Know Your Status Project: HIV Case Management as a Model of Improvement of Quality of Care

Know Your Status Project: HIV Case Management as a Model of Improvement of Quality of Care Leslie Ann Smith and Jocelyn Andrews

This Session is sponsored by:

Presenters:

Jocelyn Andrews, Regional Director of Primary Health Care and Population Health

Leslie-Ann Smith, Nurse in Charge

First Nations and Inuit Health Branch - Saskatchewan (FNIHB-SK)

April 2013

Know Your Status Project: HIV Case Management

as Model of Improvement of Quality of Care

Introduction

• HIV/AIDS remains an issue of concern for Canada.

• In Canada, the number of new infections in 2011 was estimated

at 3,175 (PHAC).

• Saskatchewan has the highest incidence of HIV in Canada, with

the highest burden among First Nations/Métis people

(Figures 1 & 2).

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

SK 2.5 3.9 5.4 7.6 10.2 12.6 16.7 19.3 16.2 17.2

Canada 7.9 7.8 7.9 7.7 7.8 7.5 7.9 7.2 6.8 6.4

0

5

10

15

20

25

Cru

de

ra

te p

er

10

0,0

00

Year of diagnosis

Figure 1: Rate of HIV cases by year, Saskatchewan and Canada, 2002 to 2011 (sources: SK Ministry of Health, PHAC)

0

30

60

90

120

150

180

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Nu

mb

er

of

ca

se

s

Year of diagnosis

Figure 2: HIV Cases by self-reported ethnicity, Saskatchewan, 2002 to 2011 (source: SK Ministry of Health)

Aboriginal Non-Aboriginal/Unspecified

Background and Context First Nations and Inuit Health Quality Improvement Framework

• Articulate First Nations and Inuit Health Branch’s commitment to

improving continuously the quality of First Nations and Inuit

(FNI) health services

• Provide common vision, language and understanding of Quality

Improvement for First Nations and Inuit Health Services

• Prepare a foundation for quality improvement action planning

BUILD PEOPLE CAPABILITIES

BUILD SYSTEM CAPACITY

Background and Context

• High rates of Chlamydia and Gonorrhea

• Increase Hepatitis C

• Sporadic cases of HIV

• IDU population identified and growing

• Initial testing in for the Know Your Status (KYS) project began in

January 2011.

• Mobile Infectious Diseases clinic with physician services held

quarterly since July 2011.

This is a first of its kind client focused,

mobile, community-based, multi-disciplinary

HIV /STI project delivered in First Nations

community.

Objectives

Key objectives are:

1. Decrease the number of new cases of HIV and STIs in

community;

2. Decrease stigma and increase understanding of HIV and

STIs; and

3. Develop community and professional capacity to manage

HIV and STIs.

Method

Approach for case management: Client Focused Care

Culturally competent care is provided by a multi-disciplinary

team with ID specialist, pharmacist, mental health worker and

community health nurses in the health clinic or directly in

patients’ homes.

• Client focused culturally sensitive care is being provided one-to-

one care by community health nurses, including assisting in the

delivery of ARV and other supportive care.

Health Indicators

Maximum Time to Care:

• Maximum time to care, from testing to treatment, is three

months. The time varies depending on the blood work. In many

cases the time to care is less than three months.

Access to appropriate care:

• Clinics are provided by Infectious Diseases Doctor quarterly, on

regular basis.

Cultural Safety:

• Case management occurs within the community. The specific

needs of each client are respected (e.g. meeting times and

locations).

Approach

• Access to testing to clients and contacts by CHNs

working in rural First Nation settings

• If positive for Chlamydia and Gonorrhea, expand

testing to all those with risky behavior for:

• Hepatitis

• Syphilis

• HIV

• Pregnancy testing for high risk

Approach

• Referrals to PA Sexual Health - relationship building

for team (nurse to nurse), better understanding of

program.

• Referrals to family physicians/NPs limited.

• Numerous home visits to same client (challenging).

• We needed one nurse to run CDC program.

• Requisition in hand-MHO needed to be on board.

• Approach was not working.

• Most clients would not go to PA-Positive living

program.

• Transportation issue to lab-even with requisition in

hand.

• Poor access to care.

• We needed to develop a community based, but also

culturally responsive program that would meet the

needs of our high risk clients.

• We needed to start testing in the community-Veni-

puncture, POCT, urinalysis.

New Ideas

Action Plan

• We advocated for change to our community health program.

• Involved Nursing Office-RNO, ZNO and NIC and met with the

Chief.

• HPPH-MHO/CDC coordinator was briefed on what we would

like to do to improve service delivery.

• ARNO-was involved in the collaboration with SDCL.

• Lab licensing - Quality Assurance testing for Tests: POCT,

Pregnancy.

• Forms for project

Action Plan

• Community Meetings with Chief and Council and

Health Director.

• Community Information Sessions - Nursing and HIV

Coordinator.

Training

• Pre and post-test counseling

• Veni-puncture training

• SDCL tour

• PA positive living program - Marlene Allen

• PA South Hill Lab

Testing and Referrals

• Testing open to everyone

• High school testing

• Treat positive Chlamydia / Gonorrhea clients

• Refer all clients with Hep C and HIV to PA Positive

Living Program

• Dr. Lanoie for methadone program

Concerns with Testing and Referrals

• Clients would not go to PA for most referrals-stigma

• Many wanting treatment but unable to do follow-up

that was needed

• Poor access to physicians and NPs

• We have an obligation to ensure clients are followed

up

• No relationship

Solutions for Testing and Referral Concerns

• Clients already had relationship with nurses and

trusted them

• Needed to develop relationships with doctors and

other health care professionals

• Very sensitive issue

• ID doctor willing to come into community for client

assessment-VIP-relationship building

Client Case Management

• Appointments

• AV Treatment

• Methadone

• Medication delivery/follow up

• Frequent testing-case management

• Social networking ongoing

Program Concerns

• POCT testing-immediate result

• CD4 & CD8 & VL

• Strict guidelines for quality specimens

• Follow-up blood work and appointments (numerous)

• Workload

• Paper overload

• Confidentiality-protecting client, community concerns

Lessons Learned and Limitations

There are three crucial elements for success of a community-

centered multi-disciplinary care model:

1. Community readiness, ownership and mobilization to ensure the

development of culturally appropriate strategies to deal with HIV

related issues and harm reduction;

2. Continuous alignment of resources, internal and external to meet

the needs of HIV clients; and

3. Creation of effective, on-going partnerships.

Conclusion and Recommendations

• Applied Quality Improvement principles & outcomes: STEEP

(Safe; Timely; Equitable; Effective and Efficient; Patient-Centered)

• The first year evaluation of the project has been finalized in

2012 and recommendations approved and endorsed by the First

Nations community

• Use of available and existing resources and tools

• Continued partnership-building

• Continuum in care and social support to clients

• Evidence-based approach

References

• Public Health Agency of Canada (2012) Estimates of HIV prevalence

and incidence in Canada

• Saskatchewan Ministry of Health (2012): HIV/AIDS Annual Report

Saskatchewan

• Saskatchewan Ministry of Health (2010): The Saskatchewan HIV

Strategy 2010-14

• Health Canada/FNIHB Project Evaluation (2012): Know Your Status. A

Comprehensive Review of HIV testing, Case Management and

Treatment in a Saskatchewan First Nation.

• Reif F, Golon SE, Smith SR (2005): Barriers to accessing HIV/AIDS

care in North Carolina: Rural and urban differences. AIDS Care, 17(5),

558-565.

Acknowledgements

To…

• Chief Morin and all key stakeholders from Big River First Nations for

their engagement in this project

• Community Health Nurses and clients involved in this project

• The Ministry of Health and Regional Health Authorities involved

• All the multidisciplinary team for their dedicated contribution and

participation in this project

…THANK YOU!

Questions?

[email protected]

[email protected]