playing to overcome barriers
- Thank you for your time -My contact information and the Impact Marketing + Communications Website are at the bottom, so please feel free to reach out any time if you have questions about our firm, the IHIP work or any other HRSA deliverables we’ve created, or if there are any marketing or communications projects we can help you with. - At this time, I’d be happy to take any questions you have about the presentation.