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ImprovingHealthOutcomesthroughtheRyanWhiteHIV/AIDSProgram:SuccessandChallengesHaroldJ.Phillips,MRPDirectorOffice ofTrainingandCapacityDevelopmentHIV/AIDSBureau(HAB)HealthResourcesandServicesAdministration(HRSA)
November3,2017
PurposeofRyanWhiteHIV/AIDSProgram
• Publichealthapproachtoprovideacomprehensivepatient-centeredsystemofHIVcare
• Ensurelow-incomepeoplelivingwithHIV(PLWH)receiveoptimalcareandtreatment
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AlignmentofHHSPrinciplesofPatient-CenteredHealthCareSystemintheRyanWhiteHIV/AIDSProgram
•ClinicalqualitymanagementisbuiltintotheRWHAP•BetterhealthoutcomesforPLWHthanPLWHoutsideRWHAPQuality•RWHAPisanationalprogram•GeographicallydiverseproviderstomeetneedAccessibility•Clientsreceiveservicesatreducedcharges•ClientscannotbedeniedservicesforinabilitytopayAffordability•Servicesprovidedarebasedonlocally-developedneedsassessment•SupportservicesavailabletoimprovehealthoutcomesbasedonneedChoices•RWHAPprovidersidentifynewapproachestoreachPLWH•NewapproachestoimprovehealthoutcomesamongallPLWHInnovation•ProvidersrapidlyadoptadvancesinmedicineandcareforPLWH•ServiceutilizationdrivenbyclientneedResponsiveness
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ContinuumofCareAmongPeopleDiagnosed*withHIVintheUnitedStates**
100
70.9
56.5 54.7
0
20
40
60
80
100
Diagnosed InCare RegularCare ViralSuppression
Percentage
Source: Centers for Disease Control and Prevention. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 dependent areas—2014. HIV Surveillance Supplemental Report 2016;21 (No. 4)
*Denominator is 615,836 persons diagnosed with HIV by the end of 2012 and alive through 2013.
**Data from 33 jurisdictions that reported complete CD4 and viral load data. Data from these 33 jurisdictions represent 69.5% of all persons aged ≥13 years living with diagnosed HIV infection at year-end 2013
5Source:HRSA.RyanWhiteHIV/AIDSProgramDataReport(RSR)2015.DoesnotincludeAIDSDrugAssistanceProgramdata.
ViralSuppressionamongClientsServedbytheRyanWhiteHIV/AIDSProgram,byState,2010–2015—UnitedStatesand2Territoriesa
VIRALLY SUPPRESSED
69.5%
83.4%VIRALLY SUPPRESSED
IN 2015
IN 2010
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Viralsuppression:≥1OAMCvisitduringthecalendaryearand≥1viralloadreported,withthelastviralloadresult<200copies/mL.aPuertoRicoandtheU.S.VirginIslands.Duetolownumbers,dataforGuamarenotpresented.
Source:HRSA.RyanWhiteHIV/AIDSProgramDataReport(RSR)2015.DoesnotincludeAIDSDrugAssistanceProgramdata.
StructuralBarrierstoPLWH-CenteredHealthCareSystem
HealthDisparities
Stigma&Discrimination
SocialDeterminantsofHealth
PublicHealthInfrastructure
PUBLICHEALTHasaKEYDRIVEROFSUCCESS
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ViralSuppressionamongKeyPopulationsServedbytheRyanWhiteHIV/AIDSProgram,2010–2015—UnitedStatesand3Territoriesa
Hispanics/Latinoscanbeofanyrace.Viralsuppression:≥1OAMCvisitduringthecalendaryearand≥1viralloadreported,withthelastviralloadresult<200copies/mL.aGuam,PuertoRico,andtheU.S.VirginIslands.
RWHAPoverall,2015(83.4%)
RWHAPoverall,2010(69.5%)
UsingClient-levelDatatoMeasureOutcomes
RWHAP client-level data, along with other epidemiologic andqualitative data, can be used for:
• Planning.Prioritizing,targeting,andmonitoringavailableresourcesinresponsetoneeds.
• Addressinggaps.IdentifyinggapsinandbarrierstocareforPLWH.
• Improvingservices.IdentifyingissuesandopportunitiestoimprovethedeliveryofservicestoPLWHaswellashigh-risk,uninfectedindividuals(e.g.,HIVtesting;linkagetopreventionservices,behavioralhealth,socialservices).
• Improvingoutcomes.Improvingengagementandoutcomesateachstageofthecarecontinuum.
ServicesProvidedbyRWHAP-FundedandNon-RWHAP-FundedOutpatientFacilities:MedicalMonitoringProject(MMP)2009-2012
64%
34%
49%
76% 82%
59% 53%
60%
71%
18% 12% 9%
15%
30% 29%
11%
22% 22%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
MentalHealth SubstanceAbuse
Treatment
DentalCare CaseManagement
AdherenceCounseling
InterpreterServices
TransportationAssistance
Nutritionist/Dietician
RiskReductionCounseling
Percentageoffacilitie
sprovidingse
rvices
RWHAP-Funded Non-RWHAP-Funded
11Source:WeiserJ,BeerL,FrazierEL,PatelR,DempseyA,HauckH,Skarbinski J.ServicedeliveryandpatientoutcomesinRyanWhiteHIV/AIDSProgram-fundedand-nonfundedhealthcarefacilitiesintheUnitesStates.JAMAInternMed2015:4095.
PercentageofVirallySuppressedClientsbyHealthCareCoverageandRyanWhiteHIV/AIDSProgramAssistance:MMP2009-2012
76% 71%
76% 76% 81%
76% 78% 79%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Private Medicaid Medicare Medicare+Medicaid
Percentageofp
atientsw
ithvira
lsup
pressio
n
Non-RWHAPPayer Non-RWHAPPayer+RWHAP
12Source:Bradley,H,MattsonC,BeerL,HuangP,Shouse,R.Luke;fortheMedicalMonitoringProject.IncreasedantiretroviraltherapyprescriptionandHIVviralsuppressionamongpersonsreceivingclinicalcareforHIVinfection.AIDS2016;30(13):2117–24.
CommunityEngagementandImplementation
StateHealthDepartments
CommunityPartners
RSRUtilization
Data
CEBACC
CEBACC:HIVProviderFocusGroups
• Patientandproviderprioritiesareoutofsync• StigmarelatedtoHIV,sex,andsexualityisveryprevalent• BlackMSMareresilientandarebuildingtheirownsupportsystemsoutsideoftraditionalfamilystructures
• BlackMSMareseekingoutproviderswheretheycanbuildpositive,affirmingrelationships
• Mustbewillingtoeducateprovidersaswellasbeeducatedbythemandnon-providers
CEBACC:BlackMSMandProviderFocusGroups
• Patientandproviderprioritiesareoutofsync• StigmarelatedtoHIV,sex,andsexualityisveryprevalent• BlackMSMareresilientandarebuildingtheirownsupportsystemsoutsideoftraditionalfamilystructures
• BlackMSMareseekingoutproviderswheretheycanbuildingpositive,affirmingrelationships
• Mustbewillingtoeducateprovidersaswellasbeeducatedbythemandnon-providers
ImprovingHealthOutcomes:EngagingandSupportingYouth
BuildingFutures:SupportingYouthLivingwithHIV• IdentifybarriersandbestpracticestosupportyouthlivingwithHIVaccessingRWHAPfundedservices
• Youthhavelowerratesofviralsuppression,weneedmoreinformationaboutwhatworksandwhytodisseminatewidely
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ViralSuppressionamongClientsServedbytheRyanWhiteHIV/AIDSProgram,byAgeGroup,2010‒2015—UnitedStatesand3Territoriesa
Viralsuppression:≥1outpatient/ambulatorymedicalcarevisitduringthecalendaryearand≥1viralloadreported,withthelastviralloadresult<200copies/mL.aGuam,PuertoRico,andtheU.S.VirginIslands.
Source:HRSA.RyanWhiteHIV/AIDSProgramDataReport(RSR)2015.DoesnotincludeAIDSDrugAssistanceProgramdata.
OtherStepstoAddressDisparities
• Secretary’sMinorityAIDSInitiativeFund– InnovativeProjects• MinorityAIDSInitiative– addressesgapsincare• SpecialProjectsofNationalSignificance/RyanWhiteHIVAIDSProgramPartF– DemonstrationProjectsdesignedfocusedonimplementationofservicedeliveryreformstocreateefficiencies,improveeffectivenessandimprovehealthoutcomes
• LearningCollaboratives– SouthernInitiativestoaddressgeographicdisparitiesbasedonInstituteforHealthcareImprovement
• IncreasedCollaborationsandPartnershipswithHUD,SAMSHA,DOL,toaddresstheintersectionalityofillness,mentalandbehavioralhealth,poverty,employmentandhousingstatus
SoutheastAETC– SuccessandChallenges
• Challenges• Viralsuppressionrateswhilerisingstilllagbehind• LinkagetocareisstillachallengeinclinicswhichofferanHIVtest
• Needtocreatetrainingopportunitiesforlowvolumeandearlycareerproviders
• TargetedMAIactivitiestobetterserveminoritiesengageprofessionalswithmentalandbehavioralhealthandsubstanceusedisordertreatmentexperience.
• EightStateregionwith28%ofnewNationalcasesin2014
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SoutheastAETC– SuccessandChallenges
• Successes- OpportunitiestoexpandHIVtesting• 1,177hospitals• 1,688CommunityHealthCenters(CHC)• 105,343internalmedicineandprimarycarephysicians• 39,448nursepractitioners• 7,334psychiatrists
• Top5trainingsin2016Trainings(ART,Adherence,Epidemiology,Race/Culture,Co-morbidities)
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T/TAGoalandTargetPopulation- CollaborationwithBPHC
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GOAL:TotrainHIVpracticecoacheswhocandrivepatient-centered,HIVpracticetransformationinupto15non-RWHAP,healthcentersinhigh-riskmetropolitanareasfromHHSRegion4(Alabama,Florida,Georgia,Kentucky,Mississippi,NorthCarolina,SouthCarolina,andTennessee).
TARGETPOPULATION:Non-RWHAPhealthcentersinhigh-riskmetropolitanareasinHHSRegion4withPCMHrecognitionornoticeofintent(NOI).
ProposedT/TAInitiativeTimeline,OutcomesandDeliverablesTentativeTimeline:21months
• 6Months:HIVPracticeCoachtraining,readinessassessments,andtailoringofpoliciesandprocedures(e.g.,October2017– March2018)
• 15months:CoP forroutineHIVtestingandHIVlinkagetocare(e.g.,April2018– June2019)
HealthCenterOutcomes:
• Increased%ofpatientswhoreceiveanHIVtest
• Increased%ofnewlydiagnosedpatientslinkedtoHIVcare
Deliverables:
• EnhancedPrimaryCareHIVIntegrationToolkit
• Apatient-centeredHIVcarecurriculumforhealthcenterpracticetransformation
• RapidQImodelforroutineHIVtestingandHIVlinkagetocare
EnsuringGoals,Strategies,ActivitiesareResponsivetotheData
1. Assesstrends
• Moredatamaybeneededtoexplainunexpectedtrends
2. Focusonmostaffectedcommunities
3. Ensurestrategiesandactivitiesculturallyappropriate
4. Engagemostaffectedcommunitiestoinformdecisionsandassistwithimplementation
5. Engagecareproviders
HABReportsandOtherResources
• Findtheclient-leveldatareportandotherresourcesonline:https://hab.hrsa.gov/data
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Resources
• RyanWhiteHIV/AIDSProgramAnnualClient-LevelDataReporthttp://hab.hrsa.gov/data/servicesdelivered.html• National- andstate-leveldataonallclientsservedbyRWHAP,includingselectindicatorsofthecarecontinuum
§ RyanWhiteHIV/AIDSProgramresourcesfordeliveryofHIVcarehttp://hab.hrsa.gov/deliverhivaidscare/index.html
• AIDSEducationandTrainingCenters(AETC):MultidisciplinaryeducationandtrainingprogramsforhealthcareproviderstreatingPLWHhttp://hab.hrsa.gov/abouthab/partfeducation.html
• AETCNationalResourceCenterhttp://aidsetc.org/• TARGETCenter:TechnicalAssistanceresourcesforprogramstobetterservepeoplelivingwithHIVhttps://careacttarget.org/
FASTTrackingtheEndofAIDS
• MoreHIVTestingwithpromptlinkagetocareorpreventionservices• Immediateantiretroviraltherapy(ART) forallHIV-infectedpeoplefortheirhealthandtohelppreventon-goingtransmission
• Usingdatatohelpdeterminewhichpopulationsarefacingdisparitiesinhealthoutcomes
• Tailoringservicestoaddressthesocialandeconomicdeterminantsofhealth
• Pre-exposureprophylaxis(PrEP) andotherHIVpreventionservices forindividualsathighriskofHIVinfection.
ThankYou!
HaroldJ.Phillips,MRPDirectorOfficeofTrainingandCapacityDevelopmentHIV/AIDSBureau(HAB)HealthResourcesandServicesAdministration(HRSA)Email:Hphillips@hrsa.gov
Web:hab.hrsa.govTwitter:twitter.com/HRSAgovFacebook:facebook.com/HHS.HRSA
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