Mid and Lower Hudson
Regional Group
April 14th, 2015
WELCOME
Systems Linkages and Access to Care for Populations at High Risk for
HIV Infection
in New York State
Welcome and Opening Remarks
Steven Sawicki
Mission of NYLinks
• NY Links addresses community needs and
statewide priorities through enhanced
collaboration and integration of quality
improvement methodology among agencies
and programs that provide HIV services to
decrease gaps in the HIV care cascade as part
of the New York State initiative to end AIDS.
3
Major strategies of NYLinks
NY Links Regional Groups will reduce the transmission of HIV across
New York State by:
• Implementing a community-based response to the HIV epidemic by
mobilizing networks of clinical and non-clinical providers,
community leaders, and community members living with or
affected by HIV/AIDS.
• Aligning programs, providers and the community to address the
goals of New York State to end the HIV epidemic through shared,
local leadership and with technical support from state and local
health departments.
• Building capacity for quality improvement in the region, identifying
and disseminating successful interventions within the continuum of
HIV services and sustaining the achieved regional results.
• Using community level data to link public health strategies with
clinic and service level improvement initiatives.
4
Introductions
Family Services of Westchester
Family Services of Westchester
Monitoring Client Labs Across
Ryan White Programs
For Progressive Health Outcomes
Family Services of Westchester
Monitoring Client Labs Across
Ryan White Programs
For Progressive Health Outcomes
•
•
•
•
Director HIV Service Programs (Partnership for Care)
Ryan White Non-Medical Case Managers
Ryan White Mental Health Clinicians
Ryan White Psychosocial Support Coordinator
• Goal of monitoring client labs across programs is to be able to
identify individuals who may be struggling with adherence
issues and/or other barriers (e.g. substance use, SMI) and
provide increased services and with a primary emphasis on
medication and treatment adherence for those clients who
are not virally suppressed.
Family Services of Westchester
Monitoring Client Labs Across
Ryan White Programs
For Progressive Health Outcomes
•
Process for implementation of project:
In an effort to identify and streamline services to those who may require less or
minimal assistance with ARV TX and place increased Adherence Education Services to
those who seemingly require such direction, the QM team thought to develop a way
to identify those individuals while monitoring the total aggregate of clients enrolled in
the Ryan White programs.
1) It was identified that the easiest and most efficient way to track and monitor client
labs was through the use of excel tracking forms
2) The program looked at several template forms from previous QM projects the FSW
had participated in through the Ryan White Case Management QI Learning Network.
3) After reviewing several different tracking tools Family Services of Westchester
developed a tracking grid that would allow to reviewer to identify one’s VL status
based on a color code system that would include the clients most updated viral load
and CD 4 count.
Family Services of Westchester
Monitoring Client Labs Across
Ryan White Programs
For Progressive Health Outcomes
4) Color code system would identify those with undetectable VL’s: Blue
Those with suppressed VL’s: Green
Those with viral loads above 200: Red for danger zone.
5) Tracking Time Frames: Since all 3 Ryan White programs under this project are
required to utilize the eSHARE data system, the most streamlined way to
document client VL’s and CD 4 counts is with their quarterly PCSM update (every
4 months per eSAHRE requirements)
6) For clients who have undetectable VL’s (<20), and attend PCP appointments
every 6 months, a No Change can be entered in the secondary/subsequent
update column, utilizing the previous quarters reported lab values.
Family Services of Westchester
Monitoring Client Labs Across
Ryan White Programs
For Progressive Health Outcomes
Implementation:
1) Each Ryan White program submitted a listing of clients in alphabetical order that
included client viral load count and CD 4 count.
2) The program Director cross-reviewed each client list to screen out duplicate clients
in order to determine the total amount of clients combined (rather then the total
amount of clients by program as a number of clients overlap programs)
3) Once duplicate client data had been cleaned , the program Director entered all
date by program category (CMNM, MHT, PSS) and then color coded the
information based on client VL count.
4) Once all data had been entered the project showed the total number of clients
enrolled in the RW programs across the board and allowed the program Director
to determine the actual number of total clients who are virally suppressed and
more importantly, the number who are not.
Family Services of Westchester
Monitoring Client Labs Across
Ryan White Programs
For Progressive Health Outcomes
•
Challenges: The biggest challenge was being able to obtain client labs from
outside providers. The team initially assumed to obtain lab reports from clients.
We felt that this approach would act to increase clients ability to become more
responsible and become better “keepers” of their health information. However
this method was not too successful. As a result staff became responsible to obtain
the required lab data from clients medical providers.
•
Next Steps: To obtain and document client labs and record during the
completion of the next 3 month reporting period. It is our expectation that
through increased treatment adherence and ongoing ARV education that clients
will continue to work to decrease their VL’s and increase their CD 4 counts in an
ongoing effort to live healthier lives.
A Tree Grows Along the Hudson
Dan Belanger & Hazel Lever
A TREE GROWS ALONG THE HUDSON:
USING TREE DIAGRAMS FOR CONSUMER-ORIENTED VIRAL LOAD
SUPPRESSION QI PROJECTS
April 14, 2015 NY Links Mid- and Lower-Hudson Regional Group
Facilitators: Hazel Lever Steve Sawicki
Dan Belanger
Agenda
• Explore various viral load suppression QI
projects
• Review the purpose and usefulness of a tree
diagram
• Develop a tree diagram
• Use a tree diagram to analyze a problem
• Use the System of Profound Knowledge with a
tree diagram
CHCQLN Viral Load Suppression
Quality Improvement Project
Boriken Neighborhood
Health Center
Miguel Bustos, Special
Projects Assistant
November 22, 2013
Improvement Project Background
• Rationale for Project: Viral load suppression is a key indicator of
HIV healthcare, and an important indicator as to how Boriken’s
viral load intervention is impacting the patients’ viral load status.
• In January 2013, began project with a total of 34 eligible patients
from 2012. There were 16 patients virally suppressed and 14
unsuppressed. Four individuals are no longer apart of the project.
Baseline Data
January 2013
3
4
16
14
14
14
1
8
4
4
4
0
0
0
0
Improvement Project Goals
• To increase the overall viral load
suppression rate by 10% over a 12
month period and help patients
sustain viral load suppression.
Plan/Do
•
•
The test of change/improvement activity, selected was a continuation of the one
used in 2012, it involved a tailor-made educational approach to educate the
patient on the importance of medical adherence, identifying barriers that could
prevent adherence, and ultimately suggesting potential solutions. The case
manager includes teach back in her sessions .
This year case conference bi-weekly meetings were added which included the
Medical Director and HIV Specialist, the HIV Coordinator, Case Manager, a
Physician, and Physician’s Assistant. At these meetings the status of the patient’s
most recent viral load test, suppression status, and medical adherence are
discussed and addressed.
Educational Check List
Do/Study
October 2013
3
4
1
6
1
6
1
6
1
6
1
8
1
7
8
Do/Study
• Virally Suppressed Patients: Sustained suppressed
status in 2013:
Current: 100% (16 out of 16 patients) October 2013
• Viral Load Tests For Suppressed Patients in 2013:
Current: 100% (16 out of 16 patients) October 2013
• Virally Unsuppressed Patients: Went from
unsuppressed to suppressed:
Current: 44.4% (8 out of 18 patients) October 2013
• Viral Load Tests For Unsuppressed Patients in 2013:
Current: 94.4% (17 out of 18 patients) October 2013
Study
• When reviewing the original process, it was observed that
improvements needed to be made to get patients that were
unsuppressed to be suppressed and those that were
suppressed to stay suppressed.
• Measures used to evaluate the tests of change included the
date of the patient’s last viral load test, their viral load, and
whether the patient received the educational intervention
with the Case Manager.
Act
• The educational sessions between the case manager and the
patient have occurred since 2012.
• Case conference meetings have been implemented since July
2013 and medical providers have been added to this initiative as
needed.
Next Steps
• Given the current results, we have implemented the education
sessions and case conferencing as a regular clinic process.
• Improvements in the status of unsuppressed patients are to be
made by outreaching more to the patient regarding their viral
load status and their medical adherence.
Viral Load Suppression Program
Updates
Heather Kowalski- Data Analyst
Katrina Balovlenkov-Program Director
Community Prevention & Treatment Services
Viral Load Suppression Importance
•
Core data element for Ryan White C, Ryan White D, and New York
State AIDS Institute Multi-Services Agency
•
Core Measure for WYH’s Performance Improvement Plan
•
–
Goal 90% VL Suppression (<200 copies)
–
–
177 Active Patients
136 Suppressed <200 (81%)
New York State
–
51% of PLWHA in NYS are virally suppressed <200
WYH Viral Load Suppression Project
• 2013 Cohort:
– 33 patients; 22 active
• 2014 Cohort:
– 39 patients; 34 active
•
•
•
•
Cohort 1: 17 active patients
Cohort 2: 7 active patients
Cohort 3: 5 active patients
Cohort 4: 5 active patients
2013 Cohort
2014 Cohort
Improvement Project Goal
• To increase the number of
patients with a suppressed
viral load (<200 copies) at
their last test from 81% to
90%
• Sustain suppression in
undetectable patients
Past & Current Success
• Treatment and Medication Adherence
Discussion
• Care Coordination
• Case Conferences
• Peer Support
Challenges
• Cohort encompasses:
–
–
–
–
Newly diagnosed patients
Patients not on ARVs
Substance users
Medication Regimen Restart/Change
• Transient Patient Population
• New Patients
• Staff Retention
Steps to Improvement
• Anti-Retroviral Treatment and Access to
Services (ARTAS)
• Simpler regimens
• Peer Support
• Improved Data
Thank you!
CHCQLN QI Activities/Tactics for
VLS
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Increased adherence counseling
Outreach phone calls
Case conference without patient
Teach back
Adherence journal
Visual aids
Pillboxes
Home and hospital visits
Group education sessions
Adherence groups
Scripted messaging
Checklist of interventions/VLS toolkit
Adherence calendars
Medication alarms
Increased VL tests
Letters encouraging appointment adherence
Peer education
Pre-visit labs
Transport to clinic for DOT
•
•
•
•
•
•
Pharmacy/medication tool to assess issues
Medication reminder texts
Motivational interviewing
Personalized treatment plans for all
unsuppressed patients
Appointment within 2 weeks if change in
medication
QI Team meetings
Making a Tree Diagram
Learning Objectives
• Learn the purpose and usefulness of a tree
diagram
• Learn how to develop a tree diagram
• Practice using a tree diagram to analyze a
problem
• Use the System of Profound Knowledge to
inform strategic tactics to attain objectives
identified in the tree diagram
Tree Diagram Description
A tree diagram is a quality instrument used to assist in the visualization
of the structural elements of a plan, a problem or another area for
investigation
Tree Diagram Usefulness
• Tree diagrams can be used to envision a
desired outcome and the structures/processes
necessary to achieve it
• Working up from the opportunity/desired
outcome, we lay out strategic objectives and
tactics (in increasing level of detail) to achieve
the goal.
• Let’s look at some examples…
Tree Diagram Skeleton
A very simple example
A bit more complex…
Building a Mid and Lower Hudson
tree diagram for involving
consumers in VLS QI
• What four objectives need to be met to
successfully involve consumers in improving
rates of viral load suppression ?
– Using the System of Profound Knowledge
framework, bear in mind factors related to:
– Psychology
– Variation
– knowledge
– systems
Our Tree: A Skeleton
Consumer
and Provider
driven VLS
QI project
Small-group discussion: Tactics
• Split into four groups
• Each group will discuss one of the four
objectives, using the discussion handout to
develop tactics informed by the System of
Profound Knowledge to reach the objectives
necessary to achieve successful consumer
involved viral load suppression quality
improvement projects
Lunch
Regional Data
Regional Cascade Impact
1
Artas
2
Appointment Procedures
3
Consistent Messaging
4
Outreach/Return to Care
5
Peer support
1,2,3,5
1,2,3,4,5
BHAE/AI/NYDSOH
3/2014
Exercise
 The Care Continuum has been split into
segments and posted on the side wall – one
for Buffalo and one for Rochester
 Participants catalogue improvement
interventions along the care continuum
 Match the intervention to the appropriate Care
Continuum section based on measure used for
testing
 Discuss your observations
Color Coded Strategy Map
 Use colored stickies to catalogue
interventions
– Blue – tested with data available
– Yellow – tested anecdotally, no data available
– Pink – in queue for testing, or other ideas
 Write your agency (ies) initials
 Write the intervention and the
measure used for evidencebased testing, if you can
remember it
Post Your Interventions on the Wall
Place each intervention on the wall near the
relevant section of the care continuum
If intervention applies to several sections, match it
based on the measure used for testing or make two
Wrap Up: Summation
Steve Sawicki
UPCOMING STAKEHOLDER MEETINGS
May—Upper Manhattan
Late July/August, Mid and Lower Hudson—Newburgh
August, Queens and Staten Island—Lower Manhattan
August, Western New York—Batavia, NY
DATA DEADLINES
April 1, 2015—NYLinks Bi-Monthly measures
April 15, 2015—Intervention data for previous month
May 15, 2015—Intervention data fro previous month
June 1, 2015—NYLinks Bi-Monthly measures
60
NY Links Website
www.NewYorkLinks.org
NY Links Blog
http://linkandretain.wordpress.com/
Evaluation
Sign in sheet
Contact Information
•Steven Sawicki, NYSDOH, SPNS Lead
[email protected], 518-474-3813
•Clemens Steinbock, NYS Director of Quality
Initiatives [email protected]
•Bruce D. Agins, Medical Director,
[email protected]
•Blog at http://linkandretain.wordpress.com/
•Website at http://www.newyorklinks.org
Adjourn! Thank you!