N ew Opportunities for Synergy in Prevention, Care and Treatment

1. New Opportunities for Synergy in Prevention, Care and Treatment Irshad Shaikh, MD, MPH, PhD Deputy Director, Policy, Programs and Science HIV/AIDS, Hepatitis, STDs and TB Administration (HAHSTA) Department of Health, District of Columbia

2. DC Department of HealthMission • to promote healthy lifestyles, prevent illness, protect the public from threats to their health, and provide equal access to quality healthcare services for all in the District of Columbia.

3. Overview of this presentation • The convergence of HIV care and health reform • Current issues for care for HIV, review the Gardner Continuum for DC • Begin to explain why DC has problems suppressing viral load • Synergies thru Patient Centered Medical Home • Role of the CBO and Accountable Community Care in Synergism • The way forward

5. Where are we? (1) • Convergence of two great movements • National HIV/AIDS Strategy (NHAS) which emphasizes suppression of viral load • Treatment is prevention • Health reform is moving towards establishment of patient centered medical homes for better care of chronic diseases • This is happening regardless of whether insurance mandates continue. • One point of convergence is an “HIV medical home”

6. Where are we? (2) • DC has the second highest health insurance coverage in the nation after Massachusetts • 93% of adults are covered in DC • 96% of children are covered, number one in the nation! • As an early adopter of Affordable Care Act, DC can now move on to issue of improving the design of the health care delivery system

7. Where are we? (3) • DC has shifted over 1000 people off of ADAP onto Medicaid to achieve “treatment on demand” • Also provides coverage for other diseases and conditions • Medicaid Expansion • Extends Medicaid eligibility to every U.S. Citizen with income at or below 133% (tax rate of 138%) of the federal poverty level (FPL)

8. The National HIV/AIDS Strategy • Great contribution that has helped focus the field • The four pillars of the strategy • Reducing HIV incidence • Increasing access to care and optimizing health outcomes • Reducing HIV-related health disparities • Achieving a More Coordinated National Response to the HIV Epidemic DC is actively scaling up the National Strategy

9. Continuum of Care for HIV Cases Diagnosed in the District of Columbia, 2005-2009 †At least one viral load test result prior to 12/31/2010 was ≤400 copies/mL. ‡All subsequent viral load test results were ≤400 copies/mL.

10. Factors Associated Challenges to Care, NYC Less Likely to Regular Care* Compared Adj Odds to Ratio Blacks Non-Blacks 2.0 Ages 13-24 Age 50 + 3.0 IDU History Non IDU History 2.7 * Regular care ≥1 visit every 6 months Torian, LV and Wiewel, EW. Continuity of HIV-Related Medical Care, New York City, 2005-2009: Do Patients Who Initiate Care Stay in Care? 2011. AIDS Patient Care and STDS. 25(2):79-88.

11. Factors Associated Challenges to Care, NYC More Likely to be Lost to Care* Compared Adj Odds to Ratio Ages 13-24 Age 50 + 1.9 Diagnosed at Diagnosed at 1.4 Early Stages Later Stages Non-Hospital Designated AIDS 1.4 Settings Centers *last visit >6 months before close of analysis Torian, LV and Wiewel, EW. Continuity of HIV-Related Medical Care, New York City, 2005-2009: Do Patients Who Initiate Care Stay in Care? 2011. AIDS Patient Care and STDS. 25(2):79-88.

12. Preliminary data in DC on continuous care • Blacks and persons 13-19 less likely to be in continuous care • Black (AOR=1.4, 95%CI: 1.0-2.0 versus White) are less likely to be continuous in care than whites in DC. People age 20-29 years (AOR=0.5, 95%CI:0.2-0.9 versus 13-19 yrs) and 50-59 years (AOR=0.5, 95%CI: 0.2-1.0 versus 13-19 yrs) were more likely to be in continuous care than persons aged 13-19.

13. Average: 86% Percentage of clients on ART, aged 13 years and older, with a diagnosis of HIV/AIDS with a viral load <200 copies/ml at last test between September 2010 and August 2011. Denominator includes clients that had at least two medical visits during the measurement year with at least 60 days between each visit; were prescribed antiretroviral therapy for at least 6 months; and had a viral load test during the measurement year.

14. Patient Centered Medical Home • Long history traced back to Almaty Declaration in early 70’s • Barbara Starfield a pioneer • Endorsed by • American Academy of Family Physicians’ (AAFP) • American College of Physicians (ACP) • American Academy of Pediatrics (AAP) • American Osteopathic Academy (AOAN) • Emerging as a key strategy in health reform to address chronic disease quality and cost of care

15. Elements of Patient Centered Medical Home • There are four core functions • Accessible • Comprehensive • Longitudinal, and • Coordinated care in the context of families and community.” (National Academy of Sciences, 1996)

16. Appropriate coordinated care • The increases in complexity may overwhelm informal coordinating functions requiring a care team that can explicitly provide coordinated care and assume responsibility for the coordination of a particular patient’s care (National Academy of Sciences, 1996). “When you have a home and you don’t make it home to dinner some one calls you.”

17. CMS Definition CMS definition of the medical home Medical homes emphasize written care plans, written protocols to ensure appointments, electronic medical records, referral networks and much more. http://www.acponline.org/running_practice/pcmh/demonstrations/two_tier.pdf.

18. HRSA/HAB providing leadership for • SPNS - Special Projects of National on medical home for the homeless • Medical Homes Resource Center • http://www.careacttarget.org/library/2012/HIV-MHRC.pdf

19. Ryan White: An Unintentional Home Builder • Convergence with long standing work by HRSA (Ryan White) to improve quality of HIV care and the medical home • HIV has a lot to contribute to medical home particularly related to patients role Saag, AIDS Reader. 2009;19:166-168

20. Specialty HIV care works… • Clinical care givers that have training and experience in HIV have better outcome • High quality HIV/AIDS support services improve outcomes • HIV community support that is connected to clinical care is highly effective but needs to be better coordinated and transformed into a home.

21. People living with HIV and AIDS are living longer and need coordination of car for many conditions • Over 50% of those positive in DC are over 40 yrs. of age • With aging people are beginning to develop all the chronic diseases of the rest of the population • HIV accelerates development of many chronic diseases • The medical home is designed to address the needs of people with multiple chronic conditions

22. Work in DC is proceeding to better define an HIV medical home • Building on the basic model • Needs to be clinical expertise in HIV • Need support services with HIV expertise • Needs community outreach customized to HIV infection populations • Places with low prevalence may need medical home with HIV emphasis versus an HIV medical home A debate in the medical home literature involves the role of specialty care. Rittenhouse, Shortell, and Fisher. N Engl J Med 2009

23. Redesign Needs Investment • Payment systems driving redesign alone may not be enough to get it right • Investments to help clinics and CBOs come together may be needed • Local tax dollars in DC “Effi Barry Program” and RW funds will be used to encourage this redesign Berensen et. al Health Affairs 2008

24. CBOs need to think of themselves as a critical part of a medical home • Strategic planning • Strategic alliances with clinics for participation on care teams • Mergers • Performance measures that demonstrate contribution to care • Contractual agreements that provide money for services rendered to clinical centers

25. Medical Home is not a panacea • Cannot solve health care’s cost and quality challenges alone. • Accountable Care Organizations also being discussed, redesign of larger units. • More research on medical home needed • team-based care, • full patient engagement, • optimal use of electronic records • Best way to implement Kilo and Wasson, Health Affairs 2010 Redesign of the health system an important role for the future of public health.

26. Three kinds of people* *This is my common sense understanding of different types of patients and levels of care they need.

27. …Accountable Care Communities: the missing link? • Contribution to health reform literature out of University of Akron • White paper emphasizes need for community based organizations to play role in improving health care quality • http://www.faegrebdc.com/webfiles/accwhitepaper12012v5final.pdf

28. Indicators of Adherence to Antiretroviral Therapy Treatment • Clinical supervision of community based programs increases adherence and viral load suppression • Without clinical supervision, no improvement Indicators of Adherence to Antiretroviral Therapy Treatment Among HIV/AIDS Patients in 5 African Countries. Etienne et. al Journal of the International Association of Physicians in AIDS Care, 2010

29. The mission of the JACQUES Initiative (J.I.) program is to provide a holistic care delivery model that provides long-term treatment success for urban populations infected with HIV. Our focus is to decrease the morbidity and mortality associated with HIV illness through care delivery while providing early intervention services through activities such as testing, outreach and linkage to care. We are committed to providing a “safe place” for our clients through delivered services and providing access to clinical research for all. We accomplish this mission through theJourney To Wellness.

30. Community treatment support model Re-entry to care HIV testing

31. Different people need different support tracts • Direct observed therapy • Treatment coaches • Weekly direct observed therapy • Treatment partners • Care partners • Standard of care • Amoroso et. al “Improving on success: what treating the urban poor in America can teach us about improve antiretroviral programs in Africa” AIDS 2004

32. Community Care Model for HIV/AIDS • Based on clinical science and a decade of experience • Five steps and all are necessary • Should be done by the same community groups • Should be linked to clinical part of the “home”

33. Moving the HIV patient centered medical home in DC • Mayor’s HIV/AIDS Commission • Strategic planning grants for smaller CBOs • Training for CBOS on “treatment support” • Development of monitoring tools around “treatment support” • Working with clinical providers to encourage movement towards medical homes • DOH working with HCFA to facilitate this movement

34. Summary • To reach the potential of “treatment as prevention” we must improve the care delivery system in coordination with community support. • The medical home provides a useful model to achieve continuity and comprehensive care. • Redesign of the health care delivery system should be a top priority for research in DC.