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Service Delivery Innovation Profile

Comprehensive, Patient-Centered Program Incorporates Strategies That Help HIV Patients Maintain Their Health, Leading to Enhanced Adherence, Better Outcomes, and Fewer Deaths


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Snapshot

Summary

Christiana Care Health Services has a comprehensive program incorporating a multidisciplinary, patient-centered approach to care delivery that assists human immunodeficiency virus patients in maintaining their health. The program includes a variety of strategies to support comprehensive care for human immunodeficiency virus patients, encourage patients' responsibility for their own health, and help patients remain connected to their providers to enhance adherence. Strategies include visit reminder calls, followup calls when visits are missed, a patient self-management program, patient advisory committees, use of peer educators, “fast-track” visits for stable patients, onsite specialty clinics, and a pharmacist-run medication adherence program. Pre- and post-implementation comparisons show that the program has increased treatment adherence, improved clinical outcomes, and reduced human immunodeficiency virus–related mortality.

Evidence Rating (What is this?)

Moderate: The evidence consists of before-and-after comparisons of key outcomes measures, including the percentage of patients adherent to their visit schedule, the percentage of patients on HAART, viral load, CD4 count, and HIV-related mortality.
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Developing Organizations

Christiana Care Health Services -- HIV Program
Wilmington, DEend do

Date First Implemented

1999
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Patient Population

Vulnerable Populations > Medically or socially complexend pp

Problem Addressed

Many human immunodeficiency virus (HIV) patients fail to show up for scheduled visits and find it difficult to follow medication regimens, leading to poorer clinical outcomes.
  • Lack of adherence a common problem: Adhering to prescribed HIV visit and medication regimens can be extremely challenging, given the multiple medications and complicated visit and dosing schedules required; adherence is especially difficult for patients with psychosocial factors such as mental illness, substance abuse, and low socioeconomic status.1 On average, HIV treatment programs experience a 15 percent lost-to-followup rate each year, with some programs reaching as high as 30 percent.
  • Leading to poor clinical outcomes: Poor adherence (particularly with medication regimens) compromises patients’ health status,2 leading to treatment failure and the development of viral resistance and associated infections.3

What They Did

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Description of the Innovative Activity

As part of its comprehensive medical management of HIV offered at seven sites throughout the state of Delaware, Christiana Care’s HIV program offers a patient-centered approach to care delivery that encourages patient self-management and medication adherence and fosters a connection between patients and the clinic's providers. More details on each strategy appear below:
  • Patient self-management program: Christiana Care offers a "positive self-management program," based on Stanford University’s Chronic Disease Self-Management Program, which teaches patients strategies for managing their condition. The premise is that patients who understand their illness, its implications, and appropriate symptom management can converse more effectively with their clinicians and achieve better clinical outcomes. A trained HIV program staff member and a peer educator colead the program, which is delivered to patients in 2-hour sessions held weekly over the course of 6 weeks. Sessions focus on goal setting/achievement and the development of action plans, covering topics such as life skills, disclosure of HIV status, stress management, the need for exercise, healthy eating habits, and managing medication side effects.
  • Medication adherence program: A clinical pharmacist leads medication adherence sessions with patients before the initiation of treatment and as needed thereafter. These one-on-one appointments allow pharmacists to evaluate a patient's readiness to adhere to his or her regimen (including, for example, whether the patient has a refrigerator and how the patient plans to incorporate the medication regimen into his or her daily life), to identify triggers to help achieve maximum adherence, and to help apparently nonadhering patients improve their ability to take medications as prescribed. A patient may have several preparatory sessions before being placed on medications. Sessions continue until clinicians confirm that the patient is stable and not suffering from significant side effects. Patients who have difficulty with medication adherence continue to be seen indefinitely for a weekly “pillbox fill,” in which the pharmacist arranges all medications in a weekly pillbox for ease of use. Information provided in August 2010 indicates that the HIV program pharmacy team has developed two new initiatives. The first is "TEAM 95," which involves group medication readiness and adherence visits. The second is focused on patients who have had "blips" in their viral load levels (previously undetectable, now slowly increasing) to identify hidden causes before viral resistance develops and medications must be changed.
  • Onsite specialty clinics: Specialists hold clinics at the HIV program site to provide one-stop, convenient care to patients. Clinics are offered for renal care, general internal medicine, mental health care, hepatitis C treatment, and women’s health. Clinic frequency varies from twice a week for commonly used specialty services to once a month for less often used services. (For more information see the associated Innovations profile Co-Locating Gynecological Services Within an HIV Clinic Increases Cervical Cancer Screening Rates, Leading to Identification and Treatment of Many Cancer Cases.)
  • Fast-track visits: Fast-track visits are available for less complex, stable patients, thereby reducing waiting times. Patients arriving at the clinic receive their usual intake assessment by a nurse; those found to be stable and taking their medications are triaged to a nurse practitioner, who provides basic care and assessment.
  • Telephone reminders and followup: Front-office staff place reminder calls to all patients several days before scheduled appointments. If a patient misses an appointment, staff call the patient the next day to reschedule it. If the patient cannot be reached by telephone after numerous attempts, the office will mail an appointment reminder. Clinicians “tag” the files of high-risk patients, spurring particularly aggressive telephone/mail followup with these individuals.
  • Peer educators: Three full-time peer educators serve the seven sites. Peer educators are patients who are managing their disease successfully and who have an interest in counseling others. Formally trained by the HIV program director, peer educators provide basic education and support during informal meetings with other patients (often held in the waiting room), offering information about HIV, medications, side effects, and lifestyle issues. Peer educators inform the nurse or the physician if a patient raises particular questions or offers pertinent information about his or her condition or circumstances.
  • Patient advisory groups: Three patient advisory groups (one located in each Delaware county) offer patients the opportunity to have direct input into HIV program development and evaluation. Meetings, which range in size from 10 to 20 participants, are cofacilitated by a patient and an HIV program staff member. Members of each group set their own meeting schedules, agendas, and rules of conduct. Dinner is provided at each meeting. Patient advisory group feedback has led to minor changes (e.g., adding coat hooks in the waiting rooms) and to more significant reforms (e.g., establishing onsite phlebotomy services). Participation is solicited via waiting room flyers and clinician discussions with patients.
  • "Young at HAART" program: Information provided in July 2011 indicates that the pharmacy team has developed a women/youth medication adherence support group called "Young at HAART" (named after highly active antiretroviral therapy). Support group meetings are held on a monthly basis, with discussions focusing on life skills and medication adherence.

Context of the Innovation

The Christiana Care Health Services HIV Program, the largest provider of HIV/acquired immunodeficiency syndrome (AIDS) care in Delaware, provides care to 1,653 patients (approximately 65 percent of all HIV patients receiving care in the state). Most patients are insured through Medicaid or Medicare, although some have private insurance and some are uninsured. Beginning in 1999, the Christiana Care HIV Program, as a Ryan White Part C grantee,4 was invited to participate in an 18-month Institute for Healthcare Improvement (IHI) Collaborative to improve clinical outcomes for HIV patients. Collaborative participants learned about plan-do-study-act (PDSA) cycles and developed quality improvement strategies based on the Chronic Care Model,5 a salient feature of which is provider support of patient self-management. Participation in the collaborative prompted Christiana Care to develop and measure the impact of its strategies.

Did It Work?

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Results

Pre- and post-implementation comparisons show that the program has increased adherence with visit schedules and medication regimens, improved clinical outcomes, and reduced HIV-related mortality.
  • Increased adherence: The percentage of patients adherent to their visit schedule increased from 54 percent in 1999 to 87 percent in October 2008. Information provided in August 2010 indicates that visit adherence has been sustained at 86 percent in 2009. The percentage of patients on HAART increased from 62 percent in November 2000 to 92 percent in October 2008; as of 2009, this number was 84 percent. In 2008, the program’s lost-to-followup rate was 8 percent a year, well below the national average of 15 percent; in 2009, this lost-to-followup rate further decreased to 3.7 percent. In 2010, adherence to visits was 88 percent and the lost-to-followup rate was 4 percent. Information provided in July 2012 indicates that in 2011, adherence to visits increased to 89 percent and the lost-to-followup rate was 4 percent. Information provided in 2013 indicates that in 2012, adherence remained at 89 percent and the lost-to-followup rate dropped to 3 percent.
  • Improved clinical indicators: The percentage of patients with an undetectable viral load (a concentration of the virus of less than 400 copies/mL, which suggests that medical therapy is working) increased from 61 percent in November 2000 to 81 percent in November 2008; information provided in August 2010 indicates that 76 percent had undetectable viral loads in 2009. The percentage of patients with a CD4 count greater than 200 cells/mm3 has remained stable over time, at 71 percent. (CD4 cells, also known as T-cells, play an important role in the immune system and are a common target of HIV infection.) In 2010, 87 percent of patients were on HAART and 75 percent of patients had undetectable viral loads. Information provided in February 2013 indicates that in 2011 and 2012, the percentage of patients on HAART remained constant, and 78 percent of patients had undetectable viral loads. 
  • Fewer HIV-related deaths: The HIV-related mortality rate among Christiana HIV program patients decreased from approximately 6.5 percent in 2000 to 3.5 percent in 2007; the mortality rate further decreased to 2 percent in 2009. Information provided in July 2011 indicates that the mortality rate in 2010 was 2 percent, with 50 percent of deaths not HIV-related. Information provided in July 2012 indicates that in 2011, the mortality rate dropped to 1.5 percent. Information provided in February 2013 indicates that this rate remained constant in 2012.

Evidence Rating (What is this?)

Moderate: The evidence consists of before-and-after comparisons of key outcomes measures, including the percentage of patients adherent to their visit schedule, the percentage of patients on HAART, viral load, CD4 count, and HIV-related mortality.

How They Did It

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Planning and Development Process

Selected key elements of the planning and development process included the following:
  • Joining the IHI collaborative: Christiana Care’s HIV program was invited to join the IHI HIV/AIDS collaborative. Christiana Care staff members, including the program director, the continuous quality improvement coordinator, and others, participated in periodic inperson meetings and conference calls over an 18-month period.
  • Developing improvement initiatives: The first PDSA cycle that Christiana Care staff members designed involved having a secretary make reminder calls to patients on the schedule and then tracking the impact of these calls on lost-to-followup rates. Other strategies (such as the fast-track visit) were identified based on staff input and patient suggestions and then were designed, tested, and evaluated through additional PDSA cycles.
  • Training providers and peer educators: Trainers from the Stanford University Chronic Disease Self-Management Program led a 1-week, onsite workshop at Christiana Care for more than 20 providers. During this session, staff members learned to teach patients to self-manage their conditions and set realistic goals. The HIV program director identified and trained the peer educators and designated a staff member to oversee the peer education program.

Resources Used and Skills Needed

The resources required to operate this program include the following:
  • Staffing: Information provided in August 2010 indicates that the program employs 3 full-time peer educators; the rest of the 52-member staff of Christiana's HIV program incorporate the patient-centered approach and associated strategies into their existing work. This staff includes six infectious disease physicians, two internal medicine physicians, one obstetrician/gynecologist, one psychiatrist, three licensed clinical social workers, as well as primary care nurses, nurse practitioners, pharmacists, psychologists, counselors, and administrative staff.
  • Costs: Program-specific expenses include training from Stanford University, salaries for the peer educators, and meals provided during patient advisory group meetings.
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Funding Sources

Health Resources and Services Administration; Christiana Care Health Services
A grant from the U.S. Department of Health and Human Services Health Resources and Services Administration covered the costs of the Stanford University training.end fs

Tools and Other Resources

Information about Stanford University’s Chronic Disease Self-Management Program is available at:
http://patienteducation.stanford.edu/programs/cdsmp.html.

Adoption Considerations

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Getting Started with This Innovation

  • Set quantifiable, achievable goals: Measure baseline data, set specific quantitative goals, and then work toward achieving them.
  • Have dedicated champions oversee improvement: New processes and programs seldom get implemented without designating someone as being responsible for design and implementation.

Sustaining This Innovation

  • Elicit and incorporate patient input: Do not make assumptions about what is important to patients. Rather, ask patients to offer relevant, actionable suggestions for improvement.
  • Support peer educators: Remember that peer educators are also patients. Support them in their work, and be understanding when they cannot be at work due to health issues.

More Information

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Contact the Innovator

Arlene Bincsik, RN, MS, CCRC, ACRN
Program Director
Christiana Care Health Services
HIV Program—Wilmington Annex
1400 Washington Street
Wilmington, DE 19801
Phone: (302) 255-1311
E-mail: abincsik@christianacare.org

Robin Bidwell, BSN, CCRC
CQI Coordinator
Christiana Care Health Services
HIV Program—Wilmington Annex
1400 Washington Street
Wilmington, DE 19801
Phone: (302) 255-1307
E-mail: rbidwell@christianacare.org

Innovator Disclosures

Ms. Bincsik and Ms. Bidwell reported having no financial or business/professional affiliations relevant to the work described in the profile other than the funders listed in the Funding Sources section.

Footnotes

1 De Truchis P, Bideault H, Linard F, et al. Treatment compliance in HIV-infection among populations presenting with multiple adverse social factors. Int Conf AIDS. 2000 Jul 9-14;13: abstract no. ThPeB4977. Available at: http://gateway.nlm.nih.gov
/result_am?query=102241453&id=102241453&itemnum=1&amhighlight=Yes&amsort=Relevance
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2 Slama L, Le Camus C, Amiel C, et al. Adherence to antiretroviral therapy during HIV infection, a multidisciplinary approach. Med Mal Infect. 2006;36(1):16-26. Epub 2005 Dec 1. (Article in French) [PubMed]
3 El-Atrouni W, Berbari E, Temesgen Z. HIV-associated opportunistic infections. Bacterial infections. J Med Liban. 2006;54(2):80-3. [PubMed]
4 Part C of the Ryan White Modernization Act, enacted in 1990, provides direct grants to public health clinics and private community-based providers who offer AIDS/HIV services to uninsured and underserved individuals in the most medically vulnerable populations, including minorities, women, and low-income populations.
5 Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Eff Clin Pract. 1998;1(1):2-4. [PubMed]
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: September 02, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: March 26, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: February 15, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.