Supporting the National HIV/AIDS Strategy (NHAS) through Performance Improvement (PI) CME: Empowering Providers with Limited Resources Cassaniti, J., Hujdich, B., Salazar, J.
HealthHIV, Washington, D.C., USA Introduction: Critical Gaps in Access to Care and Treatment Highlight Need to Prepare Primary Care Providers to Support the United States NHAS Major gaps exist in the HIV care cascade (Figure 1), including the need for expanded HIV testing and improved care/treatment. Improving the capacity of primary care providers (PCPs) to deliver HIV testing or care can fill these gaps, expand HIV testing, and improve care. HealthHIV research demonstrates that many PCPs are already treating patients living with HIV2 and are prepared for an increased number of patients. HealthHIV’s HIV Primary Care Plus program focuses on increasing the quality of HIV care in primary care settings through performance improvement and supports the National HIV/AIDS Strategy4 goals of: 1. Reducing HIV incidence 2. Increasing access to care and optimizing health outcomes
Materials and Methods: First of Its Kind PI CME for HIV in Primary Care The goal of HealthHIV’s HIV Primary Care Plus program is to build the capacity of primary care providers (PCP) to identify and treat HIV positive persons by providing guidance and support to those providers using Performance Improvement. Performance Improvement Continuing Medical Education (PI CME) PI CME is an American Medical Association certified CME activity that uses a three-stage process. It begins with an assessment of each provider’s current practice using identified evidence-based performance measures and comparing performance to national benchmarks and the performance of peers. The second stage involves the development and implementation of interventions based on the assessment. Stage three involves reevaluating performance, including reflection and summary of outcome changes resulting from the PI CME activity. At the completion of the activity, 20 AMA PRA Category 1 Credits™ are awarded to each participant. PI CME Stages Stage A: Learning from current practice performance assessment Stage B: Learning from the application of PI to patient care Stage C: Learning from the evaluation of the PI CME effort HIV Primary Care Plus is an 8-12 month process using the AMA PI CME format. The target audience is primary care providers (MDs, DOs, NPs, or PAs) who provide HIV care in medically underserved communities and meet the eligibility requirements. Based on organizational assessment and pre-intervention questionnaires, target area and indicators are selected and validated though chart reviews. Coached by an HIV expert, improvement plans are developed, and reassessed after implementation to evaluate effectiveness of plan and interventions.
Figure 1. Major gaps in the care cascade exist, including the need for improved HIV testing and care/treatment.
Results: Primary Care Providers Achieve Performance Improvement in Women’s Health and HIV, HIV Medical Management, and HIV Testing Supporting Goals 1 and 2 of the United States NHAS Thirteen health centers (selected from 50 health centers) with 25 prescribing providers that provide care to over 2,400 people living with HIV enrolled in the program. Providers and their PI coach selected 12 performance measures, completed baselines, and established goals based on national standards, staff commitment and time. Fifteen different interventions were selected to support established goals. Providers identified educational activities to improve services from three target areas: 1. HIV testing options for patients in all healthcare settings 2. Medical management of HIV for treatment-naïve and treatment-experienced patients 3. Counseling and care options for women with HIV who are of childbearing age
Participants by Provider Type
NP, 24%
MD, 66%
PA, 10%
Figure 3. Most participants in HealthHIV’s HIV Primary Care Plus program were Medical Doctors, followed by Nurse Practitioners and Physician’s Assistants.
Figure 5. Improvements were documented in medical management of HIV with some measures such as HBV testing and GC/CT testing improving significantly more than others. Target Area
Performance Measure HBV immunization Medical management of (n=2) HIV treatment‐naive and HCV screening treatment‐experienced ever patients (n=3) Syphilis (RPR) in last year (n=3) TB (PPD) in last year (n=3) GC/CT test in last year (n=2) HIV Positive patients who receive flu and pneumococcal vaccine (n=1) % of HIV positive clinic patient who have one or more medical visit with a PCP quarterly (n=1)
Standard none
Average Average Average Average Baseline Goal Progress Change 11%
80%
53%
42%
90.9% HRSA/HAB mean (2006)
92%
98%
93%
1%
70% HRSA/HAB mean (2006)
59%
90%
80%
21%
56% HRSA/HAB mean (2006)
51%
85%
61%
10%
62.3 HIV Qual mean (2007)
28%
100%
75%
47%
77%
_
90%
13%
78%
90%
80%
2%
77% HIV Qual mean (2007)
82.8% HIV Qual mean (2007)
Figure 4. Performance Improvements were achieved in the women’s health and were consistently greater than changes in HIV Medical Management and HIV testing.. Target Area
Counseling and care options for women with HIV who are of childbearing age
Performance Measure Women with HIV who had a pap test in the measurement year (n=4)
Standard 70.8% HRSA/ HAB mean (2006)
Women age 15-44 None receiving contraceptive option counseling during the year (%) (n=4) Percentage of nonNone pregnant women tested for HIV ages 14-64 (n=1)
Average Average Average Baseline Goal Progress
Average Change
Figure 6. Performance also improved in HIV testing. Target Area
50%
94%
66%
16% HIV Testing
17%
40%
97%
70%
44%
90%
27%
Performance Measure The number and percent of HIV tests offered (n=2) The number and percent of HIV tests done (n=2)
Standard Average Average Average Average Baseline Goal Progress Change None 60% 75% 80% 20% None 10%
75%
41%
31%
50%
Conclusions: HIV Primary Care Plus Improves Provider Performance in Women's Health and HIV, HIV Medical Management, and HIV Testing
Implications: PI CME Should be Considered as an Effective Method to Advance the United States NHAS
HealthHIV’s HIV Primary Care Plus program was successful in improving the performance of participating providers. Improvement plans and interventions developed by the participating providers improved HIV care delivery. Demonstrated improvements in HIV testing support Goal 1 of the NHAS to reduce new HIV infections. Measured improvements in the medical management of patients with HIV advances Goal 2 of “Increasing Access to Care and Improving Health Outcomes for People Living with HIV”.
PI CME programs can be utilized as an effective mechanism to advance goals of the NHAS. PI CME can help new and existing HIV providers develop and sustain change using a structured, long-term process targeting performance gaps. These gaps are addressed utilizing interventions to specifically reach evidenced-based standards that are tied to national quality measures. Improvement toward these standards is demonstrated using accepted, quantifiable, performance indicators. Support for expanding PI CME projects to is needed to examine broader impact on HIV access and on the NHAS.
Literature cited 1. 2. 3. 4.
HealthHIV Research. Results of the Second Annual State of HIV in Primary Care survey. HealthHIV website. 2012. Available at http://www.healthhiv.org/modules/info/2nd_annual_state_of_hiv_primary_care_survey.html Agency for Healthcare Policy and Research. Primary Care Workforce Facts and Stats No. 1: The Number of Practicing Primary Care Physicians in the United States. AHRQ Publication No. 12-P001-2-EF, October 2011. Available at http://www.ahrq.gov/research/pcwork1.htm HealthHIV Research. The State of HIV in Primary Care: A Fractured Landscape, HealthHIV website, 2012. Presented at the 2012 International AIDS Conference in Washington DC Office of National AIDS Policy. National HIV/AIDS Strategy. Available at http://www.whitehouse.gov/administration/eop/onap/nhas