AIDS Healthcare Foundation (AHF) Upland Healthcare Center helped gay, bisexual, and other men who have sex with men (MSM) of color reach viral suppression through intensive case management, by leveraging their participation in the Center for Quality Improvement Innovation (CQII) end+disparities ECHO Collaborative.
Upland and Riverside, CA
While overall rates of viral suppression at AHF are high, AHF identified MSM of color who were not virally suppressed. This work pinpointed a need to explore reasons for lack of engagement in care, examine medication adherence, and identify strategies to better support these individuals and the population overall.
AHF used the Disparities Calculator developed by CQII to calculate rates of viral suppression by key population as part of the agency’s effort to address disparities in health outcomes. AHF then identified individuals within its client population who were MSM of color and not virally suppressed.
The AHF program administrator then connected these individuals to intensive case management services. She contacted clients and educated them on the importance of viral suppression and the services and supports offered through case management that could help them reach viral suppression.
AHF’s multidisciplinary care team assessed clients’ barriers to care—including issues with transportation, food, housing, substance use, mental health, and domestic violence—and developed a detailed care plan for each client. AHF case managers worked with community partners to connect clients to needed services.
AHF case managers provided continuous education to clients on the importance of medication adherence. Educational messages were reinforced through volunteer “consumer liaisons” (i.e., peers), pamphlets, the clinic lobby television, and a new support group for clients to share their challenges and successes.
AHF helped clients establish mail order medication delivery and provided daily/weekly pill planners to promote adherence.
Clients who were not virally suppressed were identified in November 2018 and outcomes were assessed in December 2019.
Health outcomes were assessed over 18 months for 16 MSM of color who were not virally suppressed at the start of the initiative.
Proportion of individuals who reached viral suppression.
Of the 16 individuals who were not virally suppressed at the start of the initiative, 14 reached viral suppression and two were lost to follow-up after 18 months.
Source: AHF ECHO Storyboard. 2019.
"This intervention is definitely embedded within our agency’s work. Forevermore it will be an expectation that we use a report to identify our patients who are really struggling with adverse health outcomes and engage them in the case management program."
- Participation in ECHO Collaborative. The CQII end+disparities ECHO Collaborative played a primary role in the development and implementation of the initiative. The AHF program administrator was new to quality improvement and reported that she greatly benefited from the collaborative’s tools and framework. The collaborative ran for 18 months and involved regular learning through biweekly calls. During the sessions, a participating provider would present a client case and members of the collaborative, facilitators from CQII, and two people with HIV would offer suggestions for improving engagement in care.
- Use of Disparities Calculator. AHF used the Disparities Calculator developed by CQII to calculate rates of viral suppression by key subpopulation and identify individuals who were not virally suppressed for a focused intervention.
- Client participation in QI efforts. Client engagement was central to the effort. Volunteer liaisons attended an intensive three-day CQII training on quality improvement and shared findings with clients locally. In addition, volunteer liaisons continue to attend biweekly regional quality improvement meetings to review data and provide input on support group topics and strategies for publicizing available resources. AHF also collected feedback surveys from clients as they came into the clinic.
“That started off a really good partnership where I felt that these were people I could really trust my patients to get quality services from.”
- AHF provided clients with messaging and the supports to encourage constructive feedback about care provision, and engaged clients in the design and implementation of this quality improvement effort.
- AHF attributes success to one-on-one client education on HIV drug resistance. Many clients were unaware that they could become resistant to their medications if they did not take them daily. AHF emphasized that even if clients “felt fine,” medications need to be taken daily for long-term health.
- Tailored communication strategies work best to meet clients’ different needs. Some clients prefer to learn from their peers in a support group, while others learn best receiving information from their medical providers. Therefore, the initiative included multiple methods to continually reinforce the message of adherence.
- AHF is willing to meet clients where they are. There is no enrollment deadline for case management services so clients can participate when they are ready. In addition, AHF can help address individual needs, such as housing challenges, even if clients are not ready for the entire suite of case management services.
- The AHF language line, a phone line staffed by interpreters and bilingual team members, was crucial in the beginning of the effort because many clients were monolingual Spanish speakers. AHF eventually hired Spanish-speaking case managers to replace the language line with in-person support.
- A strong working relationship between the AHF data analyst and an analyst from ARIES, the California Ryan White HIV/AIDS Program (RWHAP) statewide data management system, was important to identify clients in need of care and produce the quality metrics for measuring changes over time. The RWHAP Quality Manager at the national level has streamlined processes to support the data requests of local AHF agencies.
- AHF emphasizes the importance of recognizing the changes that occur at the individual level as opposed to solely focusing on overall rates of viral suppression, which may be hard to change.
- Finally, AHF notes that every client has different needs and perceptions of service quality. The initiative is not about how providers feel they are delivering services; it is about how clients perceive service delivery.