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Improving retention of hiv patients in care


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Speaker Kathleen Clanon

Published in: Health & Medicine
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Improving retention of hiv patients in care

  1. 1. Quality Improvement and Retention in Care <ul><li>Slides Courtesy </li></ul><ul><li>Bruce Agins, MD MPH </li></ul><ul><li>bda01@ </li></ul><ul><li>Presented by K. Clanon, MD </li></ul><ul><li>[email_address] </li></ul>
  2. 2. Continuum Engagement in Care Not in Care Fully Engaged Non-engager Sporadic User Fully Engaged Health Resources Service Administration (HRSA) Unaware of HIV Status (not tested or never received results) Know HIV Status (not referred to care; didn ’ t keep referral) May Be Receiving Other Medical Care But Not HIV Care Entered HIV Primary Medical Care But Dropped Out (lost to follow-up) In and Out of HIV Care or Infrequent User Fully Engaged in HIV Primary Medical Care
  3. 3. Why Is Retention Important for People Living with HIV? Population Appointments Health Outcome 123 patients, primary care clinic, (Rastegar, 2003) Baltimore Not specified which appts. included Associated with VL> 500 copies/ml 273 patients, large urban clinic in Baltimore (Lucas, 1999) Nursing, psychiatry, dermatology, neurology and gastroenterology Associated with failure to suppress VL 195 patients, JHU outpatients center (Sethi, 2003) “ Scheduled clinic visit” Associated with viral rebound and clinically significant resistance 366 patients, HIV clinic in Cleveland (Valdez, 1999) “ Clinic visit” Missing <2 appts. associated lower VL (<400 copies/mL)
  4. 4. Missed Visits and Mortality Mugavero, et. al. 2009 UAB. CID 48:248-56. <ul><li>543 new patients followed who were alive 12 months after their first visit </li></ul><ul><li>Visits during first 12 months of care analyzed from 1/00-12-05 </li></ul><ul><li>325 pts (60%) missed visit in first year </li></ul><ul><li>32/325 died whereas 10/218 died among those who did not miss a visit [mortality rate 2.3/100 person-years vs. 1.0 per 100 person-years; p =.02] </li></ul><ul><li>No difference in mortality based on whether 1 or >1 visit missed </li></ul><ul><li>Predictors of missed visits: younger/female/black/risk other than MSM/public insurance/substance use disorders </li></ul>
  5. 5. Measuring Retention Rates <ul><li>Examples: </li></ul><ul><ul><li># of unique clients with at least 1 visit in past 4 months </li></ul></ul><ul><ul><li># of unique clients with at least one visit in past 12 months </li></ul></ul><ul><ul><li># pts with at least 1 visit during 3 month interval after 12 month period </li></ul></ul><ul><ul><li># pts with 3 or more visits in the 12 mo. period (* 1 in last 6 months) </li></ul></ul><ul><ul><li># pts with 2+ visits during the defined 12-month period </li></ul></ul><ul><ul><li># pts in the clinic registry during the defined period </li></ul></ul><ul><ul><li># pts with no visit during the past 4 months </li></ul></ul><ul><ul><li># pts with at least 1 visit during past 12 mos </li></ul></ul>
  6. 6. Texas Data <ul><li>Collected via Aries 2009 and 1 st Q 2010 </li></ul><ul><li>Analyzed by the Cross-Part Collaborative </li></ul><ul><li>Caveat: Data entry into Aries </li></ul><ul><li>Roundtable after this session you can get your agency’s data……. </li></ul>
  7. 7. Why Do HIV Patients Not Come to Clinic? <ul><li>Patients at a community based clinic: conflicts with work schedules, lack of child care, no transportation, family illness and hospitalization (Norris, 1990) </li></ul><ul><li>Women patients: forgetting the appointment, having a conflicting appointment and feeling too sick to attend the visit (Palacio, 1999) </li></ul><ul><li>NYC clinic: no specific explanation, forgot, meant to cancel, unexpected social reasons (Quinones, 2004) </li></ul>
  8. 8. What’s Working in Texas? <ul><li>Austin: Lynda Blakeslee and Rhonda Ray </li></ul><ul><li>Also: see handout…… </li></ul>
  9. 9. Evidence Base for Strategies to Connect Patients to Care
  10. 10. Outreach Initiative: HRSA SPNS Multi-site Evaluation <ul><li>Goals: </li></ul><ul><ul><li>To engage people in HIV care </li></ul></ul><ul><ul><li>Turn sporadic users of care into regular users </li></ul></ul><ul><ul><li>Promote retention in care </li></ul></ul><ul><li>Program models </li></ul><ul><ul><li>Scripted behavioral interventions, accompanying clients to appointments, home-based services, health literacy & life skills training </li></ul></ul><ul><li>Evaluation </li></ul><ul><ul><li>Quantitative and qualitative methodologies </li></ul></ul><ul><ul><li>Link to outcomes </li></ul></ul>
  11. 11. Outreach Initiative: Major Findings (Cabral, et. al. 2007; AIDS Patient Care & STDs) <ul><li>Increased frequency of contact results in fewer gaps in care during first 12 months of follow-up </li></ul><ul><li>773 patients from 7 sites followed and interviewed </li></ul><ul><li>Purposive sampling; prospective nonrandomized with single arm </li></ul><ul><li>Contact by clinicians, peers, and paraprofessionals </li></ul><ul><li>Contact may occur in office, out of office, not face-to-face </li></ul><ul><ul><li>Types of contacts: </li></ul></ul><ul><ul><ul><li>Appointment reminder/reschedule, Service coordination, Relationship building, Provide concrete services (food, transport), Counseling, Provide information about the program, provide HIV education, Accompany client to appointment, Refer to or make appointment for health care, other </li></ul></ul></ul><ul><li>Patients with 9 contacts during first 3 months were about half as likely to have a substantial gap </li></ul>
  12. 12. Outreach Initiative: Qualitative Findings Rajabiun 2007: AIDS Patient Care & STDs <ul><li>Determinants of sporadic use: </li></ul><ul><ul><li>level of acceptance of being diagnosed with HIV </li></ul></ul><ul><ul><li>ability to cope with substance use, mental illness, and stigma </li></ul></ul><ul><ul><li>health care provider relationships </li></ul></ul><ul><ul><li>presence of external support systems </li></ul></ul><ul><ul><li>ability to overcome practical barriers to care </li></ul></ul><ul><li>Outreach interventions helped connect participants to care by: </li></ul><ul><ul><li>dispelling myths and improving knowledge about HIV </li></ul></ul><ul><ul><li>facilitating access to HIV care and treatment </li></ul></ul><ul><ul><li>providing support </li></ul></ul><ul><ul><li>reducing the barriers to care </li></ul></ul>
  13. 13. Clinic Operation and Information System Strategies <ul><li>Clinic Organization </li></ul><ul><ul><li>Ensure coverage for provider vacations and time-off to avoid canceling or re-scheduling appointments </li></ul></ul><ul><ul><li>Establish patient database to track adherence with appointments </li></ul></ul><ul><li>Pre-Appointment </li></ul><ul><ul><li>Reminder cards with date/time/location of visit mailed to patients </li></ul></ul><ul><ul><li>Reminder calls made 48 hrs prior to appointment to allow patient time to make arrangements, if needed </li></ul></ul><ul><ul><li>Reminder calls to patients made by providers, case managers or other staff closely involved w/ patient's care </li></ul></ul><ul><ul><li>Schedule labs to be done prior to visits to maximize time spent w/ provider </li></ul></ul>
  14. 14. Preventing Loss to Follow-up: Work with New and ReturningPatients <ul><li>Conduct new patient orientation sessions and include discussion of staying in care </li></ul><ul><li>Schedule one-to-one sessions for new patients unable to attend group orientations </li></ul><ul><li>Develop written patient materials on the importance of staying in care </li></ul><ul><li>Staff education - routinely discuss patient retention w/ all staff </li></ul>
  15. 15. Small Group Work: Solution Fish What Ideas Can We Try for Improvement ?
  16. 16. Contacts <ul><li>Bruce D. Agins, MD MPH </li></ul><ul><ul><li>Director, National HIVQUAL Project </li></ul></ul><ul><ul><li>Medical Director, NYSDOH AIDS Institute </li></ul></ul><ul><ul><li>[email_address] </li></ul></ul><ul><li>Kathleen Clanon, MD </li></ul><ul><li>NQC Consultant </li></ul><ul><li>[email_address] </li></ul>