chronic hiv care with art. challenges to self-management and quality chronic care the acute care...
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Chronic HIV Care with ARTChronic HIV Care with ART
CHALLENGES TO SELF-MANAGEMENT AND QUALITY CHRONIC CARE
The acute care paradigm- Reactive care- Patient who is in office now- Little continuity - Diagnose and treat- No time- Competing demands- Physician centered- No system or infrastructure- Self-Management: “Not my role”
Institute of Medicine & Committee on Quality of Health Care in America (2001) “Crossing the Quality Chasm: A New Health System for the 21st Century; National Academy Press
CHRONIC (PLANNED) CARE MODEL
Acute Care Planned Care
Reactive Proactive
Visit Based Population Based
Little Continuity Planned - Schedule
Diagnose and Treat Assess and Support
Physician Centered
Directed to “Urgent”
Patient Centered
Directed to Major Causes Disease
Wagner E, et al. (1996) Milbank Quarterly 74(4):511-544
Transition to good chronic HIV Transition to good chronic HIV carecare
Common current Common current situation:situation:
Health services Health services provide episodic provide episodic acute care for HIV acute care for HIV complications. complications. [Exception: TB][Exception: TB]
Patient-held records Patient-held records for each acute for each acute episodeepisode
Only organized Only organized chronic care is chronic care is home-basedhome-based
To introduce and scale-up To introduce and scale-up ART:ART:
Need to establish good Need to establish good chronic HIV care in facilitychronic HIV care in facility
Good care by an Good care by an individual doctor or individual doctor or specialist does not specialist does not replace the need for replace the need for establishing good chronic establishing good chronic care with a clinical team!care with a clinical team!
Patient HIV care/ART Patient HIV care/ART record and registers, record and registers, reporting formsreporting forms
Sequence of care Sequence of care
Task ShiftingTask Shifting
Allows non-doctors to play a significant role in Allows non-doctors to play a significant role in HIV care/ARTHIV care/ART both in peripheral facilities and on the district both in peripheral facilities and on the district
clinical teamclinical team
Centralor Provincial
Specialised referral (physicians)
DistrictSupervision and referral
services provided by doctors and/or medical officers
Health CentreFirst-line treatment and care provided by nurses,
clinical officers and ART Aid on clinical team
Community SupportCare and support provided by treatment supporters, community health workers
and care givers from within the community
Community PreparednessMobilization and sensitization to increase treatment
literacy of community
Consider task shifts to allow scale-upConsider task shifts to allow scale-up
Care, treatment & preventionCare, treatment & prevention Specialized physicians to Specialized physicians to
doctorsdoctors Doctors to nursesDoctors to nurses Nurses to Nurses to PLHA HIV care/PLHA HIV care/ART ART
aids—education, psychosocial aids—education, psychosocial support, adherence support, adherence preparation and support can preparation and support can be taught to PLHA, other lay be taught to PLHA, other lay providers, nursing assistantsproviders, nursing assistants
Clinical team to patient: Clinical team to patient: Self-managementSelf-management
Clinical team to community- for Clinical team to community- for treatment support, drug refills, treatment support, drug refills, simple monitoring simple monitoring
TrainingTraining Expert patient-trainersExpert patient-trainers
PLHA on ARTPLHA on ART Present cases, provide Present cases, provide
feedback to health workersfeedback to health workers Patient tracking- treatment Patient tracking- treatment
card to register, monthly reportcard to register, monthly report Choose those who like Choose those who like
particular aptitude particular aptitude PLHA, other lay providers or PLHA, other lay providers or
nursing assistants nursing assistants Build functional clinical teams Build functional clinical teams
within a district systemwithin a district system
Technical basis for task shiftsTechnical basis for task shifts
Emphasize safetyEmphasize safetyValidate ability to make critical decisions Validate ability to make critical decisions
by validation studies (during guideline by validation studies (during guideline development)development)
case review, close supervision, monitoring case review, close supervision, monitoring (during implementation)(during implementation)
ART AidART Aid
Increased need of HR in the context of scale up Increased need of HR in the context of scale up ART Aids (counsellors, health educators, PLWA) ART Aids (counsellors, health educators, PLWA)
are often more effective than doctors and health are often more effective than doctors and health officers/clinical officers at patient education and officers/clinical officers at patient education and adherence support. adherence support.
Basic ART Aid Course is designed for people Basic ART Aid Course is designed for people with little or NO clinical background—LAY with little or NO clinical background—LAY PROVIDERS can become ART Aid PROVIDERS can become ART Aid
Can provide important insights during team Can provide important insights during team meetings about "difficult" patients.meetings about "difficult" patients.
ART AidART Aid speaks the same language speaks the same language
patient as the patient patient as the patient comes from the community to comes from the community to
the clinical team the clinical team is a link with the community is a link with the community knows what is available at knows what is available at
community levelcommunity level progressively learns what is progressively learns what is
needed at community level for needed at community level for ART and HIV care scale up ART and HIV care scale up
inform patients and the rest of inform patients and the rest of the clinical team on the the clinical team on the community services community services
advocates with community advocates with community stakeholdersstakeholders
Roles of the Basic ART AidRoles of the Basic ART Aid
Adherence preparation (includes ART Adherence preparation (includes ART preparation and initiation)preparation and initiation)
Monitoring and supporting patients on ARTMonitoring and supporting patients on ART Post-test and on-going psychosocial supportPost-test and on-going psychosocial support Patient education on HIV/AIDS, disclosure, Patient education on HIV/AIDS, disclosure,
prevention, and positive living in the context of prevention, and positive living in the context of clinical careclinical care
TriageTriage Peer supportPeer support Community supportCommunity support
WHO Basic ART Aid Training WHO Basic ART Aid Training CourseCourse
Index
Section 1 Introduction to the BASIC ART Aid course
Section 2 Roles and responsibilities of the ART Aid as part of the clinical team
Section 3 Care for HIV/AIDS
Section 4 Communication skills
Section 5 Treatment available for HIV/AIDS: cotrimoxazole and ART
Section 6 Adherence preparation
Section 7 Adherence initiation
Section 8 Adherence monitoring and support
Section 9 Prevention in the context of clinical care
Section 10 Disclosure
Section 11 Post-test and ongoing support
Section 12 Positive living
Section 13 Triage
What is needed to integrate community What is needed to integrate community members more effectively?members more effectively?
Lay provider needs to Lay provider needs to "formally" integrated in "formally" integrated in the health system with the health system with regular jobs as trainers regular jobs as trainers and ART Aid. and ART Aid.
"Emergency" policy "Emergency" policy decisions to create new decisions to create new posts for LP in the posts for LP in the context of the clinical context of the clinical team and for community team and for community support and education support and education
3 levels/approaches to communityIntegrated management of HIV/AIDS at facility with linked community interventions: prevention, treatment and care (IMAI/IMCI) Systems for facility-community links: home visits, trace
patients, monitoring, refills, back-up to home-based care CHW training Peer support groups- trained facilitators Use of same patient education flipchart Caregiver booklet
Targeted community interventions with outreach: sex workers, IDU, MSM, othersBroad-based community prevention and treatment preparedness