Part A Treatment Adherence Site Visit reviews

Kinga Cieloszyk, MD,MPH Deputy Medical Director of Clinical Care , NYCDOHMH,

HIV Care, Treatment, and Housing Program

Jacqueline P. Colon, MHAPart A Program Manager, NYSDOH, AIDS Institute

Quality Management Program

Purpose of Site Visit

Joint effort by the NYC and NYS Department of Health in support of quality improvement efforts across all Part A programs

Unexpectedly low service performance scores in several quality indicators

Address questions related to program scores Assessment of service provision and gaps that

may have impacted program’s ability to meet each quality indicator

Address program's ongoing service performance needs through quality improvement activities

Part A Programs Reviewed

Six Part A Treatment Adherence Programs reviewed:

Two Community Based Organizations (CBO’s)

Two clinic based programs Two hospital based providers

Overview of Treatment Adherence Indicators

Indicators are established with the involvement of various key stakeholders:

Part A service providers Clinical consultants, educators Treatment Adherence Quality Learning

network committee members NYSDOH Part A Quality Management staff NYCDOHMH, HIV Care, Treatment, and

Housing Program staff other representatives as deemed appropriate.

Overview of Treatment Adherence Indicators

Once indicators are chosen, a statistician assists with developing a method for the sampling of records.

The sampling plan ensures that enough records are reviewed to provide reliable, meaningful data, without requiring the review of more records than necessary.

Barriers with Treatment Adherence Indicators

Program staff at the various facilities reviewed identified indicators were too rigid

Too many indicators for initial review Difficulty to assess all indicators Different standards addressed by AI and

NYCDOHMH versus the program’s current contractor

Barriers with Treatment Adherence Indicators

Indicators are too clinical in nature for the various programs

Providers identified based on level of importance i.e. standard of care such as VL and CD 4 values) was most important to collect) and other support services were not relevant to integrating TAS

Barriers with Treatment Adherence Indicators

Documentation of the TA indicators was time consuming and did not occur at every intervention (i.e. due to the onset of client needs)

Unable to meet minimum requirements (i.e. adherence to ARV therapy has been quantified and documented every 4 months) versus various provider’s collecting information from PCP at 6 month intervals

Barriers with Treatment Adherence Indicators

Inability to obtain indicator information in a timely manner (CD 4 and VL values) since most programs are not co-located

Some indicators are not very important and do not accurately reflect what occurs at all facilities

Indicator Compliance

Not meeting initial documentation standards

Documentation activities do not reflect treatment adherence activities

Information was difficult to find Staff retention issues affected some

programs

Indicator Compliance

Counseling activities and other interventions offered did not support treatment adherence activities

The integration of treatment adherence services was not clear

Evidence does not suggest effective integration of care for some programs

Review of Program Models

Elements of a Treatment Adherence Program Target population/enrollment

criteria/intake process Barrier identification/treatment

readiness assessment How, when and how often services will

be delivered ART assessment & Quantification of

adherence

Review of Program Models

Treatment adherence support tools (curriculum-based education, individual and/or group counseling, peer support, pillboxes, DOT, etc.)

Link to non-medical case management (includes advice and assistance in obtaining social, community, legal, financial, and other needed services)

Review of Program Models

Staff training/supervision Multidisciplinary team

communication/rounds Strategies to engage, re-engage and

maintain clients in care Criteria for service

intensity/step-down/program completion

Responses from Part A Treatment Adherence Questionnaire

Barriers to Program Implementation

Frequently missed appointments/ lost-to-follow-up

Patient fails to obtained ordered labsPatient barriers: mental health,

substance use, legal issues, housing needs

Responses from Part A Treatment Adherence Questionnaire

Barriers to Program Implementation

Lack of co-location with limited record access

Working with multiple providers Limited staff (case managers, outreach

workers, data entry)

Review of the Evaluation Process

Indicators NYCHSRO average score

6 Site Evaluation Process

CD4 & VL Assessed every 4 months

Average =21%

6 Reviewed Programs (Range) =20-56%

Scoring inconsistent at 2-3 sites 60-70% CD4/VL assessed every 4 mos. 80-90% CD4/VL assessed every 6 mos.

Barriers Lack of co-location Multiple charting/reporting systems Documentation

ART Adherence Assessed & Quantified

Average =31-37%

6 Reviewed Programs (Range) =20-56%

Most scoring consistent, some discrepancy at 1-2 site Quantified is an important part of assessment Lack of an adherence record keeping Documentation

Adherence Treatment Plan

Average =22.6 %

6 Reviewed Programs (Range) =0-56%

Most scoring consistent, some discrepancy at 1-2 site Sites asked to review own charts Lack of adherence treatment plan forms Documentation

Documentation

Documentation Improvement

Proper documentation is critical Chronological record of patient care that

contributes to high quality Allows treatment to be planned and

monitored over time Effective ‘communication’ between staff

and improves hand-offs

Documentation

Documentation Improvement

Appropriate utilization review and quality of care evaluations

Assists in the defense of staff in the event of legal cases

Service reimbursements Collection of data that may be useful in

data evaluation and research

Documentation

Documentation Improvement Programs

Part of a site’s ‘Quality Improvement Project in HIV Care

Comprehensive and well-designed program focused at developing a well-documented adherence record system

Key components of documentation

Adherence record should be complete and legible (date and legible identity of staff)

Best practice: Adherence section

Treatment Plan (date, reason for enrollment/referral, barrier assessment, ART treatment review, service intensity (e.g. frequency of follow-up), use of supportive tools (e.g. pillbox) , assessment/service plan, follow-up/next appointment, communication with PCP/team)

Progress notes (date, reason for encounter, medication review, adherence quantification, labs, assessment/plan, next follow-up)

Flow sheet Trend: labs, ART, adherence rate

(quantified), etc.

Date CD4/ %

VL % of doses missed

HAART (regimen & dose, start date, date end, reason for change)

Treatment Plan Developed

Barrier Assessment

SAMPLE FLOW SHEET

Summary of Finding & Recommendations

Identified Challenges Improving the Process

Indicators Too manyDifficult to measureChanging standardsSome not very relevant

Re-evaluate & re-consider some chosen indicators (relevance, measurability, accuracy, improvability)Run an ‘indicator pilot test’

Treatment Adherence Program Models

Range of program models – from weak to strong Lacking ‘Treatment Adherence Program’ elements

Present ‘Best Practice’ Program ModelsTreatment Adherence Learning Networks – share experiencesStandardize ‘best practice’ program elements

Documentation Varied across programs – missing treatment adherence forms, plan updates, dedicated adherence sections, flow sheets

QI- Documentation Improvement Projects!

Review process

Multiple reviewers (NYSDOH/ PHS/ DOHMH)Weak collaboration and information sharing

Review findings to validate resultsFeedback from providers –what worked well and what posed challengesAnalyze and share resultsDOHMH/NYSDOH/PHS improve measurement process & work together!

Questions & Comments

Thank you

Contact Information

Kinga Cieloszyk, M.D., MPH Deputy Medical Director of Clinical Care , NYCDOHMH,

HIV Care, Treatment, and Housing Program

Tel: (212) -788-4660

Email: kcielosz@health.nyc.gov

Jacqueline Colon, MHAProgram Manager, Part A Quality Management Program

Tel: (212) 417-4615

Email: jpc19@health.state.ny.us