City of Kansas City, Missouri Health Department
Improving Health Outcomes and Advancing the HIV Care Continuum Through Linkage to Care Innovations
BRIEF DESCRIPTION (BRIEF DESCRIPTION OF KCHD-LOCATION, DEMOGRAPHICS OF POPULATION SERVED)
Kansas City, Missouri (KCMO), the 37th most populated city in the nation is home to a diverse urban community on the Missouri-Kansas border (total population, 459,787). Population demographics show an even male to female ratio within a changing racial and ethnic landscape represented by approximately 60% White and 30% Black.
Kansas City Health Department (KCHD) is a nationally accredited Health Department whose mission is to promote, preserve, and protect the health of Kansas City residents, visitors, and workers through its diverse programs and services.
Since 1994 KCHD's HIV Services Program has been the recipient of the federal Ryan White (RW) Part A (formerly Title I) funding which provides assistance to the cities most severely impacted by the HIV epidemic. KCHD's HIV Services Program serves an 11-county bi-state region, with a population of 2.069 million including 7 Missouri counties (Jackson, Clay, Platte, Cass, Clinton, Lafayette and Ray) and 4 Kansas counties (Johnson, Wyandotte, Miami, and Leavenworth). In CY16, the KC-TGA reported 217 new cases with a total of 3,812 Persons Living With HIV (PLWH).
GOALS AND OBJECTIVES OF THE PROPOSED PRACTICE
Starting in 2016, KCHD implemented several new practices with the goal to improve health outcomes and effectively link newly diagnosed HIV positive individuals to care. The two primary objectives at the forefront of what we do are:
1. Increase the number of newly diagnosed HIV positive individuals in the KC-TGA linked to care within 30 days of diagnosis to 85% by 2020, and;
2. Linkage to Care (LTC) Coordinators respond in-person to 90% of referrals for newly diagnosed PLWH following a confirmatory test result in the TGA by 2020.
Defining Linkage to Care
Linkage to Care in 30 days of diagnosis is evidenced in the KC-TGA by a verified HIV medical care appointment/Viral Load/CD4 lab draw within 30 calendar days of the individual's confirmatory positive test draw date. The use of laboratory test result (CD4 or viral load) is accepted as proxy for care so TGA data can be compared to local surveillance data.
RESULTS/OUTCOMES (LIST PROCESS MILESTONES AND INTENDED/ACTUAL OUTCOMES):
Actions conducted to meet the objectives of this practice involved implementing changes to the KC-TGA's long-standing LTC Program. Although the full impact of these changes will not be measurable until 2018, several key milestones and activities have been completed to support the project's objectives of successfully link PLWH to care and responding to LTC referrals in-person. Milestones include: 1) co-location of LTC Coordinators at strategic locations to enable rapid in-person responses to referrals for newly diagnosed PLWH, 2) increase the number of overall LTC Coordinators, 3) standardized policy and referral response procedures through the creation of a LTC Manual, and 4) developed mechanisms within the HIV Services Program client database (SCOUT) to track and monitor encounters with preliminary positives, in-person referral responses, and provider/testing site performance. Additionally, LTC Coordinators were cross trained in HIV testing and adopted a new tool to track client progress and client accomplishments toward achieving treatment goals and advancement towards case management/HIV treatment.
WERE ALL OF THE OBJECTIVES MET?
In FY17 the KC-TGA aligned LTC performance measurement with the National HIV AIDS Strategy (NHAS2020) and began tracking linkage to care in 30 days from diagnosis, rather than linkage to care in 90 days from diagnosis. Recognizing the transition from 90 days to 30 days as an ambitious target, the KC-TGA implemented mechanisms to promote more effective responses to newly diagnosed persons, and systematic improvements in tracking data related to linkage to care.
Adopting a linkage in 30 days standard prompted the KC-TGA to evaluate and improve responses to newly diagnosed persons (standardize in-person responses; standardize response times; co-locate LTC coordinators at testing sites; add additional LTC Coordinator staff) and refine data collection methodologies.
WHAT SPECIFIC FACTORS LED TO THE SUCCESS OF THIS PRACTICE?
The collaboration and commitment to shared goals amongst community stakeholders and partners across the TGA is at the forefront of our success and is shaping change of coordination of services. These priorities work across all our core activities as we pool resources with community partners and stakeholders to ensure success of the LTC Program. Our plans, strategies, and proposed activities are coordinated between Prevention and Care programs to maximize resources and achieve outcomes with all RW Parts as well as non-RW providers. This collaboration and dynamic community engagements strengthen the KC-TGA towards strategic long-range service delivery of our coordinated system of care.
STATEMENT OF THE PROBLEM/PUBLIC HEALTH ISSUE:
PLWH who are not engaged in HIV care are at a higher risk for transmitting HIV to others and for experiencing poor HIV health outcomes. Newly diagnosed PLWH face potential barriers to care including a lack of access to health insurance, co-morbidities including addiction and mental health issues, unstable housing, as well as fear and stigmatization. Through comments from DIS, LTC and testing site staff and based on interview results from the Lost to Care project, the KCHD HIV Services program believes the stigma and fear associated with HIV in addition to other personal/psychosocial issues contributed to the population of PLWH who choose not to engage in HIV medical care.
WHAT TARGET POPULATION IS AFFECTED BY PROBLEM? WHAT IS TARGET POPULATION SIZE?
A total of 217 PLWH in the KC-TGA were newly diagnosed in CY16. KCHD Surveillance data for newly diagnosed PLWH on the Missouri side of the Stateline show 68.6% report a risk/exposure factor of Men who have sex with Menâ€ (MSM). Most newly diagnosed in the MSM exposure category were between the ages of 25-44. Among all new cases, 24% are Black males and Hispanic males represent 14.7% of the regions newly diagnosed population.
Newly diagnosed females are at their highest since CY12, totaling 38. Among newly diagnosed females, 28 are non-White (74%). Newly diagnosed women over age 30 total 58% of all newly diagnosed females and those aged 45-65 total 36.8%. During CY16, 35.9% of newly diagnosed Hispanics in the KC-TGA entered care with or developed to Stage 3 (AIDS) within the same year. In total CY16 saw 67 PLWH in the KC-TGA diagnosed with Stage 3 HIV or who developed into Stage 3 (AIDS) in the same year, 33% of which are Black. The KCHD HIV Services program recognizes the system is not finding these new cases soon enough or reaching the population with the kind of critical messaging and outreach required.
WHAT PERCENTAGE DID YOU REACH?
In FY16 (March 1, 2016-February 28, 2017) 287 individuals were referred to the KC-TGA LTC Program out of which 206 (72 percent) successfully completed enrollment. Eighty-one individuals were unable to enroll; although 38 were still eligible to complete their enrollment during the next reporting period. So far in FY17 with two quarters of data available (March 1, 2017-August 31, 2017) 115 referrals were made to the KC-TGA LTC Program of which 93 (81 percent) successfully completed enrollment.
WHAT HAS BEEN DONE IN THE PAST?
In September of 2004 the Kansas City CARE Clinic (KCCC), a KC-TGA Ryan White sub-recipient began participation in the ARTAS pilot project. Since the end of the pilot in 2007 The KCHD HIV Services Program has operated an effective and successful Linkage to Care (LTC) Program. The KC-TGA LTC Program is based off of the ARTAS model, an evidenced based practice that uses strengths based approach to identify and overcome individual and system barriers to treatment while gaining an acceptance and understanding of their diagnosis. The KC-TGA LTC Program provides a higher level of engagement, guidance, and education than can be provided through long term Medical Case Management or other programs. The intervention takes place during a minimum 90 day period during which the focus is on ensuring the client is successfully linked into HIV care, prescribed Anti-Retroviral Treatment, and able to address any initial barriers that would prevent or hinder the patient's ability to access and maintain care. The LTC program utilizes a 24 hour a day pager service which providers, partners, and testing sites are instructed to call anytime an HIV test result is positive. LTC program expectation is to respond to all referrals within 20 minutes of a page.
Prior to the ARTAS pilot project, the KC-TGA Ryan White depended on a system of informal referrals from HIV testing sites to get PLWH connected to HIV medical care and other services. This usually took the form of providing the newly diagnosed person with the contact information for a Ryan White case management agency. There was no immediate tracking of what happened to those persons once they left the testing site. Although there was acknowledgement that a significant portion of the PLWH population was not in enrolled in the Ryan White program, there was no conceptual connection between those numbers and the post-test referral process.
WHY IS CURRENT /PROPOSED PRACTICE BETTER?
The National HIV/AIDS Strategy 2020 (NHAS2020) and the Health and Human Services' Health Resources and Services Administration (HRSA) performance measure calls for individuals to be linked to care, measured by attending a routine HIV medical care visit, within 30 days of their HIV diagnosis. Previous performance standard measures for linking clients to care were based on a 90 day time period. Many of the changes implemented as part of this practice are intended to address the challenges posed in regard to the new performance measure of the NHAS 2020. Striving to achieve the performance measure will be better for the overall LTC and Ryan White system because linking clients to treatment and care quicker will result in better health outcomes and encourage committed engagement to HIV treatment.
Since 2015 the TGA has added three new LTC Coordinator positions. LTC Coordinators are tasked with responding to all referrals following a new HIV diagnosis from any testing site throughout the 11 county KC-TGA however, the large geographic coverage area and multiple testing sites throughout the TGA have impacted response times.
In 2016 the KCHD entered into an MOU with KCCC to provide office space to KCCC LTC staff to be on site a minimum of three days per week. LTC Coordinators can respond within minutes to any new HIV positive test result/diagnosis at KCHD and at neighboring Truman Medical Center. KCHD has the highest prevalence of new HIV positive test results in the KC-TGA, followed closely by Kansas City Care Clinic, and Truman Medical Center. By having LTC Coordinators located at both KCCCC and KCHD the MO testing sites with the highest incidents of new positives are covered by LTC staff who can respond rapidly to referrals. Another MOU for co-location at the Wyandotte County (KS) Health Department, is now in place for 2018. This testing site has the highest rate of incidence for new positives in the KC-TGA's Kansas counties. This will only add to GSPs established co-location at the Johnson County Health Department in Kansas.
In late 2016 KCHD HIV Services staff developed data elements within the SCOUT database which enable the LTC Program and the HIV Services Quality Manager to track information on preliminary positives, LTC Coordinator responses in-person vs over the phone, testing site performance, and other standards of care for linkage. 2016 also saw the development of an LTC Policies and Procedures manual to standardize the practices and develop protocol for how to respond to referrals, how to document preliminary positive clients, and formalizing objectives and timelines for LTC staff. In late 2017 KCHD sub-recipient Kansas City CARE Clinic (KCCC) added another LTC Coordinator position to focus on newly diagnosed youth, bringing the total to seven LTC Coordinators in the KC-TGA. The current practices are better because they represent an investment into LTC resources and have increased the bench strength of LTC staff and improved their ability to serve this vulnerable population. The added personnel enable the staff to provide additional one on one time for client education and guidance with the intended outcome of client empowerment and an increase to the likelihood of meeting milestones and overcoming barriers which empower the client to be successful in their treatment and in long term medical case management. Standardization and data tracking mechanisms are a better means for KCHD to show the impact of the practice and make adjustments quicker based on quantitative data. The impact of these changes will not be fully measurable until 2018, but these forward-thinking objectives will positively impact the entire KC-TGA Medical Case Management system for years to come.
IS CURRENT PRACTICE INNOVATIVE? HOW SO/EXPLAIN?
The LTC Program is funded under the Early Intervention Services (EIS) services category. Until 2016 LTC Coordinators' job functions focused on two of four components for EIS. Having LTC staff cross trained in HIV testing and taking an active role in outreach and education for providers cultivates new points of entry. and expand testing efforts allows the TGA to be more comprehensive, centralized, and efficient in the delivery of the four EIS components. As of November 30, 2017 LTC Coordinators have conducted 18 trainings with new and existing testing sites. In 2018 Good Samaritan Project (GSP) will sign a new Linkage agreement/ MOU with the Wyandotte County Health Department who will provide office space available for the LTC Coordinator. In 2018 GSP's LTC Coordinator will also take the lead on education and fostering relationships with providers and testing sites on the Kansas side of the TGA.
IS IT NEW TO THE FIELD OF PUBLIC HEALTH
IS IT CREATIVE USE OF EXISTING TOOL OR PRACTICE
Having a Ryan White program based on the ARTAS model of linking clients to care is not new to the field of public health. How the KCHD has adapted and expanded upon that practice is what makes it innovative. It is a creative use of an existing tool that has been modified to fit the evolving landscape of federal performance measures and an understanding that success early with engaging in HIV care creates better odds of success downstreamâ€ in medical case management and overall treatment and health outcomes.
IS THE CURRENT PRACTICE EVIDENCE BASED?
The National HIV/AIDS Strategy 2020 (NHAS) includes a goal to increase access to care and improve health outcomes by establishing a seamless systems to link people to care immediately after diagnosis and support retention in care to achieve viral suppression that can maximize the benefits of early treatment and reduce transmission risk.â€ NHAS points out the United States Preventive Services Task Force asserts people who are diagnosed as HIV positive need to be connected to appropriate clinical care and supportive services. In order to effectively connect individuals to care and support services the NHAS calls for Linkage to be provided when and where HIV screenings are provided in order to help overcome barriers to care. Several of the activities for this model practice support the goals and evidenced based practices outlined by NHAS including expanding LTC program and staff, co-location of LTC Coordinators at or near high volume testing sites, cross-training LTC Coordinators in HIV testing, as well as the Practice objective and performance measure to link clients to care in 30 days.
Anna Atcher Johnson, MPH an epidemiologist and supervisor at the HIV Incidence and Case Surveillance branch of the CDC's Division of HIV/AIDS examined data from the National HIV Surveillance System. According to the research presented at the 2015 National HIV Prevention Conference, 79% of enrolled patients were linked to care within 3 months, and 81.7% of those patients were linked to care within 1 month. The mean time to viral suppression for all patients diagnosed within 3 months was 15.9 months, with 63.6% and 75.5% achieving viral suppression at 12 months and 24 months, respectively. Compared with those linked to care within 1 month, a significantly lower proportion of patients linked to care within 2 to 3 months achieved viral suppression at 12 months (64.9% vs. 58.2%) and 24 months (76.1% vs. 72.7%). Outcomes were much worse for those who were not linked to care for more than 3 months, as viral suppression was only achieved by 17% at 12 months and 32.7% at 24 monthsâ€. Johnson's research shows that linkage within 1 month improves likelihood of viral load suppression compared to those linked in 2-3 months.
Hall HI, et al. Abstract 5057. Presented at: National HIV Prevention Conference; Dec. 6-9, 2015; Atlanta.)
HIV in the U.S.
GOAL(S) AND OBJECTIVES OF PRACTICE
Starting in 2016 KCHD implemented several new practices with the goal of improving health outcomes and effectively linking newly diagnosed HIV positive individuals to care. KC-TGA LTC Program had been operating with a performance measure of linking newly diagnosed clients to care within 90 days from their diagnosis and experiencing success on that performance measure. In FY16 KCHD successfully linked 83 percent of newly diagnosed individuals in the KC-TGA to care in 90 days, near the TGA's goal of 85 percent. Although FY16 fell short of the 85 percent goal, FY14 and FY15 exceeded the goal with linkage rates at 87 percent and 86 percent respectively. In 2015 HRSA announced the performance measure for linking clients to care would be changing from a 90 day measure to a 30 day measure. In order to align with HRSA, the KCHD adopted Linkage to Care in 30 days beginning in the FY17 program year and continues working to increase the number of newly diagnosed in the KC-TGA linked to care to 85 percent by 2020. In order to improve health outcomes and successfully link newly diagnosed individuals to care, the region's Linkage to Care Coordinators have the objective to respond in-person to 90% of referrals for newly diagnosed persons following a confirmatory test result in the TGA by 2020.
WHAT DID YOU DO TO ACHIEVE THE GOALS AND OBJECTIVES? STEPS TAKEN TO IMPLEMENT THE PROGRAM?
To meet the goal and objectives of this practice KCHD utilized existing professional partnerships and has receives a high level of cooperation and participation from two of the sub-recipient agencies, Kansas City CARE Clinic and Good Samaritan Project. The KCHD HIV Services Program's plan for linking newly diagnosed positives to care continues to be greatly enhanced by the combined efforts of KCHD HIV Surveillance/Care Project (Care Project), KCHD's Disease Intervention Specialists (DIS), Ryan White Part A Hospital Liaisons, Kansas Department of Health and Environment's expanded Not-In-Care Kansas (NICK) Program, and HIV Prevention Outreach. Additionally, the LTC program enhances the impact of the Expanded Testing Initiative and existing partnerships with local area AIDS Service organizations, clinics, hospitals, and medical providers. Each serves as a vehicle for identifying Persons Living with HIV (PLWH) who are not engaged in HIV medical care; all work together to reach the newly diagnosed and encourage their engagement in care.
All newly diagnosed/re-diagnosed PLWH are referred to LTC. Some referrals originate with the Care Project, charged with locating and engaging a MO PLWH cohort that is lost to care or never engaged in care. Others come from Ryan White Hospital Liaisons who connect with lost to care PLWH who are admitted to either of the major hospitals that provide most HIV-related inpatient care. Most referrals to Part A LTC result from the coordinated efforts of DIS, HIV Prevention Outreach and LTC.
There are three significant changes to the program that were implemented in the last two years:
1. Tracking linkage to care at both 30 days and 90 days to monitor progress toward the ultimate goal of linkage in 30 days: A report was built within the client-level database (SCOUT) to track clients newly diagnosed and the number of days from diagnosis the individual: 1) received a response from a LTC Coordinator; 2) tracked the amount of contact between the individual and LTC Coordinator while in a preliminary positive status prior to receiving a confirmatory draw; 3) had an intake encounter post confirmatory draw with a LTC Coordinator to begin the process of scheduling an HIV medical care appointment and enrollment in Ryan White services; 4) tracked days between diagnosis and attending a verified HIV medical care appointment; and 5) tracked number of days from diagnosis with a viral load lab draw (not including a confirmatory test draw). Target timeframes were established at each stage of contact between LTC Coordinators and persons testing positive to create standards of care and response time. If the amount of days from diagnosis for any other above mentioned stages exceeded the established target (e.g. more than 30 days before having a verified medical care appointment; more than a same day response to a new positive), the amount of days would appear in red font on the report as a visual alert to substandard care. If the amount of days met or exceeded targets, the value would appear in green to signify success in meeting TGA standards. The report is used for quality assurance monitoring by Recipient staff and LTC sub-recipient program administrators for continuous program evaluation and improvement.
2. A tracking mechanism referred to as Reasons Not Linked to Care was created and implemented in midFY15 for those who did not meet the linkage to care target, which in FY15 was 90 days from diagnosis. This mechanism proved especially valuable once the linkage time frame was shorted from 90 days to 30 days in support of the NHAS 2020 goal. The tracking mechanism allows the KC-TGA to look upstreamâ€ as to why individuals do not complete enrollment in the Ryan White LTC program, and subsequently do not engage in HIV medical care. LTC Coordinators captured Reasons Not Linked to Care such as, Did Not Keep Appointments/Did not return calls,â€ Declined/Refused Services,â€ and Information from DIS issueâ€ for all individuals not meeting the linkage target. The purpose was to identify patterns or trends in the data and implement systematic improvements to promote linkage to care. For example, if there were many instances of Information from DIS issue,â€ LTC staff would coordinate with regional Disease Investigators to ensure efficient, timely, and accurate in-person referrals when someone tests positive for HIV.
Data from 3Q FY15 â€“ 2Q FY17 identified the following most common trends to explain why individuals did not enroll in LTC services, nor get subsequently linked to HIV medical care within the established timeframes: Reasons Not Linked to Care reported from September 1, 2015 through May 31, 2017 are in order from most common to least common: 1) Potential for Completed Enrollment Next Quarter, 2) Not Enrolled, 3) Unable to Contact/Fully Enroll, 4) Missed Appointments(DNKA)/Did not return calls, 5) No confirmatory draw, and 6) Information from DIS issue.
Preliminary lessons learned from collecting Reasons Not Linked to Care was that most clients do successfully enroll in LTC (76 percent, 433 of 571 clients) which allows them to access Ryan White services including ambulatory outpatient HIV medical care and Antiretroviral (ARV) medications paid for by Ryan White dollars. For persons who do not get linked to care in 30 days, some elect to not enroll in services (not enrolled), or some do not respond to LTC phone calls or scheduled appointments (Unable to Contact/Fully Enroll; Did Not Keep Appointment (DNKA)/Did not return calls). Additionally, part of the drop off in enrollment and attending a verified medical care appointment may be due to clinic availability. The data depict clients often weren't successfully enrolled and subsequently linked to care due to the process of enrollment. In some instances, clients did not provide all necessary documentation to enroll them in services paid for by Ryan White in the first 30 days of their diagnosis (e.g. providing proof of income). In other instances, LTC Coordinators are evaluating the enrollment process to determine if it is client-centered, and/or if the process should be re-evaluated to ensure clients are not overwhelmed with paperwork, but are met where they are at and given time to process their diagnosis.
3. Tracking in-person referral responses: Before FY17, the TGA did not have a reliable, automatized way of quantifying the number of in-person responses. The inability to quantify responses by type (in-person or not) created anecdotal perceptions of LTC response times and standard of care. The multi-disciplinary team charged with creating the LTC Manual developed processes for documenting and tracking in-person referrals in support of the TGA's goal of responding to 90% of newly diagnosed persons. Responses to newly diagnosed would be categorized in one of three ways:
Respond to Referral in-person- The encounter would document instances when the LTC Coordinator responds and meets with the client in-person following a referral and positive test. This is the ideal response to all newly diagnosed persons.
Respond to Referral via Phone- The encounter would document instances when the LTC Coordinator communicates with client via phone following a referral and positive test result.
Respond to Referral Source- The encounter would document instances when the LTC Coordinator is unable to have direct communication with the individual being referred but is able to obtain and document pertinent information regarding client and/or the coordination of linkage or outreach to client.
In FY16, the first year the TGA was able to delineate referral response type, 50.5 percent of newly diagnosed were responded to in-person. Most recent data for FY17 (March 1, 2017- December 1, 2017) show 45 percent of newly diagnosed individuals are being responded to in-person. This percentage is expected to increase throughout the end of the program year. This data is useful in establishing a baseline from which to work toward the 90 percent in-person response target.
A central component to this practice is expanding and integrating the LTC program into other strategic locations in and around the KC metro area. In the Fall of 2016 a MOU agreement allowed KCHD to provide office space, free of charge, to Kansas City CARE Clinic's Linkage to Care Coordinators. KCCC is the owner of the Linkage to Care Pager number and until 2017 was the only Ryan White sub-recipient in the KC region to receive and respond to referrals for newly diagnosed or lost to care PLWH. The office space allows for the LTC Coordinators to have office inside the same facility which has the highest incident of HIV+ test and neighbors Truman Medical Center two blocks to the West which sees the 3rd highest incidents of new HIV cases next to Kansas City CARE Clinic. This means the agency responding to referrals for new PLWH would be onsite (or two blocks away from) locations which make up 28 percent (116 of 413 persons for CY15 and CY16) of all new positive test results in the region. KCHD is also the home to the regions Disease Intervention Specialist (DIS), front line public health staff, who work with newly diagnosed individuals on partner solicitation and conduct epidemiologic investigations. LTC Coordinators and DIS staffs communicate and coordinate with one another to ensure clients are reached and connected to the LTC program and not falling through the cracks.â€
Although KCCC LTC Coordinators service all 11 counties in both the Kansas and Missouri side of the TGA, historically there was no physical presence on the Kansas side of the Stateline. Wyandotte County Kansas has some of the highest density of PLWH in the entire TGA as well as a significant occurrence of new HIV diagnosis each year. In Spring of 2017, the TGA added a sixth LTC Coordinator position at Good Samaritan Project (GSP). GSP was ideal for this expansion of the LTC program because they have office space located in the heart of Wyandotte County and Kansas City, Kansas. Recognizing the strength and utility of the new LTC position, GSP sought to relocate the Wyandotte office space into a more strategic and effective location. In January of 2018 GSP will have an MOU in place providing them with office space located within the Wyandotte County Health Department. Wyandotte County Health Department made 33 referrals for newly diagnosed clients from January 2015 to December 2016 making them the third highest source for LTC referrals in the entire TGA over that period.
2017 also saw the creation of a new Youth Linkage to Care Position at Kansas City CARE Clinic. This position, funded by the Missouri Ryan White Part D (Women, Infant, Children, and Youth) will serve newly diagnosed PLWH aged 13-24. The Youth LTC position will begin taking clients in December 2017. Moreover, the Kansas City CARE Clinic has also developed a Retention in Care Position funded by the State of Missouri's Ryan White Part B program which will work closely with KCHDs Surveillance and DIS workers to seek out and re-engage PLWH who are determined to be lost to care or never in care based on lack or a 12 month gap since the last reported medical visit and labs for CD4 and viral load. The Kansas Department of Health and Environment (Ryan White Part B recipient) has also created a similar position to operate on the Kansas side as part of their Not-In-Care Kansas (NICK) Program. The Kansas position will act in a hybrid role as both a DIS and Retention and Care Case Manager to seek out individuals with no reported verified medical care visit or labs over the last 9 months. Each of these programs will have their own means for determining success based on re-engagement and the removal of barriers with the intention to move them to long term or medical case management. The expected outcome of these additional positions will be LTC Coordinators with a narrower more specialized focus on newly diagnosed PLWH and additional time to devote toward the intervention, education, and performance measures required to successfully link clients to HIV care and prepare them for long term case management and maintenance of their disease.
In Fall of 2016 the KCHD Quality Manager developed and implemented mechanisms in the SCOUT database to allow KCHD HIV Services to quantify and track data related to referral responses and LTC activities, including encounters with individuals who had only a received a preliminary (rapid) positive HIV test result, but pending a confirmatory test result. Initiating contact with clients as early as possible has multiple benefits but is not without challenges. Namely, certain providers in the region are unable to schedule clients for an HIV medical appointment any earlier than 30 days out from when they are contacted. This makes meeting the project's first objective nearly impossible. Despite this, early contact helps the client know there is a support system and persons available to help them understand their diagnosis navigate the HIV healthcare system, and early contact enables the LTC Coordinator and the client to establish a rapport even before the diagnosis is confirmed.
Around the same time in Fall 2016, the Medical Case Management System Administrator developed a draft Policy and Procedure Manual for the TGA's Linkage to Care Coordinators. The new Manual's focus is on the performance standards for the TGA's Linkage to Care Coordinators and the delivery of quality services provided to clients newly diagnosed as HIV Positive. The Manual provides instruction and expectations for how to respond to referrals and how to use the mechanisms implemented by the Quality Manager. The draft Manual was shared with the Missouri Ryan White Statewide Managers Group who decided to use the draft Manual as the template to develop a Statewide Linkage to Care Manual allowing many of the practices perfected by the KC-TGA to be standardized across the state. Each regional LTC program across the state had opportunity to provide input and suggest amendments throughout the Spring and Summer of 2017. In October of 2017 the final draft of the Statewide LTC Manual was sent to the Missouri Department of Health and Senior Services for final review and will be presented to Missouri Ryan White all Parts Recipients for adoption in early 2018. In preparation for the release of the Statewide Manual the Statewide Medical Case Managers group has organized a retreat scheduled for February 2018 to bring LTC Coordinators from all across the state to join together and share the strengths and best practices of each region.
Other Linkage to Care activities revolved around ways to better identify and overcome barriers to care for the newly diagnosed. Because many of the goals clients in the LTC program have are short term goals marked by certain milestones, the assessment completed for all Ryan White enrolled clients (the Bio-psycho Social Acuity Index-BAI) is not always the most relevant or practical tool for developing service plans or outlining where the client is at in regard to personal and program goals. Washington University Hospital in St. Louis, Missouri (Ryan White Part C/D Recipient) developed a tool called the My Goals Checklist. The My Goals Checklist outlines client specific areas related to medical access, health, support, and personal goals, with each listing specific milestones needing to be completed and what actions will be taken to meet said milestones and goals. The new tool allows the client to track and visualize their progress toward each goal and serve as a reminder for actions or tasks that need to be completed. The purpose of this strengths based tool is to encourage clients to take an active and engaged role in their treatment and is forward thinking in its ability to prepare newly diagnosed PLWH for understanding long term goals of HIV treatment and medical case management.
LTC Coordinators have integrated the tool into their intervention as a means to help prepare the client for long term case management. For the time being this helps LTC clients better identify more relevant goals. In 2018 Missouri Ryan White case managers will adopt a new Assessment, Medical Case Management Assessment Tool (MCMAT). In order to make the assessment more relevant to newly diagnosed individuals the Statewide LTC Workgroup will adapt the MCMAT so the focus is on client views and knowledge of HIV/care so as to better identify barriers or strengths that may lead to care seeking behaviors.
Transportation needs for newly diagnosed PLWH also tend to be higher than those of other PLWH. A higher amount of medical appointments required early on combined with the potential for multiple appointments necessary to coordinate care and access treatment can be a barrier to individuals without any means of transportation. KCHD HIV Services recognized this potential barrier and makes available monthly bus passes to clients enrolled in the LTC program. Providing a means of transportation works to remove that barrier and promote early linkage and engagement in care for the most vulnerable and at risk (those who are not virally suppressed).
LTC Coordinators and Supervisors have also been engaging in outreach efforts within the TGA to promote opt out testing (Expanded Testing Initiative) and educate providers and testing sites about the LTC program and how/when to use the pager. From January 1, 2016 to November 30, 2017 KCCC staff designated 14 new Expanded Testing Initiative (ETI) sites by providing training on opt out testing and how the LTC referral process works. The total number of ETI sites in the KC-TGA is 39 clinics at 32 different locations. In addition to cultivating new ETI sites, the KCCC LTC staff also does outreach to promote LTC and provide annual trainings at established ETI sites. As of November 30, 2017 KCCC LTC staff has conducted 18 such outreach training activities at clinics throughout the Kansas City metro area. By increasing the number of clinics and providers offering HIV testing and utilizing the LTC referral process, the KC-TGA is in a better position to identify PLWH who are unaware of their status and before the disease progresses to stage 3. The more testing sites which utilize the LTC referral process will also help ensure newly diagnosed PLWH are linked to care quickly and provided with the resources and tools necessary to be successful in their treatment.
Another way to expand HIV testing efforts in the KC-TGA was having all seven of the LTC Coordinators cross trained in HIV testing. Being cross trained allows LTC Coordinators to play an active role at testing and outreach events as well as provide partner testing to clients already enrolled in the LTC program. Having the LTC Coordinators cross trained in HIV testing also meets a funding requirement for the Early Intervention Services category for which the LTC Coordinators fall under.
The innovative and multifaceted efforts of the KC-TGA LTC Program supports a public health approach incorporating many of the Ten Essential Public Health Services:
1. Monitoring health status to identify community problems -Done via the Expanded Testing Initiative and through KCHD Surveillance.
2. Diagnosing and investigating health problems and hazards in the community- Done via DIS with collaboration from the Retention in Care and NICK Case Managers who can investigate and connect with lost to care PLWH who without engagement in treatment could transmit HIV to others in the community.
3. Inform, educate, and empower people about health issues-The ARTAS intervention helps to educate newly diagnosed so as to empower them in treatment and long term success. LTC Coordinators and Supervisors provide education to providers and testing sites so they understand the purpose and public health benefit of testing and referring new positives to LTC.
4. Mobilize community partnerships to identify and solve health problems- The practice would not be possible without the partnerships between KCHD, the sub-recipients KCCC and GSP, the State Ryan White Part B programs, and all the community partners committed to testing and making referrals to LTC.
5. Develop policies and plans that support individual and community health efforts- LTC Manual created to standardize the practices and referral responses for the TGA's LTC Program. This will help ensure individuals receive high quality care in which their needs are responded to rapidly and they are provided treatment quickly and efficiently so as to minimize the health impacts on the individual and the community.
6. Link people to needed personal health services and assure the provision of health care when otherwise unavailable-For many, if not most HIV positive individuals, Ryan White is the only program with the resources and network of dedicated stakeholders equipped to provide the support and assistance necessary for successfully linkage and engagement in care.
7. Assure a competent public health and personal health care workforce-By cross training the LTC Coordinators in HIV testing they are more knowledgeable and better equipped to serve the public. The ongoing education and relationship building efforts of LTC staff will help ensure that
8. Evaluate effectiveness, accessibility, and quality of personal and population-based health services- Adding new data elements and mechanisms into the SCOUT database to better track linkage, referral responses, and encounters with preliminary positives provides for better evaluation of the effectiveness of the program.
The KCHD's HIV Services LTC Program's goal, objectives, and activities are intentional, innovative and forward thinking. The KC-TGA works toward improving Linkage to Care by identifying areas to improve upstreamâ€ at both a client level and using a systems approach. The collaborative work of KC-TGA is done in recognition that successes early on through identification and quick linkage to care, starting ARVs, removing barriers, and preparing new positives for long term treatment and engagement not only improves the individual's overall health, but also supports lower rates of transmission and reduced infection, thereby improving the KC Metro's overall population health and moving us toward realizing our mission of Kansas City being a place where new HIV infections are rare.
ANY CRITERIA FOR WHO WAS SELECTED TO RECEIVE THE PRACTICE (IF APPLICABLE)?
The criteria for any consumer receiving the practice must have received a positive preliminary HIV test result. To continue receiving the practice and enrollment into the Linkage to Care program consumers would need a confirmation of a confirmatory HIV positive test result and be a resident within the 11 county Kansas City TGA.
The two sub-recipients (KCCC and GSP) were awarded their LTC positions based on applications submitted in response to the KCHD HIV Services Ryan White Part A Request for Application (RFA).
KCCC selects sites for outreach and Expanded Testing Imitative (ETI) based on considerations related to at risk populations served and community partnerships. Because the ETI efforts are funded by the state of Missouri, ETI outreach is limited to sites on the Missouri side of the KC-TGA.
WHAT WAS THE TIMEFRAME FOR THE PRACTICE
The time frame for the practice is 30 days to meet the HRSA performance measure and a minimum of 90 days for the client to complete the Linkage to Care program and transfer into long term medical case management and treatment. Overall the timeframe to meet the objectives is by the end of the 2020 Ryan White fiscal year (February 2021).
WERE OTHER STAKEHOLDERS INVOLVED? WHAT WAS THEIR ROLE IN THE PLANNING AND IMPLEMENTATION PROCESS
Both Kansas City CARE Clinic and Good Samaritan Project are invaluable partners and stakeholders in these efforts. At multiple opportunities both of these sub-recipients were brought to the table to discuss how to effectively implement the changes to the LTC program. LTC Coordinators were consulted throughout the drafting of the LTC Policy Manual. Having the buy-in and investment from the sub-recipients in these regards allows all parties to share ownership of the direction of the program and its intended goals and objectives.
Without collaboration and cooperation from all the community testing sites, clinics, and hospitals this practice would have no means of success. Similarly, success is possible because of the KCHD Surveillance Division and HIV Services Quality Manager's commitment to tracking and improving data as a critical means to validate and confirm that the efforts of the program are beneficial. Support from both Missouri and Kansas Ryan White Part B programs comes in the form of creating infrastructure through funded positions which add to and complement the LTC program like the Retention in Care, Youth LTC, and Never In Care Kansas (NICK) case management positions.
Each quarter the performance measures for the LTC Program are presented to the KC-TGA Comprehensive Prevention and Care Planning Council. This information contributes to the HIV Prevention and RW planning processes for the KC region. The feedback from the KC-TGA Planning Council also contributes to the ongoing development of the KC-TGA LTC Program. For example, feedback from PC stakeholders about the role of LTC staff during collaborative, community outreach events was one of the reasons cross-training on HIV testing was considered.
WHAT DOES THE LHC DO TO OFFSET COLLABORATION WITH COMMUNITY STAKEHOLDERS? DESCRIBE THE RELATIONSHIPS AND HOW IT FURTHERS THE PRACTICE?
The KCHD HIV Services Medical Case Management System Administrator meets with both LTC Supervisors every month to discuss developments in the program and case conference any issues and challenges that arise. These monthly meetings are also an opportunity to gain input regarding statewide LTC efforts and policies. In February, 2018 the KCHD HIV Services Program has organized a statewide LTC retreat to bring together all LTC Coordinators in the state of Missouri to share and learn from one another's programs. KCHD HIV Services also conducts bi-annual sub-recipient meetings which ensure all LTC funded stakeholders meet; receive the same information; and can share information with other RW service providers about any new LTC developments or changes in practice.
The HIV Services Program convenes bi-annual, sub-recipient meetings to ensure all RW and HUD funded stakeholders (including LTC managers) have opportunities to meet in-person; receive the same programmatic information; and can share information with other HIV service providers about new/changing practices of the LTC Program.
One of the key partnerships for LTC efforts is the local Expanded HIV Testing Program. This program provides education to medical providers to encourage the adoption of opt-out HIV testing policies. One of the key point of emphasis by the Expanded HIV Testing Program is to 24/7 availability of the LTC Coordinators. Historically one of the reservations medical providers cite for not administering more HIV test is concern about what happens after they deliver the test results. Most medical providers are not trained in HIV medical care and therefore cannot provide immediate clinical follow-up for a positive HIV test.
ANY START UP OR IN-KIND COSTS AND FUNDING SERVICES ASSOCIATED WITH THIS PRACTICE? PLEASE PROVIDE ACTUAL DATA IF POSSIBLE. OTHERWISE, PROVIDE AN ESTIMATE OF STARTUP COSTS/ BUDGET BREAKDOWNS
For the FY17 Program Period (March 1, 2017 to February 28, 2018), the KC-TGA Planning Council has allocated $322,366 for Early Intervention Services (EIS). This is the RW service category that KC-TGA uses to support the LTC Program. The preliminary allocation for FY18 is the same amount. Money allocated for EIS is used to fund six LTC Coordinator positions, five at KCCC and one at GSP. Average salaries for LTC Coordinators are between $40,000-$45,000 plus benefits. EIS/LTC was prioritized as the #1 service for FY17 and is prioritized as #5 for FY18. Due to ongoing data sharing regarding EIS/LTC outcomes, the PC continues to regard this service as a key part of the KC-TGA HIV Care Continuum.
WHAT DID YOU FIND OUT? TO WHAT EXTENT WERE YOUR OBJECTIVES ACHIEVED? PLEASE RE-STATE YOUR OBJECTIVES.
1. Increase the number of newly diagnosed HIV positive individuals in the KC-TGA linked to care within 30 days of diagnosis to 85% by 2020. This is a new objective adopted for the FY17 program year. The previous objective was to link 85% of newly diagnosed PLWH to HIV medical care within 90 days. Second quarter results for FY17 showed only 65% of newly diagnosed persons were linked to care within 30 days. Mid-Year FY17 outcomes (March 1, 2017-August 31, 2017) report 71 percent of newly diagnosed persons linked to care in 30 days (30 of 42 persons). In applying a 90-day timeframe, this percentage increases to 93 percent (39 of 42 persons). In FY16, the LTC Program successfully linked 83 percent of newly diagnosed individuals in the KC-TGA to care in 90 days. Although FY16 fell short of the 85 percent goal, FY14 and FY15 exceeded the goal with linkage rates at 87 percent and 86 percent respectively.
1.2. Linkage to Care Coordinators respond in-person to 90% of referrals for newly diagnosed PLWH following a confirmatory test result in the TGA by 2020. This is also a new measure piloted in FY16 and adopted in FY17. In FY16 just over half (50.5%) of the LTC referrals received an in-person response. This objective was developed to test the anecdotal observation that PLWH who receive in-person responses when diagnosed are more likely to link to HIV care and remain engaged in HIV care. As the LTC Program moves forward, this objective will evolve to include a measure of medical visit frequency for PLWH who received an in-person LTC visit immediately after diagnosis.
DID YOU EVALUATE YOUR PRACTICE?
o LIST ANY PRIMARY DATA SOURCES, WHO COLLECTED THE DATA, AND HOW
Data is entered, collected, and queried through the TGA's client-level database, SCOUT. Information such as date of diagnosis, date of contact with LTC Coordinators, date of first verified medical care visit, and date of viral load/CD4 lab draw are queried through standardized reports designed specifically for the KC-TGA's LTC program. LTC Coordinators enter data on each newly diagnosed individual. Sub-recipient LTC managers, and the TGA's Quality Manager routinely query LTC reports for quality assurance and monitoring of progress toward LTC goals. Results for adopted measures are presented to the Assessment Committee of the KC-TGA RW Planning Council.
o LIST ANY SECONDARY DATA SOURCES USED (IF APPLICABLE)
o LIST PERFORMANCE MEASURES USED. INCLUDE PROCESS AND OUTCOME MEASURES AS APPROPRIATE.
Secondary data sources include client medical records, and HIV Surveillance HIV lab results data.
Two performance objectives are applied to the LTC program. First, increasing the number of newly diagnosed HIV positive individuals in the KC-TGA linked to care in 30 days of diagnosis to 85% by 2020 and, second, Linkage to Care Coordinators respond in-person to 90% of referrals for newly diagnosed patients following a confirmatory test result in the TGA by 2020.
Most recent data for FY17 (March 1, 2017- December 1, 2017) report 71 percent of newly diagnosed persons linked to care in 30 days (49 of 69 persons). In applying a 90-day timeframe, this percentage increases to 93 percent (64 of 69 persons).
FY17 will be the first program year KCHD will track LTC in 30 days and will therefore act as a baseline. In the preceding years the KC-TGA reported consistently linking 83-90 percent of newly diagnosed clients to care from FY14-FY16. A review of data from FY16 and FY15 showed that without any intentional effort to meet the new performance measure the KC-TGA was linking 53 percent of clients to care within 30 days. Taking successes learned from the 90-day measure and applying them to a 30-day measure, combined with the new practice activities, is already showing a positive impact. After switching to the new measurement in FY17 and with intentional effort applied, the percentage linked to care in 30 days has already jumped to 71 percent (March 1, 2017- December 1, 2017).
o DESCRIBE HOW RESULTS WERE ANALYZED
The KCHD HIV Services Medical Case Management System Administrator meets with both LTC Supervisors every month to discuss developments in the program and case conference any issues and challenges that arise. These monthly meetings are also an opportunity to gain input regarding statewide LTC efforts and policies. Sub-recipient LTC managers, and the KC-TGA's Quality Manager routinely query LTC reports in the SCOUT database for quality assurance and monitoring of progress toward LTC goals.
The HIV Services Program also has a Quality Advisory Committee (QAC) with membership from provider agencies and RW consumers. The QAC conducts a quarterly review of the results for performance objective for all services provided to PLWH living in the KC-TGA. The QAC also does an annual review of the actual objectives to determine if changes to the objective targets or the actual objectives are needed. This process includes a review of national and/or state performance for the same or similar measures. The QAC also discusses any changes to the national objective/measures from HHS, HRSA, CDC or HUD. When appropriate changes to local objectives will be recommended to mirror changes to federal measures/objectives. The change from 90 days to 30 days for the LTC measure for connecting newly diagnosed PLWH to HIV care is an example of this.
o WERE ANY MODIFICATIONS MADE TO THE PRACTICE AS A RESULT OF THE DATA FINDINGS?
1) Three LTC Coordinators added over the last three years including one to specifically address newly diagnosed youth. 2) All seven of the LTC Coordinators (six funded by RW Part A and one funded by RW Part D) were cross trained in HIV testing. 3) An LTC Policy Manual was developed to address differences between LTC processes and regular case management processes. 4) A new assessment tool was adopted that allows clients to track and visualize their progress toward each goal and serve as a reminder for actions or tasks that need to be completed.
LESSONS LEARNED IN RELATION TO PRACTICE:
Collaboration and Buy-In early on from LTCs: The group formed to talk about Linkage, to offer recommendations for how to improve data tracking; write the manual; standardize processes; standardize reporting. This happened very early on and I believe KCCC reviewed everything at staff meetings to ensure buy-in and direct input from front line staff.
Collaboration and Buy-In From Stakeholders: DIS, Surveillance; MO SWMM; All RW Grantees (KC-TGA local & MO statewide)
Commitment to the Impact of early LTC: We didn't change the KC-TGA LTC objective simply because HRSA created a 30 dayâ€ measure. We take each new positive seriously and the subsequent efforts/standard of care to link them. Once the stakeholders agreed that 30 day was within local capabilities, then the decision to change the objective was easy.
It takes time to build Capacity/Infrastructure: We've been building a successful LTC program for years. Three positions have been added over five years, staff worked on coordinating a systematic approach and recent efforts in support of the NHAS have been going on for 2 years. We have to be patient with ourselves and committed to incremental changes overtime.
LESSONS LEARNED IN RELATION TO PARTNER COLLABORATION
KCHD and the sub-recipient agencies consider several factors when considering effective sites to co-locate LTC Coordinators. Factors include a facility's experience in treating HIV, a high incidence of HIV positive test results at a location, number of referrals to LTC or Ryan White Case Management, geographic locations with a high prevalence of PLWH or populations at a higher risk for HIV (African American or Hispanic populations), and community based organizations serving consumers in high risk populations. What was learned is that these factors alone are not enough to ensure successful co-location for an LTC Coordinator. The fact that a site provides treatment for several PLWH or has a high number of HIV tests performed come back positive is not a guarantee co-location will be the most effective position to place one of the LTC Coordinators. Similarly, even if a social service agency is located in a community with high incidence of HIV and/or serves a demographic statistically more at risk for HIV does not mean that co-locating on site will empower PLWH. What is important is the site for co-location must support the overall Ryan White network and function within that network as opposed to operating as a standalone entity who provides services to mutual clients. PLWH and in particular newly diagnosed PLWH may not want to utilize co-located LTC or other Ryan White services at another Community Based Organization due to concerns regarding stigma within their community and the potential for their HIV status to be accidentally or involuntarily disclosed when accessing HIV services.
Up until 2017 the KC-TGA's LTC Program was operated out of one agency, Kansas City CARE Clinic. For 13 years KCCC were the sole provider of the LTC service in the region and have established much of the logistical infrastructure for the program like ownership of the LTC pager number. When LTC services were expanded and opened up to another sub-recipient the logistics of how the new position with GSP would be integrated into the existing program was a challenge. KCHD did bring both sub-recipients together prior to bringing on the new LTC staff at GSP to discuss coordination and integration of the new position into the LTC team. (This process also made integration of the LTC position created by the state of KS easier.) Certain aspects of the LTC program could not be uncoupled from KCCC administration like the pager and access to staff schedules. The lesson learned from this is that when establishing an LTC program (or any new service) it may be best for the recipient (KCHD) to take ownership those infrastructure resources so as to not cause confusion or disruption if and when the program needs to be expanded beyond one agency.
DID YOU DO A COST/BENEFIT ANALYSIS? IF SO, DESCRIBE.
KCHD has not done a cost benefit analysis of the practice and practice activities but is willing to explore the type of analysis in future program years.
IS THERE SUFFICIENT STAKEHOLDER COMMITMENT TO SUSTAIN THE PRACTICE?
Stakeholder commitment, collaboration, and cross-agency partnerships strengthen the TGA and enable strategic long-range service delivery sustainability planning as a coordinated system of care. Future sustainability plans include the integration of newly funded LTC Coordinators staffed at Good Samaritan Project (GSP) to adopt the same data collection methodologies and contribute to the overall LTC program evaluation and monitoring.
Continuous outreach, training, and education efforts by both KCCC and GSP support the ongoing identification of clinics or agencies that may not understand the purpose of LTC, the referral process for new positives, appropriate ways to use the pager, or why opt out testing helps HIV prevention and care efforts and promotion of public health in the KC area.
Sustainability efforts will incorporate routine dissemination of data, outcomes, and process improvement initiatives. Progress will be widely disseminated to and with RW-parts, the Planning Council and its various committees, the Quality Advisory Council (QAC), with Part A subcontractors, with Prevention stakeholders, and within the KCHD as a whole.
DESCRIBE SUSTAINABILITY PLANS
As the Ryan White Part A recipient, the KCHD HIV Services program is committed to maintaining Ryan White funding stream(s) and executing the grant to a high standard of quality and service delivery. In October, 2017 the KCHD HIV Services program submitted the application for continued Ryan White Part A funds for the Grant period March 2018 to February 2019. Once awarded, how funds are allocated for each Ryan White service will be up to the KC-TGA Planning Council to decide. Each year the Planning Council goes through a priority setting process to identify and prioritize service categories they think are the most important and/or best use of the Part A dollars. In June of 2017, the Planning Council ranked EIS fifth out of 28, giving that service category clear support for funding in FY 2018 -2019.
In order to maintain status as an eligible Part A recipient the KC region will need to identify at least 200 new cases of HIV infections each year. If the number of new positives declines below that level the KC region would no longer be eligible for those funds. Currently the TGA is not at a risk to lose that eligibility however if new incidence of HIV decline in the KC region it would be up to the Missouri and Kansas Part B programs to decide whether or not to continue funding and managing the LTC program. Ongoing outreach and testing efforts throughout the TGA will help ensure that the region is identifying as many new positives as possible given the available resources.
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