FEATURE ARTICLE
Patient-Centered HIV Care in Delaware

Poor health outcomes occur when patients don't show up for medical appointments or find it hard to follow medication schedules. Poor adherence invariably leads to treatment failure, viral resistance, and related infections. Adherence can be particularly hard for patients who are dealing with additional problems such as mental illness, substance abuse, and low income. Studies indicate that HIV treatment programs can experience a 15 percent lost-to-follow up rate each year. For some programs, the rate is as high as 30 percent.

The HIV Program at the Christiana Care Health System in Delaware made changes in how they organize and deliver HIV/AIDS care in order to address these problems. Their data show it made a difference:

• Adherence rates went up (for kept appointments and taking medications on schedule).
• Viral loads and deaths went down.

These findings are summarized in their 2010 Ryan White Grantee Meeting poster session: winner of the Innovation in Research Award. This is how they did it.

Program Innovation

The Christiana Care Health System's HIV Program participated in an Institute for Healthcare Improvement Collaborative to improve clinical outcomes for patients infected with HIV utilizing the Chronic Care Model as a foundation for quality improvement strategies. Their multi-disciplinary and patient-centered approach to care delivery is designed to enhance the care connection between patients and providers. The approach involves these key ingredients:

• Patient self-management program. Christiana Care offers a "positive self-management program," based on Stanford University's Chronic Disease Self-Management Program, which teaches patients strategies for managing their chronic conditions. The premise is that patients who understand their illness, its implications, and appropriate symptom management can talk more effectively with their clinicians. As a result, they can achieve better clinical outcomes. Sessions focus on goal-setting/achievement and the development of action plans. These plans cover topics such as life skills, disclosure of HIV status, stress management, the need for exercise, healthy eating habits, and managing medication side effects.
• Medication adherence program. A clinical pharmacist leads medication adherence sessions with patients before the initiation of treatment and as needed thereafter. These one-on-one appointments allow pharmacists to evaluate a patient's readiness to adhere to his or her regimen. For example, the pharmacist finds out if the patient has a refrigerator and how the patient plans to incorporate the medication regimen into his or her daily life. Patients who have difficulty with medication adherence continue to be seen indefinitely for a weekly "pillbox fill."
• Onsite services and specialty clinics. Onsite phlebotomy services are provided to patients. Specialists also hold clinics at the HIV program site to provide one-stop, convenient care. Clinics are offered for renal care, general internal medicine, mental health care, hepatitis C treatment, and women's health.
• "Fast-track" visits. Fast-track visits are available for stable patients, thereby reducing waiting times. Patients arriving at the clinic receive their usual intake assessment by a nurse. Those found to be stable and taking their medications are triaged to a nurse practitioner, who provides basic care and assessment.
• Telephone reminders and follow up. Front-office staff place reminder calls to all patients several days before scheduled appointments. If a patient misses an appointment, staff members call the patient the next day to reschedule. If the patient cannot be reached by telephone after numerous attempts, the office will mail an appointment reminder. Clinicians tag the files of high-risk patients, spurring more aggressive telephone/mail follow up with these individuals.
• Peer educators. Three full-time peer educators serve the seven sites. Peer educators are patients who are managing their disease successfully and who have an interest in counseling others. Peer educators provide basic education and support during informal meetings with other patients (often held in the waiting room), offering information about HIV, medications, side effects, and lifestyle issues.
• Patient advisory groups. Three patient advisory groups (one located in each Delaware county) offer patients the opportunity to have direct input into HIV program development and evaluation. Meetings are co-facilitated by a patient and an HIV program staff member. Members of each group set their own meeting schedules, agendas, and rules of conduct.

Program Results

Pre- and post-implementation comparisons show that Christiana's program has increased adherence with visit schedules and medication regimens, improved clinical outcomes, and reduced HIV-related mortality.

• Increased adherence. The percentage of patients that are adherent to their visit schedules increased from 54 percent in 1999 to 88 percent in 2010. The percentage of patients on highly active antiretroviral therapy increased from 62 percent in 2000 to 86 percent in 2010. In 2010, the program's lost-to-follow up rate was 3 percent.
• Improved clinical indicators. The percentage of patients with an undetectable viral load increased from 61 percent in November 2000 to 76 percent in 2010. The percentage of patients with a CD4 count greater than 200 cells/mm3 has remained stable over time, at 71 percent.
• Fewer HIV-related deaths. The HIV-related mortality rate among Christiana HIV program patients decreased from approximately 6.5 percent in 2000 to 1.4 percent in 2010.

Lessons Learned

• Assisting patients in self-management skills improves adherence and empowers patients
• Improved patient adherence (with visits and treatments) results in positive clinical outcomes
• Providing multiple services under one roof results in patient satisfaction and improved compliance
• Integrated consumer participation (Peer Education and Patient Advisory Committees) creates a teamwork atmosphere between patients and providers
• A multi-disciplinary (MD, RN, PharmD, Social Worker, Peers), patient-centered approach to care improves patient satisfaction, clinical outcomes, productivity, and efficiency

Learn More

• Agency for Healthcare Research and Quality Summary Report on Christiana Care's HIV Program.
• Institute for Healthcare Improvement. Maintaining the "Care Connection" in a Statewide HIV Program Christiana Care Health Services HIV Program.
• Self-Management and the Chronic Care Model. HRSA CAREAction, March 2006.
• Information about the Chronic Care Model.
• Stanford University's Chronic Disease Self-Management Program.

For more information about Christiana's program, contact Robin Bidwell, CQI Coordinator, Christiana Care
Health System HIV Program, Wilmington Annex, 1400 Washington Street, Wilmington, Delaware 19801
Phone: (302) 255-1307.