In 2013, Columbus Public Health (CPH) received the Ryan White Part A HIV Emergency Relief Grant from the U.S Dept. of Health &Human Services Health Resources & Services Administration (HRSA). Part A of the Ryan White HIV/AIDS Treatment Extension Act of 2009 provides assistance to Eligible Metropolitan Areas (EMAs) and Transitional Grant Areas (TGAs) – locales that are most severely affected by the HIV/AIDS epidemic. An area must have reported 1,000 to 1,999 AIDS cases in the most recent 5 years and have a population of at least 50,000 to be eligible for TGA status. Columbus Public Health Ryan White (RW) Part A Program Linkage to Care program (L2C) and its partners provide access to necessary health care for those living with HIV/AIDS are in need of financial assistance. The program links people to care including outpatient medical, housing, mental health and alcohol & drug services. In order to be eligible for the program individuals must be: living with HIV/AIDS, be income qualified and have a primary residence in Franklin, Delaware, Licking, Fairfield, Pickaway, Madison, Union or Morrow counties.
Columbus Public Health
Ryan White Part A Linkage to Care Program
CPH is protecting health and improving lives as the local health department for the nation's 15th largest city, Columbus, Ohio. CPH identifies and addresses public health threats, enforces laws that protect health, and provides services to prevent and control disease. Over 40 distinct programs – which focus on environmental health, maternal and child health, infectious disease, community health, disease surveillance, linkage to care, planning, and emergency preparedness – are supported by a budget of $50 million and over 450 full and part-time employees. CPH is governed by a Board of Health, whose members are appointed by the Mayor of Columbus. CPH now serves more than 1,000,000 residents, visitors and workers in Columbus and Worthington. The 2010 census states that the racial makeup of the city was 61.5% White, 28.0% African-American, 0.3% Native American, 4.1% Asian, 0.1% Pacific Islander, 2.9% from other races, and 3.3% from two or more races. Hispanic or Latino of any race was 5.6% of the population. The goal of the Columbus TGA RW Part A program is to prevent new HIV infections by achieving viral suppression among all persons living with HIV/AIDS. For persons without access to care and earning less than 500% of the Federal Poverty Level (FPL), RW services are available to help link and retain individuals in medical care. High quality, culturally competent medical care is a top priority and is available through academic medical centers, community-based organizations, and private providers. Medication adherence is achieved with completeness of care through L2C program, medical case management, mental health and social support services, specifically housing, emergency financial assistance, and medical transportation. Columbus, Ohio (Franklin County) has the highest rate of HIV infection in the state of Ohio and over 200 new diagnoses are made each year. Suppressing the community viral load is imperative to the state of public health. New HIV infections could be averted by linking all newly diagnosed and all previously diagnosed Persons Living with HIV/AIDS (PLWHA) to the medical care needed for treatment. The goal of the L2C program is to link at least 90% of the newly identified, confirmed HIV-positive clients to medical care, and to help 75% of the newly identified, confirmed HIV-positive clients attend their first medical care appointment within 90 days of the positive test result. In addition, 100% of the HIV-positive pregnant women will receive necessary interventions and treatment for the prevention of perinatal transmission. RW Part A funding allowed CPH to create the L2C program which assures medical, supportive, and prevention services are offered to all persons testing positive for or are living with HIV within 90 days of initial contact using the –ARTAS- (Anti-Retroviral Treatment & Access) intervention. Beginning FY 2013, CPH funded 4 full-time L2C Service Coordinators and 1 full-time L2C Service Program Manager.RW Part A also required accessible software for managing and monitoring HIV clinical and supportive care. CAREWare will quickly produce a completed Ryan White HIV/AIDS Services Report (RSR). Everyone receiving Part A funding in the Columbus TGA is required to enter data into CAREWare. To guide the RW Part A program with the planning, implementation, and evaluation process, a Planning Council was established. It was important to have participation from PLWHA and other key stakeholder to determine the priority setting and resource allocation of grant funding. The Community Service program expanded their community based testing sites to reach high-risk populations. The program offers testing, counseling, education and risk-reduction strategies, free condom distribution and/or access to PrEP (Pre-exposure Prophylaxis). The L2C program has been highly successful. 100% of the newly identified, confirmed HIV-positive individuals were being referred to medical care in 2014. In addition, 97% of the newly identified, confirmed HIV-positive clients attended their first medical care appointment within 90 days of the positive test date. 100 % of HIV-positive pregnant women received the necessary interventions and treatment for the prevention of perinatal transmission. Collaborations, partnerships and stakeholder involvement made these objectives a success. Quality improvement is an ongoing process but the baseline for the L2C program, CAREWare, Planning Council and the flexibility of CPH Community Services program has been successful. Widespread testing and linkage to care enables PLWHA to access treatment early. Community viral suppression among PLWHA will reduce the rate of HIV transmission. In addition, access to complete PrEP services for those whom it is appropriate and desired will provide a high level of protection against HIV and even more effective when it is combined with condoms.
HIV is a preventable disease. Individuals who get tested for HIV and learn that they are infected can make significant behavior changes to improve their health and reduce the risk of transmitting HIV to their sex or drug-using partners. The CDC estimates that 1 out of 8 people do not know that they are infected. Per Health and Human Service Administration (HHSA), more than 50% of the new HIV infections occur as a result of the 13% of people who have HIV but do not know it. Prevention work with PLWHA focuses on identifying, linking to and staying in medical care/treatment, increasing the ability of ongoing HIV prevention interventions and providing prevention services to their partners. In addition, it is important to foster wider availability of comprehensive services for PLWHA through partnerships among community-based organizations (CBOs), health care and social service providers.
The CPH L2C program and Community Service program is aligned with the 2020 Healthy People guidelines and the revised 2010 White House released National HIV/AIDS Strategy to reduce the number of people who become infected with HIV, increase access to care and improve health outcomes for PLWHA and reducing HIV-related health disparities. The ultimate U.S. Public Health goal is to inform all HIV- positive persons of their status and bring them into care in order to improve their health status.
The Columbus TGA has been severely affected by the HIV epidemic. In 2014, Columbus TGA had 5,268 PLWHA. Therefore, the prevalence rate of HIV in the Columbus TGA is 268.1 HIV-diagnosed persons per 100,000 populations. Franklin County, which includes Columbus, reports the majority of cases, with 88% of the total number of PLWHA. PLWHA in the Columbus TGA represents nearly 25% of PLWHA in Ohio, yet only 16% of the state’s population resides in the area. In 2012, the Columbus TGA identified several special needs population groups based on epidemiological and other health- related information. The HIV/AIDS epidemic within the Columbus TGA disproportionably impacts Black/African American non-Hispanic men, Youth (13-29), White non-Hispanic men who have sex with men (MSM), and Black/African American non-Hispanic MSM. The highest impact is on young non-Hispanic MSM.
Black/African American non-Hispanic persons represent 15% of the overall Columbus TGA population, but account for 36% of the total PLWHA population in the Columbus TGA. In addition, 43% of all new HIV diagnoses in 2014 were Black African/American non-Hispanic persons. The HIV disease prevalence rate for Black/African American non-Hispanic males is nearly 2.5 times that reported among White non-Hispanic males and the rate for Black/African American females non-Hispanic females is over 10 times that for White non-Hispanic females. Youth (13-29) constitute 14% of the PLWHA in the Columbus TGA but account for about half (46%) of the new HIV diagnosis.The majority of the PLWHA in the Columbus TGA are men. Of the 5,268 PLWHA, 81% are men and 19% are females. That differs greatly from the general population, where men comprise 49% of the population and women 51%.
Successful linkage is defined as 2 medical appointments and successful transition to long-term medical case management within a 90-day period. The total number of newly HIV-positive in the Columbus TGA in 2014 was 235 individuals. In 2014, the L2C program enrolled 185 HIV- positive individuals. 175 L2C cases (97%) were closed in 2014 (10 were still open within the 90-day window). 170 of the clients successfully completed the program. Of the 185 enrolled L2C clients, 81% were males and 19% were females, 52% were white, none-Hispanic and 39% were Black/African/American, none-Hispanic. In addition, 17% were youth (13-29), 54% reported male-to-male sex (MSM).
CPH, as an Ohio Department of Health Federal Prevention grantee, is mandated to provide HIV counseling; Testing and Referral (CTR), Partner Service (PS) and CDC endorsed evidence based prevention interventions for persons living with HIV and for persons at high risk for acquiring HIV. Using Federal Prevention funds, CPH oversees all CTR sites in Franklin County and ensures that all CTR sites provide services in an appropriate, competent and culturally sensitive manner in settings most likely to reach persons who are infected, but unaware of their status. The CPH Community Service program has a long history of going out in the community to conduct STI’s testing. However, now testing sites are chosen by focusing on high - risk populations. In the past, newly diagnosed HIV-positive clients were interviewed by CPH Partner Service staff and notification of sex partners where offered to the individual. Clients were given contact information for the CPH Ryan White case manager and offered a resource list of HIV medical providers in the community. No follow-up was provided to newly diagnosed individuals to ensure enrollment with the medical case manager and/or linkage to medical care.
Effective HIV prevention requires a combination of behavioral, biomedical, and intervention strategies. CPH, in collaboration with the Ohio Department of Health, will continue to support and provide increased HIV testing in the Columbus TGA to decrease the number of people living in the TGA who do not know they are infected with HIV. CPH testing efforts focus on Blacks/African American, Youth, and MSM communities in clinical and community based settings. In addition, every reported confirmed HIV test or detectible viral load reported to the Ohio Disease Reporting System (ODRS) is followed-up. The L2C program ensures that most newly diagnosed individuals are linked to a medical provider and/or linked to a Ryan White medical case manager. Using the ARTAS intervention the program serves both newly diagnosed and previously diagnosed persons not receiving HIV medical care and helps ensure linkage to medical care for HIV-positive persons living in the Columbus TGA. Successful linkage to care is defined as two medical appointments and enrollment in Ryan White long-term medical case management. Ryan White case managers provide access to the Ohio AIDS Drug Assistance Program (OHDAP) for those who are income eligible (300% FPL). If linked to and maintained in care, every eligible PLWHA in the Columbus TGA has access to anti-retroviral therapy. Achieving and maintaining an undetectable viral load is the outcome of a successful L2C HIV-positive client. In addition, high-risk individuals have access to testing and if desired prescribed Pre-exposure Prophylaxis (PrEP).
CDC supports a linkage model incorporating multiple sources of testing locations; the ARTAS Intervention. The CPH L2C program utilizes the ARTAS intervention to serve both newly diagnosed and previously diagnosed persons in the Columbus TGA who are not “in care”. Individuals who are not “in care” meet HRSA’s definition of unmet need, which is defined as the need for HIV-related services by individuals with HIV who are aware of their HIV status but are not receiving regular primary health care. In this case, primary health care refers to the medical evaluation and clinical care that is consistent with the U.S. Public Health Service guidelines for the treatment of HIV/AIDS. Such care includes access to anti-retroviral and other drug therapies, including prophylaxis and treatment of opportunistic infections and combination antiretroviral therapies.
Applying a strength - based model approach, the ARTAS intervention, helps clients create goals for themselves and establish effective working relationships with the Linkage to Care (L2C) coordinators. ARTAS consists of up to 5 client sessions conducted in a 90 day period or until the client is successfully linked to medical care – whichever comes first. ARTAS views the community as a resource for the client and client sessions are encouraged to take place outside the office or wherever the client feels most comfortable. Following the final client session, the client may be linked to a long-term Ryan White medical case manager and/or another service delivery system to address his/her longer term barriers to remaining in care, such as substance use treatment, mental health services or housing.
The core element of the ARTAS intervention is to build an effective, working relationship between the L2C coordinator and the client. The ARTAS intervention allows the L2C coordinator to focus on the client’s strengths: conducting strength-based assessments and encouraging each client to identify and use his/her strengths, abilities and skills to link to medical care and accomplish other goals. The L2C coordinator facilitates the client’s ability to identify and pursue their own goals and develop a step-by-step plan to accomplish those goals using the ARTAS Session Plan. The coordinator maintains a client-driven approach by conducting one to five structured sessions with each client, conducting active, community-based case management by meeting each client in his/her environment and outside the office, whenever possible, coordinating and linking each client to available community resources, and advocating on each client’s behalf, as needed, to link him/her to medical care and/or other needed services.The success of the L2C program is due to the hard work and commitment of the linkage to care coordinators implementing the ARTAS intervention as the coordinators provide client centered services that are flexible and accommodating. Linkage coordinators meet with the client early morning, late evenings and weekends. Linkage coordinators provide advocacy, referral, education, transportation and emotional support to clients in an effort to build a trusting relationship and send text messages, emails, voicemails, and use multiple communication strategies including letters to support service agencies in their client’s behalf.
Although the ARTAS intervention and the Federal HIV Prevention Grant define successful linkage to medical care as linking newly diagnosed individuals to their first medical appointment within 90 days of diagnosis, Columbus TGA believes this falls short of addressing the unmet need for PLWHA who are not in care. The Columbus TGA Early Identification of Individuals with HIV/AIDS (EIIHA) plan seeks to provide all HIV-positive individuals living within the TGA, who are not receiving regular primary care, access to Early Intervention Services (EIS). The Columbus TGA does not believe that attendance at one medical appointment suffices as being considered “in care”. Without the development of a trusting and ongoing relationship with a medical provider – and access to insurance or funding to cover the cost of medical care, anti-retroviral therapy, and other HIV-related medical needs – retention in HIV medical care is not likely. The CPH L2C program is very innovative. The Columbus TGA believes that successful EIS and Linkage to Care must assure: the client has completed two medical appointments that include HIV-related Lab work and a treatment plan developed with a medical provider; and the client has the ability to be maintained in care through insurance or self-pay, or has enrolled into Ryan White medical case management if Ryan White financial assistance is needed for continued medical care or other client needs. To access services, newly diagnosed or previously diagnosed individuals can be referred to the HIV CARE line: #614-645-CARE. The CARE line is staffed Monday, Wednesday, Thursday and Friday from 8A to 4PM and Tuesdays from 8A to 7PM. Messages are returned within one business day. During these hours, an L2C coordinator can be dispatched to meet with the client immediately or an appointment can be made. Because EIS services are so easily accessible through the CARE line, medical providers refer newly diagnosed or out of care patients to CPH L2C program. L2C coordinators can meet the client to access RW Part A funding for HIV-related medical services. Other non-medical providers such as food pantries, churches, LGBTQ organizations, shelters, substance abuse and treatment programs, and youth service organizations have access to the CARE line. ARTAS is an evidence–based CDC intervention: https://effectiveinterventions.cdc.gov/en/HighImpactPrevention/PublicHealthStrategies/ARTAS.aspx
Focused testing leads to early HIV diagnosis and entry into medical care. Offering HIV prevention services like PrEP to high risk populations reduces the risk of becoming HIV-positive. In the spring of 2015 the CPH Community Service program and community partners announced the support for PrEP and jointly link high risk individuals into PrEP medical care. In accordance with CDC guidelines and recommendations, CPH is launching a citywide call-to-action geared towards community providers in order to expedite discussion, screening and administration of PrEP to high-risk patients as it has been shown to be one of the most effective methods for primary HIV prevention.
HIV in the U.S.
The National HIV/AIDS Strategy (NHAS) has three primary goals: 1) reducing the number of people who become infected with HIV, 2) increasing access to care and optimizing health outcomes for people living with HIV, and 3) reducing HIV-related health disparities.CPH L2C and Community Service program are aligning with these goals by increasing the number of individuals who are aware of their HIV status, increasing the number of HIV positive individuals who are in medical care and increasing the number of HIV negative individuals referred to services that help keep them HIV negative.
In 2014, the CPH Community Service program and partners administered a total of 12,638 HIV tests in various clinical and non-clinical testing sites with 93 newly diagnosed HIV-positive individuals identified in the same time period utilizing the Community Service testing sites, Ohio Disease Reporting System and the CARE-line the L2C program had 175 cases and 97% of these cases successfully completed the L2C program. To reduce the number of people who become infected with HIV, CPH initiated the L2C program that implements the ARTAS evidence based intervention for PLWHA. The intervention allows CPH L2C to build a long-term (90 days) relationship with a client and develop a care plan based on the client’s goals, strengths and challenges. It is also the goal of the L2C program for all clients to complete 2 medical appointments and enroll in the RW medical case management if warranted. Client completion of the program ensures that the client is under full medical care and starts anti-retroviral treatment (ART) as soon as possible. The goal is to get the client virally suppressed reducing the risk of further infection in our community. To increase access to care the CPH L2C programs purpose is to link the client to a medical provider of their choice upon entry into the program helps build a relationship with the client and the chosen provider. Care Coordinators help the client navigate the system by providing assistance with any paperwork necessary for the visit, transportation to the appointments as well as participate in the medical visit. This hands-on approach ensures the client’s comfort level with the medical visit and advocates for the client should issues arise. Ensuring the initial medical visits are successful safeguards return visits in the future and therefore can give some reassurance of the client’s continued medical care.
The success of the L2C program is in large part because of knowledgeable staff. Care Coordinators are trained around cultural competency, trust building and personal advocacy. These attributes help to build the relationships that are so vital in the beginning or reentry of medical care. In addition, Care Coordinators help break patterns of social determinates of health associated with health disparities such as poverty, lack of education, stigma and unequal access to health care by advocating on the client’s behalf. They often help navigate difficult systems with clients to show them how to be self-sustaining, direct them to job trainings and placement agencies or becoming an educated patient asking the medical questions that are necessary to good healthcare.Collaborations, Partnerships and stakeholders involvements also make this a successful program. A formal Planning Council was established to bring together the stakeholders that include PLWHA who are RW consumers and non-consumers, medical providers, Community Based Organizations, public health officials, community mental health providers, RW Part A, B C, and F grantees, the Ohio Department of Health HIV prevention and HIV Care program, was well as others. The Planning Council determines the priority setting and resource allocation for the coming Fiscal Year grant period. The Planning Council also collaborates with the Ohio AIDS coalition (a statewide advocacy organization) to conduct consumer recruitment activities. To keep track of data and case notes CPH and their partners received a free scalable software tool called CAREWare from HRSA. This software is used for managing and monitoring HIV clinical and supportive care and will quickly produce a completed Ryan White HIV/AIDS Services Report (RSR). In addition, a spreadsheet was created by L2C program to identify data when a client was enrolled into the program, medical appointment dates, when a client was referred to medical case management, and when a client enrolled with a medical case manager. This spreadsheet identifies timeline data and is used for performance measures for staff and identifies service timeline gaps. The L2C program was established in 2013. The program is an ongoing program as long as HRSA will continue funding the Columbus TGA. Performance measures have been established and they will be monitored for the entire 12 months grant period. CAREWare was installed during the 2013 Fiscal Year and data is being pulled and monitored on a monthly basis. The program will continued to be funded after the initial success and data evaluation of FY 2014 grant year.In February 2014, the first applicants were appointed to the Planning Council by Mayor Michael Coleman. Both voting and non-voting members are afforded frequent opportunities to engage in community planning efforts through the various subcommittees and Planning Council meetings. All decisions have been made by consensus and in the event that consensus cannot be reached, voting members are responsible for reaching a decision by majority vote. The Planning Council votes on standard operating procedures and important leadership decisions. Participation from PLWHA is considered essential to every facet of the RW Part A, including CPH L2C program, planning and service delivery process. The PLWHA Planning Body members reflect the demographics of the PLWHA in the TGA, including White MSM, African American MSM, African American male youth, White male youth, and African American women. Other stakeholders are part of the Planning Council as well; HIV service providers, Community leaders, Public Health officials and other community members. Data informed discussions, transparent decision-making, and meaningful dialogue are the expectations of the Planning Council. The Planning Council is responsible to allocate services and funding dollars to meet the needs of the HIV positive community which includes medical services and support services that are not met by any other program. Those could include, for example, primary medical care, dental services, case management, and mental health care, substance abuse treatment, housing assistant, transportation, and nutrition services. In addition to the Planning Council, CPH has always utilized a community planning process. The mission of the Central Ohio Planning Alliance (COPHA) is to identify the prevention, care and housing needs of the Central Ohioans affected by HIV and reduce the spread of HIV infection. COPHA plays an integral part in developing priorities for resources of Federal HIV Prevention funds. The community planning body was formed as a coalition between HIV Care, HIV Prevention, and the HIV Housing Community. Representatives from COPHA attend Planning Council meetings and Planning Council Coordinators attends the COPHA meetings. In June of 2014, COPHA and Planning Council representatives attended a training conducted by the National Quality Center on merging care and prevention planning bodies. In FY 2015 COPHA and the Planning Council will continue to work toward combining community planning efforts in the TGA.
CPH agreed with the Ohio Department of Health recommendation that grantees implement the ARTAS intervention to PLWHA not in medical care and assure that individuals attend their first medical appointment within 90 days of starting the intervention. Fiscal Year 2012, CPH was able to allocate $999.94 for the HIV Prevention Coordinator to travel to Atlanta to attend the Train-the-Trainer ARTAS Intervention. This training is intended for individuals who will be responsible for conducting the ARTAS sessions with clients, (i.e., Linkage Coordinator). The HIV Prevention Coordinator became a certified instructor for the ARTAS Linkage to Care intervention and is able to train and certify all L2C coordinators in-house. The L2C program is staffed by 4.5 FTE Linkage Coordinators.
Applying a strength - based model based approach – ARTAS – (Anti-Retroviral Treatment & Access to Service) where clients will create goals for themselves and establish successful working relationships with the Linkage to Care (L2C) coordinator is effective. The goal of the L2C program is by to use the ARTAS intervention linking HIV+ individuals to medical providers and, if needed, to long-term RW medical case manager within a 90 day period.
ARTAS Intervention is a highly intense program that is based on a Strengths-Based Case Management (SBMC) model, which is rooted in Social Cognitive Theory (especially the concept of Self-Efficacy) and Humanistic Psychology. SBCM is a case management model that encourages the client to identify and use personal strengths; create goals for himself/herself; and establish an effective working relationship with the Linkage Coordinator. With the guidance of the L2C coordinator the client focuses on his/her own self-identified strengths; creates an action plan with specific goals, including linking to medical care. The intense working relationship between the HIV positive individual and the L2C coordinator creates a trust building relationship where the client is able to get his/hers presenting concerns met and the CPH L2C program achieves a very high linkage rate. A core value of CPH is to implement evidence-based practice, which includes assessment of epidemiologic findings and local surveillance systems into the design, implementation, and evaluation of all public health programs. All service providers receiving RW Part A funds are required to use Ryan White CAREWare, the HRSA (Health Resources & Services Administration) recommended data management program, to report client level data. Primary data is pulled from CAREWare to identify performance measures and gaps in services. CPH L2C and other RW part A providers enter data and notes into CAREWare system which allows for the collection of detailed information on all the clients served. The CAREWare software application allows the RW Quality Improvement team to manage and monitor HIV clinical and supportive care and will quickly produce needed reports.
The Ohio Disease Reporting System (ODRS) provides real-time secured access for state and local public health practitioners to report infectious diseases. ODRS allows local health departments with jurisdictional responsibility and relevant ODH program staff to have immediate access to infectious disease reports on a 24/7/365 basis for disease control and disease surveillance purposes. HIV related test results are being reported to this system and ODH forwards case report to the jurisdictional local health department to initiate investigation. L2C program staff has access to the system and are able to identify newly reported HIV cases and allows quick follow-up with providers to engage HIV+ individual into care. The data pulled from the ODRS system is helpful to identify newly diagnosed individuals and the time it takes for the HIV+ individual to engage in care. ODRS is also helpful in identifying gaps in care since all HIV related lab tests are being followed up by the L2C program. For example if a HIV lab test was reported by a local emergency room a L2C staff follows up to see if this is a newly diagnosed person or if this is a person who has fallen out of care. Then the L2C person contacts the individual to engage/re-engage him/her into care again.
The following performance measures are based on the US Department of Health and Human Services guidelines and will be monitored for the entire 12 months grant period. The measures will be monitored continually based on the data collected through CAREWare and, if needed, client files. The Quality Measurement (QM) Leadership Team in collaboration with subcontractors implement quality improvement initiatives to facilitate the attainment of the designated measures. If the goal for an indicator is met or exceeded in two consecutive data extractions, the QM Leadership Team will update the performance measure by the extra data extraction period. HIV Viral Load Suppression: Percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year. Numerator: Number of patients in the denominator with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement years.Denominator: Number of patients, regardless of age, with a diagnosis of HIV with at least one medical visit in the measurement year.Prescription of HIV Antiretroviral Therapy: Percentage of patients, regardless of age, with a diagnosis of HIV prescribed antiretroviral therapy for the treatment of HIV infection during the measurement year. Numerator: Number of patients from the denominator prescribed HIV antiretroviral therapy1 during the measurement year. Denominator: Number of patients, regardless of age, with a diagnosis of HIV with at least one medical visit in the measurement year.Gap in HIV Medical Visits: Percentage of patients, regardless of age, with a diagnosis of HIV who did not have a medical visit in the last 6 months of the measurement year. Numerator: Number of patients in the denominator who did not have a medical visit in the last 6 months of the measurement year. Denominator: Number of patients, regardless of age, with a diagnosis of HIV who had at least one medical visit in the first 6 months of the measurement year.
Performance measures for HIV-positive diagnosed individuals linked into medical care will be adopted from the Department of Health and Human Services (DHHS) common indicators in the future but current definitions used by the Columbus TGA and are as followed: Numerator is the number of clients who completed the L2C program successfully during the measurement year. Denominator is the number of clients who enrolled in the L2C program during the measurement year.
Information gathered by the Quality Improvement program, including client-level health outcomes data, is used as part of the Columbus TGA planning process and ongoing assessment of progress toward achieving program goals and objectives. While L2C is a new program and still in the evaluation process a service gap has been identified between L2C and the medical case management team. Through the quality improvement process various barriers had been identified and a protocol was created to ensure a timely, warm hand-off client service between L2C and the medical case management team.
While the CPH Community Service program is focusing on identifying newly diagnosed HIV+ individuals in the community, the L2C program identified a large number of HIV+ individuals that have fallen out of care or never received care in the past. CAREWare data was used to capture the date of an individual first HIV diagnosis and date when client engaged in care. ODRS reported HIV+ individuals, medical community, self-referrals and other social service programs are able to call the L2C CAREline phone number, as well as clients enrolled in the L2C program can name their partners to be tested or for L2C to enroll them. With these additional resources, the CPH L2C program is able to capture data on a population that was under-served and unreachable before.
The Planning Council gives the HIV community a voice. With assistance from HRSA and CPH, this group had technical assistance that includes team building and education. The Planning Council has been trained and utilizes the HIV Care Continuum to assess gaps in services and determine where additional resources are needed. Participation from the PLWHA is considered essential to every aspect of the RW Part A planning and service delivery process. Specifically, PLWHA expressed the need for additional HIV testing in the community. This led to the Planning Council allocating additional funds to Early Intervention Services to supplement other HIV testing efforts in our TGA. Planning Council also has various subcommittees. The financial subcommittee looks at the total allocation, money spent, and number of clients served in each service category. This information was utilized when deciding Fiscal Year 2015 allocations. Although health insurance premium and cost sharing assistance was considered a high priority, no resources were allocated to this category because of the coordinating RW Part B to cover those costs. During a Planning Council meeting discussion was led by better ways to integrate HIV prevention planning. This was accomplished by changing the leadership configuration of the Planning Council to a 3-Chair structure. There will be a representative from HIV care, HIV prevention, and an individual that is HIV- positive chairing the council.There is also a current medical case management network quality improvement project that is focusing on standardizing and improving the efficiency of medical case management services being received by consumers, and is aimed at ultimately improving retention in care for PLWHA. This project involves the development of an acuity scale to prioritize client need and the standardization of medical case management documentation across all agencies and Ryan White Parts.
HIV testing is an effective method for identifying new HIV infections. Avoiding late diagnosis allows for an earlier initiation of ART, which substantially reduces HIV transmission in addition to increasing survival. There is a growing consensus that initiating ART immediately after detection is beneficial regardless what the individual’s lab results show. Early detection of HIV through frequent testing also promotes risk reduction in previously undiagnosed HIV-positive patients by decreasing partnership acquisition rates and increasing safe sex practices with perceived HIV-negative partners. According to the National HIV Prevention Strategy for every HIV infection prevented, an estimated $355,000 is saved in the cost of providing lifetime HIV treatment.
The U.S. National HIV Strategy plan vision is that national the U.S. will become a place where new HIV infections are rare, and when they do occur, every person, regardless of age, gender, race/ethnicity,sexual orientation, gender identity, or socio-economic circumstance, will have unfettered access to high quality, life-extending care, free from stigma and discrimination. HIV continues to be a priority on the state and local level. While the diagnosis of HIV is no longer a death sentence and is being considered a chronic disease, it is nevertheless a preventable disease as attention of the HIV disease has shifted to prevention it is vital to conduct focused testing, finding the newly diagnosed and fallen out of care HIV+ individuals and getting them into care to suppress their viral loads. Suppressing the individual’s viral load makes them less likely to spread the disease and therefore we are able to decrease the disease in our communities.
CPH will continue to receive RW Part A and HIV Prevention funding and standardization Process is in place. Funded programs, including L2C and Community Service programs continue to be monitored which allows for quality improvement and which helps sustain the program. Efficiency and effectiveness continues to be monitored and improved. Developed policies and procedures support a sustainable infrastructure.