DataforCare(D4C)AlabamaAClinic-Wide,RiskStra<fica<onReten<oninCareInterven<onMichaelJ.Mugavero,MD,MHSconbehalfofD4CALTeamUniversityofAlabamaatBirmingham(UAB)Co-DirectorUABCenterforAIDSResearch

HIVTreatmentCascade(CareConInuum),2014–U.S.

hNps://www.cdc.gov/hiv/pdf/library/slidesets/cdc-hiv-prevenIon-and-care-outcomes.pdf

Background

§  ImprovingretenIonincare(RiC)thegreatestopportunityalongcareconInuumtoadvanceprevenIonandtreatmentbenefitsforPLWH

§  Incontrasttolinkagetocare(e.g.,ARTAS)and

re-engagementincare(e.g.,D2C),nolargescaleprogramsimplementedforRiC

§  UniqueinfrastructureaffordedbyRWHAPforsystemaIc,clinic-wideHIVRiCprogram(s)

DataforCare(D4C):“BigPicture”

§  RiskstraIficaIon:Clinic-wideriskstraIficaIonbaseduponmissedvisitsprior12months

§  ResourceallocaIon:DeliveryofREPC

intervenIontointermediateandhighriskpaIents(+bestavailableRiCresourcesforHR)

§  ConInuousqualityimprovement:IteraIveclinic-wide(andindividual)monitoring,riskstraIficaIon,andtargetedRiCservicedelivery

WhyFocusonMissedVisits?

§  Missed(“noshow”)HIVvisit(s)associaIons:Ø  DelayedARTiniIaIon&longerImetoVSØ  Gapsincare&losstofollow-upØ  GreatercumulaIveviralloadØ  Racial/ethnicdispariIesØ  Mortality

§  Missed(“noshow”)HIVcarevisits

Ø  UniquelycapturedbyHIVmedicalclinicsØ  Immediatelymeasured&acIonable

Mugaveroetal.ClinInfectDis2009;48,Zinskietal.AJPH2015;105,Thompsonetal.AnnalsofInternalMedicine2012;156

Retention in Care measure

Need missed visit data?

Ease of calculating

Follow-up time

Missed visits Yes Easy ~1 day

Appointment adherence

Yes Moderate ~1 yr

No-show rate Yes Moderate ~1 yr

Constancy: Visit per 3, 4 or 6 mo intervals

No Moderate ~1 yr

Gap in care No Easy ~1 yr

HRSA/HAB No Mod-to-difficult 1 yr

DHHS No Mod-to-difficult 2 yrs

Adaptedfrom:GiordanoTP(2012)MeasuringretenIoninHIVcare.www.medscape.com.

D4CRiskStraIficaIon

§  Dataquery:missedprimaryHIVcarevisitsprior12monthsØ  LOWrisk:zeromissedvisitsØ  INTERMEDIATErisk:1-2missedvisitsØ  HIGHrisk:>3missedvisits

§  Matchclinic-wideriskstraIficaIonwith

appointmentschedulingsystemforupcoming3monthsidenIfyingscheduledappointmentsforINTERMEDIATEandHIGHriskpaIents

CNICSRiskStraIficaIon(n~12,000)

Pence.11thInternaIonalConferenceonHIVTreatmentandPrevenIonAdherence,FtLauderdale,FL;9-10May2016,AIDS&Behavior(underreview)

D4CResourceAllocaIon

§  INTERMEDIATEandHIGHriskpaIentsreceiveevidence-basedretenIonthroughenhancedpersonalcontact(REPC)

D4CResourceAllocaIon:REPC

Enhancedpersonalcontact(EC)

Interim phone call

Reminder phone calls

Missed visit phone calls

Brief face-face visits

ECplusbehavioralskills(EC+)

Strengths-based discussion at 2-week visit

Unmet needs assessment & skills modules:

Organizational skill

Communicating skills

Problem skills

Standardofcare(SOC)

Usual practices for established and new patients

Referrals to social worker or case manager, as usually done

Usual visit reminders (automated or individual, telephone or written, etc)

D4CResourceAllocaIon:REPC

GardnerLIetal.ClinInfectDis2014;59;ShresthaRKetal.JAIDS2015;68

REPCTakeHomePoints:§  10%increaseinRiCbyConstancy&HRSAHAB§  5%increaseinvisitadherence§  Noaddedbenefitofskillsmodules(EC+)§  Efficacious:women,AA/Black,lowSES§  Dose-responseb/t#ofcontacts&RiC§  NOTefficacious:unmetneed(s),illicitdruguse

D4CResourceAllocaIon

§  INTERMEDIATEandHIGHriskpaIentsreceiveevidence-basedretenIonthroughenhancedpersonalcontact(REPC)

§  HIGHriskpaIentsreceivehighestintensityresourcesavailableateachclinic(e.g.,intensivecasemanagement,peermentor,outreach)

§  LOWriskpaIentsreceive24-48hourmissedvisitcallandtransiIontoINTERMEDIATEriskforremindercontacts

D4CAlabama(D4CAL)

§  Design:Non-randomizedstepwedge§  Sites:7RyanWhiteHIVClinicsinAlabama

§  Data:Individual-levelandclinic-widesocio-demographic,lab,andvisitdatamirroringRSR

§  EvaluaIon:Processandoutcomemetrics

“TheAlabamaRegionalQualityManagementGroupexiststoensurethatthoselivingwithHIV/AIDSinthestateofAlabamareceivequalityhealthcarethroughthecollaboraIonofhealthcarepartnersthroughoutthestate.ThiscollaboraIonaimstoconInuouslyimprovethequalityofHIVcareconsistentwithrecognizednaIonalstandardsandcurrentHIVresearch”

CourtesyofAshleyTarrant,MAO,andJiteshParmar,ThriveAlabama

AlabamaRegionalQualityManagementGroup(ALRQG)

A B

D

G H

CourtesyofAshleyTarrant,MAO,andJiteshParmar,ThriveAlabama

ALRQG;Missedvisitindicator

D4CAL:CQIusingPDSAFramework

D4CAlabama(D4CAL):Timeline

D4CAlabama(D4CAL)Metrics

§  Process:Ø  Fidelityofclinic-wideriskstraIficaIonØ  FidelityofREPCreminder&missedvisitcallsØ  Measuring“best”RiCprogramsforHR@sitesØ  FidelityofHRpaIentsreceiving“best”RIC

§  Outcomes:Individual-levelandclinicwideØ  Missedvisits,visitadherence&HRSAHABØ  ViralSuppression

§  ImplementaIonScienceMetrics?

Acknowledgements

§  JiteshParmar(THRIVE),AshleyTarrant(MAO)&ALRQGSiteLeadsandClinicDirectors