THE GREATER CLEVELAND HIV CARE CONTINUUM · oMedical co-morbidities oUtilization (hospital, ED) Outcome vs Process. Process-was the appropriate diagnostic or monitoring test ... Diabetes

THE GREATER CLEVELAND HIV CARE

CONTINUUM

FINDINGS FROM THE GREATER CLEVELAND HIV HEALTH

INFORMATION PROJECT (CHHIP)

Ann Avery, MDMetroHealth Medical Center

Objectives

1. Describe the local HIV care continuum

2. Understand trends and factors affecting HIV retention in care and viral suppression

Disclosures

Gilead- Participated in the Steering Committee for PrEP

HIV Continuum of Care

Test and Treat- and problems with the concept

MMWR Dec 2,2011. Vol. 60 , No. 47

35%

National HIV/AIDS Strategy ( NHAS)

Reducing New HIV infections (by 25%)

Increasing Access to Care and Improving Health Outcomes for People Living with HIV

Reducing HIV-Related Health Disparities

Challenges to a local Health Care Continuum (HCC)

• Ohio Department of Health (ODH) does not provide data to care information ( though planned)

• Local Health Dept ( CDPH) data is different than ODH

• Ryan White data does not cover entire population

• Patients that move in or out of area and not necessarily accounted for by health department

• A single system would limit generalizability

• No one single source for desired information

CHHIPGREATER CLEVELAND HIV HEALTH

INFORMATION PROJECT

LEVERAGING EMRS TO IMPROVE HEALTH OF PATIENTS LIVING WITH HIV/AIDS (PLWHA)

The GoalDevelop & pilot community-wide clinical information systemoBuild data system that integrates quality metrics (i.e., CD4 count, viral load, treatment adherence) with patient characteristics & needs (i.e., demographics, risk factors, co-morbidities, food stamp use)

Optimize individual and population healthoCoordination of intervention activities for all practicesdelivering care to PLWHA

Electronic Medical Records (EMR)

Epic is used in most partner organizations, all have some type of EMRoLabs

oAmbulatory visits

oMedical co-morbidities

oUtilization (hospital, ED)

Outcome vs Process

Process

-was the appropriate diagnostic or monitoring test completed or captured?

Outcome

-what was the result?

Better Health Greater ClevelandIndependent, grant-funded 501(c)(3)oEstablished in 2007oRobert Wood Johnson Foundation’s Aligning Forces for Quality initiativeoLeverages data to identify opportunities & best practices in improving care & outcomes within a peer network of primary care professionalsDiabetesHypertensionHeart failure

Why Cleveland Rocks!

•Comprehensive connection of HIV care providersoCurrent CHHIP partners oUH, CCF, Care Alliance, Free Medical

oAgreed upon HIV care standards & metricsoMaximize delivery impact on both individual & community•Dedicated manpower for population management•Consistent identifier to track movement

CDPH participation for all reported cases

Bi-directional sharing to determine:

1. people who are HIV+ but not reported to the health department

2. people who have died or moved out of the area

3. people who are HIV+ (tested by health department) but not linked to care

Who is missing from data?

Veteran’s Administration Medical Center ( VAMC)

AIDS Health Care Foundation

St Vincent Charity

Some community CCF sites ( new in 2016)

Free Medical Clinic (missing only for 2015-16)

Small non- affiliated providers

Ryan White HIV Care Continuum

Cuyahoga County Board of Health Ryan White Part A program- CareWare data

0

500

1000

1500

2000

2500

3000

3500

4000

Total unique #reported in the

time period(year)

# linked (1 visitin year)

# engaged (visitin 1st and 2nd

half)

# engaged (CD4or VL in 1st and

2nd half

prescribed HIVmeds in any

quarter

# undetectable

2777

2532

17931695

2226

1545

3729

3192

21481982

2288

2552

Cuyahoga County HIV HCC 2016

Y2012 Y2013 Y2014 Y2015 Y2016

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

# linked (1 visit inyear)

# engaged (visit in1st and 2nd half)

# engaged (CD4 orVL in 1st and 2nd

half

prescribed HIV medsin any quarter

undetectable (<200)

Cuyahoga County HIV Care Continuum 2012-2016

Y2012 Y2013 Y2014 Y2015 Y2016

Source: Ohio Department of Health Persons Living with a Diagnosis of HIV Infection Reported in Ohiohttps://www.odh.ohio.gov/-/media/ODH/ASSETS/Files/health-statistics---disease---hiv-aids/2016/Ohio2016.pdf?la=en

39544179

4381 45124662

27772994

31893338

3729

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

Y2012 Y2013 Y2014 Y2015 Y2016

Reported HIV Prevalence in Cuyahoga County by ODH vs CHHIP data

Reported number living with HIV Reported in CHHIP data

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

Y2012 Y2013 Y2014 Y2015 Y2016

39.1%42.4%

50.2%50.5%

54.7%

Cuyahoga County undetectable (<200)

Uses CHHIP data 2016 and reported prevalence from ODH for denominator

Data from MHS, UH, Care Alliance and Cleveland Clinic

0

500

1000

1500

2000

2500

3000

3500

4000

Total unique #reported in the

time period(year)

# linked (1visit in year)

# engaged(visit in 1st

and 2nd half)

# engaged(CD4 or VL in1st and 2nd

half

prescribedHIV meds inany quarter

#undetectable

(< 200)

CHHIP Cuyahoga County 2016

80%%

Males n=2914, Females n=815

85.4 86.3

56.860.6

52.555.6

79.9 80.2

Cuyahoga County HCC by gender

Data from CHHIP 2016

12271098

775710

946

2288

1912

12461163

1455

0

500

1000

1500

2000

2500

Total unique # reported inthe time period (year)

# linked (1 visit in year) # engaged (visit in 1stand 2nd half)

# engaged (CD4 or VL in1st and 2nd half

# undetectable

2016 Cuyahoga County HCC AA vs White

White or Caucasian African American or Black

76%

86%

Data from CHHIP 2016

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Total unique #reported in the time

period (year)

# linked (1 visit inyear)

# engaged (visit in1st and 2nd half)

# engaged (CD4 orVL in 1st and 2nd

half

# undetectable

HCC 2016 Ethnicity

Non-Hispanic (n=3412) Hispanic (n=298)

Data from CHHIP 2016

2016 HCC by age group

85.7

77.5 79

.581

.0 85.5 89

.0 91.7

57.1

38.0 43

.451

.4 56.4

63.4

72.1

57.1

35.7 39

.946

.8 52.3

59.3

65.3

75.0

60.0

67.2

75.0 79

.886

.287

.1

Data from CHHIP 2016

Data from CHHIP 2016

84.1

89.6

97.8

53.9

68.0

87.5

51.2

57.9

72.8

80.1 78.782.7

Depression/Psych Status 2

Total unique # reported in the

time period (year)

# linked

(1 visit

in year)

# engaged

(visit in 1st and

2nd half)

# engaged (CD4 or

VL in 1st and 2nd

half

prescribed HIV meds

in any quarter

medical visit

within period

# undetectable

None 2928 2463 1577 1498 1558 2463 1973Yes, < 2 Psych Visits 665 596 452 385 599 596 469

Yes, >= 2 Psych Visits 136 133 119 99 131 133 110

Primary Insurance Class

Total unique # reported in the

time period (year)

# linked

(1 visit

in year)

# engaged

(visit in 1st and

2nd half)

# engaged (CD4 or

VL in 1st and 2nd

half

prescribed HIV meds

in any quarter

medical visit

within period

# undetectable

Missing or Unavailable 46 46 21 9 37 46 24Commercial or Private 1035 926 604 571 608 926 789

Medicaid 1576 1338 880 795 992 1338 997Medicare 794 715 548 517 513 715 618

Uninsured or Self-Pay 207 106 55 56 74 106 69Other Class 71 61 40 34 64 61 55

Data from CHHIP 2016

89.584.9

90.1

51.2

85.9

58.455.8

69.0

26.6

56.3 55.250.4

65.1

27.1

47.9

85.2

74.5

86.4

65.1

90.2

Cuyahoga County HCC by Insurance Status

Neighborhood Income

Total unique # reported in the time

period (year)

# linked (1 visit

in year)

# engaged

(visit in 1st and

2nd half)

# engaged (CD4 or

VL in 1st and 2nd

half

prescribed HIV meds

in any quarter

medical visit

within period

# undetectable

($0K ,$20K] 215 183 108 95 188 183 129($20K , $30K] 850 701 447 373 707 701 523($30K , $40K] 753 607 391 340 618 607 483($40K , $50K] 734 641 441 367 613 641 497($50K, ] 585 515 329 286 499 515 427

Data from CHHIP 2016

85.5 85.1 83.988.4

86.0

51.956.5 55.0

62.159.0

47.751.3 50.7

56.0 57.1

70.9

77.880.1 81.0

85.8

Cuyahoga County 2016 HCC by Neighborhood Income

97.3 97.2 98.2 98.3

69.9

80.877.4 79.1

76.5

84.9

78.7 78.9

59.5

81.884.3

92.0

Cuyahoga County 2016 HCC by Immune Status

Data from CHHIP 2016

Highest rate of reported cases 65%

viral suppression

2nd highest rate of

reported cases 70%

viral suppression

Conclusion

Viral suppression is excellent among patients who engage in the care system- even if just once in a year

Efforts should be coordinated and target to address disparities

Priority groups are youth, poverty and those with advanced disease

Acknowledgements

CHHIP PartnersAlan Taege & Sarah Schram(CC)Barbara Gripshover & Michelle Kucia (UH)Lisa Navracruz & Rachel Deighton (CA) Adriana Whelan & Fatima Warren (Circle)Sister Susan (St Aug)

IS staff at MHS, CC and OCHIN

Data Management and StatsSteve LewisAshley TillisonMichelle Del Toro

FundingMelissa FedermanThe Board of AIDS Funding Collaborative

Discussion and Questions

aavery@metrohealth.org