Enhanced care coordination improves HIV viral load suppression rates.

OBJECTIVES: Optimizing HIV treatment benefits the health of the individual and the community at large. Health department HIV surveillance data matched with Medicaid managed care rosters can be used to target people with HIV infection who have an unsuppressed viral load or are unengaged in care. MetroPlus Health Plan, a Medicaid managed care organization, implemented a 2-pronged approach: street outreach and peer care connection interventions. STUDY DESIGN: A cohort study that included demographics, program contact type and frequency, antiretroviral therapy refill pattern, and CD4 count and HIV viral load values/ranges and dates. METHODS: Members without a viral load test result during the prior 9 months (not engaged) received outreach, and those with unsuppressed viral loads received intensified care coordination and peer support. A retrospective statistical analysis was conducted on cohort members with sufficient viral load data. A subanalysis excluded members who had suppressed viral loads at baseline. RESULTS: A total of 1429 (82%) members in the state cross-referenced list were still enrolled in the plan at study initiation. Successful contact with targeted members by outreach was 60% compared with 40% by care coordination and peer support combined. Members who were successfully contacted by the program had a 44% suppression rate (<200 copies/mL) and a greater likelihood of achieving viral load suppression (odds ratio, 1.55; 95% CI, 1.23-1.95; P <.01) than those who were not. CONCLUSIONS: Surveillance data were successfully used to target HIV-positive Medicaid members who had an unsuppressed viral load or were unengaged in care. Individuals with an unsuppressed viral load can achieve suppression through intensified outreach, care coordination, and peer support by a Medicaid managed care plan.

Vital Signs: Increased Medicaid Prescriptions for Preexposure Prophylaxis Against HIV infection--New York, 2012-2015.

BACKGROUND: Approximately 3,000 incident cases of human immunodeficiency virus (HIV) infection occur in New York state each year. Daily HIV preexposure prophylaxis (PrEP) with the oral antiretroviral medication Truvada is a key component of New York's plan to end HIV/acquired immunodeficiency syndrome (AIDS) as an epidemic in the state by 2020. METHODS: Prescription data from the New York state Medicaid program from July 2012 through June 2015 were analyzed with an algorithm using medication and diagnoses codes to identify continuous use of Truvada for >30 days, after excluding use for postexposure prophylaxis or treatment of HIV or chronic hepatitis B infection. RESULTS: During July 2012-June 2013, a total of 259 persons filled prescriptions for PrEP in the Medicaid program. During July 2013-June 2014, a total of 303 persons filled prescriptions for PrEP. During July 2014-June 2015, a total of 1,330 persons filled prescriptions for PrEP, a substantial increase over the previous 12 months. Across all periods studied, 1,708 Medicaid recipients filled at least one prescription for PrEP, most of whom were New York City (NYC) residents, male, aged <50 years, and, for those with available data on race, white. CONCLUSIONS: PrEP use by Medicaid-insured persons increased substantially in the years following statewide efforts to increase knowledge of PrEP among potential prescribers and candidates for PrEP. Other jurisdictions can follow New York state's example by taking similar steps to remove the financial and knowledge barriers experienced by both potential users and prescribers of PrEP. IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Although both state and local health department efforts contribute to the availability and use of PrEP, their collaboration enhances the successful implementation of strategies to increase PrEP use. In addition, the decision by the state Medicaid agency to cover PrEP recognizes the long-term benefits of preventing HIV infections.

An expenditure analysis of high-cost Medicaid recipients with HIV disease in New York State.

A retrospective analysis was conducted of federal fiscal year (FFY) 2007 New York State Medicaid claims and expenditure data to examine variation in expenditures among New York State Medicaid recipients with HIV disease and the extent to which this variation could be attributed to the prevalence of comorbidities and other chronic conditions unrelated to HIV disease. Median expenditures per person for the period for a high-cost group (those for whom expenditures exceeded $100,000 for the period) were over $157,000, with 40% of total expenditures for this group for treatment unrelated to their HIV disease. The prevalence of comorbidities in the high-cost population is very high, the most common being substance abuse and mental illness.

Beyond satisfaction: using the Dynamics of Care assessment to better understand patients' experiences in care.

BACKGROUND: Patient perceptions of and satisfaction with care have become important indicators of the quality of services and the relationship of services to treatment outcomes. However, assessment of these indicators continues to be plagued by measurement problems, particularly the lack of variance in satisfaction data. In this article, we present a new approach to better capture patient perceptions of experiences in care, the Dynamics of Care (DoC) assessment. It is an in-depth approach to defining and assessing patients' perspectives at different junctures in care, including their decisions about whether and where to seek care, the barriers encountered, and the treatments and services received. METHODS: The purpose of this article is to describe, validate, and discuss the benefits and limitations of the DoC, which was administered as part of a longitudinal study to evaluate the New York State HIV Special Needs Plan (SNP), a Medicaid managed care model for people living with HIV/AIDS. Data are from 426 study respondents across two time points. RESULTS: The results demonstrate the validity and value of the DoC. Help seeking decisions and satisfaction with care appear to be situation-specific, rather than person-specific. However, barriers to care appear to be more cross-situational for respondents, and may be associated with clients' living situations or care arrangements. Inventories in this assessment that were designed to identify potential deterrents to help seeking and difficulties encountered in care demonstrated clear principal component structures, and helped to explain satisfaction with care. The problem resolution index was found to be independent from satisfaction with care and the data were more normally distributed. DoC data were also associated with subsequent utilization and change in quality of life. CONCLUSION: The DoC was designed to be a flexible, integrated measure to determine individuals' salient service needs, help seeking and experiences in care. One of the many strengths of the assessment is its focus on specific problems in context, thus providing a more sensitive and informative way to understand processes in care from the patient's perspective. This approach can be used to direct new programs and resources to the patients and situations that require them.

The Events in Care Screening Questionnaire (ECSQ): a new tool to identify needs and concerns of people with HIV/AIDS.

The purpose of this paper is to present validation data on the Events in Care Screening Questionnaire (ECSQ), which was designed to identify the needs and concerns of people living with HIV/AIDS (PLWHA) in nine specific domains: adherence to medical instructions; medical problems; specialty and inpatient hospital care; preventive health care and screening and behavioral health; sexual risk behavior; family planning; psychological symptoms; substance use; and life circumstances and demands. The ECSQ is the anchor for a more comprehensive measure called "The Dynamics of Care," and was administered in the context of a longitudinal study to evaluate New York State's HIV Special Needs Plan (HIV SNP), a Medicaid managed care model for PLWHA. Participants in the study, which began in March 2003 and closed recruitment in January 2007, were NYC PLWHA who were enrolled in either a Medicaid HIV SNP or Fee-For-Service plan. Participants were recruited through HIV SNP enrollment lists, direct on-site recruitment, and fliers. The specific event domains covered in the ECSQ were selected based on the purpose of the HIV SNP and the literature describing the needs and challenges that PLWHA face. Analyses are based on data from 628 study respondents over two times points. Results suggest that the concerns identified by PLWHA were largely consistent with their health care situation, heath status, risk behavior, and personal characteristics. Findings presented here lend support for the construct validity of the ECSQ and demonstrate its value as a starting point for inquiring more fully about the experiences of patients and improving the care they receive.

Integrating multiple programme and policy approaches to hepatitis C prevention and care for injection drug users: a comprehensive approach.

BACKGROUND: New York State is home to an estimated 230,000 individuals chronically infected with hepatitis C virus (HCV) and roughly 171,500 active injection drug users (IDUs). HCV/HIV co-infection is common and models of service delivery that effectively meet IDUs' needs are required. A HCV strategic plan has stressed integration. METHODS: HCV prevention and care are integrated within health and human service settings, including HIV/AIDS organisations and drug treatment programmes. Other measures that support comprehensive HCV services for IDUs include reimbursement, clinical guidelines, training and HCV prevention education. Community and provider collaborations inform programme and policy development. RESULTS: IDUs access 5 million syringes annually through harm reduction/syringe exchange programmes (SEPs) and a statewide syringe access programme. Declines in HCV prevalence amongst IDUs in New York City coincided with improved syringe availability. New models of care successfully link IDUs at SEPs and in drug treatment to health care. Over 7000 Medicaid recipients with HCV/HIV co-infection had health care encounters related to their HCV in a 12-month period and 10,547 claims for HCV-related medications were paid. The success rate of transitional case management referrals to drug treatment is over 90%. Training and clinical guidelines promote provider knowledge about HCV and contribute to quality HCV care for IDUs. Chart reviews of 2570 patients with HIV in 2004 documented HCV status 97.4% of the time, overall, in various settings. New HCV surveillance systems are operational. Despite this progress, significant challenges remain. DISCUSSION: A comprehensive, public health approach, using multiple strategies across systems and mobilizing multiple sectors, can enhance IDUs access to HCV prevention and care. A holisitic approach with integrated services, including for HCV-HIV co-infected IDUs is needed. Leadership, collaboration and resources are essential.

Promoting HCV treatment completion for prison inmates: New York State's hepatitis C continuity program.

This article describes the development of a statewide program providing continuity of hepatitis C virus (HCV) treatment to prisoners upon release to the community. We discussed length of stay as a barrier to treatment with key collaborators; developed protocols, a referral process, and forms; mobilized staff; recruited heath-care facilities to accept referrals; and provided short-term access to HCV medications for inmates upon release. The Hepatitis C Continuity Program, including 70 prisons and 21 health-care facilities, is a resource for as many as 130 inmates eligible to start treatment annually. Health-care facilities provide fairly convenient access to 87.1% of releasees, and 100% offer integrated HCV-human immunodeficiency virus/acquired immunodeficiency syndrome care. As of March 2006, 24 inmates had been enrolled. The program was replicated in the New York City Rikers Island jail. The program is operational statewide, referrals sometimes require priority attention, and data collection and other details are still being addressed.