Improving retention of hiv patients in care

THE HIVQUAL PROJECTNYS Dept of Health AIDS Institute

DHHS/HRSA/HAB Division of Community-Based Programs

Quality Improvement and Quality Improvement and Retention in CareRetention in Care

Slides Courtesy

Bruce Agins, MD MPHbda01@ health.state.ny.us

Presented by K. Clanon, MD

[email protected]



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ContinuumEngagement in Care

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

Not inCare

Fully Engaged

Non-engager Sporadic User

FullyEngaged

Health Resources Service Administration (HRSA)



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)



Missed Visits and MortalityMugavero, et. al. 2009 UAB. CID 48:248-56.

543 new patients followed who were alive 12 months after their first visit

Visits during first 12 months of care analyzed from 1/00-12-05 325 pts (60%) missed visit in first year 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]

No difference in mortality based on whether 1 or >1 visit missed Predictors of missed visits: younger/female/black/risk other than

MSM/public insurance/substance use disorders



Measuring Retention Rates Examples:

# of unique clients with at least 1 visit in past 4 months# of unique clients with at least one visit in past 12 months

# pts with at least 1 visit during 3 month interval after 12 month period # pts with 3 or more visits in the 12 mo. period (*1 in last 6 months)

# pts with 2+ visits during the defined 12-month period# pts in the clinic registry during the defined period

# pts with no visit during the past 4 months# pts with at least 1 visit during past 12 mos



Texas Data

• Collected via Aries 2009 and 1st Q 2010• Analyzed by the Cross-Part Collaborative• Caveat: Data entry into Aries• Roundtable after this session you can get your

agency’s data…….



Why Do HIV Patients Not Come to Clinic?

Patients at a community based clinic: conflicts with work schedules, lack of child care, no transportation, family illness and hospitalization (Norris, 1990)

Women patients: forgetting the appointment, having a conflicting appointment and feeling too sick to attend the visit (Palacio, 1999)

NYC clinic: no specific explanation, forgot, meant to cancel, unexpected social reasons (Quinones, 2004)



What’s Working in Texas?

• Austin: Lynda Blakeslee and Rhonda Ray• Also: see handout……



Evidence Base for Strategies to Connect Patients to Care



Outreach Initiative:HRSA SPNS Multi-site Evaluation

Goals: To engage people in HIV care Turn sporadic users of care into regular users Promote retention in care

Program models Scripted behavioral interventions, accompanying clients to

appointments, home-based services, health literacy & life skills training

Evaluation Quantitative and qualitative methodologies Link to outcomes



Outreach Initiative: Major Findings (Cabral, et. al. 2007; AIDS Patient Care & STDs)

Increased frequency of contact results in fewer gaps in care during first 12 months of follow-up

773 patients from 7 sites followed and interviewed Purposive sampling; prospective nonrandomized with single arm Contact by clinicians, peers, and paraprofessionals Contact may occur in office, out of office, not face-to-face

Types of contacts: 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

Patients with 9 contacts during first 3 months were about half as likely to have a substantial gap



Outreach Initiative: Qualitative FindingsRajabiun 2007: AIDS Patient Care & STDs

Determinants of sporadic use: level of acceptance of being diagnosed with HIV ability to cope with substance use, mental illness, and stigma health care provider relationships presence of external support systems ability to overcome practical barriers to care

Outreach interventions helped connect participants to care by: dispelling myths and improving knowledge about HIV facilitating access to HIV care and treatment providing support reducing the barriers to care



Clinic Operation and Information System Strategies

Clinic Organization Ensure coverage for provider vacations and time-off to avoid canceling

or re-scheduling appointments Establish patient database to track adherence with appointments

Pre-Appointment Reminder cards with date/time/location of visit mailed to patients Reminder calls made 48 hrs prior to appointment to allow patient time to

make arrangements, if needed Reminder calls to patients made by providers, case managers or other

staff closely involved w/ patient's care Schedule labs to be done prior to visits to maximize time spent w/

provider



Preventing Loss to Follow-up:Work with New and ReturningPatients

Conduct new patient orientation sessions and include

discussion of staying in care

Schedule one-to-one sessions for new patients unable to

attend group orientations

Develop written patient materials on the importance of

staying in care

Staff education - routinely discuss patient retention w/ all

staff



Small Group Work: Solution FishWhat Ideas Can We Try for Improvement?



Contacts

Bruce D. Agins, MD MPHDirector, National HIVQUAL ProjectMedical Director, NYSDOH AIDS Institute

[email protected]

Kathleen Clanon, MDNQC Consultant

[email protected]

Improving retention of hiv patients in care

Health & Medicine

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