Ryan White Part A Program Services Client-Level Data Report – FY2014

Baltimore-Towson EMA

June, 2015

Improve the quality of life for people living with HIV/AIDS and their families in Baltimore city and the surrounding counties through a fiscally responsible subcontracting of Ryan White funds for the provision of HIV primary care and support services.

Monitor fiscal, program, and quality management activities in order

to ensure provision of high-caliber, integrated medical and support services.

Provide comprehensive guidance to Ryan White providers and the

Baltimore Planning Council to ensure compliance with Ryan White legislations and standards of care.

Mission

2014 RWA-CLD Report 2

Ryan White Part A (RWA) Program Overview

RWA Client-Level Data Report (CLD) Background

Client Demographic and Service Data

Continuum of Care in Baltimore EMA using RWA CLD

Summary

Presentation Overview

2014 RWA-CLD Report 3

Ryan White Part A Services Overview

2014 RWA-CLD Report 4

A system of care through primary medical care and essential support services for uninsured/underinsured and low-income people living with HIV (PLWH)

Serves PLWH in Baltimore City and surrounding counties, reaching over 10,ooo people every year

RWA program is funded at $17 million in fiscal year 2015

Ryan White Part A HIV/AIDS Program

2014 RWA-CLD Report 5

Increase access to care for people living with HIV

Payer of last resort – safety net for uninsured/underinsured and low-income/unemployed individuals living with HIV/AIDS

Provide coverage for needed services that may not be covered by other types of insurance or assistance

Provide an entry way to medical care and assist in enrolling in other more comprehensive coverage

Role and Intent of Baltimore Ryan White Part A Program Post ACA

2014 RWA-CLD Report 6

Funding a comprehensive care systems for low-income PLWH that:

1. Reduces new HIV infections

2. Improves health outcomes and increases quality of life for PLWH

3. Decreases HIV-related health disparities

Including PLWH in the planning of services

Employing a public health approach to care and treatment

The Ryan White HIV/AIDS Program supports the goals of the National HIV/AIDS Strategy by:

2014 RWA-CLD Report 7

Client-Level Data Report (CLD) Background

2014 RWA-CLD Report 8

RWA grantee office collected basic demographic and Ryan White funded service data since 2001

In 2009, the grantee implemented the first RSR report and collected CLD from providers serving RW funded OAHS, MCM, or CM services

2010 - 2014, all providers providing any RW funded service successfully submitted annual RSR/CLD to HRSA/HAB and quarterly CLD to BCHD

In 2015, HRSA/HAB changed funded-scope RSR data reporting to eligible-scope data reporting because HAB believes that Eligible Scope is the best reporting method for the following reasons:

• Continue creating the continuum of care post ACA

• To more fully capture the efforts of the Ryan White Program in a time when more people have access to health insurance

• Continue measuring client health outcomes and progress towards achieving the National HIV/AIDS Strategy that envisions a future America that is free from HIV/AIDS

Ryan White Part A/MAI Client-Level Data Background

2014 RWA-CLD Report 9

Client Level Data Highlights, 2010 - 2014

2010 2011 2012 2013 2014

CLD Reports 37 38 37 37 37

Clients Served 9,481 9,753 10,356 10,079 9,801

Visits 88,000 112,000 106,000 87,000 83,400

OAHS-PMC Providers 15 15 15 15 14

OAHS Visits 50,000 69,000 44,500 45,800 14,305

OAHS Clients Served 6,520 6,525 6,675 6,683 2,800

2014 RWA-CLD Report 10

CLD Processes and Data Management Plan

M A M J J A S O N D J F

Data Review and Feedback

Data Cleaning

Data Aggregation

Analytic Files/Data Analysis

Data Reporting

2014 RWA-CLD Report 11

Client Demography and Service Data

2014 RWA-CLD Report 12

Clients Served by Gender

Male, 64.1%

Female, 34.4%

Transgender, 1.5%

Gender, N = 8,701

2014 RWA-CLD Report 13

Clients Served by Ethnicity

Hispanic/Latino, 5.2%

Non-Hispanic/Latino,

94.8%

Ethnicity, N = 8,620

2014 RWA-CLD Report 14

Clients Served by Race

69.7%

29.2%

0.9% 0.0% 0.2%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

Black White Asian NH/PI AI/AN

Race, N = 8,265

2014 RWA-CLD Report 15

Risk Category Distribution

31.2%

22.6%

43.9%

1.5% 0.7% 0.2% 0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%

MSM IDU Heterosexual Blood Perinatal Hemophilia

Risk, N = 6,542

2014 RWA-CLD Report 16

Clients Served by Age

1.1% 0.4%

3.4%

14.6%

16.7%

34.1%

24.2%

5.4%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

< 13 13 - 18 19 - 24 25 - 34 35 - 44 45 - 54 55 - 64 65+

Age, N = 9,801

2014 RWA-CLD Report 17

Health Care Coverage

13.3%

19.2%

41.8%

22.3%

1.4% 0.3% 1.7%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

Private Medicare Medicaid,CHIP or other

public plan

No Insurance Other Plan VA, Tricareand othermilitary

health care

Multiple

Insurance, N = 8,637

2014 RWA-CLD Report 18

Federal Poverty Level

71.1%

13.0% 9.7%

2.9% 2.5% 0.5% 0.3%

< 100% 100 - 138% 139 - 200% 201 - 250% 251 - 400% 401 - 500% > 500%

FPL, N = 7,233

Note: 84.1 percent of the consumers were eligible for Medicaid expansion through ACA 2014 RWA-CLD Report 19

Clients served by Housing Status

78%

11% 11%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Stable Temporary Unstable

Housing, N = 7,393

2014 RWA-CLD Report 20

Clients Served in FY14 by Year of HIV Diagnosis

3 2 6 3 9

37 31 43

72 88 84

123 130 116

128 145 153

139 161

174

123

172

109

159

333

263 245

276

305

355 349

277 293

398 415

0

50

100

150

200

250

300

350

400

450

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014

Year of HIV Diagnosis, N = 5,719

2014 RWA-CLD Report 21

Clients Served by Service Category

37.5%

28.4%

23.1%

20.6%

19.2%

14.6%

13.6%

12.4%

9.5%

8.4%

7.3%

7.1%

6.7%

4.4%

2.4%

1.4%

0.3%

0.3%

0.1%

0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0%

MCM

PMC

Transptn.

HI

EFA

Oral

Outr.

MH

NMCM

MNT

Food

Co-Morb.

Housing

Psych.

SATO

Legal

SATR

Hospice

ChildCare

Percent of all Clients Receiving any RWA Funded Service (N=9,801)

Note: Percent does not add up to 100% since a client may receive service in more than one service categories

2014 RWA-CLD Report 22

Between 2010 and 2014, most demographic characteristics were stable; however, there were a few changes in the following areas:

• Age

• Race

• Ethnicity

• Housing

• Health Care Coverage

2010 – 2014 Demographic Trends

2014 RWA-CLD Report 23

Clients Served by Age 2010 - 2014

1.8% 5.0%

32.6%

58.4%

2.2% 1.1% 3.8%

31.3%

58.3%

5.4%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

< 13 13 - 24 25 - 44 45 - 65 65+

2010 (N = 9,479)

2014 (N = 9,801)

2014 RWA-CLD Report 24

Clients Served by Race 2010 - 2014

84.8%

14.6%

69.7%

29.2%

0

10

20

30

40

50

60

70

80

90

Black White

Pe

rce

nt

2010 (N = 8,740)

2014 (N = 8,265)

2014 RWA-CLD Report 25

Clients Served by Ethnicity 2010 - 2014

1.8%

5.2%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

2010 (N = 9,261) 2014 (N = 8,620)

Hispanic/Latino

2014 RWA-CLD Report 26

Clients Served by Housing Status 2010 - 2014

82%

14%

4%

78%

11% 11%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Stable Temporary Unstable

2010 (N = 5,556)

2014 (N = 7,393)

2014 RWA-CLD Report 27

Clients Served by Medical Insurance 2010 - 2014

19.2%

12.2%

35.3%

29.9%

13.3%

19.2%

41.8%

22.3%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

Private Medicare Medicaid No Insurance

2010 (N = 5,944)

2014 (N = 8,638)

2014 RWA-CLD Report 28

2010 – 2014 Service Utilization Trend

Service Category 2010 (N = 9,481) 2014 (N = 9,801) Increase/Decrease

1 Outpatient Ambulatory Health Service 68.5% 29.3%

2 Medical Case Management 31.5% 37.5%

3 Health Insurance Premium 28.9% 20.6%

4 Transportation 23.5% 23.1% =

5 Outreach Services 13.5% 13.6% = 6 Case Management 12.2% 9.5%

7 Oral Health 12.0% 14.6%

8 Mental Health 6.8% 12.4%

9 Medical Nutritional Treatment 8.6% 8.4% =

10 Food Bank 8.5% 7.3% =

11 Psychosocial Services 5.3% 4.4% = 12 Housing Services 3.3% 6.7%

13 Substance Abuse Treatment (Outpatient) 3.1% 2.4% = 14 Legal Services 2.7% 1.4% Note: Percent does not add up to 100% since clients may receive service in more than one service categories

Continuum of Care in Baltimore EMA

2014 RWA-CLD Report 30

2014 EMA Treatment Cascade Using the First Post ACA Client-level Dataset

11,668

100% 9,801

84% of infected

2,779 24% of infected 28% of enrolled

2,197 19% of infected 79% of linked

1,574 13% of infected 54% of linked

68% of retained

1,848 16% of infected 67% of linked

84% of retained 0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Estimated Infection(estimated based on 16 %

of HIV infected peoplewho are unaware of

their status)

Diagnosed(enrolled in Ryan WhitePart A services in 2014)

Linked to Care(at least one pmc

visit in 2014)

Retained in Care (atleast two pmc visits in

2014)

Prescribed ART(indicated to have been

prescribed HAART in2014)

Virally Suppressed (most recent VL for

Black subpopulation in 2014 that is

undetectable or ≤ 200 copies/ml)

Note: The numbers in red indicate a significant decrease in the number of Ryan White funded OAHS consumers after the implementation of ACA – reason why HAB moved to Eligible Scope data requirement for the 2015 RSR and beyond. 2014 RWA-CLD Report

31

Continuum of Care in Baltimore EMA, using 2013 RSR data

14,543

100% 12,216

84% of infected

8,223

57% of

infected 67% of

enrolled

7,465

51% of infected

61% of enrolled

91% of linked

7,014

48% of infected

57% of enrolled

85% 0f linked 94% of

Retained

5,994

41% of infected 49% of

enrolled 80% of

Retained 85% of on ART

Estimated Infection(estimated based on 16 %

of HIV infected peoplewho are unaware of their

status)

Diagnosed(enrolled in Ryan WhitePart A services in 2013)

Linked to Care(at least one pmc

visit in 2013)

Retained in Care (atleast two pmc visits

in 2013)

Prescribed ART(indicated to have been

prescribed HAART in2013)

Virally Suppressed (most recent VL for Black

subpopulation in 2013 that is undetectable or ≤

200 copies/ml)

Baltimore Ryan White Part A HIV Treatment Cascade, 2013

2014 RWA-CLD Report 32

Continuum of HIV Care in Baltimore EMA and areas of future efforts towards Zero New Infection

100%

67%

61%

57%

49%

0%

20%

40%

60%

80%

100%

Diagnosed Linked to care Retained in care Prescribed ART Virally Suppressed

Continuum of HIV Care In Baltimore EMA, 2013

Goal Not Met

Goal Met

100% Zero New Infections

100% 100% 100%

2014 RWA-CLD Report 33

Retention, ART, Viral Suppression by Race and MSM Risk Factor, RSR 2012 - 2013

86% 83%

74% 75% 72%

75%

82%

55%

79%

70%

78% 78%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Retention - All(at least two pmc visits

that are at least 90days apart for all

people)

ART - All(indicated to havebeen prescribed

HAART for all people )

VS - All (most recent VL for all

people that is undetectable or ≤ 200

copies/ml)

VS - MSM (most recent VL for

MSM that is undetectable or ≤ 200

copies/ml)

VS - Black (most recent VL for

Black that is undetectable or ≤ 200

copies/ml)

VS - Hispanic (most recent VL for

Hispanic that is undetectable or ≤ 200

copies/ml)

2012

2013

2014 RWA-CLD Report 34

Retention in Primary Care and Viral Suppression by Age – CLD 2014

44.8%

68.4% 67.2%

77.9% 82.6% 84.0% 83.6%

90.0%

92.6%

71.0%

82.9% 81.8% 83.3% 79.2%

85.4%

96.5%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

< 13 13 - 18 19 - 24 25 - 34 35 - 44 45 - 54 55 - 64 65+

Retention VS

Note: Retention = percent of clients with at least any two primary care visits in 2014; Viral Suppression = percent of clients who had at least one primary care visit and one viral load result with last viral result of 200 cells/ml or less.

2014 RWA-CLD Report 35

Retention and Viral Suppression for Black-MSMs by Age, CLD 2014

86.70%

78.40%

83.80%

79.30%

62.10%

59.60%

0% 20% 40% 60% 80% 100%

Black MSM - All

Black MSM - 18 - 24

Black MSM - 25 - 34

VSRetention

2014 RWA-CLD Report 36

Overall EMA’s Retention and Viral Suppression Rates, 2010 – 2014

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

2010 2012 2014

Retention

VS

2014 RWA-CLD Report 37

Retention and Viral Suppression by Gender and Race, 2014

Retention and VS by Gender, 2014 Retention and VS by Race, 2014

80.6% 78.4%

92.5% 75.9%

81.1% 76.3%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Retention

VS

94.5% 87.6%

100.0%

83.4%

72.7%

92.3%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

White Black Asian

Retention

VS

2014 RWA-CLD Report 38

Summary of Client-Level Data Results

Notable changes in Ryan White service utilization pattern, especially in OAHS, MCM, HI, and Housing

Decline in the volume of Ryan White funded OAHS (OAMC) consumers

Steady increase in viral suppression rates across all groups and sub-groups between 2010 and 2014

Young black MSMs (18 – 34) trail behind the most in viral suppression among all sub-groups

Retention in care remains steady above 80 percent for most groups except the youth (13 – 18)

Disparity in retention and viral suppression exists across several groups and sub-groups but needs further investigation for better understanding

2014 RWA-CLD Report 39

Thank You ! Yohannes Abaineh, Epidemiologist

Yohannes.abaineh@baltimorecity.gov

410-396-1408