Workshop IIC New Approaches to HIV Testing

Transcription

1 Workshop IIC New Approaches to HIV Testing Facilitator: Maureen Malave 8 th The Floor Power 803 of Quality in Programs 1:30AM 3:00 PM Anca 3 rd Giurgiulescu Floor Library Reading Room Improving the Routine HIV Testing Process Wyckoff Heights Medical in an Urban Emergency Department: Facilitator: Julie Shahroudi Center Findings from a Time Study at Wyckoff Heights Medical Center Nadine Akinyemi Loretta Samuels Bridging Access to Care Leveraging QI Activities to Improve Sero-positivity Rate & Linkage to Care Eishelle Tillery Andrew Frazier GMHC Never Too Old to Know Your Status: GMHC s EIP Testing Initiative and Linkage to Care Success

2 Improving the Routine HIV Testing Process in an Urban Emergency Department: Findings from a Time Study at Wyckoff Heights Medical Center The Power of Quality Improvement: Ryan White Part A Providers Work to End the Epidemic November 17, 2015 Anca Giurgiulescu, MPH Director of Prevention Programs

3 Background: Wyckoff Heights Medical Center Safety-net community hospital established in 1889, serves Central and Northern Brooklyn and Southern Queens communities 32% patients live below the Federal Poverty Level 60,000 patients served in 2014 of which 515 patients living with HIV In Brooklyn, 41.5% of persons aged have never been tested for HIV 1. In Bushwick, the rate of HIV diagnoses is nearly double that of Brooklyn: 66.0 vs per 100,000 population 2 Prevention and Care services co-located under one roof, and include: HIV, STD, and Hepatitis testing and treatment; PEP and PrEP; case management and behavioral health counseling NYCDOHMH Community Health Survey ( healthpsi.nyc.gov/epiquery/) 2 NYC HIV/AIDS Annual Surveillance Statistics, 2012

4 HIV Testing Policies at Wyckoff Hospital Testing criteria: All patients aged at least 13 years of age, who have the capacity to consent, will be informed of a routine HIV test at least once during their hospital visit in the Inpatient unit, in the Emergency Room, and in Ambulatory primary care clinics including during Ob/Gyn prenatal screenings. HIV Testing Technology available at Wyckoff Hospital: Screening Tests: 4 th Generation HIV 1 Antigen, HIV 1/2 Antibody (Architect Technologies) HIV 1/2 Antibody Rapid: oral fluid (Orasure Oraquick Technologies) Confirmatory Tests: HIV-1/HIV-2 Multispot / Antibody Differentiation Immunoassay Monitoring Tests: Cobas TaqMan HIV-1 RNA/Viral Load Genotype, HIV-1

5 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 1,400 Wyckoff Hospital HIV Testing ,200 1, Hospital-wide Tested ED Tested Outpatient Tested Inpatient Tested

6 70,000 ED HIV Testing Cascade: January - September ,000 60, % 50,000 45,236 44,803 10% of Triaged 40,000 74% of Triaged 99% of Eligible 30,000 20,000 6,071 5,223 4, , % of Offered 12% of Offered Triaged Eligible ( 13 y.o.) Offered Accepted at Triage Accepted*Adjusted = Accepted at Triage - Declined after Triage 82% of Accepted Adjusted 0.3% of Tested Tested Positive

7 HIV Testing in the Wyckoff Emergency Room 1. Triage Nurse prompted by EMR to offer HIV Test 2. Nurse places HIV test order for Accepted offer. 3. Nurse Technician or Nurse draws blood for HIV testing. 4. Nurse sends blood specimen to Labs via Labs chute. 5. Lab Tech processes test (~ 1 hour) and enters results in EMR. 6. Labs call Director of Prevention and Ordering Physician to inform of Positive test result. 7. Negative results given in person (ED) or via phone (Positive Health). Positive results given in person by HIV counselor. 8. Follow up care/linkage to Care for Positives scheduled at Wyckoff ID clinic or HIV clinic of patient s choice.

8 ED HIV Testing Challenges PEOPLE Insufficient Lab Staffing Insufficient LPN Staffing in Fast Track PROCESS Test not being ordered in triage Specimen not collected until after triage Delay in delivery of specimen to lab Delay in processing results in lab Patients Discharged without Results Policy outdated, did not detail process appropriate to current staffing POLICY Limited space and high volume in fast track Laboratory delays related to utilization of Multi Platform Analyzer (MPA) PLANT Use a fishbone diagram to list the problems

9 ED HIV Testing QI Project Goals: 1. Improve HIV test completion rates 2. Improve HIV test result turnaround cycle: reduce average HIV testing cycle time so that test is processed sooner in ED visit and results available before discharge QI Project Interventions: 1. Modified Process: Shift Nurse ordering and blood draw for HIV testing from Assessment to Triage. Implemented: April Revised Policy: More detailed policy developed including revised roles and responsibilities. 3. Improved staffing: Utilized grant funds to purchase additional LPN

10 Methods: ED HIV Testing Time Study/QI Intervention Evaluation Time stamps were collected from electronic ED charts for: Registration Triage/HIV offer HIV test order Specimen collection Specimen received in labs Results entered in EMR Discharge Data analysis performed on 273 complete records using Excel and averages between time points were calculated: 110 Records in the 3 months pre-intervention (January 1, 2015 March 31, 2015) Compared to 122 records from 3 months post-intervention (May 1, 2015 July 31, 2015).

11 ED HIV Testing Time Study Results January - July 2015 (N = 273) ED HIV Test Time Study: Average Times Jan-Mar 2015 (Pre- Interventio n) Test Accepted to Test Ordered Test Ordered to Specimen Collected Specimen Collected to Specimen Received in Lab Specimen Received in Lab to Results Entered Results Entered to Pt. discharge Registration to Discharge Cycle Time (Test Accepted to Results) Entered 75m 11m 45m 2h 26m -45m 4h 12m 4h 38m May-Jul 2015 (Post- Interventio n) 50m 8m 36m 2h 39m -33m 3h 58m 4h 14m

12 ED HIV Testing Time Study Results Pre -Int Post - Int 20 0 Test Accepted to Test Ordered 11 8 Test Ordered to Specimen Collected Specimen Collected to Specimen Received in Lab Specimen Received to Results Entered

13 ED HIV Testing Completion Rates 140 ED HIV Testing: Completion Rates Jan-Sep % % % 75.8% % % 90.0% % 88.5% 90.0% 88.3% 80.0% 70.0% % 50.0% Missed Tests 2015 Not Ordered % Not Drawn Completion Rate % % 10.0% 0 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep %

14 Lessons Learned & Sustaining Improvements in Quality Monthly meetings with ED nursing to monitor sustainability of improvements in cycle time and test completion Testing Cycle Time reduced from 277 minutes to 253 minutes, but average testing Cycle Time was still greater than ED Cycle Time Test completion increased from 77% to 89% Intervention successfully reduced time in non-laboratory steps, but time for processing in lab increased, offsetting some of the gains Further improvements will be needed to increase the percentage of patients who receive results prior to discharge

15 THANK YOU to the Multidisciplinary Team at Wyckoff Hospital!! Leads: Anca Giurgiulescu, MPH, Director of Prevention Yvonne Spence, MS, RN, BSN, ED Nurse Manager Zachary Dusckas, Medical Student Data Analyst Administration: Gustavo DelToro, MD - CMO Cathy Simon, MS, RN CNO Lisandro Irizarry, MD Chairman, ED Zachariah Hennessey, MA Director, Evaluation Positive Health Management: Olga Badem, MD - ID Jyoti Gupta, MD - ID Stephany Fils-Aime - PHM Emergency Department: Marina Levin, MD - ED Jacinth Green, RN, BSN ED Laboratory: Deborah Sirica, MT ASCP - Lab Carol Anne Thomas, MD - Lab Pamela Berger, MT - Lab

16 THANK YOU! Questions? Comments? Anca Giurgiulescu, Director of Prevention Programs (O)

17 Leveraging QI Activities to Improve Sero-positivity Rate & Linkage to Care Nadine Akinyemi, MHA Loretta Samuels

18 Leveraging QI Activities to Improve Seropositivity & Linkage to Care Rates Introduction Background SNS HIV Testing Model Goals Methods Results Conclusion Lessons Learned Next Steps SNS HIV Testing Model

19 Identify the Barriers Systematize Changes Develop Strategies ESN Quality Improvement Project Process for Identifying and Systemizing Change Evaluate change outcomes Plan and Test Interventions or change Investigate the Strategies

20 Background SNS HIV Testing Model Statement of Problem Social Network Strategy (SNS) testing program challenged by low seropositive rates Unmet projection for 2% seropositivity and 90% Linkage to Care Low linkage to care (LTC) rates for newly diagnosed HIV positive individuals Low HIV testing targets

21 Goal The aim was to use QI methodology within the context of BAC s Social Network Strategy HIV testing program to increase HIV seropositive rate from 0.74% to 1.77% and subsequent linkage to primary care from 67% to 100%.

22 Methods Identify Barriers Recruiters and Network Associates (NAs) Number of HIV tests an NA could receive in the contract year Develop and Test various strategies to increase outcome targets NEW model Service integration with the Brooklyn Men Konnect (BMK) program to target MSMs Target Positive Life Workshops convened at BAC to elicit viable Recruiters Partner with Recruiters to conduct screening, enrollment, and testing of NAs in their neighborhoods or hang outs.

23 Methods Data Collection Baseline Data from Eshare Quarterly site visit data Chart Reviews to include Number of potential recruiters screened, Number of recruiters producing viable NAs, Number of NAs who became recruiters, Quality of screening and orientation process, and Assess target population being reached Direct observation of coaching sessions

24 Methods Use the same data subset to evaluate 2014 and ongoing Develop a contingency plan to mitigate failures and reduce barriers Evaluate data monthly for change in performance after QI activities were implemented Systematize successful changes into daily workflow process for the program Modified or discard unsuccessful changes

25 Results Findings

26 Implementing effective QI strategies improved recruiter and network associate cohort Increase performance Increased seropositivity Results Successful Change Using and collaborative model of service delivery by integrating service with BMK to target specific populations such as MSMs proved a viable team approach Leveraging the resources of HIV-positive individuals such as the Positive Life workshops to target potential recruiters proved productive.

27 Findings: Linkage to Care # New tested HIV Positive # Linked to Care LTC Rate

28 Findings: Changes in Seropositive Rates 3.50% 3.00% 2.50% 2.00% 1.50% 1.00% 0.50% 0.00% Newly Dx Seropositve Rate Overall Seropositive Rate

29 Findings: NA Conversion to Recruiters NA Conversion to Recruiters

30 Findings Overall seropositive rate increased in 2014 Newly diagnosed HIV positive individuals increase significantly from 0.74% in 2013 to 1.83% in 2014 LTC of newly diagnose HIV+ individuals increased from 67% in 2013 to 100% in 2014 # Test Performed # Newly identified HIV In the first 2 quarters of 2015, LTC was at 75% and seropositive rate at 2.6%

31 Conclusion Imposing Effective QI Strategies

32 Conclusion Lessons EFFECTIVE Learned CHANGE Imposing effective QI activities and integrating an evaluation plan to assess the integrity of QI activities can provide important information to inform improvement strategies. Testing and implementing strategies as well as managing interventions can improve access to valuable resources that provide opportunities to achieve expected outcomes. Staff adherence to the integrity of the model augments the success of the program as well as imposed interventions for change. Developing an effective contingency plan can aid in mitigating failures and reducing barriers to program success. Flexibility in engagement approaches to reach targeted populations using specific navigation strategies proved beneficial.

33 Thank You Leveraging QI Activities

34 Never Too Old to Know Your Status: GMHC s EIP Testing Initiative and Linkage to Care Success Eishelle Tillery, MSW: Managing Director of Programs and Prevention Services Andrew Frazier, Client Navigation Specialist

35 Background: In ,575 (18.0%) of newly diagnosed individuals in the US were age 50+ Several factors can attribute to late testing and diagnoses including: Perceived risk because of age Lack of testing by health care providers Centers for Disease Control and Prevention, 2015 Background Goals/Aims Methods Results Discussion

36 Background: EIP Program Collaborates with partners in NYC who provide services to individuals 50 and over. EIP services include: HIV Testing Linkage to care Monitoring Background Goals/Aims Methods Results Discussion

37 Background: Why Target Individuals 40+? Geffen Center observed individuals in their 40 s had similar retention and linkage to care challenges/barriers to those who were 50+ Statistics show that 9,781 (20.5%) of new infections in the US are among people aged (CDC) Centers for Disease Control and Prevention, 2015 Background Goals/Aims Methods Results Discussion

38 Background: Barriers to Linkage to Care for People over 40 Perceived lack of social support from social networks Long term effects of mistrust of medical systems on an individual s desire to seek out medical care Lack of confidence in understanding selfmanagement of HIV in conjunction with other diseases Background Goals/Aims Methods Results Discussion

39 Goals/Aims: Expand targeted testing population by partnering with funder s of EIP program to implement a new policy that includes individuals who are over 40 Background Goals/Aims Methods Results Discussion

40 Methods: Managing Director decided to implement a new policy to change targeted testing population Met with Contract Manager to bring forth new initiative to address this service gap Initiative approved for contract year Linkage to care efforts were ramped up to address the specific needs of individuals testing positive through EIP program Background Goals/Aims Methods Results Discussion

41 GMHC s Linkage To Care Initiative (LTCI)

42 Core Elements of GMHC s LTCI Engage Empower Enhance Enable

43 GMHC s Linkage To Care Initiative: Heavily focused on collaboration with medical providers Most significant being Mount Sinai Medical Comprehensive Center Utilizes a modified ARTAS evidence based intervention approach Developed detailed protocol for tracking LTC & RTC w/ Mount Sinai

44 GMHC s Linkage to Care Initiative: - During pre-test ct. informed of LTC services -Confirmatory test done -CNS meets with client discusses LTC svcs/escorts -Client returns for confirmatory result -Client meets with NYCDOHMH FSU Client receives initial comprehensive visit -CNS obtains CD4 and viral load lab work to verify linkage to care - LNS follows up with medial provider to obtain CD4 and viral load labs at six months and one year & ART info -Medical provider provides ongoing services for treatment adherence -Client receives additional supportive services at GMHC or outside provider

45 GMHC s Linkage To Care Initiative: Linkage Dedicated Client Navigation Specialist (CNS) Same day connection to medical care & supportive services Coordination with medical provider(s) to verify linkage to care and retention in care

46 GMHC s Linkage To Care Initiative: Vital Role of Client Navigation Specialist (CNS) Immediately builds rapport and provides emotional support Escorts client to medical provider Partners with NYCDOHMH Field Services Unit for PNAP Refers clients to support services at GMHC Verification of medical appointments via medical providers Tracks clients through weekly update submissions

47 GMHC s Linkage To Care Initiative: Supportive Counseling Program Supportive counseling program dedicated to newly diagnosed individuals and those who have fallen out of care: Counseling for partners and family members Pastoral spiritual counseling Group counseling Accompaniments, home visits, and provider case conferencing (if needed)

48 Results: EIP Testing and Linkage to Care # of Tested Individuals Through EIP Contract: # of Positive Confirmed Test Results: # of Individuals Successfully Link to Care: Note: numbers are from start of contract till 7/31/ (2.4%) 12 (2.2%) 4 (1.7%) 7 (77.8%) 11 (91.7%) 4 (100%) Note: Seroconversion rate is not based on full contract year, rate subject to change. Background Goals/Aims Methods Results Discussion

49 Discussion: Unique Issues of Clients 40+ Established relationships between clients and primary care providers allows for easier linkage Linkage to care conversations must involve discussions surrounding other aging related health issues (diabetes, heart disease, etc.) Longer history and greater severity of substance abuse and mental health issues Background Goals/Aims Methods Results Discussion

50 Lessons Learned: Individuals 40+ vs. 50+ face similar barriers and challenges when it comes to testing and linkage Initiative alleviated barrier of delayed later diagnoses due to targeted population testing Immediate linkage to care may ensure these individuals will continue to survive despite acquiring virus at later age Background Goals/Aims Methods Results Discussion

51 Questions and Answers

52 Thank You