engaging hard-to-reach populations into hiv care: inreach

Engaging Hard-to-Reach Populations: InreachMay 1, 2013

Agenda

Introduction to SPNS Integrating HIV Innovative Practices (IHIP) project Sarah Cook-Raymond, Impact Marketing + Communications

Presentations from SPNS grantees on using data to improve inreach Jane Herwehe & DeAnn Gruber, Louisiana Public Health

Information Exchange (LaPHIE) Peter Gordon, New York-Presbyterian Hospital/Columbia

University Jesse Thomas, RDE Systems

Brief post-Webinar questionnaire

Q & A

IHIP Resources:Innovative Approaches to Engaging Hard-to-Reach Populations Living with HIV/AIDS into Care

IHIP Tools on Engaging Hard-to-Reach Populations Training Manual Curriculum Webinar Series

Outreach – April 18; archive recording to be up soon! Inreach – May 1 Empowering the Patient - May 15

Engaging Hard to Reach Populations Engaging Hard to Reach Populations thru In reach thru In reach

HRSA Ryan White spns webinarHRSA Ryan White spns webinarMay 1, 2013May 1, 2013

A Collaborative Initiative funded in part by:

HRSA HIV/AIDS BureauOffice of Science and PolicySpecial Projects of National SignificanceGrant # H9HA08476

A carefully designed two-way electronic information exchange

Uses OPH surveillance data to generate point of care messages for providers in the LSU HCSD (public hospital) system in Louisiana

Targets patients with HIV who have fallen out of care, or never received test results, as well as persons with TB or syphilis who are in need of treatment

LaPHIE ServerLaPHIE DatabaseCommunication system: MIRTH – open source (behind OPH firewall)

Filtered dataset after

business rules applied HIV Surveillance Database Laboratory Database

Target populations:Persons considered “not in care”

(no record of CD4/VL in 9* months)Persons who have not received test results and may be unaware of HIV statusHIV-exposed infants in need of follow-up

Office of Public Health Firewall LSUHCSD Firewall

Admission Information

Registration

EMR

Interface EngineLaPHIE Server

Disease AlertDisease Alert

Response

Disease Alert

Response

Admission Information (ADT)

Disease Alert Response (PRR)

Disease Alert (PPR)

Patient comes to clinic, hospital, or ED for non-HIV service

Real time communication with surveillance system alerts physician that patient needs attention for HIV/AIDS

Physician follows on-screen steps to re-engage patient into care and provide HIV treatment, as appropriate

HIV clinic

10

Established partnership, governance and agreements Assessed and modified technical infrastructure

Designed messaging with iterative prototype process

Conducted consumer research

Participated in an ethics review by national experts in biomedical ethics, public health ethics and AIDS privacy

Requested a legal review of legislation related to sharing of public health information

Raised community awareness and readiness

Prioritized open dialogue and established feedback mechanisms

Essential questions: We have the information and the technical ability to

inform clinicians about patients in need of care … BUT SHOULD WE?

Would this be accepted by patients, providers, and the public?

Do state laws and regulations allow the proposed information exchange?

Is surveillance data reliable as a basis for clinical interventions?

Can we adequately address security/privacy concerns?

Legitimate public health purposes

Respect rights of individuals and communities Seek input from those to be impacted Minimize undue burden

Privacy and security standards

46% <35 years of age Mean age 37.8 years [sd 11.4], median age 36 years

87% black/African American 38% female

21% had no prior labs in OPH system

41% had no monitoring for > 18 months Mean time out of care 25 months (sd 21.0, range 0.2-109 months,

median19 months)

Among 84% with a CD4 following alertAbsolute CD4 mean 282 (sd 235)42% < 200

Among 79% with a viral load following alertHIV RNA copies/mL mean167,488 (sd 467,160) 66% HIV RNA copies/mL > 10,000

Substantial formative and evaluative work with consumers demonstrated acceptability

N=24 qualitative interviews of LaPHIE identified patients Acceptable Positive experience of LaPHIE communication Perception that it is a “good system” System helped re-engage in care

No negative calls to OPH hotline Provider ease of use, acceptable

Source: Qualitative data

Using LaPHIE, we were able to: Identify over 989 (thru 3/31/2013) HIV-infected individuals who

had been out of care thereby reducing missed opportunities to intervene

Offer clinical services to improve individual- and population-level health

Determine that system is acceptable to both patients and providers through feedback processes

Confirm that a well developed, stakeholder involved process promotes success in implementing novel approaches in addressing linkage and retention.

Patient and provider acceptance of the interventions

Stakeholder engagement Management of public opinion Importance of data validity Importance of engaging legal experts early

on Mission/scope/guiding principles and

governance % of hits on persons known HIV+ in the LSU

system already - and possibility to intervene in absence of HIE

Patients

LSU/TU clinicians

UH Infection Control

Delta Region AETC

LSU SPH Medical Informatics & Telemedicine

HCSD CEO, CMO, CIO/CMIO

LIS Core Group

HCSD Programming Support

OPH HIV, STD and TB programs

OPH Nurses

OPH Epidemiologists

OPH Disease Intervention Specialists

OPH Medical Directors

DHH Legal Counsel

LPHI

DeAnn Gruber, PhDAdministrative

[email protected]

ov504-568-7474

Jane Herwehe, MPHProject [email protected]

Louisiana DHH OPHSTD/HIV Program

LSU Health CareServices Division

mailto:[email protected]

mailto:[email protected]

Using Data and Innovative HIT to In-Reach and Out-Reach to Difficult to Engage Populations

Peter Gordon, MDMedical Director, CHPNYP/Columbia

Using Data and Innovative HIT to In-Reach and Out-Reach to Difficult to Engage Populations

The Problem: The HIV care cascade illustrates the falloff that occurs between being ‘linked’ and retained in care, and between ‘receiving’ care and adequately suppressed viral loads. Why are we not doing better? We generally have poor tools to effect group or population managementMultiple IT systems that:

• Do not ‘talk’ to each other• Cannot ‘extract’ information easily• Result in ‘shadow’ processes that

result in duplicative workDivert critical personnel manpower from service provision to data abstraction

The ACA and Health Homes

• The Affordable Care Act of 2010 created an optional Medicaid State Plan benefit for states to establish Health Homes to coordinate care for people with Medicaid who have chronic conditions. CMS expects states health home providers to operate under a “whole-person” philosophy. Health Homes providers will integrate and coordinate all primary, acute, behavioral health, and long-term services and supports to treat the whole person.

Health Home Services• Comprehensive care management• Care coordination• Health promotion• Comprehensive transitional

care/follow-up• Patient & family support• Referral to community & social support

services

So how can we use innovative IT tools to harvest, process, and better utilize all of this very important data that we already collect as part of care provision and care coordination activities?

How much data?

NYP/Columbia must track and manage over 800,000 data elements annually for grant and regulatory reporting purposes:

• HRSA, NYC DOHMH, AIDS Institute, CDC • RSR, AIRS, eSHARE • 95 ‘users’ who need to contribute, add, manage, and export data

So one approach is to ‘tap’ into the ‘Medical Record’ , which in many institutions is typically an amalgamation of multiple electronic systems, tied together by an IT network that exchanges information.

What is the data?

NYC DOHMH MCM Program RW Part D WICY Program

Often duplicative and derived from common sources

So one approach is to find a trusted IT partner, ‘think’ interoperability, and utilize IT tools made available by HRSA and others…

To develop an IT system and approach that utilizes the critical individual information already routinely collected and provides tools for group or population management

Once you have the data what can you do with it? Automated data transfer (HIE)

398,000 data elements updated/added via HIE since March 2012 (demographics, visits/services, staff assignment)

PCP and Care Coordinator Assignment Calculated from HIE visit feeds, highly accurate, no evolutionary divergence

Care Engagement and Population Management Calculated from HIE visit feeds, FORC and LTFU derived, enables care coordination team to generate population level care engagement work lists

How much is automated vs. manual?

0

1000

2000

3000

4000

5000

6000

7000

8000

1 2 3 4 5 6

System Adoption After Launch

Num

ber of tim

es accessed

Week

Admin2%

Clinical7% DBA

8%

Care Coordinator

41%

Medical3%

Socialwork35%

Viewonly4%

Who uses NYP eCOMPAS?

Master Database Master Database

Automated Data Transformation

Engine


Engine

Data Feed 2

6.3 million HL7 Messages

1,000 est. hours saved each year!

1,000 est. hours saved each year!

398,000 Data Elements


PCP and Care Coordinator Assignment Care Engagement and Population Management

Direct Data Integration

Data Feed 3

Data Feed 1

Summary

Using innovative HIT tools and approaches can transform a program’s ability to practice group or population management

Effective, sustainable program in-reach or out-reach efforts require such tools

The diffusion of effective HIT tools need to accelerate if the important goals of the NAS and ACA are to be met

Find good partners, collaborate, innovate, share

And special thanks….. to SPNS!

Especially,Adan CajinaChief, Demonstration and Evaluation Branch

1. SPNS in Hawaii (Part B + Part C)

2. SPNS in New Jersey (Part A)

Two Stories of SPNS-Supported In- Reach InnovationTwo Stories of SPNS-Supported In- Reach Innovation

(The very definition of SPNS replication and adaptation working in very different regions!)

Population 1,288,198

Network Data Sharing Model

SPNS Helps State Part B via Part C Data Exchange Initiative

Data Sharing Combined with

Web-Based Analytical Tools…

Tools

• Visual Analytics

Outcomes

“Life Foundation case managers use e2 for in-reach and engaging hard to reach population by viewing client’s visits to doctors at Spencer Clinic or Waikiki Health Center and lab entry in the service entry sections.” --HIV Care Services Director

331 276

1,260

1,792

-200 400 600 800

1,000 1,200 1,400 1,600 1,800 2,000

ADAP Recertifications

and New Applications

Monthly Reports Requests for RW Assistance

Client Office Visits

Hours Saved by eCOMPAS Per Year

Total of 5,659 Hours Saved by

e2Hawaii Each Year

An additional 2,000 hours of savings is projected by the Waikiki Health Center based on the e2Hawaii Electronic Health Record Data Exchange Module developed by RDE Systems for a total of 5,659 hours saved per year.

Has e2Hawaii helped users view clients’ past treatment history before planning and

providing services to consumers prior to each visit?

160% Improvement

“Also, the case managers can also see if clients are accessing Gregory House or Food Baskets in the service entries section. With that information, the case managers are aware that the client is accessing services and… we can follow-up with the providers. ”--HIV Care Services Director

City of Paterson Part A:A Case Study in SPNS Innovation

Interactive Reports+

Data Sharing+

Proactive Alerts

City of Paterson

“…we have used the Cross Collaborative reports and RSR to achieve same goal of gathering information in order to send letters/make calls and get persons back in care.” --Program Coordinator

eCOMPAS Retention Reporting“In regards to retention, we have used the retention tab as a guide to see which patients needed to be sent letters or make calls to remind them to come in for overdue labs, missed appointments.”– Program Coordinator

Outcomes

Comparative Benchmarks Spur Healthy Competition

Statewide Recognition of Bergen-Passaic Providers

Bergen-Passaic

eCOMPAS SPNS

Agencies

Bergen-Passaic

eCOMPAS SPNS

Agencies

Launching Now:

in+care eCOMPAS Dashboard

•At-a-glance•Visual•Red/Green•Populations•Region vs. Provider•Drilldown

Agency Alerts“We have used the QM tab - summary of current alerts (categories such as Active clients who have not received any services in the past 6 months, missing labs and missed appointment) in order to flag these patients and send reminder letters or make reminder phone calls. We have used the alerts emailed to us to also gather this information and improve retention”-- Program Coordinator

Agency Alerts Drilldown

Email Alerts• Proactive, regular, push notification

• Supervisors are more likely to read email

Outcomes

Usage of Alerts Makes a Difference

Alerts Usage vs. Number of Alerts

2100

2150

2200

2250

2300

2350

2400

2450

11/3/09 11/23/09 12/13/09 1/2/10 1/22/10 2/11/10 3/3/10 3/23/10 4/12/10 5/2/10

Date

Cum

ulat

ive

Num

ber

Of C

lient

s (n

ot u

ndup

licat

ed)

0

50

100

150

200

250

300

350

400

450

500

Cum

ulat

ive

Num

ber

Of T

imes

A

cces

sed

CD4 Past Due

VL Past Due

Alerts Usage

Data entry + charts SPNS QM + Alerts

Undetectable VL improved 38.6%

2006-2007 prior to SPNS, all medical patients

International Journal of Medical Informatics, October 2012

Consumers who access their key care information personally…

are by definition more engaged in their own healthcare…

Care Information.Care Information.


All of your critical medical

history is just one click away

Comprehensive

summary designed to

help you understand

your medical

information without

feeling overwhelmed

Alerts & Reminders.Alerts & Reminders.


Never miss an appointment again, with the easy to use To-Do list.

Alerts help you better manage your health

Emergency Cards.


With MyHealthProfile, you can easily create

and print temporary emergency cards, so

that your

…so that your

information can be

accessed when you

need it the most.

Peter Gordon, MD

NewYork-Presbyterian /

Columbia University Medical

Center

Critical Success Factors

Involvement Responsive and User-friendly Platform Organic process Collaboration

The platform and culture facilitates continuous quality improvement through a direct relation between the system, the process and the people.

ProcessPeople

Technology

Leadership

Process over Product

(from left to right) Denise Coba, Pat Virga, Jesse Thomas, Millie Izquierdo, Jimease Green, Maria Cordova, Doug Mendez, Pricilla Moschella, Jerry Dillard, Ellen McNamara, Larry Rodgers, Blanca Roman, Anthony Fazzinga, Sandra Murillo, Maryann Collins, Irene Panagiotis, Serge

Virodov, Chantia Douglas, Kathy Lebron.

Thank you from all of us on the Paterson SPNS Team…

Q&A

Twitter: @impactmc1| Facebook: ImpactMarCom |www.impactmc.net | 202-588-0300

Connect with UsSarah Cook-Raymond, Managing Director |Impact Marketing +

Communications |

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newsletter email [email protected].

engaging hard-to-reach populations into hiv care: inreach

Health & Medicine

hiv treatment

patientsoph hiv

public health ethics

need of care

good system system

oph surveillance data

hiv rna copiesml

hivinfected individuals