HIV/AIDS Interface Technology Systems (HITS): A Program UpdateSPNS IT Grantees MeetingMarch 17, 2004

County of Los Angeles Department of Health Services

Office of AIDS Programs and Policy

2

Project Staff

Ijeoma Nwachuku, Ph.D. Principal InvestigatorEduardo Alvarado, MPH Epidemiologist, Prevention ServicesAssefa Seyoum Application Development Manager, Information SystemsSophia Rumanes, MPH Section Manager, Prevention Services

* Estimates from LAC HIV Epidemiology Program and CDC as of February 2004 3

Estimated Persons Living with HIV/AIDS in Los Angeles County

0

10,000

20,000

30,000

40,000

50,000

60,000

All HIV

Undiagnosed HIVDiagnosed HIV PLWA

Estimated 54,000 living

with HIV/AIDS in Los Angeles

County

12,000-15,000

19,000-27,000

18,000

4

CDC Funded HIV TestingCTS 2002, Los Angeles CountyNumber of Tests

70,229New HIV Diagnoses

908New Positives Who Did Not Return for Results

19.71%67% of new positives who did not return

for results were anonymous testers

5

HITS Project Objectives

Increase Disclosure Rates for HIV-Positive Test Results

Decrease Time Between Disclosure and Entry Into Care

Improve Eligibility Screening of Enrolled Clients

6

HIV Information Resources System (HIRS )

Standardized Data and Processes Integrated Data and Application

SystemsAccurate Data Maintenance and

ManagementHighly Secured Systems

7

Prevention Systems, HIV Counseling and Testing (HCT) Services

CLIENTREGISTRATION

CLIENT RISKASSESSMENT

CLIENTHIV TESTING

CLIENTDISCLOSURECOUNSELING

PREVENTION/CARE

REFERRAL

POSTDISCLOSURECOUNSELING

PCRSCOUNSELING

CLIENTPREVENTIONFOLLOW-UP

CAREREFERRAL

COUNSELING

CAREREFERRAL

FOLLOW-UP

CLIENT GETSCARE

SERVICES

PREVENTIONREFERRAL

COUNSELING

CLIENTINTERVENTION

SERVICE/S

8

Information Management of AIDS Cases and Services IMACS/Casewatch

Used by OAPP-Contracted Care Providers

Client-Server Architecture Maintains Information

Client RegistrationDemographicServices Utilized

9

HITS Process FlowHIV Information

Resources System (HIRS)

HIV Prevention System - HCT ModuleHIV/LA

ResourceDirectory

IMACS/Casewatch

AnonymousTesting Client

ConfidentialTesting Client

Enc

ount

er: H

IV T

estin

g an

d C

ouns

elin

g

Enc

ount

er: H

IV T

est R

esul

ts

Does notreturn: can't

follow up

HIV +

HIV +

Technology: HIVReferral Follow-upSystem (HRFUS)Program: C/T Follow-up

PreventionInterventions

Enc

ount

er: E

ligib

ility

Scr

eeni

ng &

Tai

lore

d R

efer

ral

Enc

ount

er: C

AR

E A

ct S

ervi

ce

Technology: CAREAct Service Eligibil-ity System (CASES)Program: Intake

UniqueIdentifier

No personalinfo: can'tfollow up

Becomesconfidential client

IntegratedSystem

Sub-systems

Interfaces(technologyadaptations)

Follow-up

Does notreturn for

test resultsDoes notaccessservices

Technology: HIVStatus Follow-upSystem (HSFUS)Program: PreventionCounselor Follow-up

HIV+ ClientReferral

HIV+ ClientFollow-Up

10

HIV Status Follow-up SystemInterface

Electronic Client Tracking SystemPrompts HCT Staff Follow-up With

Confidential Testing Clients Who Do Not Return for Disclosure

Encourages Clients to Test Confidentially

11

HIV Referral Follow-up SystemInterface

Tailored Referrals Using On-Line Resource Directory

Referred Client Information Sent to Care System

Documents Entry Into CarePrompts HCT Staff With Various

Follow-up Notifications About Referred Client

12

CARE Act Services Eligibility System Interface

Electronically-Enhanced IMACS/Casewatch Client Eligibility Screening Module

Enhances Screening for EligibilityScreening Begins at HCT Site

Allows Client-Tailored Referrals

13

HITS Process/Interface Flow

HIRS-HCTDisclosure

HIRS-HCTCARE

REFERRAL

SPNSFinancialScreening

SPNSSEARCH &

SELECTPROVIDERS

SPNS to/from

CasewatchINTERFACE

Casewatchto/fromSPNS

INTERFACE

CasewatchCARE

SERVICEDELIVERY

CareServices

(Casewatch)Intake/

Rgistration

LAC-AIDSSERVICE

DIRECTORY

HIRS-HCT

HIRS-HCT SPNS

CASEWATCH

LAC-ASD

HIRS-HCT & SPNS Task GridOUTSTANDING TASKS

HCT Disclosures

Scheduled for Disclosure But No-Show

Follow ups for Disclosures

HCT Care Referrals

HCT Care ReferralsView/Reports

Casewatch to HIRS-HCT-SPNS Care Referrals

SPNS Care Referrals

LAC-ASD SearchCare Providers

Care Referral (HIRS-SPNS)Client Reg./Intake Records

HIRS-HCT CareReferrals Transactions

Client Record Sent to Casewatch

Client No-Show for Care (Reg./Intake)

Client Reg. But No Care Service

Client Received Care ServiceHCT-SPNS Care Referrals

SPNS Financial Screening

SPNS Care ReferralsView/Reports

View/Report SPNSFinancial Screening

Select CareProviders/ Agencies

LAC-ASD SelectCare Providers

HIRS-HCT-SPNS to CareReferrals Transactions

Casewatch to HIRS-HCTCare Referral Follow-ups

Care (Casewatch) Follow-up toHIRS-HCT-SPNS Transactions

HIRS-HCT-SPNS to CareReferrals (Casewatch) Interface

Care Follow-ups (Casewatch)to HIRS-HCT-SPNS Interface

HIRS-HCT Care Follow-up Transactions

Care (MOP)Service Delivery

Care (MOP) ServiceDelivery View/Reports

Care Referral (HIRS-SPNS)Client Reg./Intake View/Report

Client (HIRS-SPNS) CareServices (Casewatch) Reg./

Intake Records

Client Care (MOP) Services/Delivery/Follow Up Records

HIRS-HCT DisclosureScheduled No-Shows

HIRS-HCT Disclosure ScheduledNo-Shows Follow-Ups

14

HITS Implementation

Evaluate CapacityHardwareSoftwareInternet Capability

Implement Security Policy Install, Configure and Test

Virtual Private Network (VPN) Tools

Internet Tools

15

HITS Implementation (Cont’d)

Phase I Sites (3)

July 2003

Phase II Sites (2)

September 2003

Phase III Sites (6)

March 2004

Phase IV Sites (9)

by June 2004

Phase V Sites (6)

by August 2004

16

HITS Implementation (Cont’d)

Training by OAPPInformation Systems DivisionEducational Services DivisionPrevention Services Division

Initial Training and Follow-UpUser’s Manual

17

HITS Implementation (Cont’d)

SupportTechnical Assistance Help Desk

9½ Hours per Day 5 Days per Week

Systems and Database AdministrationApplication Programming

Process, Forms ReportsDatabase Programming,

Administration and ManagementDatabase, Applications and

Operating Systems Security

18

Implementation PlanStaggered Implementation

Highest Volume AgenciesOutpatient Medical Providers with

CasewatchOAPP-Contracted HCT Providers 18

Sites (>300)

Medical Outpatient Providers 23Sites (35)

Certified HCT Counselors 500Confidential HIV-Positive Tests Annually 600

19

Orientation ProcessSteering Committee

Community Based OrganizationsOAPP

Capacity Building for SustainabilityAssessmentBatch to BusinessTrainingMonograph Development

20

Lessons Learned: OAPP

Changing Service Requirements at State and Federal LevelsPEMSELI

Changing Data Collection InstrumentsCDC CTSHIV-6

Policy Development

21

Lessons Learned: Providers Technologic Issues

Varying Levels of Capacity and Capability

Changing PhilosophiesConfidential vs. Anonymous TestingSelf-Referral vs. Outside-Referral

Programmatic IssuesDifferent Methodologies by ProviderClient-Centered PhilosophiesTrust in SystemTraining

22

EvaluationBaseline Data Were Analyzed

Calendar Years 2000 Through 2002HIV Counseling and Testing DatabaseCare Services Databases

Follow-up Years Include April 2004 Through March 2006

Anticipated ImprovementsService DeliveryQuality of CareCost-Effectiveness

23

Service Delivery OutcomesDecreased Time From Testing to

DisclosureMedian Time to Disclosure

2000 (13 days; n=605; P1=0 and P99=112)

2001 (12 days; n=542; P1=0 and P99=75)

2002 (9 days; n=566; P1=1 and P99=62)

More Clients Access Medical Care ServicesUtilization and Consumption Year Clients Service Units

2000 7,667 68,761

2001 12,301 111,861

2002 15,824 120,443

24

Service Delivery (cont.)

12,3017,66715,824

120,443111,861

68,761

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

2000 2001 2002

YEAR

VA

LU

E

Utilization Consumption

Service Units

Clients

25

Quality of Care Outcomes Improved Health Status on Entry

Year HIV-Positive AIDS Unknown2000 2,088 603 6212001 1,485 890 02002 3,002 1,844 428

Improved ReferralsComparison of HITS and Non-HITS

Clients July 2004 Through March 2006 Survey

Data

*HIV-negative clients not depicted 26

Quality of Care (cont’d)

63%

18% 19%

57%

34%

0%

52%

32%

7%

2000 2001 2002

HIV AIDS Unknown

Status of Clients Entering Care

27

Cost-Effectiveness Outcomes

Increased Use of Payor SourcesIdentification of Non-RWCA Payor Sources Year n Proportion

2000 5,384 33% 2001 6,571 49% 2002 10,805 58%

Increased Efficiency at Provider SitesComparison of Baseline and Follow-up

Provider Survey Data March Through May 2004 January Through March 2006

28

Cost-Effectiveness (cont.)

0%

10%

20%

30%

40%

50%

60%

Private 6% 8% 16%

Medicare 1% 7% 3%

Medicaid 15% 28% 34%

Other Public 12% 4% 1%

Other 0% 3% 4%

No Insurance 37% 51% 42%

Unknown 29% 0% 0%

2000 2001 2002

Third Party Payor Sources

29

Successes

Improvement in Data Quality Integration of Services Increased Tracking of Linked ReferralsCross-OAPP CollaborationMonitoring of HCT Counselors for

Compliance

30

Next Steps

Identify and Address Policy and Procedural Changes Needed to Sustain System

Assist Users Transitioning from Current Systems to HITS

Allow Resulting Data to Inform the Direction of HITS and Other Similar Endeavors