The Virginia Commonwealth University (VCU) Ryan White HIV/AIDS Program (RWHAP) implemented a clinical quality improvement project to increase linkage to HIV medical care within 30 days and initiation of antiretroviral therapy (ART) at the first visit by making “Rapid Access” appointments available each week for individuals newly diagnosed with HIV.
VCU does not conduct HIV testing and relies on referrals from community partners and the health department. Many newly diagnosed clients were youth. Historically, there was a lag from the time of diagnosis to the first appointment due to client readiness, availability of appointments, and passive referrals. Appointments typically were scheduled six to eight weeks after diagnosis of HIV. Rapid Access appointments reduce wait times for appointments and promote ART prescriptions in the first medical visit by anticipating potential barriers and eliminating them prior to the appointment.
A Rapid Access care team consisting of a clinician (such as a nurse practitioner), nurse educator, patient navigator, and case manager work together to facilitate access to an initial appointment for individuals newly diagnosed with HIV and collect information to support ART initiation at the first appointment. This approach facilitated rapid engagement and linkage to care for clients.
Select clinicians set aside designated appointment times for Rapid Access appointments. These Rapid Access appointments are 30 minutes (instead of the usual 60 minutes) with no requirement for full intake or labs prior to the visit. This also required a change in the Electronic Medical Record (EMR). If Rapid Access appointments are not filled within 24–48 hours of the appointment time, they are released and made available to returning patients.
If the hospital call center screens a client as eligible for a Rapid Access appointment, the call center forwards client information to the clinic nurse educator who will engage the Rapid Access care team and initiate the Rapid Access process. A member of the care team will schedule the appointment directly with the client.
The case manager will obtain the confirmatory test results and any information from the health department; the case manager contacts the client for an initial intake; and the nurse educator will contact the client to schedule the appointment within two weeks. All activities are documented in the EMR. Prescriptions are filled at the hospital pharmacy.
|Evaluation data||2018 EMR data on Rapid Access clients|
The program depends on partnerships with the health department and community-based organizations for testing, and with the health department and the RWHAP Part B AIDS Drug Assistance Program (ADAP) for medications.
- Identify the initial points of contact for individuals who are newly diagnosed with HIV (such as community health workers, department of health, hospital scheduling system) and outline the steps to connect the contacts with the Rapid Access care team.
- Identify providers who are able to add Rapid Access appointments to their schedules or convert existing appointment slots to Rapid Access slots. The intervention started with one provider who was “willing to give up her lunch.”
- Clearly identify roles of each care team member—nurse practitioner, nurse educator, patient navigator, and case manager—and
develop a process map illustrating all the steps.
screening tool for scheduling entity (such as a call center) to determine eligibility for Rapid Access appointments.
- Work with the health department to facilitate access to confirmatory test results and ADAP eligibility.
- Coordinate with pharmacy or pharmacies to develop processes to confirm drug coverage and fill prescriptions the same day.
- The case manager and nurse educator work with the client prior to appointment to confirm RWHAP and ADAP eligibility. The nurse educator schedules the first appointment with the provider, works with the client to get labs, and ensures ARTs are available. If eligibility has not been established or labs are not available, the first Rapid Access appointment still takes place.
- Document all activities in EMR and share data regularly with the care team.
- The strategy is fully integrated into routine care in a RWHAP-funded clinic, but depends on a team-based approach and collaborative efforts of a nurse practitioner, nurse educator, case manager, and patient navigator. Ideally, the process will be able to be replicated for those who are also re-engaging in care so they do not have to wait six to eight weeks for an appointment (currently Rapid Access is limited to people diagnosed in the last 30 days). The availability of providers and appointments are the limiting factors.
- Ideally, labs are collected before or the same day as the visit but the team has been successful conducting initial visits virtually and obtaining labs at another point. Labs are no longer required before ART can be prescribed.
- To prevent RWHAP eligibility or insurance coverage from being a barrier to the first appointment, 340B program income is used if eligibility is not confirmed and the client experiences any gaps in coverage.
- Prior to implementation, it is important to consider all the ways that clients may be referred to the clinic and make appointments, and develop processes for all referrals to connect with the Rapid Access program.
- Working with the scheduling department was a barrier previously to getting clients in to care. Having a person who sits in the HIV clinic to schedule clients has been successful in getting around this challenge.
- At the beginning of the intervention, the Rapid Access team met once every two weeks, but they were able to scale back the meeting frequency over time and now only meet when needed.
- Receiving a direct referral from the testing site has proven to be more effective in linking clients quickly to ART. Some referrals come in through another linkage to care team, but direct referrals lead to the shortest gap between diagnosis and the first medical appointment.