HIV Quality of Care Advisory Committee Meeting Las Americas, 55 Exchange Place, New York, NY June 9, 2016, 12:00PM 5:00PM

Transcription

1 HIV Quality of Care Advisory Committee Meeting Las Americas, 55 Exchange Place, New York, NY June 9, 2016, 12:00PM 5:00PM AGENDA ITEM/TOPIC DISCUSSION/ACTION ITEMS RECOMMENDATIONS/FOLLOW-UP Welcome and Announcements Drs. Pete Gordon, Kelly Ramsey, and Christine Kerr CAC Update Julian Brown and Michelle Lopez - Dr. Pete Gordon welcomed the committee and introductions were made around the room. - A special welcome was extended to the visiting Haitian delegation. - Julian Brown gave a brief overview of key discussions from the Consumer Advisory Committee meeting the day before. Key highlights included a review of new CAC bylaws, discussion about prioritized ehivqual indicators, selection of key populations on which to focus stigma reduction efforts, and conversation about consumer engagement in the ETE Dashboard. The G.R.E.A.T. Study Dr. Kevin Fiscella and Michele Boyd - Dr. Kevin Fiscella and Michele Boyd delivered a presentation on Get Ready and Empowered About Treatment (G.R.E.A.T.), a PCORI-funded study currently being conducted at the University of Rochester. The objective of this study is to improve PLWH s engagement in their healthcare by providing them with an ipod application that allows them to create and monitor their own customized personal health record. To measure the effect of the intervention on patient empowerment, the study used the Patient Activation Measure, a tool developed by Hibbard et al., to assess patients perceived confidence, autonomy, and proactivity in managing their health. While the study is ongoing, interim results showed significant improvements in patient empowerment. - Participants asked questions about the study, including how subjects stayed engaged with the application, continued use of the application following study initiation, difficulties encountered with subjects who were not technologically savvy, and lost or stolen study materials. - The presenters responded that this is currently the only interactive health record that has been made available to consumers. As this study is ongoing and complete 12-month data has yet to be collected, the presenters could not say for certain whether use of the application decreased among study subjects over time. The presenters opined that peer learning, social support and ongoing application alerts could be leveraged to enhance program sustainability and keep patients engaged. Trainings were designed to ensure proper understanding and use of the application. Very few ipod devices and other items were stolen during the study. - Participants requested clarification regarding application features, including automatic reminders, medical record synchronization, tracking the simultaneous use of other applications, and dependence on Wi-Fi or cellular data. The presenters responded that the application features automatic appointment and medication reminders, and that personal health information cannot be automatically synced with electronic medical records and must be entered manually. To respect user privacy, data were only extracted from the application and not from users devices. WiFi or cellular data are only needed initially to download the application.

2 Improving Flow and Using Checklists to Improve Quality at Gobabis State Hospital Dr. Leonard Kabongo - Senior Medical Officer Dr. Leonard Kabongo gave a presentation on efforts to improve health outcomes at Gobabis State Hospital in Namibia. These efforts focused on perioperative safety, maternal and newborn outcomes, and linking PHC/HIV/SRH services. To address these issues, the hospital implemented an adaptation of the WHO s Surgical Safety Checklist and Safe Childbirth Checklist. By the end of the implementation period, checklist usage was 100% and mortality fell to 0%. This quality improvement project also resulted in a 25% reduction in high risk practices after only three months. - In addition to checklists, the hospital adopted a model of integrated services in ambulatory care supported by UNFPA and WHO which involved redesign of clinic flow. The model resulted in more centralized care, increased retention and ARV medication pick-ups in each nurse prescriber s patient room, improved efficiency, and heightened levels of patient and staff satisfaction. Dr. Kabongo s project also resulted in decreased levels of perceived stigma among patients. - In response to questions about generating staff buy-in and consumer involvement, Dr. Kabongo explained that buy-in was enhanced by training and empowering staff members. Patients were involved using service evaluations before and after project implementation. Dr. Kabongo emphasized that many patients valued being paired with a nurse who spoke their language. Measuring the Social Determinants of Health: e-icare Sabrina Ramos, Miguel Mendez, Ginny Shubert and Chanchal Gandhwani Using Data Systems to More Effectively Address the HIV Epidemic in Haiti Kurt Jean Charles - The Housing Works IT team presented an overview of e-icare, an electronic record system that is used by all of their supportive services programs and as a tool to coordinate care. The presentation focused on three major features of this system: (1) structured fields for assessing social determinants of health using validated assessment tools and required assessment tools from funding agencies; (2) an internal communication tool between medical and non-medical service providers to coordinate care that allows sharing of records, forms, and internal messaging systems; and (3) an innovative platform developed in collaboration with Healthix that allows information from the Regional Health Information Organization (RHIO) to be sent as an alert to the agency service providers and community organizations participating in their network in Brooklyn when patients are hospitalized or using emergency services. - The presenters mentioned that the tool was initially developed to reduce the number of redundant assessments. - The presenters concluded by discussing ways the system could help coordinate care. Next steps include the addition of a predictive analytics component to the software so users can track their health outcomes. - Kurt Jean Charles, of Solutions SA, the contractor for the Ministry of Health in Haiti assigned to design and manage its integrated data warehouse, presented a review of the informatics platform used to address the HIV epidemic in Haiti. The three core goals of the program that he and his colleagues developed are to (1) empower care providers, (2) build awareness of the HIT system, and (3) engender accountability. - The data platform provides real-time information on the epidemic by integrating electronic health.

3 records, surveillance and monitoring reporting systems, as well as QI program data. Additionally, it now includes a new community health tracking feature to improve retention in care. - The Haitian informatics platform began with an aggregate reporting platform, primarily to report outcomes and processes to funding agencies such as PEPFAR. Local and national HIV dashboards have been generated. In 2005, the country introduced a national EMR system which is currently used by approximately 145 clinical sites. The EMR automatically populates the aggregate reporting system. A case notification platform, which satisfies mandatory reporting requirements, is embedded in the same web platform. - The newest system for community health tracking, developed by NASTAD, automatically lists patients in the HIV registry who lack evidence of HIV care in the past 200 days and is updated daily. - For patients lost to care, community health workers enter into the system the circumstances under which the patient was lost to care, including refused to come back, lost to follow up, voluntarily changed HIV providers, or deceased. The task allocation system algorithmically assigns tasks to community health providers; many tasks are related to acquiring more information to confirm whether that the person is truly lost to care. Stigma Subcommittee Update Dr. Barry Zingman ehivqual 2015 Indicator Review Results Dr. Bruce Agins - Dr. Barry Zingman presented a brief update on the stigma subcommittee. The group has decided to use the Health Policy Project s globally tested Measuring HIV Stigma and Discrimination among Health Facility Staff comprehensive questionnaire, developed by Laura Nyblade and colleagues, to measure organization-level stigma in NYS healthcare facilities. Subcommittee members elected to add questions to the Nyblade tool to measure population-specific stigma. - Dr. Zingman shared results from the Delphi survey conducted at the June 8th CAC meeting to select five key populations on which to focus Results from 23 consumer responses indicated that transgender individuals, individuals of color, MSM, women, and individuals with a mental health diagnosis should be prioritized. Participants expressed concern about stigmatized populations that the CAC did not select to address in the survey. In the following discussion, it was noted that, although only the five selected key populations would receive direct attention, everyone would stand to benefit from the baseline effort being made to address stigma. - Dr. Bruce Agins divided his presentation into two parts. First, he presented draft results from the ehivqual 2015 Indicator Review. This review includes only preliminary data from Azara sites (described further below). He then discussed the results of a survey sent to members of the CAC and QAC which aimed to determine which ehivqual indicators were most important moving forward. - The 2015 NYS ehivqual data report consists of traditional data, generated by facilities through chart reviews, and Azara data, generated from Federally Qualified Health Centers (FQHCs) that extracted data from electronic medical records (EMRs). The complexity of data mapping for the Azara system caused delays and discrepancies that led to two separate reports, Azara and non-azara. Ultimately, it - Develop supplemental survey questions to identify practices in healthcare facilities that stigmatize the five prioritized key populations. - Finalize provider/staff survey and disseminate. - Identify/develop a second survey to measure organizational stigma from a consumer perspective. - The NYCDOHMH is conducting a comprehensive site survey to acquire details on providers and facility practices. - Decisions about measures for the 2016 ehq data will

4 Update on Service Utilization Among PLWH Lost to Care Daniel Feller was decided that comparative numbers will be published rather than a single consolidated report. The final report is delayed until the data issues are sorted out with the Azara files. Since not all of the data quality issues had been resolved by the time of the presentation, the data presented were noted to be preliminary. Assigning patients to clinics and determining patient eligibility for review were two major challenges associated with the use of the Azara database. - Dr. Agins highlighted patient retention, which rose 2% from 2013 to 2014 in the non-azara data. While the Azara sites were shown to have lower retention rates, it was noted that additional analysis is required to determine if this lower performance in Azara is significant. There tended to be more discrepancies in VLS between Azara and non-azara data in the bottom quartiles which included a number of community health centers. The data showed good performance for the ARV measure with a surprisingly wide range of scores from the 1st to 3rd quartiles. Additionally, it was mentioned that Azara facilities may include more low-census sites than the non-azara sites, although historical scores are roughly comparable, suggesting that this did not skew the results. - Dr. Agins reported that there continue to be issues with extragenital and pharyngeal testing rates for gonorrhea and chlamydia without significant improvement from last year. Screening rates are higher in the Azara data, which includes several sites with a long history of providing care to the LGBT population. Surprisingly, facilities in the bottom quartile had an overall screening rate of 0%. These facilities are likely ones with small caseloads and even lower numbers of MSM and transgender patients, the subject of these indicators. Rates of tobacco use screening and cessation counseling are improving and show less discrepancy between the two data sets. - Dr. Agins mentioned that it is unclear if the retention in care frequency and gap measures are still effective measures as they do not reflect the changing needs of consumers. There was a particularly large discrepancy between providers and consumers on the importance of coordination of care. STI treatment was also not prioritized by most respondents. Dr. Agins suggested that measures with consistently high performance scores might have been rated as low-priority even though they are still critical. Other important indicators may have received lower scores because they are difficult to measure. Providers comments on the survey reflected wide variation about how to prioritize measures. It was hypothesized that this variation is likely due to a number of factors related to past experience with performance measurement, sophistication about specific measures (e.g. retention, STIs), and individual program characteristics (e.g. HIV specialty programs vs. primary care clinics; health centers vs. hospitals; experience with DSRIP). - Dr. Agins briefly reviewed priority rankings from the STI indicator survey. While the results were not uniform, they reflected the different concerns and priorities of the Advisory Committees. - Dr. Agins concluded by reporting that syphilis guidelines are under active review and will be revised for NYS soon. - Daniel Feller presented the most recent version of the map displaying missed opportunities to reengage PLWH who are out of care. By clicking on each facility on the map, Mr. Feller demonstrated that one can see the number of out-of-care patients who visited that facility, as well as the number of times those individuals visited that particular site. be presented at the next QAC meeting. - The report from this round of data will be developed as soon as discrepancies from the Azara mapping inconsistencies are resolved.

5 - The data were updated to reflect corrections related to validation of HIV diagnosis. While results are preliminary and require additional validation, these changes did not alter the main findings that there are many PLWH that remain unretained in care. - Decisions about future work on this project are pending following Mr. Feller s departure from his position at the AIDS Institute. Medication Access Survey Results Dr. Rona Vail and Maggie Brown - Maggie Brown presented results from the February 2016 Medication Access Survey. Notably, of 2,101 screened patients, 149 had an issue that prevented them from getting their medication for three or more days. - The most commonly reported issues were related to prior authorization, insurance plan changes, and mail order pharmacy. Younger patients and those who had been on medication for less than three months were more likely to experience access issues. - Maggie Brown to write up survey results - Findings will be incorporated into the Pharmacy Committee s implementation strategies for the ETE Blueprint. For further information on this meeting, please contact Dan Ikeda at daniel.ikeda@health.ny.gov