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 must present CD4 counts and viral loads to VDH every six months to remain eligible, and 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 on a monthly basis 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 2017, 97 clients were enrolled in Direct ADAP. 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 * Visits * that received services at the Inova Juniper Program (IJP) were given the option to continue to receive their medications through our 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. 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 Measure 2.1 Client satisfaction survey 8% ADAP Clinic Client Satisfaction Survey 1% 1% 1% 1% 1% 1% 3% 2% 2% Goal = 95% Agree or 2% 2% 4% 9% 9% Strongly Agree 16% 1 11% 11% 92% 91% 87% 87% 84% 89% 86% 86% 37/37 66/69 82/85 37/37 69/70 82/85 Overall Satisfaction Information was clear Strongly Agree Agree Disagree Strongly Disagree ADAP Client Satisfaction Survey: Services Provided in an Easily Understood Language 2% Goal = 98% 37/37 65/66 83/83 Clinic services were offered in a language I could easily understand. Yes No Survey conducted twice a year, capturing all clients served over a twoweek period, using a paper survey in English and Spanish. response rate was 75%. Satisfaction among those responding to the survey was high on the following areas: receiving services in a language they could easily understand, receiving information that was clear, and being treated professionally by staff and overall satisfaction. Stay the course. Page 3

4 In the response rate increased from 66% to 75% because staff was encouraged to actively ensure clients were doing the survey. Stay the course Satisfaction in these three areas will continue to meet or exceed goal of 95% agreeing or strongly agreeing. Page 4

5 Q4 17/37 Charts 48/193 Charts 128/155 Charts Q4 35/37 Charts 182/193 Charts 152/155 Charts Q4 24/37 Charts 157/193 Charts 118/155 Measure 2.2 Clinical documentation of VDH eligibility, pick-up log, and lab results Goal = 95% 54% Audit of Chart Documentation 5% 6% 2% 2% 17% 17% 35% 19% 24% 24% 46% 75% 25% 83% 83% 95% 94% 98% 98% 65% 81% 76% 76% Current Eligibility Pick-up log Lab Results Correct Documentation Missing Documentation In Q4, 5 of active clients were reviewed. To simplify data collection, all records were audited twice a year starting in. The audit focused on compliance with VDH documentation requirements, specifically current documentation of client eligibility, completeness of the required medication pick up log, and documentation of viral load and CD4. In 65% of clients had all documentation correct, an increase from 27% in. o with current (within 6 months) documentation of eligibility increased to 83% o with complete medication pick up logs increased slightly 98% o with current lab results (within 6 months) decreased slightly to 76% ADAP staff rely on VDH to provide current eligibility and lab result data on all clients through a system called VMARS. The information in the system is out dated and VDH is working to improve the data, especially on eligibility. Public Health Nurses contacted all clients medical providers to obtain the latest lab results. Continue to work with VDH to obtain current data on every client and work with providers to obtain missing lab results. 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 who pick up their medications before they run out 6% 5% 5% 94% 95% 95% 566/603 Pick Ups Goal = 95% 651/688 Pick Ups % of pickups before medication depleted % of pickups after medication depleted At 95% 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 as a way 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. The ADAP team chose one staff member 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. 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 22% 21% 24% 24% 78% 79% 76% 76% 56/72 89/113 66/87 Goal = 9 (projected) 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. without recent viral load results are excluded. was available on 87 of the 97 clients. Per CDC, for surveillance purposes, undetectable viral load is 50 copies/ml 76% of our population achieved viral suppression, which is very high compared to 47% in Virginia and 58% nationally. 1 For clients whose lab results do not indicate viral suppression, we examined the length of time in the program, providers, other health conditions, and frequency of missing appointments. Several clients were new to ADAP, or returning to the program after changes in insurance status, and may have had problems accessing medications with their previous insurance. One client came sporadically, despite the ADAP staff making reminder phone calls for pick up and follow up calls if appointments were missed to find convenient times to pick up medications. 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, 2016, Selected National HIV Prevention and Care Outcomes in the United States, Centers for Disease Control, 2016, Page 7