Disclosures. Outline 6/12/2018. Telehealth Strategies for Extending HIV Prevention and Care Services

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1 Telehealth Strategies for Extending HIV Prevention and Care Services Michael Ohl, MD MSPH Division of Infectious Disease University of Iowa Center for Access and Delivery Research and Evaluation (CADRE) Iowa City VA June 27, 2018 Disclosures Research Funding from: Gilead Pharmaceuticals VA HSR&D VA Office of Rural Health Outline Telehealth Brief Background HIV Care - Telehealth Collaborative Care in VA HIV Prevention Iowa TelePrEP 1

2 Telehealth Tele-Jargon Telemedicine mhealth ehealth Telemonitoring Teletubbies Telehealth HRSA Definition Use of electronic information and telecommunication technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration Four Telehealth Modalities Live Video Store and Forward Remote Monitoring mhealth 2

3 Extension for Community Health Outcomes (ECHO) Model Specialty HUB Site Primary Care Spoke Sites Telehealth Payment - Medicare Live Video Patient must be: In a clinic, hospital, dialysis center, or skilled nursing facility In a rural area Iowa Telehealth Law (HF 2305) January 1, 2019 [A] policy, contract, or plan providing for thirdparty payment or prepayment of health or medical expenses shall not discriminate between coverage benefits for health care services that are provided in person and the same health care services that are delivered through telehealth. Only live videoconferencing covered No payment parity 3

4 Extending HIV Care Services Telehealth Collaborative Care for Veterans with HIV Iowa City VA Health Care Network Vignette Mr. Z is 62 year old man who drove three hours to HIV clinic for a follow up visit. Takes TDF/FTC/EFV one pill a day to control HIV CD4 900 cells/mm 3, HIV viral load < 20 copies/ml Co-morbidities: hypertension, hyperlipidemia, type 2 diabetes, tobacco use, depression. Complains of chronic back pain. Wishes to start insulin for diabetes based on prior discussions. 4

5 Telehealth Collaborative Care - overview Team members dispersed across sites - Primary care team members in spoke clinics - HIV specialty team via video conferencing from hub-site Registry for population management across sites Central nurse care manager - Patient navigator across sites - Triage tasks and maintain role clarity in teams Telehealth Collaborative Care EHR Telephone Primary clinic Provider (NP/PA) Nurse manager Telehealth tech Patient Registry for population management Case finding by validated algorithm* Data from VA Corporate Data Warehouse (CDW) Criteria for data inclusion: - Prevalent drivers of risk (e.g. cardiovascular risk factors) - Modifiable - Standard terminology (LOINC, health factor definitions, etc.) * Backus et al, JAMIA, 16:

6 Registry: data elements Labs: CD4, HIV viral loads, lipids, blood glucose Vital signs: blood pressure measurements Tobacco use Alcohol use by AUDIT-C Depression screen by PHQ Central nurse care manager In HIV clinic at hub-site Patient care navigation Acute care triage Chronic care task management across sites / team members Population management - Registry maintenance - Registry queries and task assignment across sites Vignette yo man with HIV, hypertension, hyperlipidemia, chronic kidney disease, and diabetes. Lives near VA primary care clinic two hours from HIV clinic. Registry query: hemoglobin A1C = 11% Saw local primary care provider, insulin started Met with local nurse for insulin education Video telehealth visit with HIV care team, followed by care coordination huddle including patient, HIV provider, local nurse 6

7 Rural patients preferred telehealth collaborative care 38 / 41 eligible patients chose telehealth over traveling to specialty clinic 2 dropped out after 18 months 85% Completely / very satisfied with care Ohl et al, JGIM, 28(9): Evaluation select findings, N=38 HIV viremia control Smoking cessation process measure Influenza vaccination Travel time (min / year) Before (%) After (%) p < < <.01 Ohl et al, JGIM, 28(9): Telehealth collaborative care clusterrandomized program evaluation Do patients use telehealth collaborative care when offered? Why / why not? What is the impact on outcomes? - Population level - Among users What is impact on utilization / costs? VA HSR&D IIR , Ohl PI 7

8 Extending HIV Prevention Services Iowa TelePrEP TelePrEP Team Vignette 3 42 year old MSM (non gay/bisexually identified) in a primary relationship with a female. MSM contact occurs infrequently with reported use of barrier most of the time. Travels 75+ miles to access rapid HIV screening services on a regular basis for fear of disclosure to a service provider within his community. 8

9 Barriers to PrEP in rural Iowa Stigma Rural provider shortage Distance to PrEP providers in larger cities The Iowa TelePrEP Model More than Telehealth Public Health Marketing self referral HIV Clinics Telephone Navigator In-home Vidyo Visit Medication by Mail Local labs Pharmacist Collaborative Practice TelePrEP Service States with Collaborative Practice Laws Protocol driven o USPHS/CDC guidelines o Approved by UIHC Pharmacy & Therapeutics Committee Collaborative practice agreement o Formal relationships between MDs and PharmDs o Registry-based population management o Behavioral counseling 9

10 Local TelePrEP Pilot: Feb 2017 March referrals (53% PH, 37% self, 10% HIV clinic) 84 (81%) referrals with telehealth visits 79 (94%) visits with PrEP starts 87% retained in TelePrEP at 6 months Local TelePrEP pilot: Feb 2017 March clients (18%) with 20 new STI diagnoses o syphilis o gonorrhea o chlamydia 1 Pregnancy Vaccines series initiated o Hepatitis A 29 o Hepatitis B 9 o HPV 11 6 (2 early) 4 (4 extragenital) 10 (7 extragenital) Home PrEP Testing Kits 10

11 TelePrEP Business Case for Sustainment Visit fee-for-service (subject to Iowa telehealth law) Truvada margin through 340B pricing and specialty pharmacy dispensing Conclusions Telehealth innovation is combinatorial Focus on building partnerships and systems, not on technology Start where you are, use what you have, do what you can - Arthur Ashe 11