Call Girls Kochi Just Call 8250077686 Top Class Call Girl Service Available
Pappas-National HIV / AIDS Strategy- Implications in Metro Washington, DC
1. Convergence of the National
HIV/AIDS Strategy and the
Affordable Care Act: implication for
HIV care delivery system in Metro
Washington DC
Gregory Pappas, MD, PhD
Senior Deputy Director
HAHSTA
Department of Health
District of Columbia
2. DC Department of Health
Mission
• 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
• Patient Centered Medical Home
• Accountable Community Care and redesign of the
care delivery system
• The way forward
4. Where are we? (1)
• Convergence of two great
movements
• National AIDS Strategy 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 disease
– This is happening regardless of
whether insurance mandates
continue.
• One point of convergence is an
“HIV medical home”
5. Where are we? (2)
• National leader in fight
against HIV and AIDS
• 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!
6. Where are we? (3)
• As an early adopter of
Affordable Care Act, DC can
move on to issue of
improving the design of the
health care delivery system
• DC has shifted over 1000
people off of ADAP onto
Medicaid to achieve
“treatment on demand”
• 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)
7. 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 DC is actively scaling up the National Strategy
Epidemic
8. District of Columbia Continuum of HIV Care*, 2010
6,000
4,879
5,000
4,172
Number of HIV Cases
4,000
3,000
2,000
1,078
1,000 823
0
Diagnosed HIV Cases Linked to HIV care as Continous HIV care Virally suppressed
of 12/31/2010 during 2010† during 2010‡
*This includes HIV/AIDS cases diagnosed in DC between 2005 and 2009 and living as of December 31,
2010.†Continuous care is defined as having 2 viral load or CD4 test results reported to the DCDOH at
least 2-4 months apart. ‡Cases are considered virally suppressed if their last viral load test reported in
2010 was ≤400 copies/mL.
9. 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.
10. 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.
11. 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.
12. District of Columbia Continuum of HIV Care*, 2010
6,000
4,879
5,000
4,172
Number of HIV Cases
4,000
3,000
2,000
1,078
1,000 823
0
Diagnosed HIV Cases Linked to HIV care as Continous HIV care Virally suppressed
of 12/31/2010 during 2010† during 2010‡
*This includes HIV/AIDS cases diagnosed in DC between 2005 and 2009 and living as of December
31, 2010.†Continuous care is defined as having 2 viral load or CD4 test results reported to the DCDOH
at least 2-4 months apart. ‡Cases are considered virally suppressed if their last viral load test reported
in 2010 was ≤400 copies/mL.
13. Difference between DC clinics for percent patients virally
100 suppressed among those on in care and prescribed
99 98
90 Average: 86%
80 84 83
77 77
70
Percent Performance
60
50 53
40
30
20
10
0
J O H P E C B
RW-funded Clinical Care Providers in DC: reported by clinics
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 13
measurement year.
14. Patient Centered Medical Home
• Long history traced
back to Altamy
Declaration
• Barbara Starfield a
pioneer
• 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
17 criteria for medical homes emphasizing 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. 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
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. 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 need
• Local tax dollars in DC
“Effi Barry Program” will
be used to encourage this
redesign
Berensen et. al Health Affairs 2008
21. What CBOs need to consider
• Strategic alliances with
clinics
• Mergers
• Performance measures
that demonstrate
contribution to care
• Participation in care
teams
• Contractual agreements
that provide money for
services rendered to
clinical centers
22. Medical Home is not a panacea
• Risk of becoming a fad and cannot
solve health care’s cost and quality
challenges.
• Accountable Care Organizations also
being discussed, redesign of larger
units than the home.
• Substantial payment redesign, overall
health system reorganization, and
much more also needed.
• 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.
23. Three kinds of people*
120
100 Some people are excellent
patients and have high
80 control
60
Me and most others. I
40 need a lot of support
maintaining my health
20
0
*This is my common sense understanding of different types of patients and
levels of care they need.
24. …
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.co
m/webfiles/accwhitepape
r12012v5final.pdf
25. 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
26. 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 the Journey To Wellness.
27. 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.
Hinweis der Redaktion
AbstractIn this era of effective antiretroviral therapy, early diagnosis of HIV and timely linkage to and retention in care are vital to survival and quality of life. Federal guidelines recommend regular monitoring of HIV-related laboratory parameters and initiation of antiretroviral treatment at specified thresholds. We used routinely reported laboratory data to measure intervals between visits by New York City residents newly diagnosed with HIV July 1 to September 30, 2005, and initiating care within 3 months of diagnosis. We measured regular care (≥1 visit every 6 months) and retention in care (last visit ≤6 months before close of analysis) through June 30, 2009. Patients were followed for 45–48 months. Seventy-seven percent (650/842) of patients initiated care within 3 months of diagnosis; 609 (93.7%) made at least one subsequent visit; 45.4% had regular care. Risk factors for not receiving regular care included age 13–24 versus 50+ (adjusted odds ratio [AOR] 3.0, 95% confidence interval [CI] 1.5, 6.0), black race (AOR 2.0, 95% CI 1.4,2.8), eligibility for antiretroviral treatment (AOR 1.5, 95% CI 1.1, 2.2), and injection drug use (IDU; AOR = 2.7. 95% CI 1.0, 7.1). In a time-to-event analysis, risk factors for loss to care were age 13–24 versus 50+ at diagnosis (adjusted hazard ratio [AHR] 1.9, 95% CI 1.1, 3.4), non-hospital site of care (AHR 1.4, 95% CI 1.0, 2.0) and early stage (non-AIDS) disease (AHR 1.4, 95% CI 1.0, 2.0). The analysis demonstrates how mandated reporting of HIV-related laboratory tests provides surveillance systems with the capacity to monitor utilization of care, identify deficits, and evaluate progress in programs designed to facilitate retention in care.
This analysis includes HIV cases diagnosed in 2008 and 2009 in DC that were linked to care by December 31, 2010. The analysis compares those that were in continuous care in the year following linkage to care to those that did not meet the continuous care definition in the year following linkage to care. The continuous care definition that was used is the HRSA definition (2 labs reported that were 3 months apart in 1 year). This graph shows that blacks were more likely than whites to be out of continuous care. Hispanics were also more likely than whites to be out of continuous care, but this difference is not statistically significant. Those 20-29 and 50-59 were less likely than those 13-19 to be out of continuous care.
2) The practice establishes written standards on scheduling each patient with a personal clinician for continuity of care and the practice collects data to show that it meets its standards on Clinical Information Systems 3) The practice uses an electronic data system that includes searchable data such as patient demographics, visit dates and diagnoses (up to 12 specific factors), and the practice uses an electronic or paper-based system to identify clinically important conditions or risk factors among its patient population. Delivery System Redesign 4) The practice establishes written standards to support patient access, including policies for scheduling visits and responding to telephone calls and electronic communication (up to 9 specific factors). 5) The practice collects data to demonstrate that it meets standards related to appointment scheduling and response times for telephone and electronic communication (up to 5 specific factors). 6) The practice defines roles for physician and non-physician staff and trains staff, with non-physician staff, involved in reminding patients of appointments, executing standing orders and educating patients/families. 7) The practice uses electronic or paper-based tools including medication lists and other tools such as problem lists, or structured templates for notes or preventive services to organize and document clinical information in the medical record. 8) The practice conducts a comprehensive health assessment for all new patients to understand their risks and needs including past medical history, risk factors and preferences for advance care planning (up to 5 specific factors). 9) For three clinically important conditions, the physician and non-physician staff conducts care management using an integrated care plan to set goals, assess progress and address barriers (5 specific factors). 10) For three clinically important conditions, the physician and non-physician staff conduct care management planning ahead of the visit to make sure that information is available and the staff is prepared as well as following up after the visit to make sure that the treatment plan (including medications, tests, referrals) is implemented. 11) The practice identifies appropriate evidence-based guidelines that are used as the basis of care for clinically important conditions. Patient/Family Engagement 12) The practice supports patient/family self-management through activities such as systematically assessing patient/family-specific communication barriers and preferences, providing self-monitoring tools or personal health record, and providing a written care plan. 13) The practice supports patient/family self-management through providing educational resources, and providing/connecting families to self-management resources. 14) The practice encourages family involvement in all aspects of patient self-management. Coordination 15) The practice systematically tracks tests and follows up using steps such as making sure that results are available to the clinician, flagging abnormal test results, and following up with patients/families on all abnormal test results (up to 4 specific factors). 16) The practice coordinates referrals designated as critical through steps such as providing the patient and referring physician with the reason for the consultation and pertinent clinical findings, tracking the status of the referral, obtaining a report back from the practitioner, and asking patients about self-referrals and obtaining reports from the practitioner(s). 17) The practice reviews all medications a patient is taking including prescriptions, over the counter medications and herbal therapies/supplements.