Routine Universal Screening for HIV (RUSH)

Routine Universal Screening for HIV (RUSH) provides non-medical case management services, opt-out HIV testing, and linkage to care for emergency department patients. The intervention automatically screens patients for HIV if they are aged 16 years or older, are having an IV inserted, or are having blood drawn for other reasons, unless the patient opts out. RUSH provides access to testing earlier in disease progression, bridging disparities that primarily impact people of color. It also promotes linkage to and retention in care for those with a positive HIV test result. Harris Health System and the Ben Taub and Lyndon B. Johnson Hospitals in Houston, TX implemented RUSH between 2008 and 2012. Clients with a positive HIV test in the emergency department who had a prior diagnosis of HIV were more likely to be retained in care and to reach viral suppression.

Houston, TX

Evidence-Informed Intervention
Clinical service delivery model
Linkage to HIV medical care; Retention in HIV medical care; Viral suppression
Diagnose
All clients
RWHAP Part A; RWHAP Part C; Centers for Disease Control and Prevention (CDC)
Hospital or hospital-based clinic
Need Addressed

In response to the 2006 CDC recommendations for routine opt-out HIV testing in healthcare settings,1 Harris Health System started the RUSH program. Routine opt-out screening programs embed HIV testing into a clinic’s existing infrastructure and workflow and increase the number of clients undergoing HIV testing.2,3 While this opt-out testing can identify people who have not been previously been diagnosed with HIV,4 Harris Health System implemented RUSH to screen patients who had previously been diagnosed with HIV but were not engaged in care to facilitate linkage or re-linkage to HIV care.

“By leveraging an organization’s existing staff infrastructure and dedicating staff to facilitating client linkage to care, organizations can identify and retain people with HIV who are unaware of their status or have fallen out of care.”

Core Elements
Opt-out testing

Any client with blood drawn in the emergency department receives an opt-out HIV test. This test is automatically added to lab orders to reduce emergency department staff burden.

Promotional materials

Promotional materials, including flyers, consent forms, and signage, are available in areas where clients receive an HIV test to clearly communicate the routine testing process and to highlight that testing is optional.

HIV counseling and linkage to care

A designated service linkage worker, who is familiar with trauma-informed care, collaborates with physicians to deliver HIV test results and HIV counseling. The service linkage worker also links the client to medical care at a partner clinic, often scheduling the first appointment for the client. The service linkage worker may also provide non-medical case management services tailored to the clients’ needs, such as assistance with insurance enrollment and transportation. The service linkage worker is available in emergency departments during business hours and performs off-hours follow-up for those who are tested outside of business hours.

Ongoing medical care

Within the Harris Health System, clients are typically linked to the Thomas Street Health Center or two satellite clinics for ongoing HIV and primary care. These clinics are located close to the emergency department, are experienced in serving people with HIV, and operate within the Harris Health System, facilitating referrals and data sharing. The Ben Taub and Lyndon B. Johnson Hospital emergency departments do not have an affiliated outpatient clinic for HIV care, so the service linkage worker refers clients to multiple other clinics in the area. After the client is linked to care, as evidenced by the completion of an outpatient visit, a case manager at the clinic takes over care coordination.

Outcomes

Harris Health System conducted a retrospective cohort study of people who received an HIV test in the emergency department between 2008 and 2012, and had received positive HIV test results at least a year before their emergency department visit. These clients were more likely to be retained in care and reach viral suppression after their emergency department encounter.

Category Information
Evaluation data RUSH identified 2,068 people with a positive HIV test in the emergency department who had a previous diagnosis of HIV. Electronic health record (EHR) data on medical visits and lab results were analyzed for these clients.
Measures
  • Retention in care (at least two appointments in six months) before and after the emergency department visit
  • Viral suppression before and after the emergency department visit
Results
  • Retention in care increased from 32.6% pre-ED visit to 47.1% post-ED visit
  • Viral suppression increased from 22.8% pre-ED visit to 34.0% post-ED visit

Source: Flash CA, Pasalar S, Hemmige V, et al. Benefits of a routine opt-out HIV testing and linkage to care program for previously diagnosed patients in publicly funded emergency departments in Houston, TX. J Acquir Immune Defic Syndr. 2015 May 1; 69(0 1): S8–15. doi: 10.1097/QAI.0000000000000578

Planning & Implementation
  • The Houston hospitals hired service linkage workers and an administrative coordinator whose job was to to streamline RUSH-specific logistics, such as communicating with providers, coordinating staff training sessions, and hiring and managing the service linkage workers. 
  • All emergency department staff, regardless of their role, were trained on the HIV testing and linkage processes. Staff with direct engagement with clients were also trained on trauma-informed care strategies. 
  • Leadership buy-in was secured through a clinical champion and steering committee comprised of upper-level administrators, clinical staff, and members of legal and communications teams. These people promoted the intervention and other implementation efforts (e.g., securing a robust data management system) to high-level executives. 
  • The Houston hospitals developed partnerships to facilitate client referrals for support services. They worked with other health system departments and the RWHAP system of care to connect clients with supportive services (e.g., transportation, housing).
  • The Houston hospitals adapted content from the American Red Cross and Centers for Disease Control and Prevention (CDC) for client informational materials. Community member feedback and Spanish translations helped ensure materials were accessible and inclusive.

“We were fortunate to have a really staunch champion in ... the doctor who was the head of the [emergency department] at Ben Taub at that time, and he spearheaded the efforts to get standing delegated orders written, which included all that was needed to do the HIV test.” 

Sustainability

The RUSH intervention requires a clear payment model that addresses gaps in clients’ health care coverage, and accounts for service linkage worker salaries. The Houston hospitals subsidized the RUSH intervention through CDC and RWHAP Parts A and C funding.

Lessons Learned
  • Clinics implementing RUSH should identify a clinical champion within the organization who can promote the intervention to leadership and other emergency department staff. This person should be able to highlight the benefits of RUSH, such as identifying HIV early in disease progression, and providing an additional opportunity to identify people out of care in order to re-link them to care. 
  • Staff turnover can increase the need for RUSH training; early in the process, those replicating RUSH should discuss barriers to delivery of training protocols and identify strategies to disseminate RUSH training to new staff members. 
  • HIV testing laws may add a barrier to implementation. Emergency departments should be aware of testing laws in their jurisdiction that place barriers to or promote access to routine testing. New York State, for example, has laws that make routine HIV testing more readily available, and people aged 13 and over can access routine HIV testing in outpatient and primary care settings.
  • In the RUSH intervention, clients are tested for HIV at intake, usually before a clinician can check for previous HIV tests. Because of this, some patients who have been previously diagnosed with HIV are tested again. While this was the population used to evaluate the intervention, other providers may not want to retest people with a prior diagnosis of HIV. Therefore, the EHR should be programmed to automatically present testing history to reduce retesting while retaining the opportunity for HIV counseling and linkage to care in the emergency department. 
  • Service linkage workers had a hard time communicating with clients after they left the emergency department. Hospitals may consider placing service linkage workers in emergency departments outside of business hours to increase the benefit of the program to clients regardless of what time they are tested in the emergency department.
Contact
Harris Health System, Thomas Street Health Center
Siavash Pasalar

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