Improving Quality Care for Marginalized HIVPositive Patients

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Improving Quality Care for Marginalized
HIV-Positive Patients

• The Prevention and Access to Care and Treatment
  (PACT) Project
• A Complementary Community-Based HIV Disease
  Management Model
• Heidi Behforouz, MD and Jessica
  Aguilera-Steinert, LICSW
• 03/10/05

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AIDS MORTALITY

• DESPITE OUR ADVANCING TECHNOLOGY
• In Roxbury, a black women is 16x more likely
  to die from her AIDS than a white man in Boston.

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The Outcome Gap Grows
Improved Outcomes
High SES
Low SES
Time
Introduction of effective technology
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Why the disparities in outcome?

• Poverty forces priorities other than health
• Poor access to care (eg insurance)
• Poor utilization of care (eg not getting tested
  till late in disease)
• System problems
• Differential treatment once in care
• Problems with adherence

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The relationship between adherence and AIDS
progression
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Impact of ART on Hospitalization Rates in
HIV-Infected PatientsGilbert et al, New York
Presbyterian Hospital AIDS Research and Human
Retroviruses. 18(7)501, 2002
Hospital Admissions Per 100 Pt-Yr
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ART is Cost-Effective K. Freedberg et al. NEJM
2001 344 824

• Greater than benefit of thrombolytic therapy in
  acute MI, XRT for early stage breast CA, and
  anti-hyperlipidemics
• Adherence Interventions are cost effective
• Sue Goldie et al.
• Any intervention that increases ART adherence by
  30 will be cost effective

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Prevention and Access to Care and Treatment
(PACT) Project

• Started in 1999 through Partners In Health Now a
  joint project of PIH the DSMHI at BWH
• Participant-driven
• Health promoters improve access to care for
  marginalized HIV patients in Bostons inner city
  as well as promote harm reduction in the
  community
• Health promoters work in conjunction with
  physicians, medical students, social scientists.

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PACT Organizational Structure
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PACT PROJECT

• Harm Reduction Initiative
• Knowledge is important but not enough
• Prevention case management services
• Peer leader outreach and harm reduction in hot
  zones
• Media campaigns, needle exchange, accompaniment
• Working with adults in early recovery and inner
  city youth

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PACT Project

• Health Promotion Initiative
• Low intensity Monitored self- administration
  with monthly health promotion
• Moderate intensity Weekly health Promotion
• High intensity DOT-Plus initiative

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WHAT HEALTH PROMOTERS DO

• Accompaniment to appointmentsmore than just
  getting the patient there
• Home based support to pt and network
• Work in concert with clinicians and other social
  service personnel to coordinate care
• Health education and translation of treatment
  recommendations into the home
• Facilitate access to and utilization of resources
• Extensive adherence counseling
• Surrogate support network and sounding board
• Normalization/setting new norms
• Advocacy
• Empowerment

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DOT-Plus

• In addition to the weekly services of a health
  promoter, patients receive daily visits from the
  DOT specialist who assists them in taking their
  once daily ART medication
• Designed with instruction from patients

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Cristina at work
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Movement through PACT
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Outcomes of Interest for HP Program

• Improved clinical outcomes (CD4/VL/OI)
• Improved engagement with health care
• Improved practice of harm reduction
• Improved self management
• Improved health care utilization
• Number of referrals to PACT
• Number graduated to successful self
  administration
• Number of relapses
• Length of time in each arm and number of
  movements between arms over time
• Resource utilization
• Sustainability

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PACT and the PDSA Cycle

• Participant action plans
• Quarterly personal objectives for peer prevention
  leaders
• Patient progress (eg Q patient report cards)
• Health promoter report card
• Program goals eg referral rates, retention
  rates, etc.

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PACT ALONE GRAPHS

• Insert Ariel Cruz graph

Viral Load (thousands/ml)
-4
4
Months Pre and Post PACT CD4 in ( )

hospitalization
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160
120
Viral Load
(thousands /ml)
80
40
MONTHS CD4 ( )
hospitalization EW visit
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Data to date

• Health Promotion
• Of those 31 meeting our new eligibility criteria
  at entry who have been enrolled for at least one
  year
• (Baseline mean CD4 131 with mean VL 61K)
• 10 with VLltassay at present
• Mean 1.35 log decrease in VL
• Mean increase in CD4 after 1 year79 cells/µl

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Data to date

• DOT-Plus
• Of 20 enrolled into DOT Plus for at least one
  year
• (Baseline mean CD4 122 with mean VL of 57K)
• Retention rate at one year 85
• 11 achieving VLltassay to date
• Mean increase in CD4 108.5 cells/µl
• Means VL reduction 1.13 log

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Yearly Expenditures for Care of HIV/AIDS Patients

• Today we estimate annual expenditures for
  patients with CD4lt50 to be around 40,000
• CD4 count measures immune strength
• PACT CD4 eligibility criteria lt350, most PACT
  patients have CD4 lt200 at enrollment

Source Bozette, S et. al. Expenditures for the
Care of HIV-Infected Patients in the Era of
Highly Active Antiretroviral Therapy. NEJM, 2001.
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What does this mean in terms of medical cost
savings?

• Average cost of PACT/patient 3200/month
• (across all three programs)
• Patients whose CD4 counts have risen from lt50 to
  gt200medical savings of
• up to 17,000/ year

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Sustainability/ Funding Challenges

• PACT is primarily a service organization as
  opposed to focusing on research or policy
• Care gets less attention than prevention
• PACT staffing ratios are deemed too costly
• It takes time and resources to prove ourselves
  and become competitive for funding
• Shrinking federal, state, and private funds-
  particularly for HIV service programs and harm
  reduction programs
• Not much interest in the plight of poor minority
  individuals with HIV or substance abuse

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Spread Challenges

• First establish best practicedevelop the
  packagecurricula, training manuals, process
  guides
• THEN barriers include
• Lack of similar organizations from whom to learn
  collaboratively, politics, money
• BUT
• The proof is in the puddingdo the work, show
  the data, always strive for quality in a
  systematic way

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