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Increasing Linkage, Retention, Viral Load Suppression for Newly Diagnosed & Lost to Care Clients

State: FL Type: Promising Practice Year: 2018

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Florida Department of Health in Broward County
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Increasing Linkage, Retention, Viral Load Suppression for Newly Diagnosed & Lost to Care Clients
Broward County is in the southeastern portion of the state of Florida, with Miami-Dade County to the south, and Palm Beach County to the north. In 2016, Broward County was the second 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 and is a minority/majority county. 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. The Florida Department of Health (DOH), operates in cooperation with the Broward County Commission under Florida Statute 154. Per the CDC in 2015, the Fort Lauderdale Division of the Miami Metropolitan Statistical Area (MSA) has the second highest rate of new HIV infections (34.8/100,000 persons) and the fourth highest AIDS case rates in the United States (16.1/100,000 persons). In 2015, Broward County had an estimated 22,357 people living with HIV/AIDS. Broward County's total population in 2015 was 1,834,008. In 2015, Broward County did not meet the National HIV/AIDS Strategy targets for the metrics associated with the Continuum of Care, except for linkage as per DOH surveillance data. Specifically, the percentage linked to care was 87% (target is 85%), the percentage retained in care was 68% (target is 90%), percentage with suppressed viral load (VL) was 63% (target is 80%). DOH-Broward has developed a T&T Action Plan to address the high rates of HIV in Broward County. The Action Plan is championed by the DOH-Broward Communicable Disease Director using the approach laid out in the Program Collaboration Service Integration Model (PCSI). To achieve the goals and objectives, DOH-Broward utilizes an Incident Command System (ICS), a component of the National Incident Management System (NIMS), to provide organizational structure, meeting formats that include Incident Action Plans (IAP) and Situation Reports, After Action and Improvement Planning to manage a non-emergency response across multiple internal and external programs. The Federal Emergency Management Agency (FEMA) defines ICS as a management system designed to enable effective and efficient domestic incident management by integrating a combination of facilities, equipment, personnel, procedures, and communications operating within a common organizational structure. ICS is normally structured to facilitate activities. Major functional areas: Command, Operations, Planning, Logistics, Intelligence & Investigations, Finance and Administration. It is a fundamental form of management, with the purpose of enabling incident managers to identify the key concerns associated with the incident—often under urgent conditions—without sacrificing attention to any component of the command system.” The Florida Department of Health (DOH) is implementing four key components to reduce rates of new HIV infection in Florida: Pre-exposure Prophylaxis (PrEP), Non-occupational Post-exposure Prophylaxis (nPEP), Test and Treat (T&T) and community outreach. DOH-Broward and the Broward County Ryan White Part A Grantee Office are working in partnership to implement T&T throughout the Ryan White Part A system of care. Ryan White Part A is the part of the Ryan White HIV/AIDS Program (formerly, Title I) that provides emergency medical assistance (EMAs) to localities disproportionately affected by the HIV/AIDS epidemic. This includes outpatient medical care, AIDS pharmaceuticals assistance, oral care, health insurance premiums and cost sharing assistance, mental health services, medical case management, outpatient substance abuse, food bank/home delivered meals, and legal services. T&T is a clinical program providing immediate linkage to HIV primary care and initiation of ART at the time of HIV diagnosis or returning to care after a gap in services. The program benefits the client's health and the community by providing initial ART while working through the issues of eligibility and linkage to ongoing HIV primary care. Key Processes that were monitored on a weekly basis includes 1.) Training/Outreach, 2.) Social Marketing, 3.) Data Monitoring and Evaluation, 4.) Ryan White Part A Provider Engagement, 5.) T&T Implementation and 6.) Pharmacy Increasing data shows a medical benefit to the client when immediate ART is initiated, particularly during acute/early HIV infection. Many clients report that the decision to start ART and the rapid achievement of viral suppression provides them with the first experience of empowerment to live successfully with HIV. www.broward.floridahealth.gov
According to the United States Centers for Disease Control and Prevention (CDC) in 2015, the Fort Lauderdale Division of the Miami Metropolitan Statistical Area (MSA) has the second highest rate of new HIV infections (34.8/100,000 persons) and the fourth highest AIDS case rates in the United States (16.1/100,000 persons). In 2015, Broward County had an estimated 22,357 people living with HIV/AIDS. Broward County's total population in 2015 was 1,834,008. In 2015, Broward County did not meet the National HIV/AIDS Strategy targets for the metrics associated with the Continuum of Care, except for linkage as per DOH surveillance data. Specifically, the percentage linked to care was 87% (target is 85%), the percentage retained in care was 68% (target is 90%), percentage with suppressed viral load was 63% (target is 80%). DHHS Guidelines currently recommend universal ART for all people living with HIV regardless of CD4 count immediately after HIV diagnosis. There are not many documented programs in the US that support this recommendation. Even with the current recommendations, only three US cities have published on immediate ART after HIV diagnosis; they include San Francisco, San Diego, and New York. What target population is affected by problem (please include relevant demographics) The top priority populations based on persons living with HIV disease (HIV prevalence surveillance data) are the following: 1. Black Heterosexual men and women 2. White Men who have Sex with Men (MSM) 3. Black MSM 4. Hispanic MSM 5. Hispanic Heterosexual men and women 6. Black Injection Drug Use (IDU) 7. White heterosexual men and women 8. White IDU 9. Hispanic IDU What is the target population size? What percentage did you reach? In 2016, Broward County was the second 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 (Black 28.5%, Asian 3.6%, Hispanic 26.9%, more than one race .2%, and White 40.8%). Per the Florida Department of Health 2015 surveillance data, there were an estimated 22,357 individuals living with HIV, accounting for 2,772 (12.4%) who are unaware of their HIV status. Of the 19,585 people living with HIV who were aware of their diagnosis, the percentage linked to care was 87%, the percentage retained in care was 68%, and the percentage with suppressed viral load was 63%. During the first 6 months of the T&T Program implementation (May 1st, 2017 through October 31th, 2017), a total of 619 individuals diagnosed with HIV and currently not on ART medication were referred to the T&T program. Of the total referred, 578 (93%) were eligible for the program, meaning they were confirmed HIV positive and 41 were ineligible. Of the total eligible for the program, 548 (95%) were successfully enrolled in the T&T Program which is determined by receipt of ART medications and 30 refused participation. Of the 548 enrolled, 253 (46%) were newly diagnosed and 295 (54%) lost to care (previous positive). T&T enrollment is the best measure of linkage to care because it ensures clients receipt of ART medications. The specific factors that led to the success of T&T were the following: 1.) utilization of incident command system, 2.) ongoing engagement in training of stakeholders, 3.) intensive linkage and client engagement. What has been done in the past to address the problem? In the past, the standards for initiation of ART after HIV diagnosis have varied and often determined by CD4 count levels and physician discretion. https://hab.hrsa.gov/sites/default/files/hab/clinical-quality-management/2014guide.pdf Why is the current/proposed practice better? Even with the current recommendations, only three US cities have published on immediate ART after HIV diagnosis; they include San Francisco, San Diego, and New York. Broward County's Strategy is unique because it addresses both newly diagnosed HIV positive and previous HIV positive individuals who are re-engaging in care. In addition, The T&T Broward program is designed to focus on re-engagement in HIV care and the delivery of comprehensive essential support services that therefore ensure PLWH continue to receive ART medications. Is it a creative use of existing tool and practice? The HIV care continuum, is a tool supported by the DHHS, consists of several steps required to achieve viral suppression. This tool measures the effectiveness of the practice of linkage and retention to HIV care and will be used to measure improvements in these measures as a result of T&T program implementation. Specifically, CDC tracks: 1.) HIV Diagnosed 2.) Linked to care (at least 1 CD4 or VL), meaning they visited a health care provider within–1 month (30 days) after learning they were HIV positive 3.) Received or were retained in care (at least 2 CD4 or VL at least 3 months apart), meaning they received medical care for HIV infection 4.) Viral suppression, meaning that their HIV VL” – the amount of HIV in the blood – was at a very low level (<200 copies/ml) Using both incidence and prevalence based HIV continuum of care methodologies, we can evaluate and monitor T&T Implementation. Source: https://www.cdc.gov/hiv/pdf/library/factsheets/cdc-hiv-care-continuum.pdf Is the current practice evidence-based? If yes, provide references (Examples of evidence-based guidelines include the Guide to Community Preventive Services, MMWR Recommendations and Reports, National Guideline Clearinghouses, and the USPSTF Recommendations.) Recently, there has been increased evidence that demonstrates better health outcomes and reduction of infectiousness, the sooner an individual initiates ART after HIV diagnosis. The latest updated National Institute of Health (NIH) Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents living with HIV, recommends ART for all individuals with HIV regardless of CD4 cell counts. This is determined to reduce morbidity and mortality associated with HIV infection. Source: https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv/10/initiation-of-antiretroviral-therapy
HIV in the U.S.
Goal(s) and objectives of practice The goals and objectives of Broward County's Test and Treat (T&T) Program are aligned with measures/indicators and targets set forth by the CDC. The CDC's most recent PS-18-1802 Integrated HIV Surveillance and Prevention Programs for Health Departments Evaluation and Performance Measurement Plan is to increase linkage and retention in HIV medical care among people living with HIV (PLWH). Increase the percentage of persons linked to care and on ART medications Increase the percentage retained in care and percentage with suppressed viral load The long-term outcome will be a reduction in community viral load; therefore, decreasing transmission of the virus and rates of new HIV infection in Broward County. What did you do to achieve the goals and objectives? Under the ICS structure, ICS Chiefs initially met daily beginning 2/5/16 where situation reports were prepared to document meeting outcomes. Also starting in February 2017, the Incident Action Plan was reviewed and updated weekly to monitor key processes that included 1.) Training/Outreach, 2.) Social Marketing, 3.) Data Monitoring and Evaluation, 4.) Ryan White Part A Provider Engagement, 5.) T&T Implementation and 6.) Pharmacy. DOH-Broward worked in conjunction with Broward County to develop this unique model to implement the program: THREE STEPS FOR T&T 1. Referral 2. ART Initiation 3. Linkage to care, retention and re-engagement Step 1: Referral for Newly Diagnosed Clients A. Newly Diagnosed Client Identified at a Testing Site that does not Provide HIV Primary Care Under the Ryan White Part A Program: 1. Each site where HIV testing is conducted will designate a T&T Key Contact. 2. T&T Key Contact will inform the DOH-Broward T & T Program Manager or designee about the newly diagnosed client immediately during normal business hours or the next business day. 3. The testing counselor will introduce the concept of T&T to the client and determine the preferred T&T provider. 4. The T & T Program Manager will determine if HIV+ client is newly diagnosed or lost to care using PRISM which is the DOH data management system for STD surveillance and investigation, eHARS surveillance systems and/or Provide Enterprise (PE). PE is a web-based relational, integrated data system used by Broward County Ryan White Part A program to collect client-level data on sociodemographic and epidemiologic characteristics, intake and eligibility, detailed procedure-level service units, clinical outcomes, invoices, and payments. This software is used system-wide across a network of providers to collect data that is subsequently utilized for electronic reporting as well as synchronized real time care coordination of Broward County Ryan White Part A Clients.. 5. If the client is newly diagnosed, the testing counselor will do an oral confirmatory test as a failsafe mechanism in case the client does not follow through with the T&T appointment and therefore does not have blood drawn for a confirmatory test. Otherwise the client with a reactive rapid test will not be counted as a confirmed case. 6. If the client is newly diagnosed, an STD Disease Intervention Specialist (DIS) and HIV LRS will arrive onsite to initiate partner services and finalize the T&T discussion. 7. The HIV LRS will contact the T&T Champion at the selected T&T Provider and make a T&T appointment for that day. 8. The HIV LRS will accompany the client to the appointment along with the testing counselor/linkage if applicable. B. Newly Diagnosed Client who is Identified at a Testing Site that Provides HIV Primary Care Under the Ryan White Part A Program: 1. Each Ryan White Part A primary care provider site, where HIV testing is conducted, will designate a T&T Champion. 2. T&T Champion will inform the DOH-Broward T & T Program Manager or designee about the newly diagnosed client immediately during normal business hours or the next business day. 3. The testing counselor will introduce the concept of T&T to the client and determine the preferred T&T provider. 4. The T & T Program Manager will determine if HIV+ client is newly diagnosed or lost to care using PRISM, eHARS and/or PE and will inform the provider. 5. If the client is newly diagnosed, the testing counselor should do an oral confirmatory test as a failsafe mechanism in case the client does not follow through with the T&T appointment and therefore does not have blood drawn for a confirmatory test. Otherwise the client with a reactive rapid test will not be counted as a confirmed case. 6. The T&T Champion will make a T&T appointment for that day and the testing counselor/ HIV LRS will accompany the client. 7. The STD DIS will follow up with the client for partner services. C. Newly Diagnosed Client Identified at a Private Physician's Office: 1. DOH-Broward STD Program will be notified about the positive HIV test as part of routine surveillance, most likely before the physician is aware. 2. The STD Program Manager will notify the T & T Program Manager who will determine if HIV+ client is newly identified or lost to care. 3. The STD Surveillance staff will contact private physician to determine who will notify the client of their HIV+ diagnosis. 4. Once client is aware of their HIV+ diagnosis, STD DIS will initiate partner services and introduce the T&T Program to the client. STD DIS will notify the HIV LRS. 5. The HIV LRS will select a T&T provider based on the client's insurance status. 6. If the client's insurance will not cover a visit to a Ryan White Part A T&T provider due to out of network, deductible etc., HIV LRS will attempt to make a T&T appointment with an in network HIV primary care physician. Step 1: Referral for Lost to Care Clients 1. Lost to care clients may be identified in various ways, including but not limited to: a. Reactive rapid test at a testing site that provides Ryan White Part A primary care or one that does not b. Contact with an HIV community based organization c. Referral to the T & T Program by Part A providers, CHD Pharmacy and ADAP (ADAP: AIDS Drug Assistance Program administered by States and authorized under Part B of the Ryan White Treatment Modernization Act. Provides FDA-approved medications to low-income individuals with HIV disease who have limited or no coverage from private insurance or Medicaid. ADAP funds may also be used to purchase insurance for uninsured Ryan White HIV/AIDS Program clients as long as the insurance costs do not exceed the cost of drugs through ADAP and the drugs available through the insurance program at least match those offered through ADAP), private physicians, ERs etc. d. Identified by Data to Care Project 2. T&T Key Contact/Champion will inform the T & T Program about the lost to care client 3. HIV LRS will conduct the appropriate research in the available data systems 4. If client is onsite, HIV LRS will arrive onsite and conduct T&T referral as described above. 5. If client is not onsite, HIV LRS will locate the client and conduct T&T referral as described above Step 1: Referral for Newly Diagnosed or Lost to Care Client Identified while Hospitalized 1. Social worker/Designated T&T Key Contact: Appointed staff member located at a community testing site that does not provide HIV Primary Care, the Emergency Room (ER), and the Hospital (inpatient) who is responsible for all correspondence of new HIV+ infections to the T & T Program contacts CIED (Centralized Intake and Eligibility Determination program funded by the Broward County Ryan White Part A Program as the entry point for Broward County HIV positive residents accessing Part A medical and support services) to complete eligibility. CIED collects and enters client's eligibility information (proof of residence, proof of income, HIV+ test) into PE (Provide Enterprise (PE): Provide Enterprise developed by Groupware Technologies, Inc. (GTI) is a web-based relational, integrated data system used by Broward County Ryan White Part A program to collect client-level data on sociodemographic and epidemiologic characteristics, intake and eligibility, detailed procedure-level service units, clinical outcomes, invoices, and payments. This software is used system-wide across a network of providers to collect data that is subsequently utilized for electronic reporting as well as synchronized real time care coordination of Broward County Ryan White Part A Clients). 2. Social worker/Designated T&T Key Contact informs the T & T Program Manager or designee about the newly diagnosed client immediately during normal business hours or the next business day or DOH-Broward may become aware through routine surveillance. 3. The T & T Program Manager will determine if HIV+ client is newly diagnosed or lost to care using PRISM, eHARS and/or PE. a. If the client is newly diagnosed, an STD DIS will initiate partner services and introduce the T&T Program to the client. STD DIS will notify the HIV LRS. b. If the client is lost to care, an HIV LRS will be assigned to the client to initiate the T&T process described below. Step 1: Referral for Newly Diagnosed or Lost to Care Clients who are identified while in the ER 1. T&T Key Contact informs the T & T Program Manager or designee about the newly diagnosed client immediately during normal business hours or the next business day. 2. The T & T Program Manager will determine if HIV+ client is newly diagnosed or lost to care using PRISM, eHARS and/or PE. a. If the client is newly diagnosed, an STD DIS and HIV LRS will arrive onsite, if the client is present, or if not, STD DIS will contact the client to initiate partner services and introduce the T&T Program to the client. The HIV LRS make contact and initiate the T&T process. b. If the client is lost to care, an HIV LRS will arrive onsite if the client is present, or if not, contact to initiate the T&T process. Step 2: T&T Visit with ART Initiation A. Recommended ART Regimens for T&T Program 1. Dolutegravir 50 mg once daily (Tivicay®) + tenofovir alafenamide/emtricitabine (Descovy®) one (1) tab once daily or 2. Darunavir/cobicistat (Prezcobix®) once daily + tenofovir alafenamide/emtricitabine (Descovy®) one (1) tab once daily or 3. Tenofovir alafenamide/emtricitabine/elvitegravir/cobicistat (Genvoya®) one (1) tab once daily with food. B. ART Availability-ART will be available on-site at all of the Ryan White Part A (Ryan White Part A: The part of the Ryan White HIV/AIDS Program (formerly, Title I) that provides emergency assistance to localities (EMAs) disproportionately affected by the HIV/AIDS epidemic. This includes outpatient medical care, AIDS Pharmaceuticals Assistance, Oral Care, Health Insurance premiums and cost sharing assistance, mental health services, Medical Case Management, Outpatient Substance Abuse, Food Bank/home delivered meals, and legal services) primary care providers. 1. Uninsured clients a. Broward Health and the AIDS Healthcare Foundation will fill initial 30-day ART prescriptions at their on-site pharmacies and bill Ryan White Part A under Tier 2 of the Ryan White Part A Formulary. b. Memorial Healthcare Systems, Care Resource, Broward Community and Family Health Centers, and Children's Diagnostic & Treatment Center will be provided with a bulk purchase of drugs on their shelves by DOH-Broward and no billing is necessary. DOH-Broward will develop and deploy an inventory tracking system for the drugs they provide. 2. Insured clients a. If the client has insurance and is having a T&T visit at a Ryan White Part A provider, the pharmacy should attempt to get a 30-day ART prescription filled. If insurance will not approve immediate fulfillment of ART prescription, Ryan White Part A will cover the cost. Client must provide proof insurance denied ART prescription (insurance statement, prior authorization, or denial of fill). b. If the client has a T&T visit at a private physician's office and receives a prescription, the client should attempt to fill the prescription at a pharmacy that accepts their insurance. If insurance will not approve immediate fulfillment of the ART prescription, the client can fill the prescription at the DOH-Broward pharmacy. Ryan White Part A will cover the cost if the client provides proof of insurance denial. C. T&T Visit Process at a Ryan White Part A Primary Care Provider Site 1. An expedited eligibility process will be conducted. The site's designated T&T Champion which is a dedicated T&T Program Staff member located at each community testing site that provides HIV Primary Care, will collect and enter client's eligibility information (proof of residence, proof of income (may be self-declaration), HIV+ test) into Provide Enterprise (PE), ensure the client completes the Authorization to Treat” form, and contact program eligibility to schedule client's appointment within two weeks. 2. Client will see the on-site HIV Primary Care physician who will perform a history and physical examination, order the necessary laboratory tests, select a T&T regimen (as deemed appropriate by the physician and acceptable by the client) and provide a 30-day ART prescription. The physician may choose from one of the three recommended ART regimens or prescribe a different regimen based on client history and clinical judgment. The ART will be prescribed with laboratory results pending. 3. Client will receive a 30 day ART regimen either through the provider onsite pharmacy or physician dispensing. 4. Ideally, the client will take the first dose of medication in the physician's office. 5. The physician will document the visit in PE. D. T&T Process for Clients who are Identified at a Private Physician's Office (Assumption is that client has insurance) (May be Newly Diagnosed or Lost to Care) 1. The physician should provide a 30-day ART prescription. a. If the prescription is provided, the HIV Linkage and Retention Specialist (LRS) will assess the client's insurance status. The client will be referred to a pharmacy that accepts their insurance and linked to HIV primary care with an in network physician. If insurance will not approve immediate fulfillment of the ART prescription, the client can fill the prescription at the DOH-Broward pharmacy. Ryan White Part A will cover the cost if the client provides proof of insurance denial. b. If the prescription is not provided, the HIV LRS will assess the client's insurance coverage and select a T&T provider based on the client's insurance coverage and preference. i. If the client's insurance will allow, the HIV LRS will implement the T&T referral and visit process described above at a Ryan White Part A Primary Care Provider. ii. If the client's insurance will not cover a visit to a Ryan White Part A T&T provider due to out of network, deductible etc., HIV LRS will attempt to make a T&T appointment with an in network HIV primary care physician. If the patient receives a prescription from the private physician, they will be referred to a pharmacy that accepts their insurance. If insurance will not approve immediate fulfillment of the ART prescription, the client can fill the prescription at the DOH-Broward pharmacy. Ryan White Part A will cover the cost if the client provides proof of insurance denial E. T&T Process for Clients who are Identified while Hospitalized (Newly Diagnosed or Lost to Care) 1. The hospital physician should provide a 30-day ART prescription at discharge. a. If the prescription is provided, the HIV LRS will assess the client's insurance status. i. Insured clients will be referred to a pharmacy that accepts their insurance and linked to HIV primary care with an in network physician. If insurance will not approve immediate fulfillment of the ART prescription, the client can fill the prescription at the DOH-Broward pharmacy. Ryan White Part A will cover the cost if the client provides proof of insurance denial. ii. Uninsured clients will have their prescription filled at the DOH-Broward pharmacy under the Ryan White Part A Program. The client will be linked to care at a Ryan White Part A primary care provider and given an appointment for full eligibility determination. b. If the prescription is not provided, the HIV LRS will assess the client's insurance status. i. If the client is insured, the HIV LRS will select a T&T provider based on the client's insurance status. If the client's insurance will not cover a visit to a Ryan White Part A T&T provider due to out of network, deductible etc., HIV LRS will attempt to make a T&T appointment with an in network HIV primary care physician. ii. Uninsured clients will be entered into the T&T process outlined above at the Ryan White Primary Care Provider of their choice. F. T&T Process for Clients who are identified while in the Emergency Room (ER) (Newly Diagnosed or Lost to Care) 1. The ER physician should provide a 30-day ART prescription at discharge. a. If the prescription is provided, the HIV LRS will assess the client's insurance status. i. Insured clients will be referred to a pharmacy that accepts their insurance and linked to HIV primary care with an in network physician. If insurance will not approve immediate fulfillment of the ART prescription, the client can fill the prescription at the DOH-Broward pharmacy. Ryan White Part A will cover the cost if the client provides proof of insurance denial. ii. Uninsured clients will have their prescription filled at the DOH-Broward pharmacy under the Ryan White Part A Program. The client will be linked to care at a Ryan White Part A primary care provider and given a CIED appointment for full eligibility determination. b. If the prescription is not provided, the HIV LRS will assess the client's insurance status. i. If the client is insured, the HIV LRS will select a T&T provider based on the client's insurance coverage and preference. 1. If the client's insurance will allow, the HIV LRS will implement the T&T referral and visit process described above at a Ryan White Part A Primary Care Provider. 2. If the client's insurance will not cover a visit to a Ryan White Part A T&T provider due to out of network, deductible etc., HIV LRS will attempt to make a T&T appointment with an in network HIV primary care physician. If the patient receives a prescription from the private physician, they will be referred to a pharmacy that accepts their insurance and linked to HIV primary care with an in network physician. If insurance will not approve immediate fulfillment of the ART prescription, the client can fill the prescription at the DOH-Broward pharmacy. Ryan White Part A will cover the cost if the client provides proof of insurance denial. ii. Uninsured clients will be entered into the T&T process described above at the Ryan White Part A Primary Care Provider of their choice. Notes: 1. For all of the above scenarios, DOH-Broward will work with clients who are non-Broward and/or non-Florida residents on a case by case basis. 2. Any client who refuses the T&T appointment or the initiation of ART will be followed by the HIV LRS. 3. Any T&T client who cannot obtain medication following the completion of the initial 30 day supply because they could not complete the RW Part A and/or ADAP eligibility process or due to private insurance or other barriers should receive a second 30 day supply of medication from the T&T provider. STEP THREE: LINKAGE TO CARE, RETENTION and RE-ENGAGEMENT A. Day 1 to 3 after ART initiation: 1. If the client was newly diagnosed and initially managed by the STD DIS, the STD DIS will transition the client to the HIV LRS. Lost to care clients managed by the HIV LRS will remain as part of their caseload. 2. The HIV LRS will document the information in PE. a. If the client is in the RW Part A system of care, the information will be documented in the T&T module of PE. b. If the client is not in the RW Part A system of care, the information will be documented in the T&T module of PE only accessible by DOH-Broward. 3. The HIV LRS will contact the client to ask about any medical symptoms or questions and convey those to the HIV primary care provider for appropriate follow up. 4. The HIV LRS will also confirm that the client has a CIED and Ryan White Part B (Ryan White Part B: The part of the Ryan White HIV/AIDS Program (formerly, Title II) that provides funds to States and territories for primary health care (including HIV treatments through the AIDS Drug Assistance Program, ADAP) and support services that enhance access to care to PLWHA and their families. This includes ADAP, Health Insurance Premium and cost sharing assistance, Home and Community Based Health Services, and Medical Transportation Services) and ADAP appointment, if appropriate, and the date of their next primary care appointment. The HIV LRS will assess and address any barriers to compliance with ART or those appointments. If the client will be following up with a primary care provide other than the one that initiated T&T, the HIV LRS will assist in making the appointment. The HIV LRS will accompany the patient to those appointments if necessary and acceptable to the client. B. Day 5 to 14 after ART initiation: 1. The client will have a visit with the medical provider to follow up on clinical care and laboratory tests. At that visit, lab results will be reviewed with the client. Any symptoms or medication side effects will be assessed. Treatment may be adjusted as appropriate. The client will make the necessary follow up appointments. 2. The client will complete their eligibility appointments as appropriate. 3. If the client is RW Part A and B eligible, the client will access other services as necessary and appropriate including RW Part A case management. 4. The client may be assigned a HIV Client Navigator as necessary and appropriate. Any criteria for who was selected to receive the practice (if applicable)? ELIGIBILITY FOR T&T A. Newly diagnosed HIV clients defined as: 1. Acute Infection: antibody (-)/RNA (+) 2. Recent Infection: antibody (+) with last documented antibody (-) within last six months 3. The client may be identified as a consequence to a reactive rapid test or a routine HIV test (blood draw). B. Previously diagnosed HIV clients lost to care defined clients who have had any interruption in their ART. What was the timeframe for the practice? T&T implementation began May 1st, 2017. However, additional planning milestones are as follows: February 2017: T&T ICS commenced February 2017: T&T Protocol was completed March – April 2017: All trainings with stakeholders and DOH-Broward staff were completed November 2017: T&T six-month process evaluation conducted What does the LHD do to foster collaboration with community stakeholders? Describe the relationship(s) and how it furthers the practice goal(s) Training/Outreach: Training and outreach on T&T protocols were conducted for HIV testing sites, primary care and infectious disease providers, Hospital and Emergency Department staff, STD Disease Intervention Specialists (STD DIS), and HIV LRS. T&T Navigators will also be developed and trained to support clients in accessing HIV care, medical care and other essential support services. All STD DIS and HIV LRS were trained in the month of April, 2017. As of October, a total of 9 HIV LRS and 3 STD DIS have been hired and 3 additional HIV LRS, 1 HIV LRS Supervisor, and 1 T & T Data Analyst are being requested to sustain the T&T program. Training and outreach will be an activity that is ongoing and will be sustained throughout the implementation of the T&T program. Social Marketing: Implementation of a T&T social marketing campaign included the development of a T&T campaign, then implementation of TV, bus, and retail frame advertisements, also the exploration of implementing gas station sign advertisements. The T&T Campaign was developed and implemented on TV in April 2017, implemented on bus advertisements in May 2017, and implemented in retail frames and gas station signs in August 2017. In addition, a debriefing on this current campaign will occur in December 2017 that will focus on discussing best campaign practices. Ryan White Part A Provider Engagement: The engagement of the Ryan White providers in T&T involved developing a T&T training protocol, identifying insurance plans accepted by Ryan White Care providers, documenting which providers and pharmacies are in network for each insurance plan, creating a directory of insurance plans, identifying Ryan White T&T Champions, ongoing contact with Ryan White Part A providers and Infectious Disease practitioners, and monthly updates of insurance status. T&T Implementation: Implementation encompassed finalizing the T&T protocol, presenting the protocol to Ryan White Part A, Broward County HIV Health Services Planning Council, South Florida AIDS Network, and the Broward County HIV Prevention Planning Council. The identification of insurance plans accepted by Ryan White Care providers, documentation of providers and pharmacies that are in network for each insurance plan, creation of a directory of insurance plans, and identification of Ryan White T&T Champions were completed in April 2017. These activities for this key process will be ongoing and continuous. 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. For Fiscal year 17-18, the allocation for Test and Treat is $2,856,250. (Below is the budget). 2 months prior to Fiscal Period 17-18, when Test and Treat began, there was an allocation of $260,000 for prescription drugs. Employee salaries and benefits = $630,600 Prescription Drugs expenses = $2,000,000 Other expenses = $38,100 Vehicles - $180,094 Collocated, Risk Management and HR Expenses = $7,456 Total for FY 17-18 = $2,856,250 Total for FY 16-17 (May 2017 to June 2017) = $260,000 for prescription drugs. Total = 3,116,250 Pharmacy: The provision of pharmaceuticals for the T&T Program required an initial bulk purchase, working with each Ryan White Provider receiving bulk purchase to determine the most effective dispensing (pharmacy versus physician) and developing a procedure and toll for inventory monitoring and reporting. The T&T Protocol was completed in February 2017, presented to Ryan White Part A in March 2017, Broward County HIV Prevention Planning Council in April 2017, HIV Health Services Planning Council in May 2017, and South Florida AIDS Network in June 2017. Implementation of T&T in Broward County began May 1st 2017. Since Implementation, total pharmacy expenditures for medications have been $644,040.64.
What did you find out? To what extent were your objectives achieved? Please re-state your objectives. In 2015, Broward County did not meet the National HIV/AIDS Strategy targets for the metrics associated with the Continuum of Care except for linkage as per Florida Department of Health surveillance data. Specifically, the percentage linked to care was 87% (target is 85%), the percentage retained in care was 68% (target is 90%), percentage with suppressed viral load was 63% (target is 80%). During the first 6 months of T&T Program implementation (May 1st, 2017 through October 31st, 2017), a total of 619 individuals diagnosed with HIV and currently not on ART medication were referred to the T&T program. Of the total referred, 578 (93%) were eligible for the program, meaning they were confirmed HIV positive. Of the total eligible for the program, 548 (95%) were successfully enrolled in the T&T Program which is determined by receipt of ART medications. Using T&T enrollment as a best measure for linkage to care, the percent enrolled is 95% which is higher than both the national target (85%) and International target (90% Set by the International Association of Providers on AIDS Care) for linkage to care. A sampling of 10% of the 548 participants, 26 (47%) had viral suppression within 30 days of being enrolled and 4 had decreasing viral load, but at 30 days had not reached viral suppression; 25 (45%) had an increase in their CD4 count. Increasing PLWH on ART will result in a reduction of viral load suppression. The goals and objectives of Broward County's Test and Treat (T&T) Program are aligned with measures/indicators and targets set forth by the CDC. The CDC's most recent PS-18-1802 Integrated HIV Surveillance and Prevention Programs for Health Departments Evaluation and Performance Measurement Plan is to increase linkage and retention in HIV medical care among people living with HIV (PLWH). Increase the percentage of persons linked to care and on ART medications Increase the percentage retained in care and percentage with suppressed viral load The long-term outcome will be a reduction in community viral load; therefore, decreasing transmission of the virus and rates of new HIV infection in Broward County. DATA, MONITORING and EVALUATION Data Monitoring and Evaluation activities included the development of variables in the current Ryan White database for non-Ryan White Clients, ensuring PE fields match desired outcome metrics, training DOH staff in PE, developing referral for ‘lost to care' clients in PE, ensuring undetectable viral loads are reported to DOH-Broward, and determine outcomes and metrics entered into Active Strategy (DOH-Broward's performance measurement system), and determine follow-up protocol. Provide Enterprise (PE) developed by Groupware Technologies, Inc. (GTI) is a web-based relational, integrated data system used by Broward County Ryan White Part A program to collect client-level data on sociodemographic and epidemiologic characteristics, intake and eligibility, detailed procedure-level service units, clinical outcomes, invoices, and payments. This software is used system-wide across a network of providers to collect data that is subsequently utilized for electronic reporting as well as synchronized real time care coordination of Broward County Ryan White Part A Clients. The referral system for the lost to care in PE was completed in April 2017 along with the determination of the follow-up protocol. In May, 2017, the development of variables in the current Ryan White database PE for non-Ryan White Clients, ensuring PE fields match desired outcome metrics, train DOH staff in PE occurred. T&T metrics and outcomes were added to Active Strategy in September 2017. The modules for Test and Treat client follow-up are currently being developed. Did you evaluate your practice? List any primary data sources, who collected the data, and how (if applicable) Data Collection 1. Ryan White Part A clients will have their information and visits documented in Provide Enterprise (PE) by the primary care provider and the HIV LRS. PE may be amended to capture the required data. 2. Non- Ryan White Part A clients will have their information documented by the HIV LRS in a separate tab of PE only visible to DOH-Broward. 3. STD DIS and HIV LRS will document in PRISM (Patient Reporting Information Surveillance Manager) using their normal procedure. List any secondary data sources used (if applicable) Not applicable List performance measures used. Include process and outcome measures as appropriate. A comprehensive Monitoring and Evaluation Protocol was completed for the T&T program. This protocol uses both incidence and prevalence based HIV continuum of care methodologies, to evaluate and monitor T&T Implementation. Using Surveillance data, a final evaluation will be conducted using 2017 data that will be available in the late summer 2018. Surveillance data is collected through both passive and active forms using mandatory HIV case reporting forms and through laboratory reporting. In addition to surveillance data, monitoring of certain T&T variables are conducted on a weekly basis. These data are collected from STD DIS and HIV LRS and then filtered through an internal T&T database. STD DIS and HIV LRS collected information through STD PRISM data-base and client and provider interviews. These monitored variables are as follows: 1. Total number of people diagnosed with HIV who are referred to the T&T program 2. Total number of individuals enrolled in the T&T program (as evidenced by receipt of ART medications) 3. Total number of individuals who refused T&T and the reasons for refusal 4. Of those enrolled in T&T what percent are newly diagnosed HIV-positive or previously diagnosed HIV-positive Metrics 1. Date of initial positive HIV test result for new HIV infections - document if Acute HIV infection 2. First date of contact for those out of care returning to care and if the client instigated the contact or who on the care team found and returned to care. 3. Date brought to T&T site 4. Date first dose of ART 5. Likert scale impression of readiness to take ART by the team at their first contact with the patient including the medical practitioner prescribing at the first clinic visit 6. Baseline CD4 and HIV viral load 7. Any laboratory finding that results in ART change; if genotype is reason for change, document resistance that caused the change 8. Any patient medication side effects resulting in ART change 9. Date first undetectable HIV viral load and most recent CD4 to that date 10. Immune reconstitution inflammatory syndrome (IRIS) resulting in additional care or hospitalization 11. Missed lab or office visits 12. Whether client is retained in care at 12 months or not Describe how results were analyzed Active Strategy will be used to monitor the process objectives above, in addition to the following monthly: 1.) The percent of clients enrolled in the T&T Program (Numerator: Total clients enrolled/denominator: Total clients referred), 2.) Percent of newly diagnosed clients in the T&T program, 3.) Percent of previously diagnosed clients enrolled in the T&T program, 4.) Percent of Clients on ART, 5.) Percent of Clients not on ART. The goals and objectives of Broward County's Test and Treat (T&T) Program are aligned with measures/indicators and targets set forth by the CDC. The CDC's most recent PS-18-1802 Integrated HIV Surveillance and Prevention Programs for Health Departments Evaluation and Performance Measurement Plan. is to increase linkage and retention in HIV medical care among people living with HIV (PLWH). In 2015, Broward County did not meet the National HIV/AIDS Strategy targets for the metrics associated with the Continuum of Care except for linkage as per Florida DOH surveillance data. Specifically, the percentage linked to care was 87% (target is 85%), the percentage retained in care was 68% (target is 90%), percentage with suppressed viral load was 63% (target is 80%). During the first 6 months of T&T Program implementation (May 1st, 2017 through October 31st, 2017), a total of 619 individuals diagnosed with HIV and currently not on ART medication were referred to the T&T program. Of the total referred, 578 (93%) were eligible for the program, meaning they were confirmed HIV positive. Of the total eligible for the program, 548 (95%) were successfully enrolled in the T&T Program which is determined by receipt of ART medications. Using T&T enrollment as a best measure for linkage to care, the percent enrolled is 95% which is higher than both the national target (85%) and International target (90% Set by the International Association of Providers on AIDS Care) for linkage to care. A sampling of 10% of the 548 participants, 26 (47%) had viral suppression within 30 days of being enrolled and 4 had decreasing viral load, but at 30 days had not reached viral suppression; 25 (45%) had an increase in their CD4 count. Increasing PLWH on ART will result in a reduction of viral load suppression. No modifications were made to the practice at this time. A full year 12-month evaluation will be conducted after May 1st 2018. The following Evaluation Indicators will be used for this process: Percent of newly HIV positive individuals enrolled in T&T (Goal: 85%), Percent of previous HIV positive individuals enrolled in T&T (Goal: 85%), Percent of HIV diagnosed individuals that achieve virologic suppression at 12 months, Percent of HIV diagnosed individuals re-enrolled in T&T, Percentage of HIV diagnosed individuals screened for risk reduction intervention needs, Percentage of HIV diagnosed individuals, screened for risk reduction intervention needs and identified as needing an intervention, Percent of HIV diagnosed individuals identified as needing an intervention who were provided an intervention (FOA Target: 85%), Percentage of HIV diagnosed individuals screened for other essential support services, Percentage of HIV diagnosed individuals, who are screened and identified as needing one or more essential support services, Percent of HIV diagnosed individuals, screened and identified as needing other essential support services that are actively referred to one or more of these services, Percentage of HIV diagnosed individuals referred to any prevention service FOA target: 80%, Percent of HIV diagnosed individuals retained in continuous medical care,
Lessons learned in relation to practice Test & Treat in Broward County provides a great opportunity to work in tandem with various hospitals, Community Based Organizations (CBOs) and other counties to learn best practices and learn common challenges. Watching the HIV LRS/Navigators that previously have not worked in such a personal but professional way with patients thrive and grow. Each one has become a leader in their own way, working well as a team, but equally well alone. Understanding the diversity in our area and working well with the Lesbian, Gay, Bisexual, Transgender, Queer or Questioning, and Intersex (LGBTQI) population. Being a front runner with Test & Treat; going the extra step where other counties will not. Broward needs better opportunities to showcase our work so that other counties will have the opportunity to develop a T&T Program to include: HIV LRS and HIV client navigators and previous positive patients. The ability to come to an agreement on what is an acceptable level of coordination between the CBO's and the T&T Program can be extremely easy with some agencies and a difficult task with others. It is important to have a relationship with all Champions to make the T&T process understandable for all while also giving the ability to work in harmony together. Lessons learned in relation to partner collaboration (if applicable) Understanding the T&T process confidentially from beginning to end and having the ability to share that confidence with the CBOs. Understanding the diversity in our community and fitting in instead of standing out. Understanding processes and mastering the necessary skills to help the work flow seamlessly easily. Understanding the collaboration between the CBOs and the DOH-Broward is a give and take, win-win situation. Understanding conflict resolution and being able to successfully sooth any issues between the T&T staff and any champion or CBO. Did you do a cost/benefit analysis? If so, describe. As the T&T program continues, further data will be collected to assess the cost/benefit of the program. Is there sufficient stakeholder commitment to sustain the practice? Stakeholder Engagement: Having the right stakeholders and subject matter experts from the appropriate organizations is necessary to establish community ownership for a plan that impacts such a large number of people. T&T Champions and T&T Key Contacts will continuously be updated to ensure proper communication channels. Describe sustainability plans Ongoing Retention and Re-engagement: 1. The HIV LRS will follow up with the client by telephone a minimum of once per month for the first 3 months to continue with the stabilization plan, to provide ongoing support and education for coping with stigma, partners/family/friends' disclosure and other barriers. The HIV LRS will make the appropriate referrals to DOH-Broward, RW and community based programs and services. 2. The HIV LRS will follow up with the client by telephone a minimum of once at the 6 month mark and once at one year by telephone. 3. The HIV LRS will monitor adherence by whether the client has missed any HIV primary care appointments, labs or any medication pickups and will institute a re-engagement process as required. Training/Outreach: Training and outreach for HIV testing sites, primary care and infectious disease providers, Hospital and Emergency Department staff, STD Disease Intervention Specialists (DIS), and HIV Linkage and Engagement Specialists (HIV LRS), and HIV Navigators will be ongoing and continuous. Ongoing Monitoring and Evaluation: A Monitoring and Evaluation (M & E) Team are in place to ensure the M and E protocol is followed and the T&T Program Evaluated. M and E meetings will continue to be held on a monthly basis to discuss process measures and annually to discuss evaluation progress.
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