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Using HIV DIS to Increase Medication Adherence

State: FL Type: Promising Practice Year: 2018

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Florida Department of Health in Broward County
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Using HIV DIS to Increase Medication Adherence
Broward County is located in the southeastern portion of the State of Florida. In 2016, Broward County was the 2nd most populous county in Florida, and the eighteenth largest county in the nation. The population of 1.9 million residents, accounts for 10% of Florida's population. Broward County also hosts an estimated 10 million visitors annually, including an estimated 250,000 seasonal residents. Broward County has a diverse population with residents representing more than 200 countries that speak over 130 languages 31.4% of the residents are foreign-born. Broward County is a minority/majority county demonstrated by its 2016 population by race. The Florida Department of Health in Broward County (DOH-Broward), is the official lead Public Health Agency in Broward County, and has been operational since 1936. The organization provides core public health functions and essential services as part of a complex public health system that includes hospitals, clinics, planning agencies, and community-based organizations. DOH-Broard operates in cooperation with the Broward County Commission under Florida Statute 154. In 2015, Florida ranked 1st among the 50 states in the number of HIV diagnoses. Broward County had a total of 19,391 cases of Persons Living with HIV/AIDS (PLWHA) in Broward County in the year 2014. Broward County's total population in 2014 was 1,796,314. In 2014, Broward County had the 2nd highest number of new HIV cases among all 67 Florida counties. In 2013, the Fort Lauderdale Metropolitan Statistical Area ranked 10th in United States for newly diagnosed HIV cases and ranked 2nd in HIV case rates. The following goals and objectives were established: Distribute workload equally Create an internal locate and search tool” to capture and track total HIV/AIDS cases Increase efficiency Increase CDC score A high level of accuracy and the ability to manage a high volume of labs results received is required. In 2016, DOH-Broward's HIV/AIDS Surveillance program received approximately 6,000 labs. The Florida Department of Health (DOH) Central Office sends labs compiled together in PDF format. DOH-Broward's HIV/AIDS Surveillance Program did not have a searchable database for the total number of labs sent by DOH annually to track and manage workload, distribute labs equally among personnel, and mitigate duplication of activities, etc. This represented a risk of workload balance and a gap in accountability. DOH-Broward's HIV/AIDS Surveillance Program internally created, at no additional cost to the taxpayer, a searchable database called Sigma (?) to assist in workload distribution, case report completion, and measuring statistical changes. Due to the higher incidences of HIV/AIDS cases in Broward County, the HIV/AIDS Surveillance Program utilizes ?, to help improve efficiency and to track progress of the process and indicators. This provides faster results in order to accomplish our goal. Through ?, the DOH-Broward HIV/AIDS Surveillance Program can capture the total labs, to increase the Centers for Disease Control and Prevention's (CDC's) required score of case report completion. The DOH-Broward HIV/AIDS Surveillance Director redistributed workload, which included, dividing facilities by zip code among personnel accordingly, allowing for changes in volume, contact with facilities, type of providers, areas, etc. The HIV/AIDS Surveillance Program created ? to improve efficiency. ? is an original idea and design. Labs reported by DOH are entered into ? by DOH-Broward. Once labs are distributed, investigations are done, then case reports are written and submitted to DOH. The completed reports have special codes assigned when scanned and those codes are saved in ?. Once case reports are completed and submitted to DOH, labs are removed from ? so management can track the progress of the case and workload. By implementing ?, tracking workload progress, and increasing efficiency the CDC score was increased. ? was created, distribution of workload, decreased duplicates, and decreased travel time, faster completion of Epidemiological investigations and case report submissions. All of the objectives met. Factors led to the success: Problem Identification Developed Action Plan Identified goals and objectives Multifunctional team effort to create and implement ? ? created the ability to facilitate the timely submission of case reporting to DOH. Thus, provided the ability, disseminate information to other DOH-Broward programs quickly by adding the lab results in PRISM which is a state of Florida surveillance, case management, standard STD functions, and record search reporting database. This step enable that department to locate patients faster and bring them to treatment especially in cases of acute infections such as with Nucleic Acid Amplification Tests (NAAT) and always under the discretion of the DOH-Broward HIV/AIDS Surveillance director. www.broward.floridahealth.gov
In 2016, Broward Country had a total of 21,338 cases of people living with HIV/AIDS (PLWHA). In 2015, Florida ranked 1st among the 50 states in the number of HIV diagnoses. Broward County had a total of 19,391 cases of PLWHA in Broward County in the year 2014. Broward County's total population in 2014 was 1,796,314 as per the US Census Bureau. In 2014, Broward County had the 2nd highest number of new HIV cases among all 67 Florida counties. In 2013, the Fort Lauderdale Metropolitan Statistical Area ranked 10th in United States for newly diagnosed HIV cases and ranked 2nd in HIV case rates. The Healthy People 2020 strategy is to target the high risk populations: Gay, Bisexual and men who have sex with men (MSM), of all races and ethnicities, because the high burden of HIV among black gay and bisexual men. Black women and men Latino men and women People who inject drugs Youth aged 13 to 24 years Transgender women because the high burden of HIV among Black transgender women What is the target population size? As of December 31, 2016: AIDS/Adults: 21,338 AIDS/Pediatric: 267 HIV/Adults: 9,901 HIV/Pediatric: 89 Per the CDC, HIV Infection Surveillance Indicators by Area report, DOH-Broward Surveillance percent of all HIV/AIDs infection cases reported with an identified risk as of December 31, 2016, was 98%. The CDC requirement is 85%. What percentage did you reach? Per the CDC, HIV Infection Surveillance Indicators by Area report, over the last four years DOH-Broward's CDC score has fluctuated between 97-99% of new cases reported in the first three months after diagnosis. In the first year, the number of new/updates of HIV and AIDS cases reported increased from 90% to 98%. The CDC requirement is 85%. What has been done in the past to address the problem? Prior to the creation of ?, the DOH-Broward HIV/AIDS Surveillance program used multiple manual Microsoft Excel spreadsheets to collect and analyze the data; thus, not having all the information in one place. We did not have a tool to improve processes for collecting, normalizing, and analyzing data to achieve the strategic outcomes that align with the HP 2020 main goals. Why is the current/proposed practice better? By using ?, the DOH-Broward HIV/AIDS Surveillance database, the program achieved multiple improvements including: The CDC HIV Infection Surveillance Indicators by Area report requirement is 85% of new cases reported in the first three months after diagnosis. DOH-Broward understood the importance of timely reporting to decrease HIV/AIDS infections in Broward County. In the first year of implementing this initiative, the number of new/updates of HIV and AIDS cases reported increased from 90% to 98%. Over the last four years, this score has fluctuated between 97-99% of new cases reported in the first three months after diagnosis. Management's ability to track each employee's weekly activity and deadlines to evaluate cases assigned, and/or pending cases Assistance in time management, allowing preventive measures to be taken Redistribution of workload: dividing facilities by zip code among personnel accordingly, allowing for changes in volume, contact with facilities, type of providers, areas, etc. Provides the opportunity of employee's self-assessment by consulting individual reports that show deadlines, facilities, etc. Assist surveillance personnel to plan work activities Decreased the chance of receiving duplicated laboratory test results. Approximately from 1% to 5% of total labs were duplicated (reported more than once) annually, an average of 150 to 300 labs per year. Identifying these duplicated labs saves time in eliminating additional reporting submission, traveling and other associated costs Ability to facilitate the timely submission of case reporting to DOH. One main goal of Healthy People 2020s (HP 2020) HIV objectives is to increase the proportion of people living with HIV, who know their serostatus to address the National HIV/AIDS Strategy (NHAS) priorities. The NHAS which was released in 2010, established the nation's priorities for HIV prevention and care. The CDC's Division of HIV/AIDS Prevention has developed a strategic plan to achieve NHAS and Healthy People 2020 priorities. ? is a creative use of the existing practice HP 2020. ? was created to improve processes for collecting, normalizing, and analyzing data to achieve the strategic outcomes that align with the HP 2020 main goals. The practice is evidence based. HIV/AIDS Surveillance is part of all Florida County Health Departments (CHDs); however, the practice of using ? as a tool to collect, normalize and analyze data is not systematically utilized in the CHDs. DOH-Broward implanted a systematic process to ensure timely reporting. The evidence-based references used by the DOH's HIV/AIDS Surveillance Program to fulfill the CDC requirements, is called the Guide to Community Preventive Services, by the Revised Surveillance Case Definition for HIV Infection. This publication includes: Scope and Applicability of the Surveillance Case Definition, recommendations, and scientific based definitions to assist Surveillance personnel, divided by sections: Section 1: Criteria for a Confirmed Case Section 2: Criteria for Classifying the HIV Type as HIV-2 Section 3: Criteria for Uninfected and Indeterminate HIV Infection Status of Perinatally Exposed Children Aged <18 Months Section 4: Criteria for Classifying the Stage of HIV Infection Appendix: Stage-3-Defining Opportunistic Illnesses in HIV Infection See: https://www.cdc.gov/mmwr/pdf/rr/rr6303.pdf DOH requires the SMART Performance Expectations for HIV Surveillance Field Staff, are developed with guidelines for management to collect, analyze and process data. The creation of ? divided workload, decreased the chance of duplication, decreased travel time, and improved results. The DOH-HIV/AIDS Surveillance Program improved on the first year the number of new HIV and AIDS cases reported from 90% to 98%. Over the last four years, DOH-Broward reporting rate has fluctuated between 97-99% of new cases reported in the first three months after diagnosis. The use of Specific, Measurable, Actionable, Reasonable, Timely (SMART) Performance Expectations for HIV Surveillance Field Staff, provides management with the ability to increase efficiency and align with HP 2020s main goals.
HIV in the U.S.
Goal(s) and objectives of practice: Distribute workload equally Create an internal locate and search tool” to capture and track total HIV/AIDS cases (new and updates) Increase efficiency Increase CDC score What did you do to achieve the goals and objectives? Problem Identification Developed Action Plan Identified goals and objectives Multifunctional team effort to create and implement ? Steps taken to implement the program? Distribute workload equally: The DOH-Broward HIV/AIDS Surveillance Director redistributed workload based on identified areas of need, which included, dividing facilities by zip code among personnel accordingly, allowing for changes in volume, contact with facilities, type of providers, areas, etc. Create an internal locate and search tool” to capture and track total HIV/AIDS cases (new and updates): The DOH-Broward HIV/AIDS Surveillance Program created ? to improve efficiency. ? is an original idea and design. Labs reported by DOH are entered into ?. Once labs are distributed, investigations are done, then case reports are written and submitted to DOH. The completed reports have special codes assigned when scanned and those codes are saved in ?. Increase efficiency: Once case reports are completed and submitted to DOH, labs are removed from ? so management can track the progress of the case and workload. Increase CDC score: By implementing ?, tracking workload progress, and increasing efficiency the CDC score was increased. Our Surveillance improvement contributes to the United Nations Millennium Development Goal 6: combat HIV/AIDS, malaria and other diseases which is to reverse the spread of HIV/AIDS. The HIV/AIDS Surveillance Program is responsible to provide the data collected which includes demography and geography. ? created the ability to facilitate the timely submission of case reporting to DOH. DOH-Broward has strong collaborative relationships with public and private health care providers such as doctor's offices, hospitals, jails, and laboratory, used to collect data. Our existing and trusted community relationships and partnerships assisted in the accurate exchange of necessary information. Any criteria for who was selected to receive the practice (if applicable)? The DOH-Broward HIV/AIDS Surveillance Program was selected to receive this practice. What was the timeframe for the practice? ? was developed over a two-month period. It was implemented in 2013 and has been in continuous operation for four years. Were other stakeholders involved? What was their role in the planning and implementation process? The DOH-Broward HIV/AIDS Surveillance Program collects confidential data from health care providers such as doctor's offices, hospitals, jails, and laboratories. The data collected is used to develop case reports. By creating ?, this provides management the ability to track each employee's weekly activity and deadlines to evaluate cases assigned, or pending. What does the LHD do to foster collaboration with community stakeholders? DOH-Broward has a long and successful relationship with partners in the community including healthcare partners, the faith-based community, educational institutions, governmental agencies, and non-profit groups, civic associations, private providers, such as hospitals, doctor's offices, and other businesses countywide. DOH-Broward has been the leading organization to mobilize community, address minority groups and health disparities including: The Coordinating Council of Broward, Broward Healthy Start Coalition, Health Care Access, Primary Care Group, Immunization Action Coalition, and Medical Services Planning. DOH-Broward works with its partners, on both a formal and informal basis, and is viewed as the central force that brings together all partners in public health to provide accessible, high quality health services within the community. Describe the relationship(s) and how it furthers the practice goal(s) These relationships assure that DOH-Broward's objectives are aligned to the Broward County Community Health Improvement Plan, the Florida Department of Health Strategic Plan, the State Health Improvement Plan, and meets the indicator goals on the CHD Administrative Snapshot, County Performance Snapshot, and the County CHD Dashboard. These plans and dashboards contain metrics that are associated with healthcare partners, the faith community, educational institutions, governmental agencies, non-profit groups and other less traditional partners such as first responders and businesses. DOH-Broward has included in Active Strategy indicators that are measured by these various groups in the community and government plans listed and linked them through cascading scorecards to programs or high level scorecards using targets and monitoring gaps in performance. Information is then used at various levels and presented to various community groups. This performance measurement system can respond to rapid, unexpected organizational and external changes in the community. 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 start-up costs/ budget breakdown. ? was built internally by the DOH-Broward Management Information System Team in conjunction with DOH-Broward HIV/AIDS Surveillance Program Team. The process was completely done without any additional cost and included training and implementation.
In not having a specialized, tailored tool to manage labs distribution, personnel assigned to each Zip Code to do investigation and data collection, follow case reports submitted to the DOH-Central Office, and the ability to achieve some of the goals and objectives established by the DOH-Broward HIV/AIDS Surveillance Program management. By implementing a mechanism to analyze the process and evaluate performance, the program is able to objectively identify strengths and opportunities for faster improvement. As a result of the alignment of the DOH-Central Office performance management system and each employee's performance evaluation, duplicated labs were eliminated. This has provided the opportunity for employees to meet or exceed predetermined metric targets. Prior to implementing ?, the DOH-Broward HIV/AIDS Surveillance Program was reliant on the previous system which used Microsoft Office Excel software that only reported the number of labs, but not all other processes involved in the expected outcome. This prior system, did not provide an opportunity to make periodic adjustments throughout the process for meeting expectations. The segmentation of data reviewed at the monthly business review meetings, provided the DOH-Broward HIV/AIDS Surveillance Program the opportunity to make adjustments by creating an efficient process through ? exceeding established targets. Objective 1 - Implement a performance management system to the program's employees Objective 2 - Decreases the number of duplicated labs Objective 3 Decreases travel time to investigate cases already submitted Objective 4 Creates efficient methodology for Program employees to evaluate how many cases were done and the number of labs pending for investigation to be done Objective 3 Establish a comprehensive multi-level review process and faster results, including each employee who access the system and the management Did you evaluate your practice? The practice is evaluated on monthly basis by both designated staff and management to realign results with performance expectations based on the prior system to ?, and the ability to improve processes. During the monthly business review meetings, the metrics are reviewed for performance. Underperforming metrics are discussed with corrective action planning implemented. DOH-Broward HIV/AIDS Surveillance Program staff utilizes multiple statewide and national data bases to collect, compile, analyze data to benchmark and set goals to determine performance levels at both organization and individual levels. Daily programmatic activities are captured into the systems listed below by internal and external stakeholders through direct data entry and electronic data transfer. Lexis Nexis Broward County Court Clerk Ryan White CAREWare Florida Correctional System Broward Sheriff's Office Federal Bureau of Prison PRISM Broward County Court System DAVID Florida Driver License Florida Shots Immunization System FMMIS (Florida Medicaid) Health Management System EHARS Environmental Health Database Broward Property Appraiser Hospital and Private Providers Medical Records List performance measures used. Include process and outcome measures as appropriate. Based on analysis, DOH-Broward HIV/AIDS Surveillance Program objectives are aligned to the DOH Central Office, and meets the indicator goals required by the CDC. Input: HIV/AIDS Surveillance Office Staff HIV/AIDS Surveillance Field Worker Car availability for field investigation Quantity of data collected Quality of data collected Output: Number of HIV Cases investigated Number of AIDS cases investigated Number of HIV to AIDS investigated Number of employees in the field Number of data collected and inputted in ? system Process: Developed Action Plan Identified goals and objectives Multifunctional team effort to create and implement ? Organizational structure Epidemiological investigation Trusted relationships between Providers and HIV/AIDS Surveillance Team Outcome: With the creation of DOH-Broward database ?, we were able to improve on the first year the number of new HIV and AIDS cases reported within 3 months from 90% to 98%. Over the last four years, this rate has fluctuated between 97-99% new cases reported on the first three months after diagnosis which demonstrates sustained performance. The DOH-Broward reference point is the Center of Disease Control and Prevention (CDC) standard of 85%. As a result of ?, field work travel per employee has decreased which enabled the staff to increase efficiencies and visit additional healthcare providers in a similar geographic area. Personnel is able to identify labs ordered by providers, dates assigned and due dates, making individual and conglomerate planning for investigation of cases easier, also decreasing time spent on investigation. Decreased the number of duplicated labs. By decreasing duplicates and by improving the capability of verifying previous cases sent by central office, DOH-Broward decreased field staff travel time. The need for employee visiting the field several times to verify the same duplicated report was eliminated. Decreased the needs to hire an additional employee due to the higher number of labs, before the removal of them, using the ?. The new employee would cost a department an average $60,000 (Salary + Benefits), plus the number of dollars of other personnel involved in the process such as time and salary for staff assistant. As a result of this effort and the effectiveness of ?, this process was shared with other health departments in Florida for implementation in their HIV/AIDS Surveillance programs. The DOH-Broward HIV/AIDS Surveillance program improved its score on Center of Disease Control and Prevention (CDC) and State indicators. We were able to improve on the first year of implementation of ? the number of new HIV and AIDS cases reported from 90% to 98%. Over the last four years, this rate has fluctuating between 97-99% new cases reported on the first three months after diagnosis. The DOH-Broward reference is the Center of Disease Control and Prevention (CDC) Standard of 85%. Were any modifications made to the practice as a result of the data findings? Not applicable
Dedicated personnel, technological, and fiscal resources need to be applied to ensure sustainability of the system. ? enables the user to better monitor their own performance and the DOH-Broward HIV/AIDS Surveillance Program Director to collect data, evaluate and analyze outcomes. Cost Benefit Analysis: DOH-Broward HIV/AIDS Surveillance Program is committed in continuing improvement in quality process and results delivery to achieve higher score required by the CDC. The creation of ? was at no additional cost to the program because it was developed internally. This efficient system permitted the surveillance program to reduce duplication which increased annual savings. The DOH-Broward HIV/AIDS Surveillance Program received 150 labs duplicated in 2016. The new system was able to track the duplicates, eliminating the travel, gas, mileage and labor hours to employee, travelling to providers to review all labs. Time of traveling round trip (round trip average 40 minutes) Time of investigation (30 minutes) Time to complete Case Report Form (10 minutes) Additional time of staff assistant reviewing, scanning etc. (10 minutes) Average per Lab: 90 minutes Total Labs 2016 in this category: 150 per year A – Amount of savings working at the office, instead driving to providers to review labs. A $60,000(salary + benefits) employee would cost $ 31.25 per hour 150 labs X 40 minutes (investigation, writing case report) = 6,000 minutes required do to all labs / 60(hour) = 100 hours 75 (labs) X 40 minutes' travel (assuming 2 labs x 1 provider) = 3,000/60 = 50 hours +100 = 150 hours X $31.25= $4,687.5 Cost of Labor for an additional employee: $4,687.5 Cost of labor to all other employees involved in the process of reviewing and scanning: (10 minutes X 150 labs) = 1500 minutes/60 (hour) = 25 hours X $31.25 = $781.25 Cost of all employees involved in this process: (if required only one visit per year) $ 4,687.5 field visit (new employee) $ 781.25 additional employees' labor Total cost per year: $5,468.75 (labor only) B – Saved gas driving from office to providers Gas used to investigate 150 labs once a year: 75 providers X 40 miles = 3000 miles / per 30 millage per gallon (Average mileage per gallon): 100 gallons X $2.80 (per gallon) = $280 Total cost of gas: $280 C – Cost of mileage to visit from office to a provider once a year We have a total over 75 providers. 75 providers X 40 miles = 3000 miles X $ 0.455 (mileage cost maintenance) = $ 1,365 Total cost with mileage: $1,365 By having ? we were able to remove the duplicates saving: Labor from all employees $ 5,468.75 Mileage - $ 1,365 Gas - $ 280 Total Savings per Year Using: $ 7,113.75
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