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

1. 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

2. 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.

3. Performance Measure Percentage of patients with a viral load of <200 at last viral load testing of the measurement year

4. 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%

5. 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.

6. 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

7. VL Received? N Lab Slip Sent? N Send LabSlip Y Reviewed By NP Y Reminder Call if no labs in 6 weeks Pt. Referred for VL Test Reminder Letter Forwarded to Data Entry & to chart & flowsheet N Labs Done PreClosure Letter (no Rx’s); CM Notified Y Appt Scheduled? N Y Call to Schedule Or Resched. Appt. Kept? Closure Letter at 9+ Months if no contact N Y Discuss Next Steps –see Clinical Process Diagram Viral Load Suppression Performance Improvement Measure: Workflow Process Diagram

8. Ongoing Monitoring of Adherence & VL Testing as indicated VL<200 Adherence Assessment at Next Appointment Yes Formulate & Implement Adherence Plan Issues Identified? VL>200 No Consider /Do Genotype Consider/Do Tropism & HLAB5701 Evaluate for Drug-Drug Interactions Consider or Make Med  Evaluate for Drug- Adherence Assessment by phone or appt. within 2 wks. 2nd VL >200 Recheck VL in 3 months or less Routine Monitoring 2nd VL <200

9. 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: • Weekly adherence evaluations of selected patients, including pill box fills and/or supervised pill box fills • Involvement of case managers to supervise pill box fills and/or perform weekly evaluation of adherence • Use of Adherence tools, such as pillbox with alarm, cell phone alarms, etc.

10. ECHO Clinic Adherence Plan Assessment Form Patient Name: DOB: MR#:

11. PSDA - Study/Results • Phase 2: Study/results

12. Repeated PDSAs

13. Overall Findings

14. Looking Ahead (next Steps)