In+Care - Improving Viral Load Suppression
A Quality Improvement Project
AIDS Activities Office
Quality Improvement Team
Carlos Castillo, RN
Roselen Villalba, RN
Lynn Nagel, BSEd, CQI Coordinator
Stephen D Sabo, AA, Data Coordinator
Length of study: February 2012 – January 2013
Focus on clients in the AAO Adherence
Program
Background Information/Rationale for QI
Project
 Clients missing doses of medication can lead to
resistance
 Lowering of one’s viral load shows responding to
treatment and following medication regiment
 Clients in the adherence education program will
show a increase in viral load suppression.
 Overall in 2007, 64% of AAO clients had a
suppressed viral load. In 2011, the percentage
was 74.
Performance Measure
In+Care 4: Percentage of clients with HIV
infection whose last viral load in the
measurement year is less than 200 copies
In Care -Baseline Data
 VL Suppression – Below 200
 All AAO clients
 Year 2011 – 528/711 = 74%
 Clients in Adherence program
 Year 2011 – 118/194 = 60%
 Clients in adherence program
 November 1, 2011 – January 31, 2012 = 84 clients were
enrolled in the adherence program. 56% (47/84) had a viral
load of <200
 Clients are referred to adherence program by physicians
Physician & patient discuss
need for medication regiment
Nurse receives
referral from
physician
Patient can not be
reached
Nurse contact patient within
2 days of referral &
schedules appointment
After 2 attempts via
phone, letter will be
sent
Nurse develops
care plan for
patient
If no response,
physician will be
notified
Nurse orders
medication from
pharmacy
Physician must
resubmit new
referral
Patient shows for
appointment
Patient does not
show for appointment
Patient picks up
medication from
pharmacy
After 2 attempts via
phone, letter will be
sent
Nurse does HIV
101 with patient
If no response,
physician will be
notified
Nurse reviews
each medication
type with patient
Physician must
resubmit new
referral
Nurse reviews
medication
regiment with
patient
If pill box, nurse will pick up
medication from pharmacy
and pre fill boxes
Nurse & patient
decides on pill box
or pre pack
Nurse reviews side effects
and special instructions
Nurse will have patient
explain what they just
learned
Nurse will emphasize the
importance of taking
medication as instructed
Nurse reviews medication
regiment a second time
Lab slip given for CBC &
CMP 2 weeks after starting
medication
If pre pack, nurse will
arrange for pills to be
delivered to office
Lab slip given for CBC &
CMP 2 weeks after starting
medication
Lab slip given for CD4/VL/
Lipid profile 4 weeks after
starting medication
Appointment given for
physician visit after 4 week
blood work is due
Nurse schedules patient for
next adherence visit
Patient has no problems
with medication regiment
Discharging a patient
who failed to follow up
within 3 consecutive
visits
Nurse follow up with client
via phone within the first 2
days
Patient has problem
with medication
regiment
Patient continues on
program until an undetectable
viral load is report for 2
consecutive labs
Depending on
what the side
effect is “Standing
Orders” are
followed
After 2 attempts via
phone, letter will be sent
If no response, physician
will be notified
Physician must resubmit
new referral
If undetectable VL is not obtained, nurse
will work with patient to try to identify
barrier to treatment, if there is any
If side effects can
be resolved,
patent will
continue on
medication
regiment
If side effects can
not be resolved,
patient is taken off
medication
regiment
Cause Diagram
PDSA – Plan/Do (First Quarter)
 Create flow diagram and review adherence process
 Create cause diagram and review with team
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Classification of clients in program, long term / short term
Frequent adherence appointments will be scheduled as needed
Frequent follow up phone calls
Review list of clients on adherence & remove those that no
longer need to be in program, lost to follow-up, moved, etc and
removed these clients from active list
 Run monthly reports with VL’s for adherence nurses to monitor
 Interventions specific to individual clients needs that are in the
Adherence Program
 Will help pay co-pays for clients
 Provide transportation assistance – bus passes or taxi vouchers
PSDA - Study/Results (First Quarter)
All AAO clients
Overall there was an increase in the
number of clients with a viral load <200 to
77% (510/727) – April 30, 2012
For 2011 74%(528/711) of clients had a viral
load <200
Incentives and perseverance on part of the
adherence nurses have shown an increase in
the number of clients with a viral load <200.
PSDA - Study/Results (First Quarter)
Clients in Adherence Program – Feb 1 – April 30,
2012
92 clients were enrolled in the adherence program.
62% (57/92) had a viral load of <200
10 clients received transportation vouchers. 60%
(6/10) had a viral load of <200
23 clients received co-pay assistance. 61% (14/23)
had a viral load of <200
2 clients received both transportation & co-pay
assistance. 0% (0/2) had a viral load of <200
57 clients did not receive any incentives. 61%
(35/57) had a viral load of <200
PSDA - Study/Results (First Quarter)
Months in Program
 VL <200
New – 2 months
 23% (21/92)
3 months – 5 months
 24% (22/92)
> 6 months
 15% (14/92)
 VL > 200
New – 2 months
 20% (18/92)
3 months – 5 months
 11% (10/92)
> 6 months
 8% (7/92)
PDSA – Act (Second Quarter)
 Next step: continue with paying co-pays,
transportation needs, frequent visits & phone
calls
 Design a bulletin board for visual reinforcement
in the clinic on the importance of medication
adherence
 Closely monitor “long term” clients for any
adherence issues
 Compare 3 month data with 6 month data
looking for trends