PROACT Program Collaborates to Improve HIV Retention in Care

LHD  and  Community Collaboration      

Goal(s) and objectives of practice

The goal and objective of this practice is to increase adherence to HIV medication therapy and reduce the number of clients that fall out of care to improve health outcomes, reduce new HIV infections and reduce community viral load.

What did you do to achieve the goals and objectives?

According to the CDC, Improving the health of persons with HIV and reducing the number of new infections in the United States will depend on increasing access to HIV medical care and eliminating disparities in the quality of care received.” Steps taken to implement the program included a series of multidisciplinary staff meetings within DOH-Broward to create and deploy action plans. DOH-Broward endeavored to find a simple, easily deployable, and cost effective method to identify LHD clients who have not picked up their HIV medication, locate lost to care clients that are referred to the DOH-Broward PROACT Program, and either re-engage clients into care as appropriate and/or consult with the client's healthcare provider to provide timely feedback so as to provide optimal care and treatment. HIV related provider agencies, Federally Qualified Health Centers notify DOH-Broward of client's lost to care through a PROACT Referral form. A supervisor reviews the information and assigns a dedicated HIV DIS to locate and find the client.

DOH-Broward's pharmacy staff works with the HIV DIS to assure that HIV clients who are enrolled in ADAP and Ryan White Pharmacy Assistance program are receiving their HIV medications as prescribed.  HIV medications are provided by DOH-Broward Pharmacy Department pursuant to prescriptions authorized from client's physicians/providers. Daily, pharmacy staff generate a return to stock” report, which identifies all prescriptions that have not been picked up for 11 days (5 days early, plus a 6-day grace period) after the prescription's date filled”.   Clients begin receiving automated prescription reminder refill calls before their prescription is due to ensure every opportunity is offered to pick up medications. This list is distributed to the PROACT Director for distribution to the Pharmacy DIS.

DOH-Broward Pharmacy HIV Disease Intervention Specialists (DIS) review the Excel file to identify which clients have not been successfully contacted by the pharmacy staff of the two centrally located DOH-Broward Pharmacies. DOH-Broward Pharmacy, Dental, Perinatal HIV DIS staff then utilize a variety of methods to locate HIV clients such as database searches to obtain the most current contact information. Some client search databases include:

• Lexus Nexus,
• Driver and Vehicle Information database (DAVE),
• STARS Surveillance Tools and Reporting System STD database,
  
• Provide Enterprise the Broward County Ryan White HIV clinical database
• Careware (HRSA database for HIV Clients),
• HMS, Florida DOH Health Management System,
• FMMIS, Florida Medicaid Management Information System,
• FLSHOTS, Florida Immunization database,
• WAGES, Wage database from Bureau of Labor eHARS, 
• Enhanced HIV AIDS Reporting System, ADAP, AIDS Drug Assistance Program,
• FDLE type of database,
•  Social Media and home visits as necessary.

The HIV DIS staff ascertain/determine the reasons for which clients' have not picked up their HIV medications and clients that are lost to care. Every attempt to re-engage clients into care is made including calling case managers, clinicians, and/or other individuals connected with the client's care.  The HIV DIS provide client contact outcome results to the PROACT/Perinatal Director such as, returned to care, unable to locate, out of jurisdiction, incarcerated, refused services, in care, and has medical insurance. The PROACT Director then ensures that the referring agency is provided with the outcomes of the referrals.

To evaluate the outcomes of the DOH-Broward HIV DIS initiative, data is exported to an Excel report to determine the number and percentage of unique HIV clients that had a prescription returned to stock (voided and/or not picked up) in a given month and whether that same client had a prescription filled during the following month.  This indicates whether the client was lost to pharmacy care.

On a monthly basis, the Director of PROACT reports to the DOH-Broward Health Officer the total number of clients referred to PROACT, the total number of clients successfully contacted by HIV DIS, and the percentage of clients who did not pick-up their prescriptions that returned to the pharmacy (retained in care).  Metrics were created in the department's performance management system, Active Strategy, to monitor this information monthly, to track trends and historical information. This information is shared and discussed at monthly business review meetings.

Any criteria for who was selected to receive the practice (if applicable)?

The criteria for those selected to receive the practice was any DOH-Broward client that was referred to PROACT from DOH Pharmacy and/or HIV Agencies that are lost to care over six months or non-adherent to medication.

What was the timeframe for the practice?

The timeframe for the practice implementation was January 2015 and is now a routine part of the DOH-Broward client care process. 

Were other stakeholders involved? What was their role in the planning and implementation process? 

Other stakeholders involved with this program were the DOH-Broward HIV/AIDS program's ADAP staff, community HIV/AIDS providers and the HIV DIS staff.  Their role in planning and implementation was nominal.

What does the LHD do to foster collaboration with community stakeholders? Describe the relationship(s) and how it furthers the practice goal(s).

DOH-Broward has developed strong partnerships with our stakeholders that are involved in the system of care in Broward County.  These include but are not limited to the grantees for Ryan White (RW) Part A, RW Part B, RW Part C, RW Part D, Community Based Organizations, Case Management agencies, Food Banks, Substance Abuse Facilities and Federally Qualified Health Centers.  DOH-Broward Pharmacy and HIV DIS work closely with staff from these agencies to assure retention in care as well as appropriate care and treatment of HIV/AIDS clients.

Any start up or in-kind costs and funding services associated with this practice?  Please provide actual data, if possible.  Else, provide an estimate of start-up costs/ budget breakdown.

Specific factors that led to the success of this practice included hiring and training of 4.0 FTE HIV DIS staff ($31,500 salary per employee), 2.0 FTE Pharmacy HIV DIS, one FTE Perinatal HIV DIS and one FTE Dental HIV to closely monitor prescription pickups, missed medical appointments and find lost to care clients. They educate clients daily to increase adherence and retention in care. Information Technology programming cost was approximately $1,000.  All the information that is gathered about these clients are entered in a local database called HIV Prevention Care Coordination (HPCC) database. This database allows us to review the staff client load and discuss outcomes.

Evaluation                                                                                                                                                    

What did you find out?  To what extent were your objectives achieved?  Please re-state your objectives from the methodology section.

The objective is to increase medication adherence and retention in care for HIVAIDS clients in order to reduce new HIV infections and improve health outcomes. 

In 2017, the average number of DOH-Broward pharmacy clients who did not pick-up their prescriptions that responded to pharmacy staff's phone calls, was 39%.  The remaining 61% of clients were evaluated by HIV DIS staff.  As of October 31, 2019, 2,711 clients were referred to the Pharmacy HIV DIS. The outcomes are:  Inactive clients 24%, 85% picked up medications, 4% unable to locate, 12% moved out of this jurisdiction, 7% had insurance, 1% deceased, 7% linked to care ,5% refused, 2% incarcerated and approximately 766 field visits were performed. This is an increase from 70% in 2016 and 81% in 2017 for a 20% increase in referrals. By increasing the percentage of PLHIV on antiretroviral and in care, community viral load will decrease as well as the number of new HIV infections. DOH-Broward learned that, of the clients evaluated by HIV DIS staff, an average of 61% of clients returned to the pharmacy the following month to pick-up their prescriptions.

DOH-Broward's objective was achieved. We continue to see a high percentage of clients retained in pharmacy care and a low percentage of HIV clients that did not pick up their HIV medication which is a measure of increased overall adherence and retention in medical care.

Did you evaluate your practice?

Yes

List any primary data sources, who collected the data and how (if applicable)

Primary data sources include: internal secure database, electronic HIV/AIDS reporting system (eHARS), Surveillance Tools and Reporting Systems (STARS), electronic lab reporting. Data was collected by the DOH-Broward Pharmacy, ADAP, and perinatal staff.

List any secondary data sources used (if applicable)

List performance measures used. Include process and outcome measures as appropriate.

Performance measures were created and tracked in the DOH-Broward performance management system, Active Strategy. These include prescriptions picked up, number of medications returned to stock, number of clients who did not pick up medications, number of client's reached by HIV DIS, pick up rates, and treatment adherence.  A pharmacy metric includes the pick up rate of ARV's from DOH pharmacies”. Metric results, variance reports and corresponding action plans are discussed at monthly business reviews to revise process as necessary.

Describe how results were analyzed. 

Due to the success of this objective, the process will continue and is supported by DOH-Broward's Director.  Every LHD that interacts and/or serves HIV clients may have the potential benefit of this program by reducing HIV transmission through ensuring the highest possible rate of medication adherence.  DOH-Broward analyzed the process and determined there is an improvement in knowledge and awareness by DOH-Broward Pharmacy and ADAP staff regarding the importance of clients understanding the importance of medication adherence to reduce or eliminate the risk of transmission of HIV thus improving health outcomes. 

Were any modifications made to the practice as a result of the data findings?

No

Sustainability

Lessons learned in relation to practice

Lessons learned were such that there was an improvement in knowledge and awareness by DOH-Broward Pharmacy and HIV DIS staff regarding the importance of retaining HIV clients in care.

Lessons learned in relation to partner collaboration (if applicable)

As a result of this practice, DOH-Broward's relations with its community partners improved through interagency collaboration. DOH-Broward is able to refer and link clients into care very effectively. Community partners are extremely appreciative of the efforts by DOH-Broward to retain HIV clients in care and alert clinicians to clients with possible adherence issues.

Did you do a cost/benefit analysis? If so, describe.  

N/A

Is there sufficient stakeholder commitment to sustain the practice?

Measuring the effectiveness of return to care programs for people living with HIV (PLWH) presents a serious issue to public health evaluation. Categorizing those who leave, and re-enter HIV care is difficult as this cycle may occur before they would traditionally be considered not retained in care (6-month minimum). The PROACT program offers may strengths not available in other return to care programs. The most common return to care program is the Data2Care program. The Data2Care program utilizes surveillance data to identify those considered out of care, however these identifications often occur long after the PLWH has left care. There is literature that states that the longer an induvial is out of care, the more difficult locating and re-engaging the individual in care was. Thus, locating and re-engaging PLWH who are considered out of care is more effective shortly after a pattern of missed visits has been demonstrated. This is the methodology PROACT program uses. The Stakeholders ( all the HIV agencies that refer to PROACT) are very satisfied with the work that we do because we are able to provide outcomes to them so they can decided what to do with this lost to care client.

Overall, the PROACT program re-engaged 73% of the clients that were found and eligible into HIV care. This number likely underestimates the true impact of the program. Many referred individuals considered unable to locate or refuse services often re-engage in care without health department assistance. These individuals are not counted as re-engaged in care per this evaluation.

Describe sustainability plans.

The HIV DIS in this program are paid thorough Ryan White Part A care and treatment dollars and the CDC HIV Prevention grants that are provided to the Health departments depending on the number of HIV individuals we serve in the county. Since, we are a high incident county in Florida we will continue to sustain the HIV DIS to do the work that they do of re-engaging lost to care clients throughout the county which then will decrease community viral load and reduce new HIV infections.