Challenges of Implementing HIV Screening in Emergency Departments – Lessons Learned

1. Challenges of Implementing HIV Screening in Emergency Departments – Lessons Learned Christina Eaton, MPH Louisiana LPS

2. Making the CDC Recommendations Fit in the Emergency Department • “Opt-Out” and routine for all patients 13-64 years of age • Part of routine clinical care in all health-care settings • Voluntary and similar to screening for other treatable conditions

3. Is There Interest? Is HIV Screening: Necessary? Cost Effective? Worth our Time?

4. 8 Steps to Routine HIV Screening – A Model

5. 8 Step Model • Pre-work • Framework • Patient Visit Process • Prep for Tracking Reactives • Setting Up/Adopting Screening Codes • Promote and Provide Training • Launch • Monitor

6. Buy -In • Within Hospitals • Administration • Laboratory • Infectious disease clinic • Behavioral health services • Legal Department • ED staff • State Medicaid programs • Medical schools/nursing schools • Professional Associations • State and county/parish medical societies • Nursing associations • Hospital associations

7. Step 1: Pre-work • Determine which test will be used • http://www.cdc.gov/hiv/topics/testing/rapid/rt-comparison.htm • Estimate the quantity needed for first 6 mo. of testing • (# unduplicated visits for patients 13-64) • Identify source for tests

8. What Support from Health Department? • Single ED support or Several ED Programs? • Total or partial funding? • How sustainable is Health Department Funding? • Indirect support • Training staff • Marketing and Program Promotion • Assist with linkages • Develop implementation protocol

9. Step 1: Pre-work • Appoint staff person to receive, manage, and coordinate test supplies • Identify medical team or dedicated staff that will perform tests • Determine whether HIV follow up care will be provided in-house of through referral • Specify referral agency(s), get name, phone & email contact of the person your staff calls when they want to make a referral

10. Step 1: Pre-work • Identify the role of Disease Intervention Specialists (DIS) in counseling or referral support • List how the state/local health departments will provide support • Schedule official start date • If multiple sites will you launch simultaneously or stagger • Identify staff member to trouble shoot any problems during launch

11. Step 2: Framework • Prepare an HIV Test Log and HIV Test Control Log • Determine how informed consent will be obtained • Adapt and print patient educational information • Prepare a tool for staff that will be discussing HIV testing to patients

12. Step 3: The Patient Visit Process • Determine where in the Patient Visit Process routine screening will occur • Determine a process to respond to negative/reactive results • Create algorithm depicting the process for response • Western Blot Confirmatory Test Results • Determine process to respond to negative, indeterminate, and positive result • Create algorithm depicting the process for response

13. Algorithm Sample √ √ NO YES √ √

14. Step 4: Identify a Point Person to Track Reactives YOU I Want to get a Confirmatory Test

15. Step 5: Adopt HIV Screening Codes for Reimbursement • As of Jan 1, 2008 providers can bill for rapid tests • Usual lab code for HIV (86701-86703) within the CPT system • Add modifier “92” for “Alternative Laboratory Platform Testing” • May 2008 • American Academy of HIV Medicine (AAHIVM) releases • Coding Guidelines for Routine HIV Testing in Health Care Settings • OR Create your own codes $ $ $ $

16. Step 6: Promote and Provide Training • Leadership present its support for and expectation around routine HIV Screening • Profession-specific training • Triage/intake staff • ED Physicians, nurses • Laboratory

17. Step 7: Launch

18. Step 8: Monitor How is the program working?

19. Caveats to Working with EDs • All EDs are different • All hospitals are different • The approach to each hospital/ED is different • The key players are different • Not all ED directors recognize risk of HIV in their area

20. What Have Been Your Challenges?

21. Challenge: Buy In • Best Practices • Identify a Champion within the Hospital and/or ED • Make sure key opinion leaders are • At your initial meetings • Involved in the planning process • Give key opinion leaders the “absolutely need to know” information • Do not overburden them • Make sure all shifts are on board with protocol • Expect a slow start • Watch volumes of tests

22. Challenge: Funding/Financing • Challenge: Opt Out?!?! • No Hospitals have successfully implemented an “opt-out” approach • “Routinely Recommended with Right of Refusal” • Opt – In is cheaper $ $ $ $

23. Monitoring • Monthly meetings with • Hospitals, core lab staff, infection control • Look at • Number of positives & indeterminates • Number of rejected samples & reason for rejection • How often a patient agreed to testing but did not receive the test • How often a patient did not receive a result (rapid or confirmatory) • Program overall • How is the program going from the perspectives of each discipline?

24. Challenge: HIV Screening at Point of Care • Challenge of point of care includes • Overseeing the timing of the test • Monitoring the proficiency of the testers • Specialized staff are needed for POC • ED staff can be utilized if the lab is utilized

25. Resources • Process Flow Charts • General Consent Form • Informed Consent Form • Data Process Form • Patient Information for a Positive, Negative, or Indeterminate Test Result • Performance Training Criteria Checklist • Patient Referral Form/Linkage to Care • Billing and Coding Guidelines for (OraQuick Advance) • Current State Regulations