1. Strategies to Engage HIV+ Women in Gyn Care Maryann Pietrowski, NP Jersey City Medical Center Center for Comprehensive Care New Jersey Ryan White Part D Statewide Network

2. Background Jersey City Medical Center is a large urban hospital in northeastern New Jersey, a few minutes from the New York City border. Provides comprehensive, quality health care in a family centered environment. Has a strong, active consumer component and offers support groups. 87% of the patients are at or below the poverty level. Demographics for the 1,100 patients include the following composition: 50% African American 41% Hispanic 9% Caucasian The hospital’s HIV clinic receives funding from Ryan White Part A, Part B, and Part D. Ryan White Part D Network Site: Jersey City

3. CQI Process Part D Network CQI Process Project leads are State administrative staff at NJDHSS CQI committee consists of administrators, consumers, and providers Data abstraction and analysis process is standardized thru 7 NJ RW Part D agencies Gyn care and Paps included as indicators Data are fed back to agencies Brainstorm areas of weakness for possible corrective actions with full Network support CQI: Our impetus for discovery and change

4. Identify Problem (CQI) Educate Staff, Improve documentation Designate Pap Police Incentives Pap Festivals Bring Paps into HIV clinic Coordinate Pap need and on-site service Measure change Brainstorm Waves of Change

5. PlanDo ActStudy PDSA Cycle Example Problem: Pap rate is still low after staff education and chart audits. Objective: Entice / introduce women into Gyn care via Pap Festivals. Set date, identify staff, include consumers, identify resources, plan evaluation Publicize free activity, host Pap Fest, document services, survey patients Reactions of the 21 participants, identify barriers and improvements thru brief survey Need better, more substantial food, and longer, more flexible hours in that day

6. Staff Ed.Chart AuditsPap Fests & Incentives HIV ANP: Paps in Clinic Pap Police–ANP Teamwork Ob/Gyn NP: On-site Paps Trends

7. Annual Screens Located in the front of each chart, on bright colored paper.

8. Women’s Risk Assessment Many factors other than just an annual Gyn visit contribute to positive health outcomes for women.

9. Environment Limited time for Pap Lack of support services Available services Gyn services unavailable on-site Time EMR function to flag provider not enabled No policy in place re: referral f/u Referrals are made with no f/u Limited time w/ MD/NP d/t large case load Overall clinic time limited Emergencies / unexpected complexity of appt. Co-located srvs not available Physical space limited Long wait time Need for Pap No process to flag need for Pap Referrals Pt. understanding Assume pt. is already informed Limited time to explain procedures Lack of pt. education re: procedure Staff responsibility to provide education not defined Not enough clinic space Walk-in appts. Delay scheduled appts. Have to wait to use exam room Space Space used by other practitioners No reminders for pt. appts. Appts. Made without consultation with pts. Low rate of Pap smears Appointments No process to remind pts. of appts. Trained staff Staff not trained to use equipment People Equipment Availability of equipment Specialty equipment not available. eg. tilting exam table Mobile Pap cart not available Liability and billing PrioritiesFear Don’t feel its needed Cost of procedure vs. other needs Unpleasant experience with colposcopy Limited funds for equipment Staff not aware of problems with Paps Competing priorities and time commitments Expectations of staff Expect pt. won’t show Assume pt. doesn’t want to do Pap Billing may not result in reimbursement Svc. not covered by malpractice insurance Competing health priorities Too busy taking care of others Staff Pap not in area of expertise Don’t want exam Don’t want to perform Pap Expectations of f/u on results Pain Negative past experience Of pain Of unknown Patients Of cancer Of diagnosis Procedures Brainstorming: A Root Cause Analysis

10. Two underlying themes emerged from the open-ended questions: 1. “I don’t get a Pap because I don’t want to hear that anything else is wrong with me. I have enough to worry about”. 2. I get my Pap because my doctor is nice. I can talk to her, she respects me, I like her. Gyn Needs Assessment Survey

11. Where to Start? 1.Staff Education: Docs don’t always have a comfort level with sexual health issues. 2.Work towards a seamless incorporation – Normalize Paps as a routine part of HIV care. 3.If you are the staff member performing Paps……be visible, be familiar, be approachable, be respectful. 4.Need “buy in” by the medical staff AND the consumer.

12. How to Start 1.Audit your charts. Know which patients need services. 2.Collaborate with Gyn staff or train HIV NPs to perform Pap screens, and bring the service into your clinic.

13. HIV+ patients’ perceived attitudes of physicians Abate patient fear and reluctance Increase patient’s internal motivation Steps to the Waves of the Future Continuous cycles of attempts SUCCESS Learn from each attempt. Learn from other Network providers. Listen to consumers.

14. NJ Ryan White Part D Contacts Jane Caruso, MS NJ Ryan White Part D Project Director Jane.Caruso@doh.state.nj.us Jane.Caruso@doh.state.nj.us 609-777-7748 Maryann Pietrowski, NP Performance Improvement Coordinator mpietrowski@libertyhcs.org mpietrowski@libertyhcs.org 201-915-2000x3579 For more information, please contact: