The MAX Clinic: A Structural Healthcare Systems Intervention Designed to Engage the Hardest-to- Reach Persons Living with HIV/AIDS

Transcription

1 Mountain West AIDS Education and Training Center The MAX Clinic: A Structural Healthcare Systems Intervention Designed to Engage the Hardest-to- Reach Persons Living with HIV/AIDS Meena Ramchandani Acting Instructor, Division of Allergy and Infectious Diseases July 14, 2016 Many slides borrowed from: Dr. Julie Dombrowski This presentation is intended for educational use only, and does not in any way constitute medical consultation or advice related to any specific patient.

2 Objectives Background: why this was started What is the MAX clinic Outcomes of MAX clinic What aspects of MAX are applicable to community based practices

3 cdc.gov US HIV care cascade (2011)

4 2014 Washington State HIV care cascade, as of June 30, 2015 Washington State Epidemiology Report 2015

5 Background Lack of evidence to guide HIV care re-engagement - Counseling, navigation, referral to support services, peer support, contingency management - Very few controlled studies Most interventions attempt to re-engage patients into the same HIV care system from which they disengaged Can we change the structure of care available to patients?

6 Eligibility criteria Patient Recruitment for MAX Clinic - Viral load (VL) >1000 copies/ml or no VL for 12 months and off antiretroviral therapy, AND - Failure to re-engage in care with public health and clinical outreach assistance Routes of Identification - Public health relinkage and partner services activities - Medical provider referral - Case managers or navigator referral (clinics, CBOs, jail) - Peer referral (occurred spontaneously, now incorporated into model)

7 MAX Clinic Components Identification of Potential MAX Patients Case Coordinators [Disease Intervention Specialists (DIS)] Intensive support & outreach Single point of contact for patients & providers Calls, text messages Meet patients in hospital, clinic, home, or jail Enrollment of Patients in MAX Clinic Walk-in medical care, 5 afternoons per week (in STD Clinic) Snacks and meal vouchers (each visit, up to once weekly) Cell phones and bus passes (contingent renewal) Cash incentives (q2 months) $25 for visit + lab draw $100 for suppressed VL & 1x bonus for 3 in a row ($100)

8 Patients Enrolled in MAX Clinic Jan-Dec 2015 (N=50) Referral Source Provider/Case Manager 23 (46%) Public Health Outreach 23 (46%) Peer 4 (8%) CD4 count (cells/mm 3 )* < (54%) (30%) >500 6 (12%) Illicit stimulant or opioid use** 44 (88%) Unstable housing 29 (58%) Hepatitis C co-infection 17 (34%) *CD4 count missing for 2 patients **Reported using methamphetamine, crack-cocaine, cocaine or heroin in past 12 months, at time of enrollment

9 HIV Care Continuum Outcomes (N=50) Enrolled Engaged Started ART Achieved VL<200 Median enrollment: 5 months 12/31/2015 5/1/ months Last VL suppressed

10 HIV Care Continuum Outcomes (N=50) Enrolled Engaged Started ART Achieved VL<200 12/31/2015 5/1/ Last VL suppressed Median enrollment: 5 months 9 months

11 6/01/ % 52% 52% Number Enrolled Number Suppressed VL<200 Percent of those enrolled who are suppressed Sept 2015 Feb 2016 June 2016

12 What I ve found works that can be applied in the community Do not need the same intervention for everyone Depends on patient population See what make up of these types of patients are and reach out to what they need - lack of housing? - substance abuse? - uncontrolled mental health issues - all of the above?

13 What I ve found works that can be applied in the community Dosing medications weekly or Q2 weeks for those who are homeless (use of fastpacks) through buildings, CM, SW Hiring a case manager: nurse CM help with medication management - Some communities have these people go out to homes Drop in features - HIV provider - Mental health providers Incentives: for labs and outcome measurement Starting treatment immediately: risks/benefits Text messaging: for patients as well as to find patients

14 Thank you JC Dombrowski MR Golden A Moore R Patrick M Fleming A Nunez S Dhanireddy RD Harrington D Spellman Madison staff