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We also have much yet to accomplish in the area of new infections.
While new diagnoses continue to decline overall in BC, diagnoses among Gay Men – particularly young gay men – continue to remain at sustained high levels.
Additionally, First Nations and Aboriginal people are diagnosed with HIV at levels that are disproportionately high.
Goals were developed by the Provincial Leadership Cte
Focus on Vancouver but available to all of VCH
Goal 1 – Given that the strategies will include efforts to engage & screen broadly for HIV, we are likely to see an initial increase in the number of new HIV cases reported. The Goals to be tested is whether incidence will actually decrease over time as a result of earlier diagnosis & engagement in effective care & treatment.
Epidemiology – Know your epidemic
Mapped current state using the client journey across the continuum of care
Community Engagement Process – focus groups and interviews at 6 month intervals
Commissioned 3 population-specific papers: MSM, Aboriginal people, women
Initial focus was expanding capacity of current activities – more tests, more clinic capacity, more supports
When VCH/PHC received the initial funding for the pilot, those of us who had been working in HIV and public health for years were very happy. We were being presented with the opportunity of a lifetime. In the midst of a recession, “new money” was being allocated to improve outcomes for one of the most stigmatized and challenging health issues of our time.
We eagerly began our planning processes, calling around the table all the people we knew who were working in HIV. We started identifying potential strategies that led us down the same roads we were already committed to, but now could run down more quickly. We started with strategies that involved doing more of what we were already doing and doing it faster. Increasing hours of testing clinics for gay men, outreach testing in the DTES, expand capacity of Vancouver Native Health and the Maximally Assisted Therapy program… We got busy and we waited with anticipation for the data to tell us of our impact. We were playing around the margins of a old approach, and found that we were having a marginal impact. Our testing, diagnosis, and treatment numbers increased slightly, but no where to the extent that would be needed to significantly impact the epidemic.
Our leadership team was at a loss – we were committed to the work but we became aware that none of the strategies that we were investing in, while important, would be adequate to meet the mandate of this project – a transformative mandate – to change the course of the HIV epidemic. There were a few “dark nights of the soul” and strategy sessions during which we realized that to be successful, we would need to let go of much of what we thought was standard gospel in HIV work. It became clear that this project wasn’t about doing more of the same, but rather about significant, system wide transformation.
While there were many tools and strategies that we have embraced in the pursuit of system transformation, the most critical has been the establishment of a comprehensive monitoring and evaluation framework.
As previously mentioned, surveillance is the diagnostic tool and clinical information for the population.
When we began, we had little more than a press release to inform our goals and accountabilities. There was a compelling idea with academic support, but no one really knew what was meant by doing “treatment as prevention”.
By using the available data we were able to analyze the current performance of our testing efforts and our treatment efforts. And we were able to both identify some very important gaps (which I will speak to in a moment) and set some clear achievable goals and targets. By developing a monitoring and evaluation framework, we were able to take a compelling idea and turn it into specific targets that informed specific strategies – it became a road map.
By taking our population-level indicators and targets, we were able to develop program-level goals, indicators and targets that were in alignment with our overall goals – rather than working with our programs and just getting busy, we were able to develop a clear and common understanding of what each of our 40 pilots were going to try and accomplish. This process helped fundamentally change our relationship with programs and contracted agencies – accountability and expectations were clear and scope was managed.
We were able to develop performance agreements (contracts or MoU) that were clearer and better understood than any we had been using previously. It also supported us in treating our direct HA programs the same as how we treat contracted agencies. From this a common culture among all the participants, across all the pilots was able to begin emerging – we knew what we were collectively accountable for and what role each of us were to play in achieving this.
Here is an example of how we used available data to analyze our system performance. This analysis was key for us in that it showed despite being very busy with the volume of tests being performed, we were doing a terrible job of diagnosing people early enough in their infection.
In fact, you can see that more than 60% of individuals were diagnosed with a CD4 count of less that 500 – past the point at which, under current treatment guidelines, they should be prescribed ART. This is a key reason our individual outcomes are not optimal and is most certainly contributing to onward transmission in the population.
When we looked at these data it became crystal clear to us that we would not be able to achieve what we needed to by simply doing more of the same. By continuing to offer HIV tests to only those who identified themselves to a healthcare provider as having had risky sex or used drugs unsafely, had the self efficacy and awareness to go forward and request an HIV test, had a good relationship with a GP, or found one of the specialized HIV testing sites or programs, and got tested – this exclusively targeted approach with limited reach, we now knew would lead us to nothing other than more of the same.
But what do these data mean for people on the ground? Of the 37 people diagnosed in acute care over the last 18 months, 4 were diagnosed too late for treatment to be of any benefit, and they died upon that admission. These are not abstract performance targets, but represent current deaths that could have been relatively easily prevented with improved efforts to test, diagnose and provide care.
Here is a second example of how data led to a transformation of our approach and the way in which we needed the system to function. This is an analysis that we call “Missed Opportunities”. When looking at available data on recent HIV diagnoses, we found that:
Of all new diagnoses, 1/3 of patients diagnosed with HIV in the past 3 years had at least one Outpatient, Lab, ER or Inpatient encounter. But, specifically, of those diagnosed late, 60% had at least one opportunity to be diagnosed earlier.
Mean # of encounters was 4.63 with 51% having had lab work
(Visits to family physicians where no laboratory tests were ordered are not captured)
So, not only were we diagnosing people significantly late in the course of their infection, those who were diagnosed had on average between 4 and 5 opportunities to be diagnosed earlier – this would likely have benefitted those individuals AND have prevented some onward transmission.
This is not to say that targeted efforts to diagnose people early are not working at all – for those who know how to, or are able to, access them, low barrier testing is working gang-busters. We need to sustain and continue to improve these efforts. But for those who don’t or can’t access these programs, our historical approach to testing produces an undeniable gap.
Clearly the system as it had been functioning could not bring the care to people when and how they needed it in order to give them the best chance for health and to prevent transmission. The way the system had been functioning was contributing to unnecessary illness, death and transmission.
There are many stories behind the data in this slide – one of them is that of a relatively young man who had experienced over 80 pounds of weight loss. For a year he had been engaged in care and a whole host of diagnostics were run, but an HIV test was not one of them. Eventually, many months later, he was tested and diagnosed with HIV. Unfortunately, this happened to late to prevent his death. Had the test been offered and had he been diagnosed months earlier, this man could have been returned to his wife and children.
We worked with our Public Health Surveillance Unit to develop a comprehensive population-level monitoring framework consisting of 18 indicators that we monitored on an ongoing basis, some of which are listed here. This let us maintain a sophisticated, ongoing picture of what was going on with the epidemic and how the system was performing in across our region.
We also needed to understand the impact of all the various interventions we were implementing – as best we could. We identified indicators and targets for each of the approx. 40 initiatives that were directly tied to the over all goals of STOP HIV – this included monitoring viral load, or HIV testing yield, etc. These were reported monthly and every intervention was assessed at 6 month intervals. Those that were performing well were supported and continued and those that were not contributing to the project goals were discontinued. There were no failures – just ongoing learning, and rapid adjustments to the system.
After the 3 years of the pilot were over, the Ministry of Health determined that the pilot had adequately demonstrated that scaled up testing and treatment could indeed significantly impact the course of the epidemic. A provincial policy paper “From Hope to Health: Towards an AIDS-free Generation” was released and the funding for the pilot was spread province-wide. For us in the Vancouver Coastal Health region, this meant taking the lessons from the pilot and solidifying the most impactful interventions into a redesigned system of care.
Expanded Chronic Care Model was an overarching framework for all of our Service Delivery Models. Given the chronic nature of HIV it was important that we looked to models that have been successful with other chronic diseases but has the flexibility to address the unique needs related to HIV.
The recent release of Hope to Health has provided us with defined goals and indicators. We have also drawn on the Cascade of Prevention and Care in the development of our Integrated System of Care. You can see in this schematic that we have highlighted how each of the SDMs addresses the cascade of care.
The 3 SDM schematics are shown on this document
The inputs and outputs represent the ongoing system of care that support ongoing modifications based on the inputs and outputs.
On this schematic we have not included the points of integration abut will come back to the integration and coordination later in the day
4) At the bottom of the schematic the key infrastructure components that support the overall system of care and each of the Service Delivery Models are listed.
We have heard directly about the importance of a “culturally” competency in every part of our System of Care
Monitoring and Evaluation is fundamental in demonstrating the effectiveness of the system of care and provides the data to assist in ongoing modifications
Information Systems-tools are required to support our system of care. There is a need to continue to break down communication silos and share client information with those directly involved in the provision of care.
Any system requires the development of policies and guidelines
Social determinants of health- in each and every engagement we have had heard the importance of social determinants in HIV care. Although not directly within our control we wanted to acknowledge the importance and advocate where appropriate.
Education- HIV care has changed dramatically over the past 20 years. It is important to continue to educate providers, clients etc
Community engagement- significant input from our community partners on the needs for future state. Need to maintain a high level of engagement with our partners. We can’t assume that we know all of the answers around what is required. Need to listen and respond to what our partners are telling us.
Regional Governance is being developed to support the HIV Program.
After looking at the epidemiology and literature review we chose the Combined Prevention Framework (structural, behavioral, biomedical) as the regional HIV prevention framework
Identified potential interventions under each component of the framework
Identified Broader Prevention Strategies that impact on vulnerabilities for HIV and where there is a need for strong linkages and advocacy
Reviewed gaps and epidemiology and identified 4 priorities for 2013/15:
Integration & Coordination
Intensive HIV Prevention Case Management
Health Promotion & Skills Building
Harm Reduction Coverage
Testing Service Delivery Model:
A gradient of approaches including routine testing and risk-based testing, looking at settings and populations.
Care and Treatment Service Delivery
A system that has a care escalator that moves in both directions – ideally matching people to the appropriate level of care.
Relies on common assessments and care definitions among multiple providers
Relies on sharing of clinical information across a number of providers
At the top of the triangle, we are implementing clinical pods – multi-disciplinary mobile teams that are attached to the major practices, but can provide outreach care for those unable to attend a physical site and to coordinate care across multiple sites. (RN, MD, SW, peer, OW).
The Stanford Social Innovation Review published an article in its Winter 2011 edition on the Five Conditions of Collective Impact. These conditions articulate what we have attempted to achieve in a results-focused redesign of the system of HIV care.
Common Agenda – clear goals that are shared among all participants . From Hope to Health is our blueprint and our common agenda
Shared Measurement – a robust monitoring and evaluation framework supported us in focusing a large number of diverse participants on a common goal and held us all accountable.
Mutually Reinforcing Activities – while all the pilots and initiatives were different, they supported and reinforced one another by taking on various parts of the continuum of services. We used the client journey as a framework that helped us roll all the activities up and to demonstrate how each activity played an important role in meeting the project goals.
Continuous Communication – While we didn’t always do as well as we could with this, transparent and timely communication across all partners has been absolutely key to motivating efforts, maintaining trust, and ensure that everyone felt connected to a common agenda.
Backbone support – We built an expert project team and resourced their roles appropriately. Without skilled project managers, business analysts, clinical analysts, evaluators and epidemiologists, we would have been lost.
The shift from a focus on clients of programs to the entire population is a simple notion but has supported a radical shift in planning and practice.
This shift has forced us out of the accountability paradigm that we had been most familiar with. Accountability could not end at the walls of a clinic or at the historical capacity of a program or at the boundaries of traditional service delivery methods. We had to acknowledging that everyone is our client.
Some implications of this include:
The critical nature of a population-level monitoring and surveillance framework – when your client is the entire population, surveillance data become your clinical information
We were forced to look beyond the traditional service delivery models and programs that only succeeded in reaching smaller segments of the population and look to wider service access models – for example: previously, HIV testing was something that specially trained people delivered to special populations in special programs. Now we are moving towards a response that leverages the entire system of care to offer an HIV test at every single access point to that system – acute care, primary care, family practice, mental health teams, addictions treatment, jail and abortion clinics – all become access points.
We were also forced to look beyond the walls of our programs and organizations. Previously, VCH community health services could ignore issues in acute care as they were other people’s problems. Capacity issues could be other people’s issue when a program was full. Most fundamentally, VCH and PHC acknowledged as organizations, we provided portions of the continuum of care to a common population and that to effectively serve a population we needed to fully integrate our planning, operations and budgets. Furthermore, we are beginning to implement initiatives across programs and have engaged over 100 physicians in family practice.