HHC Integration of HIV Testing Within Routine Care
-
Upload
aquilino-gabor -
Category
Documents
-
view
186 -
download
0
Transcript of HHC Integration of HIV Testing Within Routine Care
1
Integration of HIV Testing Within Routine Care in a Large Public Hospital System
Joanna OmiSenior Assistant Vice President
Corporate Planning and HIV ServicesNew York City Health and Hospitals Corporation
New York, NY
November 6, 2007
Copyright 2007, Joanna Omi, [email protected]
2
Topics covered
• Overview of HIV and the HIV Testing Expansion Initiative
• Corporatewide and facility results• Lessons learned
Copyright 2007, Joanna Omi, [email protected]
3
8.2 million peoplelive 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
Copyright 2007, Joanna Omi, [email protected]
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
Copyright 2007, Joanna Omi, [email protected]
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
Copyright 2007, Joanna Omi, [email protected]
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
Copyright 2007, Joanna Omi, [email protected]
9
The percentage of unique patients tested at HHC hospitals steadily increased while overall volume remained stable
FY05 outpatient and ED Pilot S ites 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 el l C I H E l m H ar l Jac K C H L i n c M e t N C B Q n s W o od A llA cu t es
% o
f vol
ume t
este
d
F Y 05 FY 0 6 F Y 07
Copyright 2007, Joanna Omi, [email protected]
10
The percentage of unique patients tested at D&TCs steadily increased while overall volume remained stable
FY05 outpatient and ED Pilot S ites Only (Source: PLM and Pilot Project Sites Reports)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 %
1 0 %
1 5 %
2 0 %
2 5 %
3 0 %
B e lv C u m b E N Y G o u v M o rr R en A l l D & T C s
% o
f vol
ume
test
ed
FY 0 5 FY 0 6 F Y 0 7
Copyright 2007, Joanna Omi, [email protected]
11
9 2 ,1 2 3
6 2 ,0 2 3
1 3 3 ,8 5 9
0
3 0 ,0 0 0
6 0 ,0 0 0
9 0 ,0 0 0
1 2 0 ,0 0 0
1 5 0 ,0 0 0
F Y 0 5 F Y 0 6 F Y 0 7
Num
ber o
f uni
que p
atien
ts te
sted
U n iq u e P re n a ta l T e st s A ll O th e r U n iq u e T es ts
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 S ites 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%
Copyright 2007, Joanna Omi, [email protected]
12
Rapid HIV testing comprised the majority of unique tests conducted in FY06 and FY07
FY05 outpatient and ED Pilot S ites Only (Source: PLM and Pilot Project Sites Reports)FY06-FY07 outpatient, inpatient and ED (Source: Facility Reports)
0
5 ,0 0 0
1 0 ,0 0 0
1 5 ,0 0 0
2 0 ,0 0 0
2 5 ,0 0 0
3 0 ,0 0 0
3 5 ,0 0 0
4 0 ,0 0 0
Q 1 Q 2 Q 3 Q 4 Q 1 Q 2 Q 3 Q 4 Q 1 Q 2 Q 3 Q 4
Num
ber
of
Uni
que
Pat
ient
s T
este
d
C on ve nti on al R H T
F Y 05 F Y 06 F Y 0 7
Copyright 2007, Joanna Omi, [email protected]
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%
1 00%
Bell Belv CIH Cumb Elm ENY G ouv H a rl Ja c K CH L inc M et M orr NC B Q ns R enn Wo od
% o
f tot
al te
sts b
y te
chno
logy
RH T Conv
Copyright 2007, Joanna Omi, [email protected]
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 %
5 3 %
1 %5 %4 %
3 5 %
5 4 %
1 %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
A S I A N B L A C K H I S P A N I C O T H E R W H I T E G r a n d T o ta l
HIV
pat
ient
s in
care
by
race
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 %
Copyright 2007, Joanna Omi, [email protected]
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
HIV
pat
ient
s in
car
e by
sex
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 %
Copyright 2007, Joanna Omi, [email protected]
17
Both the total number of unique patients who tested HIV positive and the subgroup newly diagnosed with HIV increased in FY07
FY06-FY07 outpatient, inpatient and ED (Source: Facility Reports)
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 tie nts
F Y06 F Y07
Tot
al H
IV p
ositi
ve a
nd n
ewly
dia
gnos
ed
8%
12%
Copyright 2007, Joanna Omi, [email protected]
18
Most networks focused their expansion efforts in the outpatient and ED areas
FY07 outpatient, inpatient and ED (Source: Facility Reports)
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. Bk ln S . Man . C orp.
% o
f tot
al te
sts
by v
enue
Outpatient Inpatien t ED
Copyright 2007, Joanna Omi, [email protected]
19
Across all networks, prevalence was highest in inpatient units
FY07 outpatient, inpatient and ED (Source: Facility Reports)
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. Bkl n G en + N . B r x N. B kln Qns S. B kln S . M an. C or p.
HIV
pre
vale
nce
by v
enue
OP IP ED
Copyright 2007, Joanna Omi, [email protected]
20
As was the percentage of newly diagnosed HIV positive patients
FY07 outpatient, inpatient and ED (Source: Facility Reports)
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. B kln G en + N . B r x N. B kln Qns S. B kln S . M an. C or p.
HIV
Pre
vale
nce
by v
enue
OP IP E D
Copyright 2007, Joanna Omi, [email protected]
21
Preliminary utilization data suggest the proportion of newly HIV positive individuals may be greater in HHC than in the city as a whole
FY07 outpatient, inpatient and ED (Source: Facility Reports)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%
Outpatient Inpatient ED
HHC Prevalence
3.78%
0.98% 1.08%
0%
1%
2%
3%
4%
Outpatient Inpatient ED
HHC Prevalence = 1.22%NYC Prevalence=1.2%
HHC Incidence = .65%NYC Incidence = .31%
Copyright 2007, Joanna Omi, [email protected]
22
Patients newly diagnosed with HIV in outpatient areas aremore likely to be scheduled for and keep their first HIV primary care appointment
FY07 outpatient, inpatient and ED (Source: Facility Reports)
94 %
6 8%
85 % 86 %90 %
77% 7 9%84 %
0 %
20 %
40 %
60 %
80 %
1 00 %
O u tp atie n t I n p a t ien t ED To tal
% o
f new
ly d
x pa
tient
s sch
edul
ed a
nd k
eepi
ng a
ppoi
ntm
ent
A p p oin tm en t M a d e A p p o in tm e n t K e p t
Copyright 2007, Joanna Omi, [email protected]
23
Of patients newly diagnosed with HIV who kept their first HIV appointment, fewer were concurrently diagnosed with AIDS in FY07 vs. FY06
FY06-FY07 outpatient, inpatient and ED (Source: Facility Reports)
2 5 %
5 4 %
3 6 %3 2 %
1 6 %
3 2 %
2 3 %2 1 %
0 %
1 0 %
2 0 %
3 0 %
4 0 %
5 0 %
6 0 %
O u t p a t ie n t I n p a t ien t E D T o t a l
F Y 0 6 F Y 0 7
Prop
ortio
n of
New
HIV
dx
conc
urre
ntly
dx
AID
S by
ven
ue
Copyright 2007, Joanna Omi, [email protected]
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).
Copyright 2007, Joanna Omi, [email protected]
25
Variables that impact the expansion of testing across HHCDrivers
– 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 facilitiesInhibitors
– 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
Copyright 2007, Joanna Omi, [email protected]
26
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.
Copyright 2007, Joanna Omi, [email protected]
27
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.
Copyright 2007, Joanna Omi, [email protected]
28
Acknowledgements and Appreciation
Terry Hamilton, Director of HIV Services, HHCDrew De Los Reyes, Senior Management Consultant, HHCJay Gabor, Senior Management Consultant, HHCJudy 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
Copyright 2007, Joanna Omi, [email protected]