aps and measurement (icap annual meeting 2007)

2007 ICAP Annual Meeting

Kjersti Schmitz

ICAP New York Clinical Unit

October 5, 2007

Psychosocial Support, Adherence and Measurement


ObjectivesObjectives

• Highlight importance of psychosocial support for patient adherence

• Suggest approach to build clinical capacity for improved patient outcomes

• Consider program measures of adherence support


Psychosocial Support and AdherencePsychosocial Support and Adherence

Patients require a fortified psychological capacity to cope with HIV disease.

Psychosocial support can strengthen patient internal capacity to seek positive treatment outcomes.

Sense of Meaning or Life Purpose “Why do”

Patient Self-Efficacy “Can do”



Attending to patients’ internal psychological capacity for self-care may seem beyond the scope of our work, yet without it, our best efforts are futile. What to do? (the shortlist)

• Build a supportive and responsive therapeutic relationship with each patient

• Learn what matters most to patient; support patient’s search for meaning

• Support patient to identify and adapt ways to care for self and prevent further illness

• Maximize opportunities to provide psychosocial support



Psychosocial support addresses emotional, mental, spiritual, and social needs.

In the context of our programs, psychosocial support can be said to include emotional, informational, instrumental and appraisal support which underpin and facilitate all aspects of patient care and adherence.



Emotional support: Communicates care to patient, building therapeutic relationship between patient and provider or other supporter.

Instrumental support: Provides tangible assistance such as transportation, food aid, or referral to needed services.

Informational support: Provides information, education, and advice on HIV, care regimen, and adherence.

Appraisal support: Provides feedback to help patient assess progress towards a goal, such as adherence assessment.


Begin with a Common GoalBegin with a Common Goal

Patient adherence to HIV care and treatment is a goal shared by providers along the continuum of care

To achieve this goal, the ICAP Model of Care includes a range of interventions to improve patient adherence such as:

Individual and group counseling

Support group meetings

Peer or ‘expert patient’ education

Tracking and tracing systems

Referral to social assistance


Psychosocial Support and Adherence

• Country programs offer a range of psychosocial support, usually carried out by dedicated counselors, peers, or other partners.

• Clinical and psychosocial staff often perceive boundaries of responsibility.

• Many adherence support interventions focus on tracking and tracing, after LTFU occurs.

• Integrated clinical and psychosocial support throughout the Continuum of Care and across cadres helps “prevent” LTFU with proactive, sustained psychosocial support at each opportunity.


Psychosocial Support and Clinical CarePsychosocial Support and Clinical Care

From a position of strengthened mental and social well-being, patients are better positioned to optimize their own health outcomes.

Positive Health Outcomes

AdherenceAccess to Care

Prevention

Support Services

Clinical Services

and Psychosocial SupportAdherence and Psychosocial

Support Activities


Review the ChallengeReview the Challenge

• Aggregate data tell us that patient adherence to care is not optimal, with large numbers of patients failing to return for follow-up care.

• We do not routinely collect patient-level data that can be used to monitor or evaluate program support for adherence

Supposition: Insufficient psychosocial support activities exist along the Continuum of Care to optimize patient adherence and clinical outcomes.


Identify Integration OpportunitiesIdentify Integration Opportunities

Continuum of Care

Each encounter along the Continuum of Care is an opportunity to

offer psychosocial support!

ART Eligible

ART Ineligible

CD4/LabEnrollment

Dia

gn

osi

s

PharmacyPre-ART

Counseling

1st Follow-up CD4/Lab

Referral: FP,STI,TB,PMTCT…

Counseling/Support..

Counseling

LTFU

LTFU

LTFU

LTFU

Follow-up


Develop a Common Approach Develop a Common Approach

With start-up emphasis on enrollment, clinical services, and reporting requirements, psychosocial support can be an adjunct to clinical services. This situation changes when psychosocial support becomes a primary component of patient care.

Suggested Two-Fold Strategy:1. Integrate psychosocial support throughout the Continuum of Care, building program capacity to support patient adherence.

2. Triangulate program characteristics, patient-level adherence measures and measures of adherence support to enable continuous program quality improvement to support patient adherence.


Routinely Collected Routinely Collected AdherenceAdherence Data Data

• CD4 test

• ART pick-up

• Active patients

• Patient outcomes


Measures of Adherence Measures of Adherence SupportSupport

Tell us what support the program offers to patients that may increase or maintain adherence to care and treatment


Program Measures of Adherence SupportProgram Measures of Adherence Support

• Expand on currently reported facility characteristics, and patient-level adherence data such as ART pick-up among ART patients, and timely CD4 testing.

• Enable routine monitoring and evaluation of key aspects of adherence support offered along the Continuum of Care.

• Suggest where to carry out more in-depth, qualitative assessment of ‘how well’ support is happening at the site level.

• Suggest opportunities for integrating psychosocial support for adherence.


Piloted Measures of Adherence SupportPiloted Measures of Adherence Support

Pilot Measure Result

% of patients with completed baseline psychosocial assessment and follow-up plan 69.7%69.7% % of patients seen with at least one counseling session that addresses adherence to care and treatment 60%60%

% of patients on ART assessed for adherence to care and treatment at follow-up visit 27.9%27.9%


Pilot Measure Result

% of patients eligible for ART with completed adherence readiness assessment and ART counseling before starting treatment

60.5%60.5%

% of patients with documented supporter

65.6%65.6%

** Appointment attendance, on-time CD4 testing and

ART pickup measures were also piloted

as measures of patient adherence to care

Piloted Measures of Adherence SupportPiloted Measures of Adherence Support


TriangulateTriangulate

Site A Program Characteristics:

Site A Patient-level Site A Patient-levelAdherence Measure: Adherence Support Measure:ART patients with on-time ART patients assessed forCD4 test result( %) adherence (28%)

A more complete picture is closer to the truth and suggests where to seek clarity.


For Consideration: For Consideration: Measures of Adherence SupportMeasures of Adherence Support

1. # of newly enrolled patients with completed psycho-social assessment and follow-up plan

2. # of ART patients assessed for adherence

3. # of patients seen for follow-up with adherence counseling session

4. # of patients starting ART with completed pre-ART counseling and adherence readiness assessment

5. # of patients with follow-up attempt after missing clinic appointment, CD4 test, and/or pharmacy pick-up

6. # of newly enrolled patients offered referral to (and attending) support group

7. # of newly enrolled patients with designated treatment supporter

8. # of patients initiating ART offered (and received) medication adherence support tools


Take Home Message…Take Home Message…

Integrate - Psychosocial Support with all Adherence and Clinical Services

and

Triangulate – Facility Characteristics, Patient-level Adherence and Adherence Support Data

aps and measurement (icap annual meeting 2007)

Technology

patient support patients

adherence emotional

program support

range of psychosocial

informational support

instrumental support

adherence patients

adherence supposition