The CrescentCare Start Initiative is a program of CrescentCare, a Federally Qualified Health Center, and the New Orleans Office of Health Policy. The initiative connects people with newly diagnosed HIV to antiretroviral therapy (ART) through intensive patient navigation and a streamlined intake process. Time between HIV diagnosis and linkage to HIV medical care has decreased from 30 days to only 1.3 days.
New Orleans has a high rate of HIV incidence, the third highest in the nation. Viral suppression is an essential tool for lowering HIV incidence because people with an undetectable viral load have effectively no risk of sexually transmitting the virus to an HIV-negative partner.1 Rapid ART, or linkage to treatment immediately after a new HIV diagnosis, has been shown to expedite viral suppression and improve retention in care.
“The last thing we should do is delay by one minute their initiation of ART if we are committed to our patients and to the community."
HIV testing sites (including CrescentCare’s Sexual Health Center and Counseling & Testing Program, Healthcare for the Homeless, and other community partners) contact the CrescentCare patient navigator via phone call or text immediately after an HIV diagnosis. The patient navigator is then responsible for scheduling an appointment with a CrescentCare prescribing clinician, a lab visit, and a session with a RWHAP/health care coverage eligibility specialist within 72 hours. The patient navigator also plays a crucial role in putting the client at ease by accompanying them to the various aspects of the first visit and talking through the components of HIV treatment and the role of ART in promoting health and reducing HIV transmission.
CrescentCare Start Initiative aims to schedule a visit with a medical care provider within 72 hours of HIV diagnosis. The initial visit with the clinician lasts 30 minutes and focuses on treatment of HIV and other immediate client concerns. The clinician reviews the safety and effectiveness of ART and provides ART during the visit, prior to receiving the results of the full lab workup. The first dose is directly observed. A longer new patient visit is scheduled three weeks from the initial visit. If no clinician slots are available within 72 hours, the patient navigator can “double book” after consultation with the clinician.
Clients with Medicaid health care coverage have their ART prescriptions immediately filled at CrescentCare’s onsite pharmacy. The clinician provides a 30-day supply at the clinic to clients who need to enroll in the state AIDS Drug Assistance Program (ADAP) or obtain approval for health care coverage of ongoing care. The 30-day supply starter packs are available through RWHAP Part A funding.
Clients meet with an eligibility specialist the same day as the medical appointment to start the enrollment process into Medicaid, RWHAP Part A and/or ADAP, if necessary. If clients have other pressing needs, such as for housing or substance use services, the patient navigator conducts a warm handoff to the case manager, who connects the client to community resources.
“The ’U=U’ message, you are lifting a burden off someone's shoulders that they have felt…after being diagnosed, by explaining once undetectable, you cannot transmit to anyone. It's just so powerful.”
The overwhelming majority of the 77 people who participated in the study (conducted Dec. 2016–Oct. 2017) started ART within 72 hours of diagnosis, the initiative’s goal.
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| Study data | Clinical outcomes identified through medical chart review |
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Source: Halperin J, Butler I, Conner, K et al. Linkage and antiretroviral therapy within 72 hours at a Federally Qualified Health Center in New Orleans. AIDS Patient Care STDs. 2018; 32(2): 39–41.
“We do a red carpet. The [patient navigator] always meets the patient at the door, brings the patient into her office so they don't have to wait in the waiting room. If they can't come, we send a Lyft to pick them up.”
- Standard operating procedure. CrescentCare developed a standard operating procedure, explaining the workflow from initial diagnosis to medication dispensing. The standard operating procedure contains different paths depending on a client’s health care coverage status. All staff received and were trained on the standard operating procedure.
- Dedicated patient navigator. A full-time patient navigator position was created. This individual is dedicated to clients with a new diagnosis of HIV and follows them through the second provider visit, at which point the client is referred to a case manager if additional supports are needed.
- Electronic health record flag. CrescentCare created a medical visit type in its electronic health record system to distinguish clients participating in the CrescentCare Start Initiative and promote immediate access to care.
- Faster lab review. An expedited process for clinicians to review lab results within a day of the clinical visit ensures the ART prescribed in the initial visit does not contraindicate with the client’s condition.
CrescentCare Start Initiative is fully integrated into CrescentCare’s day-to-day operations. Louisiana expanded Medicaid for low-income adults in 2016 and has expedited ADAP enrollment for people with a new diagnosis of HIV, which has improved cost coverage of ART. Ongoing funds available through RWHAP cover the patient navigator position and medication starter packs until coverage starts (e.g., three weeks for Medicaid).
- Clinicians may be hesitant to prescribe ART before reviewing the full panel of lab results. Provider agencies should discuss the reasoning behind the change of process, using outcomes data when possible, and incorporate clinician feedback into changes in protocol.
- Immediate access to ART must be coupled with ongoing adherence supports, which should include flexible clinic hours, navigation services for clients, and ongoing case management.
- Incorporating new clients within an already busy clinic schedule can be a challenge. Prior to launching the initiative, CrescentCare clinicians committed to fitting people with newly diagnosed HIV into their schedules. The 30-minute appointment and streamlined clinical workup has made it easier to slot clients in.
- Halperin J, Butler I, Conner, K et al. Linkage and antiretroviral therapy within 72 hours at a Federally Qualified Health Center in New Orleans. AIDS Patient Care STDs. 2018; 32(2): 39–41. doi.org/10.1089/apc.2017.0309
- Halperin J, Connor K, Butler I, et al. A care continuum of immediate ART for newly diagnosed patients and patients presenting later to care at a Federally Qualified Health Center in New Orleans. Open Forum Infectious Diseases. 2018; 6(4), ofz161. doi.org/10.1093/ofid/ofz161