Integrated care for people with HIV OHTN HIV Endgame Claire Kendall
Presenter disclosure I have no relationships with commercial interests to disclose.
Success: Improvements in HIV care 4 Burchell et. al (2015)
Problem: Fragmentation of HIV care delivery Colorectal cancer screening Cervical cancer screening Mammography * Any receipt of ART Odds ratio (ref = Exclusively specialist care) 0 1 2 3 4 5 6 5 Kendall et. al (2015)
Problem: Fragmentation of HIV care delivery Colorectal cancer screening Cervical cancer screening Mammography * Any receipt of ART Odds ratio (ref = Exclusively specialist care) 0 1 2 3 4 5 6 6 Kendall et. al (2015)
Problem: Fragmentation of HIV care delivery Colorectal cancer screening Cervical cancer screening Mammography * Any receipt of ART Odds ratio (ref = Exclusively specialist care) 0 1 2 3 4 5 6 7 Kendall et. al (2015)
Problem: Fragmentation of HIV care delivery 100% 80% Percentage of patients prescriebed 60% 40% ART (95% CI) 20% 0% <=5 6‐49 >=50 <=5 6‐49 >=50 <=5 6‐49 >=50 Exclusively primary Family physician Specialist dominant care dominant co‐ co‐management management Family physician HIV experience (number of HIV patients) 8 Kendall et. al (2015)
Problem: Fragmentation of HIV care delivery Exclusively HIV specialist care 5.3% Co‐manager (Specialist 30.7% principal HIV provider) Co‐manager (FP principal HIV 10.1% provider) Exclusively primary care 52.7% Low engagement 8.6% 0% 10% 20% 30% 40% 50% 60% 9 Forrest (2009), Kendall (2015)
Problem: Fragmentation of HIV care delivery 75% Exclusively HIV specialist care 5.3% have <= 5 people Co‐manager (Specialist 30.7% with HIV principal HIV provider) in their Co‐manager (FP principal HIV practice 10.1% provider) Exclusively primary care 52.7% Low engagement 8.6% 0% 10% 20% 30% 40% 50% 60% 10 Forrest (2009), Kendall (2015)
Problem: Fragmentation of HIV care delivery 250,000 number of visits/3 years 200,000 150,000 100,000 50,000 0 Kendall et. al (2015)
Problem: Fragmentation of HIV care delivery 250,000 number of visits/3 years 5 visits/year 200,000 150,000 100,000 50,000 0 Kendall et. al (2015)
Integrated care: Chronic Care Model Barr et. al (2003)
Integrated care: Chronic Care Model Barr et. al (2003)
Integrated care: Chronic Care Model Barr et. al (2003)
Integrated care: Chronic Care Model Barr et. al (2003)
Integrated care: Chronic Care Model Barr et. al (2003)
Health Quality Ontario Recommendations 1.Smooth out transitions
Health Quality Ontario Recommendations 1.Smooth out transitions 2.Improve access to care in the community
Health Quality Ontario Recommendations 1.Smooth out transitions 2.Improve access to care in the community 3.Reduce inequities
Health Quality Ontario Recommendations 1.Smooth out transitions 2.Improve access to care in the community 3.Reduce inequities 4.Enhance performance measurement
HQO recommendation #1 Smooth out transitions
Smooth out transitions between sectors – linkage to care within 90 days Kendall and Antoniou
Smooth out transitions between sectors – linkage to care within 90 days ← 90% of those diagnosed in hospital ← 45% of those diagnosed in the emergency department Kendall and Antoniou
Smooth out transitions between sectors – end of life Kendall and Tanuseputro (2016)
Smooth out transitions between sectors – end of life Kendall and Tanuseputro (2016)
Smooth out transitions between sectors – end of life Kendall and Tanuseputro (2016)
Smooth out transitions between sectors – end of life Kendall and Tanuseputro (2016)
Smooth out transitions – within sectors 50,000 number of visits/3 years 40,000 30,000 20,000 10,000 0 Kendall et. al (2015)
Smooth out transitions – within sectors 50,000 number of visits/3 years 40,000 30,000 20,000 10,000 0 Kendall et. al (2015)
Smooth out transitions – within sectors 50,000 number of visits/3 years 40,000 30,000 20,000 10,000 0 Kendall et. al (2015)
Smooth out transitions – within sectors 50,000 number of visits/3 years 40,000 1000 visits/year 30,000 20,000 10,000 0 Kendall et. al (2015)
Smooth out transitions – within sectors Specialist MD Allied health Pharmacist
Smooth out transitions – within sectors Specialist MD Allied health Pharmacist
Smooth out transitions: Decision Support Barr et. al (2003)
HQO recommendation #2: Improve access to care in the community
Improve access to care in the community
Improve access to primary care in the community: Consistent
Improve access to primary care in the community: Consistent • People with HIV have greater use of emergency department visits (adjusted rate ratio 1.58, 95% CI 1.51–1.65]) • Results held when restricted to visits for Ambulatory Care Sensitive Conditions Ng and Antoniou et. al. (2016)
Improve access to primary care in the community: Comprehensive
Improve access to primary care in the community: Comprehensive
Improve access to primary care in the community: Comprehensive
Improve access to primary care in the community: Comprehensive
Improve access to primary care in the community: Comprehensive Lower colorectal cancer screening [41.4% (95% CI 41.3% to 41.5%) versus 49.1% (95% CI 46.5% to 51.7%)] Antoniou (2015), Kendall (2016)
Improve access to primary care in the community: Comprehensive Lower colorectal cancer Lower breast cancer screening screening [41.4% (95% CI [50.1% versus 63.4%, p<0.001] 41.3% to 41.5%) versus 49.1% • More likely if they have a (95% CI 46.5% to 51.7%)] family physician Antoniou (2015), Kendall (2016)
Improve access to primary care in the community: Coordinated
Improve access to primary care in the community: Coordinated communication
Improve access to primary care in the community: Coordinated Specialist MD Allied health Pharmacist
Improve access to primary care in the community: Coordinated Specialist MD Allied health Pharmacist
Improve access to primary care in the community: Coordinated communication role definition
HQO recommendation #3: Reduce inequities
Reduce inequities ‐ geographic • 8% of people with HIV in Ontario live rurally • 5% of family physician practices • 0% of internal medicine and ID specialist practices
Reduce inequities ‐ socioeconomic
Recommendation #4: Enhance performance measurement
Enhance performance measurement Johnston, Kendall et al.
Enhance performance measurement PROMS Johnston, Kendall et al.
Enhance performance measurement PROMS PREMS Johnston, Kendall et al.
Enhance performance measurement– Patient reported outcome Kendall and MacPherson
Chronic Care Model: Self‐ management supports Barr et. al (2003)
Enhance performance measurement – Patient reported experience measure Patient Assessment of Chronic Illness Care Rachlis, B. and Rourke, S.
Chronic Care Model: Self‐ management supports Barr et. al (2003)
Enhance performance measurement
Enhance performance measurement
Microcosm approach Barr et. al (2003)
Integrated population‐based system‐level approach Barr et. al (2003)
Acknowledgements
Integrated care for people with HIV OHTN HIV Endgame Claire Kendall
Smooth out transitions – within sectors Mental health condition Myocardial infarction Congestive heart failure End stage renal disease Peripheral vascular Asthma disease Diabetes Stroke Hypertension Mental‐physical comorbidity Multimorbidty (>=2) HIV ON Standardized 0 1 2 3 4 Kendall et. al (2014) 69
Multimorbidity patterns reflect ON population 100 Prevalence (%) 80 60 40 HIV 20 ON 0 18‐35y36‐50y51‐64y >65y 18‐35y36‐50y51‐64y >65y ≥1 chronic condition ≥2 chronic conditions Multimorbidity burden by age goup (Women)
Multimorbidity patterns reflect ON population 100 Prevalence (%) 80 60 40 HIV 20 ON 0 18‐35y36‐50y51‐64y >65y 18‐35y36‐50y51‐64y >65y ≥1 chronic condition ≥2 chronic conditions Multimorbidiy burden by age group (Men)
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