Kjersti Schmitz ICAP New York Clinical Unit October 5, 2007 Psychosocial Support, Adherence and Measurement
Objectives <ul><li>Highlight importance of psychosocial support for patient adherence </li></ul><ul><li>Suggest approach to build clinical capacity for improved patient outcomes </li></ul><ul><li>Consider program measures of adherence support </li></ul>
Psychosocial Support and Adherence Patients require a fortified psychological capacity to cope with HIV disease. Psychosocial support can strengthen patient internal capacity to seek positive treatment outcomes. Sense of Meaning or Life Purpose “Why do” Patient Self-Efficacy “Can do”
Psychosocial Support and Adherence <ul><li>Attending to patients’ internal psychological capacity for self-care may seem beyond the scope of our work, yet without it, our best efforts are futile. What to do? (the shortlist) </li></ul><ul><li>Build a supportive and responsive therapeutic relationship with each patient </li></ul><ul><li>Learn what matters most to patient; support patient’s search for meaning </li></ul><ul><li>Support patient to identify and adapt ways to care for self and prevent further illness </li></ul><ul><li>Maximize opportunities to provide psychosocial support </li></ul>
Psychosocial Support and Adherence Psychosocial support addresses emotional, mental, spiritual, and social needs. In the context of our programs, psychosocial support can be said to include emotional, informational, instrumental and appraisal support which underpin and facilitate all aspects of patient care and adherence.
Psychosocial Support and Adherence Emotional support: Communicates care to patient, building therapeutic relationship between patient and provider or other supporter. Instrumental support: Provides tangible assistance such as transportation, food aid, or referral to needed services. Informational support: Provides information, education, and advice on HIV, care regimen, and adherence. Appraisal support: Provides feedback to help patient assess progress towards a goal, such as adherence assessment.
Begin with a Common Goal Patient adherence to HIV care and treatment is a goal shared by providers along the continuum of care To achieve this goal, the ICAP Model of Care includes a range of interventions to improve patient adherence such as: Individual and group counseling Support group meetings Peer or ‘expert patient’ education Tracking and tracing systems Referral to social assistance
Psychosocial Support and Adherence <ul><li>Country programs offer a range of psychosocial support, usually carried out by dedicated counselors, peers, or other partners. </li></ul><ul><li>Clinical and psychosocial staff often perceive boundaries of responsibility. </li></ul><ul><li>Many adherence support interventions focus on tracking and tracing, after LTFU occurs. </li></ul><ul><li>Integrated clinical and psychosocial support throughout the Continuum of Care and across cadres helps “prevent” LTFU with proactive, sustained psychosocial support at each opportunity. </li></ul>
Psychosocial Support and Clinical Care <ul><li>From a position of strengthened mental and social well-being, patients are better positioned to optimize their own health outcomes. </li></ul>Positive Health Outcomes Adherence Access to Care Prevention Support Services Clinical Services and Psychosocial Support Adherence and Psychosocial Support Activities
Review the Challenge <ul><li>Aggregate data tell us that patient adherence to care is not optimal, with large numbers of patients failing to return for follow-up care. </li></ul><ul><li>We do not routinely collect patient-level data that can be used to monitor or evaluate program support for adherence </li></ul><ul><li>Supposition: Insufficient psychosocial support activities exist along the Continuum of Care to optimize patient adherence and clinical outcomes. </li></ul>
Identify Integration Opportunities Continuum of Care Each encounter along the Continuum of Care is an opportunity to offer psychosocial support! ART Eligible ART Ineligible CD4/Lab Enrollment Diagnosis Pharmacy Pre-ART Counseling 1st Follow-up CD4/Lab Referral: FP,STI,TB,PMTCT… Counseling/Support .. Counseling LTFU LTFU LTFU LTFU Follow-up
Develop a Common Approach With start-up emphasis on enrollment, clinical services, and reporting requirements, psychosocial support can be an adjunct to clinical services. This situation changes when psychosocial support becomes a primary component of patient care. Suggested Two-Fold Strategy: 1. Integrate psychosocial support throughout the Continuum of Care, building program capacity to support patient adherence. 2. Triangulate program characteristics , patient-level adherence measures and measures of adherence support to enable continuous program quality improvement to support patient adherence.
Routinely Collected Adherence Data <ul><li>CD4 test </li></ul><ul><li>ART pick-up </li></ul><ul><li>Active patients </li></ul><ul><li>Patient outcomes </li></ul>
Measures of Adherence Support <ul><li>Tell us what support the program offers to patients that may increase or maintain adherence to care and treatment </li></ul>
Program Measures of Adherence Support <ul><li>Expand on currently reported facility characteristics, and patient-level adherence data such as ART pick-up among ART patients, and timely CD4 testing. </li></ul><ul><li>Enable routine monitoring and evaluation of key aspects of adherence support offered along the Continuum of Care. </li></ul><ul><li>Suggest where to carry out more in-depth, qualitative assessment of ‘how well’ support is happening at the site level. </li></ul><ul><li>Suggest opportunities for integrating psychosocial support for adherence. </li></ul>
Piloted Measures of Adherence Support 60% % of patients seen with at least one counseling session that addresses adherence to care and treatment 27.9% % of patients on ART assessed for adherence to care and treatment at follow-up visit 69.7% % of patients with completed baseline psychosocial assessment and follow-up plan Result Pilot Measure
Piloted Measures of Adherence Support ** Appointment attendance, on-time CD4 testing and ART pickup measures were also piloted as measures of patient adherence to care 65.6% % of patients with documented supporter 60.5% % of patients eligible for ART with completed adherence readiness assessment and ART counseling before starting treatment Result Pilot Measure
Triangulate Site A Program Characteristics: Site A Patient-level Site A Patient-level Adherence Measure: Adherence Support Measure: ART patients with on-time ART patients assessed for CD4 test result( %) adherence (28%) A more complete picture is closer to the truth and suggests where to seek clarity.
For Consideration: Measures of Adherence Support <ul><li># of newly enrolled patients with completed psycho-social assessment and follow-up plan </li></ul><ul><li>2. # of ART patients assessed for adherence </li></ul><ul><li>3. # of patients seen for follow-up with adherence counseling session </li></ul><ul><li># of patients starting ART with completed pre-ART counseling and adherence readiness assessment </li></ul><ul><li># of patients with follow-up attempt after missing clinic appointment, CD4 test, and/or pharmacy pick-up </li></ul><ul><li>6. # of newly enrolled patients offered referral to (and attending) support group </li></ul><ul><li># of newly enrolled patients with designated treatment supporter </li></ul><ul><li># of patients initiating ART offered (and received) medication adherence support tools </li></ul>
Take Home Message… Integrate - Psychosocial Support with all Adherence and Clinical Services and Triangulate – Facility Characteristics, Patient-level Adherence and Adherence Support Data