Adapting the HIV Care Delivery System for a Chronic Disease

1. Adapting the HIV Care Delivery System for a Chronic Disease Julia Hidalgo, ScD, MSW, MPH Positive Outcomes, Inc. & George Washington University A Presentation Made At the National AIDS Update Conference, AMFAR, March 2005

2. SESSION OBJECTIVES • Introduce the HIV chronic care model • Describe the HIV chronic care collaborative undertaken by the Institute for Healthcare Improvement (IHI) and funded by the HRSA HIV/AIDS Bureau • Discuss practical challenges to adopting the chronic care model at the client, provider, system, and financing levels • Learn what a local HIV clinic would encounter in adopting the chronic care model

3. HIV CARE MODELS ADOPTED DURING THE US HIV EPIDEMIC INTEGRATED, ONGOING PREVENTION-BASED CHRONIC DISEASE MODEL CRISIS- DRIVEN, REACTIVE EPISODIC CARE MODEL PASSIVE DEATH AND DYING MODEL

4. Chronic Care Model Community Health System Resources & Policies Health Care Organization Self-Management Support DeliverySystem Design Decision Support ClinicalInformationSystems Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Improved Outcomes

5. CHRONIC CARE MODEL GOALS • Maximize the length and quality of the lives of persons living with HIV (PLWH) and address their needs by: • Creating partnerships between PLWH and care providers • Embracing organizational change to improve systems of care • Rapidly adopting new scientific knowledge • Addressing the concerns of HIV care providers

6. CHRONIC CARE MODEL OBJECTIVES • HIV clinics and community health centers (CHCs) participating in the IHI collaborative identified specific areas for improvement that relate to increasing the rates of PLWH: • On HAART • With a CD4 count > 200 that receive HAART • On HAART with an undetectable viral load • With a primary care visit within the three months • On HAART with an adherence counseling/ intervention at their last primary care visit • Other objectives were identified by participating clinics and CHCs • Reminder: Title I funds due support “CQI”

7. THREE MODELS ARE USED • The Learning Model encourages all participants to become part of network of experts • The Care Model outlines the key elements that have an impact on good chronic care • The Improvement Model enables care teams to rapidly test and implement changes to improve care

8. LEARNING MODEL • Interdisciplinary team engage in learning sessions to improve their skills in high quality HIV care and methods for testing and implementing changes • Action periods take place between the learning sessions to try out changes in processes, collect data, and measure the impact of changed processes Learning Session Action Period And Repeat Planning Pre-Work

9. CARE MODEL Focuses on a proactive effort to keep PLWH as healthy as possible through key elements • Emphasis on self management and adherence through collaboration between PLWH and their care team: define problems, set priorities, establish goals, create care plans, and solve problems as they are encountered • Clinic guidelines and other evolving practice strategies are explicitly incorporated into clinical decision making • Primary care providers incorporate information obtained from specialists to adjust the care plan

10. CARE MODEL • Client-level data are used to inform the care team about the course of treatment, anticipate problems, and track improvement • The care delivery system is designed to allow advanced care planning, based on the PLWH’s needs and self-improvement goals, with non-medical staff trained to undertake parts of the plan • The effort to improve care is integrated at all levels of the organization • The community and other organizations are critical partners

11. IMPROVEMENT MODEL: PDSA CYCLE PDSA cycles can be linked or simul-taneous

12. CHALLENGES TO IMPLEMENTING A CHRONIC CARE MODEL: ORGANIZATIONAL, SYSTEMIC, AND FINANCING BARRIERS

13. ORGANIZATIONAL BARRIERS • Agencies are experiencing significant increases in new, high intensity clients • Many new clients enter care in advanced stages of HIV disease • Many new and existing clients live in psychosocial crisis, have high rates of drug addiction, severe mental illness, unemployment, and unstable housing • It is hard to set aside time to plan for the long term when the client’s immediate future is unclear • The chronic care model works best when clients are highly motivated, have basic life planning skills, and can envision that they have a future • High appointment no-show and loss to follow-up rates make joint client-provider care planning difficult

14. ORGANIZATIONAL BARRIERS • Chronic care processes take time and coordination of the care team, client, and their family or other care givers • Increasingly, agencies report that they are unable to retain experienced case management and clinical staff • Wage differentials in the job market make it hard for HIV clinics and other agencies to compete • Staff turnover and persistent vacancies • Inadequate experience with QA processes such as the PDSA model • External resources are needed for training, materials, and coaching

15. ORGANIZATIONAL BARRIERS • Doing “more for less” is not just the Target slogan; funders’ have not reduced their expectations • Funders’ performance measures may not be compatible with the topics identified for a PDSA cycle • Many clinical, case management, and other HIV providers are insolvent or reliant on CARE Act, CDC, or HOPWA funds • Hospital and university-based HIV clinics are experiencing significant pressure from their agencies to be more efficient, reduce costs, and generate greater income • Short-term fixes are often adopted rather than planning for long-range problem solving • Some programs are loosing their ability to self-determine their futures

16. SYSTEMS BARRIERS: MOVING TOWARDS AN INTEGRATED CHRONIC CARE MODEL Current System Linked System Integrated Chronic Care

17. SYSTEMS BARRIERS • The HIV care system in many communities is fragmented, duplicative, and inefficient • While community-based case management, psychosocial, and prevention providers are critical partners in the chronic care team • It is difficult for medical providers to coordinate the many organizations serving their patients • Non-medical personnel are often not adequately trained in the medical aspects of HIV, are not familiar with the medical model of care planning, and do not fully participate as a team member • There is a growing divide between “community” and “medical” case management`

18. SYSTEMS BARRIERS • Some gate-keeping functions assigned to case management agencies make it difficult for medical providers to access resources needed by clients • While behavioral care providers are critical participants in the care team • Some HIV mental health and addictions agencies are not licensed, do not ensure adequate licensed supervision, and employ untrained, uncredentialed personnel • HIV counseling is not a substitute for personnel that can conduct differential diagnosis and treatment, including prescribing psychotropics • The “mainstream” behavioral health system is overwhelmed or being systematically constrained by funders

19. SYSTEMS BARRIERS • HIV systems planning bodies tend to focus on “planning to procure” rather than planning to deliver a truly seamless, coordinated care system • With cuts in the CARE Act, CDC, and HOPWA, planning bodies in a growing state of crisis and are unable to calmly assess the current system and plan for the long term • Increasing pressure will be experienced to sustain existing providers, regardless of whether the models of care funded are optimally efficient and address the long term needs of clients

20. FINANCING BARRIERS • Recently, local and State governments have experienced dramatic budgetary downturns • Cross-the-board cuts have been made • Funding for “non-essential” services have been eliminated or severely reduced • Some jurisdictions are unable to maintain their CARE Act requirements for matching funds and maintenance of effort • The ADAP funding situation has resulted in cuts to HIV care services • HIV programs have experienced significant cuts in funding • Medicaid programs has significantly narrowed eligibility criteria and coverage • Medically needy programs have been eliminated in many states

21. FINANCING BARRIERS • Traditionally, third party insurance is designed to fund incremental medical services • Insurers tend to pay for treatment, not for planning and process • Many of the activities undertaken by the chronic care team are not currently fundable by Medicaid or other insurers • Increasing pressure is on insurers to reduce reimbursable services, not expand them • No coding systems exist to pay for many services undertaken by the chronic care team • Many HIV care agencies are not reimbursable because they do not meet licensure and credentialing requirements

22. FINANCING BARRIERS • In managed care systems, which at least theoretically embrace a preventive chronic care for the disabled, the HIV care team is not likely to be empowered to make clinical decisions without prior authorization or involvement of a “care manager” • Behavioral health care is commonly provided in a parallel system

23. FINANCING BARRIERS • The CARE Act, Medicaid, other insurers, and other HIV funders are increasingly seeking ways to cost-shift to others • HAB payer of last resort policies have been interpreted by some Title I EMAs and Title II State programs to exclude Medicaid and VA beneficiaries from CARE Act funded services • CARE Act grantees that use unit cost-based reimbursement tend to exclude care planning, coordination, and PDSA activities are covered services • Often unit cost-based systems are not based on time studies that identify resource requirements

24. Is the current crisis in HIV organization, delivery, and financing a blessing or a curse?How can we adopt a new care model at a time of crisis?

25. PDSA MODEL: NOT JUST FOR CARE PROVIDERS • Aspects of the chronic care model need to be adopted by HIV planning and financing systems • The PDSA cycle should be used to identify problems within the HIV care delivery and financing system • HIV prevention and planning activities need to move towards truly planning for clients rather than planning “how the pie will be cut” • The HIV care system needs to have meaningful representation in planning for the future • It is no longer practical to exclude care providers from “the table” because of conflict of interest

26. PDSA MODEL: NOT JUST FOR CARE PROVIDERS • Systematic assessments and PDSA cycles can be used to identify gaps, inefficiencies, and duplication in service and financing • Meaningful organizational partnerships need to be put in place to insure culturally acceptable and accessible care, while recognizing organizational strengths and weaknesses • Co-location of services can address credentialing and capacity challenges experienced by CBOs • Example: Placement of medical personnel in CBOs

27. PDSA MODEL: NOT JUST FOR CARE PROVIDERS • The PDSA approach should be considered to plan for a continuum of care that includes prevention, counseling and testing, and care • Teams of consumers, front line staff, management, policymakers, and funders need to work as a team to adopt practical aspects of the chronic care and PDSA models to address the tremendous challenges facing the HIV care system in the US