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1 Improving Care for Patients on Antiretroviral Therapy: Improving Care for Patients on Antiretroviral Therapy: Testing the ART Framework in Nicaragua.

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Presentation on theme: "1 Improving Care for Patients on Antiretroviral Therapy: Improving Care for Patients on Antiretroviral Therapy: Testing the ART Framework in Nicaragua."— Presentation transcript:

1 1 Improving Care for Patients on Antiretroviral Therapy: Improving Care for Patients on Antiretroviral Therapy: Testing the ART Framework in Nicaragua and Tanzania Larissa Jennings USAID Health Care Improvement Project University Research Co., LLC - Center for Human Services 7200 Wisconsin Avenue, Suite 500, Bethesda, MD 20814

2 USAID HEALTH CARE IMPROVEMENT PROJECT Presentation Outline Part 1: Conceptual Overview of ART Framework Part 2: Description of Components for Application in the Field Questions & Comments

3 USAID HEALTH CARE IMPROVEMENT PROJECT I.Conceptual Overview of Strategic Framework

4 USAID HEALTH CARE IMPROVEMENT PROJECT What is good quality ART care? Everyone who needs ART receives it Everyone who receives ART is retained in care Everyone in care has a good clinical outcome

5 USAID HEALTH CARE IMPROVEMENT PROJECT Quality Indicators for Care of PLWHAs: Coverage: Percent of PLWHAs eligible for ARTs who actually receive ART Retention: Percent of PLWHAs who receive ART and are still on therapy at any given time Clinical Outcomes: Percent of PLWHAs who are currently on therapy and have good clinical outcomes

6 USAID HEALTH CARE IMPROVEMENT PROJECT How many PLWHAs will need ARTs? 5,000 PLWHAs (CA=100,000 & P=0.05) 10% Annual Progress to ART Eligibility 90% Annual Survival Rate Planning ART Programs using a Chronic Care Model: 10-yr Model

7 USAID HEALTH CARE IMPROVEMENT PROJECT Framework for Improving Care for Patients on ART

8 USAID HEALTH CARE IMPROVEMENT PROJECT Premise for Monitoring Quality Indicators Identify Gaps in Provision of Care Gap 1: Coverage Gap 2: Retention Gap 3: Clinical Outcomes Causes for Gaps? Potential Solutions? Effectiveness of Solutions? Expected Outcome? Quality Improvement Research Prompts P S DA Monitoring Quality Indicators

9 USAID HEALTH CARE IMPROVEMENT PROJECT Breaking Improvement Challenges into Smaller Problems GapCause Coverage Insufficient HIV testing Distance to health facilities Weak links with other services (e.g. PMTCT, TB, etc. ) Stigma and discrimination Inefficient clinic functioning Retention Distance to health facilities Inconvenience Lack of education about need to return to clinic Out-migration Outcome Start therapy during late stages of disease Poor adherence to medication Poor drugs or supply of drugs Viral resistance to medication Poor infection control Poor management of opportunistic infection and side effects

10 USAID HEALTH CARE IMPROVEMENT PROJECT Quality Indicator #1 - Coverage: ART Estimation Model & Dataset Sites enter local estimates Calculates # Eligible for ARTs

11 USAID HEALTH CARE IMPROVEMENT PROJECT Quality Indicator #1 -Coverage: ART Estimation Model & Dataset New patients started on ART Cumulative (Ever started on ART)

12 USAID HEALTH CARE IMPROVEMENT PROJECT Quality Indicator #1- Coverage: ART Estimation Model & Dataset Automatically Generated to Graph

13 USAID HEALTH CARE IMPROVEMENT PROJECT Quality Indicator #2 - Retention: ART Estimation Model Retention: Percent of PLWHAs who started ART and are still on therapy at any given time Definition  Patients still on ART Measures: –The ideal measure would be the number of people who took their ART today –Proxies for this could be: Number of people seen in the clinic last month Number of ART doses dispensed last month –Numerator: # still on therapy –Denominator: # ever started  excluding deaths & transfers (Expected ART Patient Load)

14 USAID HEALTH CARE IMPROVEMENT PROJECT Quality Indicator #2 - Retention: Patients returning to Clinic Doses dispensed at Pharmacy Expected ART Patient Load

15 USAID HEALTH CARE IMPROVEMENT PROJECT Measurement of Quality Indicators: #3 - Clinical Outcomes Clinical outcome: Percent of PLWHAs who are currently on therapy and have good clinical outcomes Definition  ART Patients who are doing “well” Measures: –Based on immunologic data (if available): –Based on virologic data (if available): –In absence of recent CD4 count and/or viral load, based on clinical criteria: Stable weight (no weight loss >2kg) Patient is ambulatory (functional status) No opportunistic infections (OI) –This requires chart reviews: These are not always recorded OI’s are not always defined correctly in charts

16 USAID HEALTH CARE IMPROVEMENT PROJECT Monitoring Clinical Outcomes: ART Model & Dataset Enter clinical data directly for unique or composite criteria 3 Quality Indicators Automatically Generated

17 USAID HEALTH CARE IMPROVEMENT PROJECT Completed ART Framework: Plotting All 3 Indicators Basis for Identifying “Gaps” for Guiding QI Activities Currently Testing in Nicaragua, Uganda & Russia

18 USAID HEALTH CARE IMPROVEMENT PROJECT ART Framework: Potential Weaknesses Model estimates assume constant HIV incidence / prevalence –Challenge of incorporating mortality Measurement Challenges –Use of proxies for retention –Variation in data source (missing / limited data) –Potential lag time Scope of framework focuses only on ART –Excludes other aspects of HIV care

19 USAID HEALTH CARE IMPROVEMENT PROJECT ART Framework: Potential Benefits Measurable definition of ‘good quality’ ART program –Focuses on three key indicators relative to local context ART Program planning –Estimate expected patient load over time –Projection of necessary resources and strategies Identification of gaps and guide QI activities –Research prompts for developing QI strategies –Test effectiveness Indirect information on quality of other HIV services –Linkages with PMTCT, VCT

20 USAID HEALTH CARE IMPROVEMENT PROJECT II. Applying the Framework to Real Situations: II. Applying the Framework to Real Situations: Identifying Causes & Testing Solutions

21 USAID HEALTH CARE IMPROVEMENT PROJECT Findings from Nicaragua: Plotting Historical Data of ART Program

22 USAID HEALTH CARE IMPROVEMENT PROJECT Premise for Monitoring Quality Indicators Identify Gaps in Provision of Care Gap 1: Coverage Gap 2: Retention Gap 3: Clinical Outcomes Causes for Gaps? Potential Solutions? Effectiveness of Solutions? Expected Outcome? Quality Improvement Research Prompts P S DA Monitoring Quality Indicators

23 USAID HEALTH CARE IMPROVEMENT PROJECT Closing the Coverage Gap: Using patients- providers interviews – What are possible causes? Lack of knowledge HIV transmission and risk factors – as well as treatment availability and efficacy Stigma and discrimination Fear of exposure of HIV status Discrimination across sectors Gender issues Women may need permission to receive testing or treatment Missed opportunities within health facilities to offer test Not all target groups are offered test or accept testing or results Lack of necessary supplies, community outreach, or adequate counseling Provider reluctance due to privacy laws Coordination and organization of services Linkage & referrals across levels of health system Coordination with NGOs and other points of service

24 USAID HEALTH CARE IMPROVEMENT PROJECT Closing the Coverage Gap: Changes being tested to improve coverage Improve pre- and post-test counseling: –Target knowledge gaps among patients Decrease missed opportunities within the health system: –Work with existing community outreach programs –Improve linkages within health care systems using technical hospital meetings –Offer testing to patients in outpatient clinic of the hospital Increase patients receiving test results: –Decrease time needed for return of HIV test results –Strengthen capacity and confidence of personnel at health post to provide HIV test results Assure patients enroll in HIV program after testing positive –Compare lists of HIV+ identified at health centers to those enrolling in HIV program to assure 100% attendance after referral (search for missing

25 USAID HEALTH CARE IMPROVEMENT PROJECT Closing the Retention Gap: Causes Reported by ART Patients and Providers Of the patients interviewed with poor attendance, reasons reported: –Feeling fine –Alcohol use –Depression –Difficulty with transportation (cost) –Side effects of medication –Long waiting time / doctor unavailable –Lack of family support –Stigma / discrimination –Lack of food to take with medication –Spontaneous travel Of the providers interviewed, reasons reported: –Poor follow-up of missed appointments –Transportation difficulties –Mental illness / depression –Migration –Complaints of side effects –Lack of family support –Lapse of memory –Substance abuse

26 USAID HEALTH CARE IMPROVEMENT PROJECT Closing the Retention Gap: Changes being tested to improve retention Targeting Patient Loss to Follow-up: Use of PLHA groups to search for patients who have missed appointments Coordinate with other clinics and NGOs Preventing Loss to Follow-up: Identify patients who miss appointments early (track % keeping appointments) Increase communication with providers between visits Develop capacity for management of social issues experienced by PLHA –Compile a list of available resources that match the needs of HIV patients –Confirm to be reliable and willing to respect patient confidentiality –Establish referral and counter-relationship

27 USAID HEALTH CARE IMPROVEMENT PROJECT Closing the Wellness Gap: Causes identified for poor clinical status for patients on ART Of the patients interviewed with a poor clinical status, reasons reported: –Started treatment late –Chose to discontinue treatment Of the providers interviewed, reasons reported: –Co-morbidity –Poor adherence to treatment Distance to clinic Side effects Dietary constraints –Fear to continue treatment

28 USAID HEALTH CARE IMPROVEMENT PROJECT Closing the Wellness Gap: Changes being tested to improve health outcomes Start assessing all HIV patients for TB and other co-morbidities –Increase TB prophylaxis and/or treatment Improve use of follow-up sheet for ART patients –Records active problems, anthropometric measures, lab test results, and patient’s clinical status Use four-day recall methods to assess reasons for non- adherence –Work with patient to understand causes for poor adherence to develop future interventions

29 USAID HEALTH CARE IMPROVEMENT PROJECT Findings from Tanzania: Plotting Historical Data of ART Program

30 USAID HEALTH CARE IMPROVEMENT PROJECT Closing the Retention Gap: Using patient interviews – What are possible causes?

31 USAID HEALTH CARE IMPROVEMENT PROJECT Closing the Retention Gap: Changes Being Tested in Tanzania Causes identifiedChange to prevent recurrence Transportation / travel  Dispense two months supply of ART to decrease number of visits  Send a relative / friend to collect ART on behalf of patient  Home based care services as a last-resort option Lack of Social Support  Share appointments schedule with someone who lives close by who can serve to remind the patient Work Schedule  Provide alternative scheduling / appointments  Pick up a two month supply of medication to decrease number of visits  Send a relative / friend to collect ART on behalf of patient Economic Factors  Discuss with patient work related issues to help him maintain income Fear of stigma / privacy concerns  Introduce a separate entrance and exit for PLWHAs  Provide a private waiting area  Bring close relative or friend to testing and counseling Missing appointments  Follow-up of patients who missed appointments by telephone or other means  Conduct home visits to provide assistance as necessary to keep appointments

32 USAID HEALTH CARE IMPROVEMENT PROJECT Lessons Learned in Early Piloting of ART Framework Retain guiding principle of what constitutes as ‘good care’ for PLWHAs –Those who need care receive it –Those who receive care are well Use of data enables programs to assess current gaps and plan interventions over time –Use run charts to follow indicators –Annotation of key changes –Reveal obstacles to effectiveness and efficiency Importance of identifying operational changes to improve quality of care –Participatory process that draws on multiple perspectives –Engaging community and other health systems representatives

33 USAID HEALTH CARE IMPROVEMENT PROJECT Implementing the ART Framework: Future Plans Continue testing in Nicaragua and Tanzania –Follow quality indicators over time –Assess effectiveness of key interventions and lessons learning from implementation Introduce the framework to HCI programs in Uganda, Russia and Cote d’Ivoire as well as partner organizations –Synthesize learning from pilot countries –Spread effective strategies for improving care –Develop and distribute a ‘How-To’ Manual Establish Community of Practice –Shared learning across QI teams –Targeted improvement strategy for PLWHAs

34 USAID HEALTH CARE IMPROVEMENT PROJECT Improving Care for Patients on Antiretroviral Therapy: Testing the ART Framework in Nicaragua and Tanzania Thank You


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