Routinizing HIV and HCV Testing Using an Innovative, Scalable and Sustainable Dual Testing Model

Transcription

1 Routinizing HIV and HCV Testing Using an Innovative, Scalable and Sustainable Dual Testing Model Catelyn Coyle MPH, MEd Public Health National Symposium June 2014

2 Outline Background Description of model Results How to replicate Challenges Lessons learned Successes

3 NNCC Background National Nursing Centers Consortium (NNCC) PHMC affiliate Supports nurse-managed health centers through technical assistance and capacity building nationally CDC and Gilead-grantee for the project Public Health Management Corporation (PHMC): Public health institute located in Philadelphia Runs 5 Federally Qualified Health Centers Joint Commission accredited for Ambulatory Care and Patient-Centered Medical Home NCQA recognized Patient-Centered

4 Funding Streams Centers of Disease Control and Prevention (CDC) Implement routine HCV testing and continuum of care into community health centers Testing -> Diagnosis -> Specialist -> Treatment -> Cure October 1, 2012-September 30, 2014 Project Goals 4000 tests Ensure 85% of patients with a positive antibody test have a confirmatory RNA test Link 75% of chronically infected patients to specialist care Anticipated 7% seropositivity

5 Funding Streams FOCUS Program- Gilead Sciences, Inc. Implement routine HIV testing and continuum of care into community health centers Concurrent HIV and HCV testing Linkage to Care Coordinator position Start date: August 2, 2013 Project Goals: 5800 tests Ensure all HIV patients are referred to medical specialist and start ART Anticipated 1.5% seropositivity

6 Testing Sites Project conducted in 5 federally qualified health centers PHMC Health Connection Targets patients living in public housing Family medicine PHMC Rising Sun Health Center Ethnically diverse patient population Patient population largely public housing residents Family medicine Congreso Health Center Primarily Hispanic patient population Treats HIV by on-site NP Ryan White funding

7 Testing Sites The PHMC Care Clinic Serves 425 HIV+ patients Ryan White funding Large at-risk patient population for HCV HCV and HIV treated on-site by nurse practitioners, physician assistants, physicians Mono-infected HCV Co-infected with HIV Mary Howard Health Center Only health center in Philadelphia to treat entirely adult homeless patient population

8 Additional Services Available at Clinics Substance abuse All health centers affiliated with in-patient and out-patient programs 1 health center participating in Screening, Brief Intervention and Referral to Treatment (SBIRT) research study Behavioral health On-site behavioral health services Behavioral Health Consultant Psychiatric Nurse Practitioner Part-time Psychiatrist Upcoming opportunities at select health centers Medical Legal Partnerships On-site pharmacy Financial Counseling Services

9 Patient Population of 5 FQHCs >75% homeless or living in public housing Additional demographics detailed in table Patient Demographics Percentage Race/Ethnicity African American 60.1 Hispanic 19.0 White 11.3 Gender Male 51.2 Female 48.8 Insurance Type Uninsured 37.1 Public 57.9 Private 5.0

10 Project Model Routine testing Medical Assistant driven model Opt-out testing Lab-based model EMR modifications Prompt Report to funders Track testing Reimbursement Linkage to Care Coordinator

11 Routine Testing Eligibility Criteria HCV All patients 18 years or older Do not have a previous HCV diagnosis Subsequent risk based testing Tattoos/piercing Drug use Intravenous Intranasal Smoking pipes Annual for HIV+ patients Formally introduced May 2014 HIV All patients 13 years or older Do not have a previous HIV diagnosis Annual testing (4 sites) Semiannual testing (Congreso) More frequent testing based on risk behaviors or at patient s request

12 Screening Protocol Automatic Reminders To identify HIV Run every Friday afternoon on patients with appointments the next week HCV One-time report to target baby boomer birth year cohort ( )

13 Testing Protocol Patient agrees to test Standing orders for MA HCV Order HCV Ab w/ Reflex to Quant RNA, Real-Time PCR HIV Order HIV-1/2 Antigen and Antibodies, 4 th Generation, w/ Reflexes Results back in 2-4 days Performed by Quest Diagnostics and Labcorp Upload test results into patient chart Abnormal results highlighted in red

14 Billing and Reimbursement Protocol Uninsured lab work Run through Quest Diagnostics HCV Chronic uninsured patient: $60 o HCV Antibody Test: $9.98 o Quantitative RNA Confirmatory Test: $50.02 HIV HIV-1/2 Antigen and Antibodies, 4 th Generation, w/ Reflexes: $14 HIV-1/2 Differentiation: $14 HIV 1 RNA, QL, TMA: $ Uninsured labs billed to Hep C Project account Facilitates billing Quest Diagnostics bill comes to Project Manager

15 Results Disclosure Protocol Test Results Negative Follow health center policy given at next appointment Positive Not given over the phone Health center staff member inform patient they need to come in to discuss lab results o Appointments typically made within 2 weeks of call for HCV and as soon as possible for HIV

16 Follow-Up Referred to Linkage to Care Coordinator by provider or RN Automatic prompt to alert provider to contact for HCV patients On-site services for positive patients Monthly support group Biweekly education classes (HCV only) Referral coordinator Social worker

17 Insurance Status If insured Referred to medical specialist Academic Medical Center Congreso (HIV) or PHMC Care Clinic (HIV/HCV) Research project If uninsured Referred to on-site Social Worker and Certified Application Counselor to start insurance application Referred to medical specialist, once insured

18 Applying for Insurance Types of insurance If below financial cutoff Eligible for Medicaid Fill out Medical Assistance form and submit paperwork to DPW Start with Medical Assistance then choose Medicaid managed plan Have 1 month to take supporting paperwork in to DPW after MA forms are If above financial cutoff Not eligible for Medicaid ACA marketplace Medical Assistance for Workers with Disabilities (MAWD) Emergency only HIV+ uninsurable If need lots of medical care/access to specialists: Health Department If stable: fee assessed and connected to Special Pharmaceutical Benefits Program (SPBP)

19 Linkage to Care Coordinator Contacted by health center directly Gets weekly list of positive HIV and HCV tests from Project Manager Tracks all patients with positive HCV tests starting 10/1/2012 and positive HIV tests starting 9/1/2013 Responsibilities Notify providers of patients that were no show or have not scheduled follow-up appointments Calls patients that are no shows Aids in rescheduling Identifies and addresses barriers for patient Determines if patients are lost to care and why Emergency contact Field visit

20 Linkage to Care Services Patient escort to appointment to receive results and first 2 medical specialist appointments Transportation services Tokens Cab vouchers Translation services Bilingual English and Spanish Arrange translation services at visit

21 HCV Testing Results 3,512 Patients Tested 291 Ab+ (8.3%) 3,185 Ab- 36 not resulted 263 had RNA test 28 did not have RNA test 174 RNA+ (66.2%) 89 RNA-

22 HCV Linkage Results 174 RNA+ 146 Received Results 28 have not received results 111 Referred to Specialist 28 not referred 42 went to specialist appointment 69 in process

23 HIV Testing and Linkage Results 3,551 Patients Tested 9 HIV+ (0.25%) 3,540 RNA- 2 indeterminate 7 went to first medical appointment 2 lost to care 6 went to second medical appointment 6 on ART

24 Previous HCV Screening Criteria All patients born between 1945 and 1965 Do not have a previous HCV diagnosis CDC s traditional risk based testing Tattoos/piercing Drug use Intravenous Intranasal Transfusion Homeless Past/Current

25 Results Before/After Bundling Labs Health Center Tests Performe d Monthly Average New Ab+ Identified Seroprev (%) Tests Performe d Monthly Average New Ab+ Identified Seroprev (%) Mary Howard Rising Sun Health Center PHMC Health Network Overall Change /1/2012-8/31/2013 9/1/2012-4/30/2014

26 Institutional Policy Change Changing dynamic from reactive medicine to proactive Buy-in early from all health center staff HIV and HCV workgroup to address systems level barriers to continuum

27 Integrated Testing Model Decreases the amount of added work for the health center staff Input from all positions at the health center Provider versus MA initiated testing Analyze patient flow to develop protocol When are labs drawn? Service integration at point of access: bundle tests and services Increases likelihood that patient will agree to testing if only need to get labs drawn once Be willing to change Adjusting protocol to meet the specific patient population

28 EMR Modifications Prompt Testing and services Billing Add separate account for requisition Reports Monitor testing progress Disseminate to health center staff

29 EMR Modifications Data uploads/organization Algorithm to extract reporting variables Templates to collect reporting variables

30 EMR Modification Results and Post-test Counseling for HCV Patients

31 EMR Modifications Organize data Patients that opt-out 11

32 EMR Modifications Patients that opt-out

33 EMR Modifications Organize data Patients that have not had test

34 Provider Training Initial training Disease etiology and epidemiology Lab results Which patients to refer Risk factors Important for Medical Assistants as providers Project specific training For entire health center- protocol affects all health center staff Medical Assistants- what is opt-out testing Provider continuing education Peer-to-peer education Updates on research, new treatments, new guidelines

35 Challenges Low linkage to care rates Patient no shows Create Linkage to Care Coordinator position Decrease barriers Money budgeted for patient travel Patient escorts Provider not referring HCV patients Peer-to-peer provider education training for primary care providers

36 Challenges Inconsistent testing numbers Weekly reports and data updates Total tests ordered and by health center Patients with positive tests Send numbers to clinical directors and MAs

37 Lessons Learned Bundle labs Increases average number of tests performed 10/1/12-8/30/13: 145 HCV tests/month 9/1/13-4/30/14: 211 HCV tests/month Eliminate risk-based HCV testing Asking screening questions was a barrier Missing patients with no known risk factors

38 Successes Routinized HIV and HCV testing across multiple sites using innovative model Able to test roughly 3,512 patients for HCV within 19 month period and 3,551 for HIV within 8 month period Diagnosed 174 new chronic cases of HCV and 9 new HIV cases of which 2 were acute that would not have been identified without standardized testing protocol

39 Successes Primary care providers able to treat HIV and chronic HCV patients as part of multidisciplinary team Improved linkage to care rates using Linkage to Care Coordinator Eliminating risk-based testing gives accurate disease burden amongst FQHC network and identifies patients with no known risk factors

40 Catelyn Coyle MPH, MEd Public Health Project Manager