Ensure access to and compliance with treatment for low-income uninsured Virginia residents living with HIV/AIDS

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1 Public Health/ CHSB Lilibeth Grandas x1211 Sharron Martin x1239 Program Purpose Program Information Ensure access to and compliance with treatment for low-income uninsured Virginia residents living with HIV/AIDS The program is federally funded through the Ryan White (RW) Program and administered through the Virginia Department of Health (VDH). PHD administers the Direct ADAP component. o VDH performs eligibility for every ADAP applicant. Criteria includes: Virginia residency, HIV positive, under medical care, CD4* and viral load** lab results within the previous six months, not eligible for Medicaid, and income below 40 of the Federal Poverty Level (FPL). Patients can access medical care at organizations that receive Ryan White funding. o Direct ADAP provides free medications to eligible uninsured individuals. Direct ADAP treating physicians submit medication orders to the VDH Central Pharmacy, which sends a 30 day medication supply to the Public Health Division or an alternate delivery site for patient pick up. The role of the ADAP staff is to: o Inventory, verify, and store medications by patient name. o Send medication requests to VDH monthly for each patient. o When a refill is needed, VDH initiates contact with the prescribing physician. If unsuccessful, ADAP staff follows up with the physician. o Schedule patient appointments for medication pick up, and contact patients to remind them of their appointment the week prior. Contact patients within one week if they miss their pick-up appointment. o Clinic hours are offered weekly, and a nurse is available to answer questions about medications and side effects. Patients can pick up medications outside of clinic hours with the Public Health Division s Nurse of the Day. As of July 2018, 63 clients were enrolled in Direct ADAP. Clients are discharged if they gain insurance, move out of the area, or are closed after 6 months of inactivity as mandated by VDH. Partners: Inova Juniper Program, VDH, Whitman Walker Clinic and private medical providers *CD4: Measures immune system strength **Viral Load: Measures the amount of HIV virus in the blood. PM1: How much did we do? Staff ADAP Total = 1.3 FTEs 0.25 FTE Nursing Supervisor 0.25 FTE Nursing Coordinator 0.4 FTE Public Health Nurse 0.4 FTE Pharmacy Technician Page 1

2 Customers and Service Direct ADAP Clients * 63** Visits *Clients that received services at the Inova Juniper Program (IJP) were given the option to continue to receive their medications through the County ADAP program or to receive them from their HIV medical provider, IJP. In October 2016, 19 of 56 IJP clients decided to transfer their medication pick up to the Falls Church location because it was more convenient. **Client census decreased because many clients have obtained insurance under the Affordable Care Act. A few clients have transferred their care to Neighborhood Health, where they receive many support services and HIV medications. PM2: How well did we do it? 2.1 Client satisfaction survey 2.2 Clinical documentation of VDH eligibility, medication pick-up, and lab results PM3: Is anyone better off? 3.1 Patients pick up their medications before they run out 3.2 HIV positive individuals whose HIV viral load is undetectable Page 2

3 Percent of Clients Measure 2.1 Client satisfaction survey ADAP Client Satisfaction Survey % 11% 11% 11% Goal = 95% 37% 37% 38% 38% 39% 39% 54% 54% 51% 51% 49% 49% 71 Clients 71 Clients 71 Clients Overall Satisfaction How well did we explain things to you? How well did we use a language you easily understood and spoke? Wow Excellent Satisfactory Unsatisfactory A new client survey was implemented as part of the Customer Experience Initiative in public health. Components of customer experience are rated as unsatisfactory, satisfactory, excellent, or wow to match division expectations of delivering an excellent or wow experience to all customers. Survey conducted twice a year, capturing all clients served over a fourweek period, using a paper survey in English and Spanish. response rate was 86%. In, 9 of clients rated their overall customer experience with ADAP services as excellent or wow ; 89% rated how we explained things as excellent or wow ; and 89% rated we used a language that they understood and spoke as excellent or wow. In, the response rate went up from 75% to 86% because the nurses received training to administer the surveys whenever the clients came for med pick up, even if it was not on their scheduled appointment time. Satisfaction will continue at about the same level Stay the course. Stay the course Page 3

4 48/193 Charts 128/155 Charts 66/107 Charts 182/193 Charts 152/155 Charts 105/107 Charts 157/193 Charts 118/155 Clients 88/107 Charts Measure 2.2 Clinical documentation of VDH eligibility, pick-up log, and lab results 17% Audit of Chart Documentation 6% 2% 2% 2% Goal = 95% 19% 38% 38% 24% 18% 18% 75% 83% 62% 62% 94% 98% 98% 98% 81% 76% 82% 82% 25% Current Eligibility Pick-up log Lab Results Correct Documentation Missing Documentation Records are audited twice a year. The audit focuses on compliance with VDH documentation requirements, specifically current documentation of client eligibility, completeness of the required medication pick up log, and documentation of laboratory results. on client eligibility is from VDH. on lab results is obtained from providers. All data is tracked in an Access database. In 5 of clients had all documentation correct, as compared to 65% in and 27% in. o Clients with current (within 6 months) documentation of eligibility decreased to 62% o Clients with complete medication pick up logs stayed steady at 98% o Clients with current lab results (within 6 months) increased slightly to 82% Continue to work with VDH to obtain current data on every client and work with providers to obtain missing lab results. Page 4

5 ADAP eligibility and lab result data on all clients is provided by VDH through a system called VMARS. The information in the system is outdated and VDH is working to improve the data, especially on eligibility. The ADAP team initiates multiple phone calls to the eligibility office in the Virginia Department of Health to obtain proof of 6- month recertification as well as letters that authorize the health department open clients in the local ADAP system. The ADAP staff calls the different medical providers to obtain lab data for each client. In, the Virginia Department of Health made a push to ensure that most clients were up to date on their financial eligibility. This measure was put in place to identify those who were not keeping up with their 6-month recertification or those who could obtain their HIV medications through other venues, even within the VDH system. In, VDH did not keep the same emphasis on ensuring clients kept up to date on eligibility. As a result, the percentage of those with up to date eligibility went down from 83% to 62%. Encourage clients to submit their ADAP recertification eligibility paperwork every 6 months. The percentage of clients with correct documentation will remain about the same in FY Page 5

6 Measure 3.1 Patients pick up their medications before they run out Patients pick up their medications before they run out 6% 5% 6% 6% 94% 95% 94% 94% 566/603 Pick Ups 651/688 Pick Ups Goal = 95% 422/449 Pick Ups % of pickups after medication depleted % of pickups before medication depleted At 94% of medication pick-ups, clients reported they had not depleted their medications. When clients arrive, they are asked if they depleted their medication before picking up the new medication. is tracked in WebVision. The ADAP team started collecting this data to capture trends and find if the same individuals tended to run out of medications. If this was the case, the nurses would follow those clients more closely. The result was that different clients missed medications at different times and there were no clear patterns. Clients that do deplete their medications, almost always pick up their new medications within a few days of depletion. The ADAP team continues to contact every client before their appointment and after any missed appointments. Continue to monitor clients to see if they start a pattern of missing meds and follow them more closely and determine if this is having a negative or positive impact on their laboratory values and in keeping the HIV under control. Stay the course. The percentage of pick-ups where the client reported not depleting their medications will remain about the same in. Page 6

7 Measure 3.2 HIV positive individuals whose HIV viral load is undetectable ADAP clients with an undetectable viral load 21% 79% 76% 89/113 Clients 24% 66/87 Clients 7% 7% 93% 93% 57/61 Clients Goal = 9 Undetectable Detectable is submitted every 6 months to VDH by the clients physicians. PHD requests a report of clients viral loads from VDH twice a year. Figures include all clients open in with viral load results within 12 months of the clients last visit, as results less than 12 months old are still clinically relevant. Clients without recent viral load results are excluded. was available on 61 of the 63 clients. Undetectable viral load defined as 50 copies/ml. 93% of our population achieved viral suppression, which is very high compared to 55% in Virginia and nationally. 1 There were only a few clients that had elevated viral loads in, and even fewer where it was due to the client depleting medication before next pick-up. The drop in the number of clients with a detectable viral load from to was largely due to clients transitioning out of receiving medications directly from ADAP. Among those clients with detectable viral loads in FY 2017 who remained in the program, the majority achieved viral suppression in. Continue to follow clients who did not achieve viral suppression and explore possible ways to help clients adhere to their medications. The percent of clients with undetectable HIV viral loads will be about the same in. 1 HIV Continuum of Care, Virginia Department of Health, 2017, Selected National HIV Prevention and Care Outcomes in the United States, Centers for Disease Control, 2018, Page 7