Improving Viral Load Suppression RatesEaston Community HIV/AIDS Organization (ECHO)

Quality Improvement Team Members

• Nurse Practitioner (& MD on prn basis)• RN• Office Manager• Medical Assistant• Case Managers

Background Information/Rationale for QI Project

Of the more than 1 million people living with HIV/AIDS in the US, 4 in 5 are not viral load suppressed.

The National AIDS Strategy acknowledges the role of HIV viral load suppression in both decreasing HIV transmission and in improving patient health outcomes.

Easton Community HIV/AIDS Organization (ECHO) is a Ryan White Part C provider serving Northampton, Lehigh, Monroe, Carbon, & Pike counties in Pennsylvania and Warren county in New Jersey.

Client base of approximately 100 patients. 100% of clients are either on Medicaid, Medicare, or are uninsured.

Performance Measure

Percentage of patients with a viral load of <200 at last viral load testing of the measurement year

Baseline Data

Percentage of patients with a suppressed viral load (<200) at the viral load test in the measurement year:

Oct. 1, 2010 to Sept. 30, 2011 -- 66.7% Dec. 1, 2010 to Nov. 30, 2011 – 68.57%

Improvement Goal

Increase percentage of patients with suppressed viral load (VL<200) at the last viral load measurement of the measurement year from 66% to 85% of patients.

Causal Analysis

Workflow Process Analysis Identified the Following Problem Steps:

No follow-up appointments scheduled for some patients with elevated viral load

Need to develop and implement formal Adherence Program

Viral Load Suppression Performance Improvement Measure: Workflow Process Diagram

Forwarded to Data Entry & to chart & flowsheet

VL Receive

d?

Lab Slip Sent?

SendLabSlip

Reminder Call if no labs in 6 weeks

Labs Done

Reminder Letter

PreClosureLetter (no Rx’s); CM Notified

Reviewed By NP

Appt. Kept?

ApptScheduled?

Closure Letter at 9+ Months if no contact

N N

Y

Y

Y

Y

N

Y

Call to Schedule Or Resched.

Discuss Next Steps –see Clinical Process Diagram

N

N

Pt. Referred for VL Test

VL <200

IssuesIdentified?

Formulate & Implement Adherence Plan

2nd VL >200

Consider /Do GenotypeConsider/Do Tropism & HLAB5701Evaluate for Drug-Drug InteractionsConsider or Make Med Evaluate for Drug-

Adherence Assessment at Next Appointment

Recheck VL in 3 months or less

2nd VL <200

Adherence Assessment by phone or appt. within 2 wks.

Yes

No

RoutineMonitoring

Ongoing Monitoring of Adherence & VL Testing as indicated

VL<200

VL>200

PDSA – Plan/Do

Changes Planned for Process of Scheduling Patients for Follow-up Visits

Appointments previously initiated by patient after labwork completed -> now will be initiated by staff after receipt of labwork

Changes Planned for Adherence Program

Initial Adherence assessment for patient with VL>200 to be done by phone or appointment within 2 weeks (previously at next scheduled appointment) of receipt of labwork

Adherence Plan Assessment Form developed to track individual patient progress More aggressive adherence strategies:

o Weekly adherence evaluations of selected patients, including pill box fills and/or supervised pill box fills

o Involvement of case managers to supervise pill box fills and/or perform weekly evaluation of adherence

o Use of Adherence tools, such as pillbox with alarm, cell phone alarms, etc.

ECHO ClinicAdherence Plan Assessment Form Patient Name: DOB: MR#:

Date Action (Pill Box Fill, Supervison, or Check, etc.) Adherence Goal

AdherenceAssessment

(Since Last Visit)

Most Recent VLDate

Most Recent VLResult

NEXT F/U DATE

PSDA - Study/Results

Phase 2: Study/results

Repeated PDSAs

Overall Findings

Looking Ahead (next Steps)