EXPANDED HIV TESTING 12/16/15 PROJECT PARTNERS KEY FINDINGS A LITTLE BIT ABOUT SAN DIEGO QUALITATIVE EVALUATION WANTING TO SHARE OUR EXPERIENCE

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1 A LITTLE BIT ABOUT SAN DIEGO EXPANDED HIV TESTING Approximately 3.2 million residents Network of community clinics, no County hospital Unaware estimate is 9.6% County of San Diego Qualitative Evaluation Findings December 16, 2015 PROJECT PARTNERS QUALITATIVE EVALUATION ROUTINE TESTING STARTED IN DECEMBER 2011 Family Health Centers of San Diego WANTING TO SHARE OUR EXPERIENCE Formative Planning San Ysidro Health Centers Vista Community Clinic North County Health Services Christie s Place San Diego Family Care Operation Samahan County detention facilities Why we wanted a qualitative evaluation What we hoped for What we got KEY FINDINGS SUCCESSES Adaptability and Flexibility Data Collection and Reporting Buy-in Champion Experience Regular lab work Billing Linkage to Care Increased awareness of HIV within each agency and in the community Finding positives not likely to be found Increased collaboration between agencies Routine testing becoming a standard of Increased awareness 1

2 CONTACT INFORMATION Lauren Brookshire County of San Diego Using Data for Quality Improvement Alameda County Expanded Testing Project October 2011-December 2014 Samantha Feld, MPH Sarah Salomon, MPH Shailey Klinedinst, MPH Routine Opt-Out Testing in Health Settings: Implement, Expand and Sustain Workshop Dec 13, 2015 Cardea Training, Organizational Development & Research and Evaluation Improve organizations' abilities to deliver accessible, high quality, culturally proficient, and compassionate services to their clients Expanded Tes;ng Partners Alameda County Office of AIDS (funder) Cardea & AETC (TA & Data Management) Testing Sites: (Lifelong not funded under ET but was also worked with us to routinize testing) Expanded Tes;ng Program Goals 1. Increase # of persons tested 2. Routinize testing in medical settings 3. Implement CDC recommendations for HIV Testing among ages Ensure continued testing at agencies beyond conclusion of ET funding Cardea s Role Data Support Worked with each site to facilitate data extraction Developed data collection forms, codebook, and CSV2XML conversion software Cleaned & formatted data and submitted data to OA Facilitated quarterly data & quality improvement meetings 2

3 Cardea s Role Training & TA Training for sites: HIV 101, Stigma, Testing recommendations, Offering, Conducting and Giving Results Protocol development for testing and linkage to Cardea facilitated data & quality improvement mee;ngs Convened all partners quarterly for ~ 3 hours Analyzed and summarized data Monthly testing trends by site & client demographics Monthly positive cases identified by site & client demographics Monitored progress toward testing & positivity goals Facilitated data review process Data review helped sites iden;fy successes and challenges Celebrating accomplishments helped to maintain energy & momentum! Detailed review of trends over time helped sites see how programmatic changes (including training) affected testing numbers Group discussions of successes and challenges lead to sharing of innovations Discussion of new diagnoses revealed common need for greater support around linkage to Total Tests with Posi;ve Cases 150 Iden;fied by Year , , # tests 9782 # positive Total Positives Cases Negative Tests Oct-Dec 2011 Corizon Jail tests by quarter Jan-Mar 2012 Apr-Jun 2012 Deputy lay-offs Jul-Sep 2012 Oct-Dec 2012 Jan-Mar 2013 Apr-Jun 2013 Jul-Sep 2013 Quarter Oct-Dec 2013 Jan-Mar 2014 Apr-Jun2014 Nurses union threatens strike Jul-Sep 2014 Oct-Dec 2014 Negative Tests Methadone Clinic tests by quarter 80 Staff training Site visits Oct-Dec 2011 Jan-Mar 2012 Apr-Jun 2012 Jul-Sep 2012 Oct-Dec 2012 Jan-Mar 2013 Apr-Jun 2013 Jul-Sep 2013 Oct-Dec 2013 Jan-Mar 2014 Apr-Jun2014 Jul-Sep 2014 Oct-Dec 2014 HAART BAART Lifeline 3

4 La Clínica tests by quarter Provider report cards Gilead support begins Agencies monitored posi;vity rate CDC Positivity Goal = 0.1% % % Oct-Dec 2011 Jan-Mar 2012 Apr-Jun 2012 Jul-Sep 2012 Oct-Dec 2012 Jan-Mar 2013 Apr-Jun 2013 Jul-Sep 2013 Oct-Dec 2013 Jan-Mar 2014 Transit Village Fremont Tiger Oak Tech San Lorenzo San Antonio Clinica Alta Vista Apr-Jun2014 Jul-Sep 2014 Oct-Dec % 0.11% Corizon HEPPAC La Clinica LifeLong PPMM PP Mar Monte monitored % of visits at which an HIV test was done* 45% 4 35% 3 25% 2 15% 1 5% Dec-12 Nov-12 Oct-12 Sep-12 Aug-12 Jul-12 Jun-12 May-12 Apr-12 Mar-12 Feb-12 Jan-12 Dec-11 Nov-11 Oct-11 Conclusions Review and analysis of data helped sites explain trends and identify opportunities for improvement Additional data would be useful for program monitoring and quality improvement, e.g. screening coverage *not unduplicated patients Thank You Center for Disease Control CA Department of Public Health State Office of AIDS Alameda County Office of AIDS Administration Pacific AIDS Education Training Center & Dr. Sophy Wong Sarah Salomon Research Manager ssalomon@cardeaservices.org Shailey Klinedinst, MPH Program Director sklinedinst@cardeaservice.org Samantha Feld, MPH Evaluation Data Manager sfeld@cardeaservices.org Contact Informa;on

5 Evalua;on Data overwhelm? It s not that complicated (really!) Too li7le data, too late? Goldilocks of eval data? ARS: Does your Expanded HIV TesLng program have: Are we measuring the right thing? 1. Too much data 2. Not enough data 3. The right amount of data 4. What data? 5

6 Measurements What measures do we need? State level measures County/LHJ level measures Site level measures Aggregate palent level measures HIV ConLnuum of Care: called the north star of HIV HIV ConLnuum of Care: imp metrics % % % infected % diagnosed % in HIV % retained in % virally suppressed 2 % infected % diagnosed % in HIV % retained in % virally suppressed TesLng Coverage New HIV diagnoses % late diagnosed %linked to % completed 1 st visit % retained in for 24 months % on ART % virally suppressed HIV Con;nuum of Care: CA benchmarks 52% % infected % diagnosed % in HIV % retained in % virally suppressed HIV Con;nuum of Care: HAB Screening & HIV Care Measures % % infected % diagnosed % in HIV % retained in % virally suppressed Implicit: TesLng 10 1 more pts know status & 10 linkage 25% increase in HIV+ pts who make 1 st visit in 90 days 2 increase: pts who receive con;nuous medical 2 increase in undetectable VL for: MSM, AF- AM and La;no pts Using BPH definilon= # HIV tests in previous 12 months/# ac;ve pa;ents in clinic in previous 12 months Using HAB definilon= #HIV+ tests/# HIV tests in previous 12 months+ (# already HIV+) Using HAB definilon= #HIV+ who akended a rou;ne HIV medical visit within 3 months of HIV diagnosis/# w with HIV diagnosis in 12- month measurement period Using HAB definilon= # pts w at least one medical visit in each 6- month period of the 24- month measurement period with minimum of 30 days btwn 1 st medical visit prior 6- month period and the last medical visit in the subsequent 6- month period/# pts, regardless of age, with a diagnosis of HIV with at least one medical visit in 1 st 6 months of the 24- month measurement period Using HAB definilon= # HIV+ pts 2 a viral load LT 200 copies/ml at last HIV viral test during the measurement year/# of HIV pts, regardless of age, with a diagnosis of HIV with at least one medical visit in the measurement year 6

7 IF HIV ConLnuum is north star, where does that leave HIV teslng? IF HIV ConLnuum is north star, where does that leave HIV teslng? What queslons do current OA measures answer? How many people are tested? Who are the people who test +? Detailed demographics, risk factors, etc Who are the people who test -? Detailed demographics, risk factors, etc Geographic localon of teslng that occurs? Type of Agency where teslng occurs? What queslons remain? What is your LHJ (county), clinic, hospital or agency HIV screening percentage? i.e. what percentage of palents are you teslng? How does your HIV screening percentage change with intervenlon? which intervenlon works best with your palents/ clinics? Is there a difference in one health agency s different sites? Within a site, is there a diff based on clinicians? What do you need to answer these queslons? A denominator, i.e. What is your aclve clinic populalon? Gives HIV screening coverage percentage From this create your own conlnuum of teslng to track program impact # tested* Current OA measures + new measures Total ac;ve pa;ent popula;on # tested + # linked to # completed 1 apptment w in 90 days of tes;ng * LifeLme = btwn ages of 15 and 65 7

8 Measures to answer queslons # tested (life;me) Bureau of Primary Health Care (FQHCs) Total Clinic ac;ve pa;ent popula;on (# with one visit in 12 months) Bureau of Primary Health Care (FQHCs) # linked to Bureau of Primary Health Care (FQHCs) # completed 1 apptment within 3 months of tes;ng ARS Are you using the Bureau of Primary Health Care measures? 1. Yes 2. No but used in past 3. Not using but familiar with it 4. No What other informalon is needed to start? Baseline data should include some other measures to help molvate teslng Missed palents (late testers) Frequent re- testers (Prep?) numerator What HIV TESTING measures look like: baseline # HIV tested (unique) # tested who need ongoing tes;ng (i.e. high risk, repeat testers) # late testers according to HAB* denominator Total clinic ac;ve pa;ent popula;on (# with one visit in 12 months) # tested # tested Track results by intervenlon ARS: Does your agency track results based on intervenlons? 1. All of the Lme 2. Most of the Lme 3. Some of the Lme 4. None of the Lme 8

9 Should be: Clearly defined Implementable Measurable IntervenLons Track results by intervenlon What intervenlon is your agency using this year? Example: generalng list of palents needing HIV test before daily huddles Is it a combinalon of intervenlons? Example: generalng huddle list and EHR popups IntervenLon measures: clinic consorlum, clinic site, clinician panel IntervenLon measures: clinic consorlum, clinic site, clinician panel numerator More frequent measures (monthly, quarterly) # tested post interven;on # tested per interven;on numerator # tested + Annual /Bi- annual Measures # tested who need ongoing tes;ng (i.e. high risk, repeat testers) # late testers according to HAB* # linked to # completed 1 apptment w in 90 days of tes;ng denominator # ac;ve pa;ent popula;on # ac;ve pa;ent popula;on denomina tor # tested # tested # tested # tested + during interven;on # tested + during interven;on Who may have difficulty with these measures? Jails May be difficult to determine palent populalon Drop- in teslng clinics (by definilon, everyone is tested) PotenLal alternalve measures focus on new palents for jail, focus on linkage (+) and Prep (- ) for drop- in clinics # tested/ New pa;ents (enrolled in clinic/jail as of current year) Other PotenLal Metrics # high risk nega;ves linked to high impact preven;on/ total nega;ves # tested per different tes;ng technology (4 th genera;on, 3 rd genera;on, etc)?? 9

10 Other PotenLal Metrics Clinic Site Level Metrics HIV PrevenLon ConLnuum: (How) do we track high risk - testers? # clinic sites with HIV tes;ng policies and procedures/# of clinic sites # of clinic sites with HIV tes;ng policies and procedures as part of CQI/# of clinic sites # of clinic sites implemen;ng a measurable interven;on to increase clinic adherence to HIV tes;ng policies and procedures/# of clinic sites? S14 CID 2014:59 (Suppl 1) McNairy and El- Sadr A Paradigm Ship: Focus on the HIV PrevenLon ConLnuum. h7p://cid.oxfordjournals.org/content/59/suppl_1/s12.full.pdf+html ARS: Does your agency track frequent testers? 1. All of the Lme 2. Most of the Lme 3. Some of the Lme 4. Never HIV teslng targets? (ARS?) What is a fair target increase for a clinic? 5% increase? 2 increase? 5 increase? Depends on the clinic. How to get there? Decide on intervenlon ImplementaLon plan Implement intervenlon with metrics Share metrics with clinical team regularly (monthly or quarterly) 10

11 Step by step Month 1-2: get buy- in from clinical director, clinic administrator, quality team, IT get baseline data by clinic site: set benchmarks (per metric) Step by step Month 3-4: Target implementalon sites based on buy- in and data (how many sites targeted/total sites) Arrange EHR data reporlng on important metrics by clinic site and by clinician panel (how many clinicians/total clinicians per site) Announce metric targets Step by step Month 5-6: Implement intervenlon Number of sites rolled out/total number of sites Number of clinicians rolled out/total number of clinicians per site Implement EHR data report back for end of Month 6 Step by step Months 6-11 ConLnue intervenlon roll out Clinic sites and clinicians/clinic site ConLnue EHR report (monthly or quarterly) By clinic site By clinician panel/clinic site Report on measures in staff meelngs Final Month 12: Analyze change based on intervenlon per metric By clinic site By clinicians/clinic site Final Month 12: Were targets met? Did teslng increase? How does overall clinic compare to LHJ (county)? How does overall clinic compare to state as a whole? 11

12 CQI Get input from staff on their analysis of how to further improve Was one intervenlon or combinalon of intervenlons more successful than the others? Revise HIV teslng strategy, implement Thank You! Nancy Warren, MPH, MA Director of EvaluaLon PAETC HIV TesLng protocol? What is the current teslng protocol? What type of teslng is your clinic doing? Or are different clinics doing different HIV teslng? i.e. one clinic is doing mostly 3 rd generalon but the main clinic is doing 4 th generalon. How does funding affect different clinic sites within one clinic consorlum? (i.e. drop- in teslng versus teslng of clinic palents) 12