Adopting a nurse-led model of care to advance whole-person health and health equity within Medicaid.

BACKGROUND: Medicaid payment reforms and delivery model innovations are needed to fully transform U.S. healthcare structuring and provision. PURPOSE: To synthesize nurse-led models of care and their implications for improving health care access, quality, and reducing costs for Medicaid recipients. METHODS: A critical review of the literature regarding nurse-led models and implications for addressing social determinants of health (SDOH), adopting population health approaches, managing complex care, and integrating behavioral and physical health care within Medicaid. DISCUSSION: Three interrelated findings emerged (a) investing in dynamic nurse-led models is important for mitigating SDOH and adopting value-based care, (b) regulations preventing nurses from practicing at the fullest extent of their training and licensure limit clinical impact and value, and (c) directed payments can establish value-based expectations for Medicaid managed care. CONCLUSION: Adoption of a nurse-led model of care has the potential to advance the goals of reducing inequity and promoting whole-person health within Medicaid and nationally.

An expanded HIV screening strategy in the Emergency Department fails to identify most patients with undiagnosed infection: insights from a blinded serosurvey.

Screening for HIV in Emergency Departments (EDs) is recommended to address the problem of undiagnosed HIV. Serosurveys are an important method for estimating the prevalence of undiagnosed HIV and can provide insight into the effectiveness of an HIV screening strategy. We performed a blinded serosurvey in an ED offering non-targeted HIV screening to determine the proportion of patients with undiagnosed HIV who were diagnosed during their visit. The study was conducted in a high-volume, urban ED and included patients who had blood drawn for clinical purposes and had sufficient remnant specimen to undergo deidentified HIV testing. Among 4752 patients not previously diagnosed with HIV, 1403 (29.5%) were offered HIV screening and 543 (38.7% of those offered) consented. Overall, undiagnosed HIV was present in 12 patients (0.25%): six among those offered screening (0.4%), and six among those not offered screening (0.2%). Among those with undiagnosed HIV, two (16.7%) consented to screening and were diagnosed during their visit. Despite efforts to increase HIV screening, more than 80% of patients with undiagnosed HIV were not tested during their ED visit. Although half of those with undiagnosed HIV were missed because they were not offered screening, the yield was further diminished because a substantial proportion of patients declined screening. To avoid missed opportunities for diagnosis in the ED, strategies to further improve implementation of HIV screening and optimize rates of consent are needed.

Shout-It-Now: A Mobile HCT Model Employing Technology and Edutainment in South Africa.

BACKGROUND: Mobile HIV counseling and testing (HCT) has been effective in reaching men, women, and adolescents in South Africa. However, there is limited understanding of effective mobile HCT programs utilizing tools like technology and edutainment to increase HIV counseling and testing rates. The authors examine data from the Shout-It-Now (S-N) program that uses such tools in South Africa. METHODS: The S-N program utilizes various forms of technology and ongoing telephonic counseling within a 6-step program of HIV testing and linkage-to-care support, and program data were analyzed over an 18-month period. Data were analyzed from women, men, and adolescent program participants. Summative statistics was conducted on participant registration, HIV risk assessment, and HIV testing profiles. HIV prevalence were estimated along with the related 95% confidence intervals using the Clopper-Pearson method. RESULTS: Over an 18-month period, there were 72 220 program participants with high representation of men, women, and adolescents and 40% of the participants being men at each site. There were 3343 participants who tested HIV positive, and a higher proportion of women tested positive. DISCUSSION: Integrating technology, quality assurance measures, and edutainment with mobile HCT has the potential to increase the number of those who test within communities. Research is needed to understand the effectiveness of this model in facilitating regular testing and linkage to care.

Ten Sites, 10 Years, 10 Lessons: Scale-up of Routine HIV Testing at Community Health Centers in the Bronx, New York.

OBJECTIVE: In response to the current CDC recommendations for routine HIV testing in clinical settings, the Adolescent AIDS Program at Montefiore Medical Center in the Bronx, New York, developed the Advise, Consent, Test, Support routine HIV testing model (ACTS) in 2003. ACTS was piloted in 10 community health centers operated by Montefiore because they serve populations most at risk for HIV/AIDS. METHODS: ACTS streamlined and codified the counseling and testing process, provided a routine HIV testing practice change plan, and provided training and communication materials that promoted routine HIV testing. To determine program success, we measured the number of patients seen at the clinics, the number of HIV test-eligible patients (those aged 13-64 years and not pregnant), the number and percent of patients receiving HIV testing, HIV test results, and the number of patients linked to care. RESULTS: HIV testing in the 10 sites increased nearly threefold during the pilot period (2003-2007), from 3,944 of 49,125 eligible patients (8%) tested in 2003 to 11,212 of 55,629 eligible patients (20%) tested in 2007. With little ongoing support, the sites continued or maintained improvements: 13,226 of 56,686 eligible patients (23%) were tested in 2008, 15,965 of 57,025 eligible patients (28%) were tested in 2011, 17,483 of 60,514 eligible patients (29%) were tested in 2012, and 17,971 of 63,172 eligible patients (28%) were tested in 2013. Sites identified 433 HIV-positive patients from 2006 to 2013 (0.2%-0.6% annual seropositivity), and 96% of them were linked to care within 90 days of HIV diagnoses (range: 92% to 98% annually). CONCLUSION: ACTS demonstrated that substantial and sustained increases in routine HIV testing can be achieved in health-care settings, not by adding personnel or financial resources, but by using the model's practice change plan and streamlined HIV testing approach.

Mamekhaya: a pilot study combining a cognitive-behavioral intervention and mentor mothers with PMTCT services in South Africa.

Nearly 30% of pregnant women in South Africa are estimated to be HIV seropositive, yet adherence to guidelines for the prevention of mother-to-child transmission of HIV (PMTCT) is often low. A pilot study was developed to see whether PMTCT services provided by the South African Government could be enhanced by the Mamekhaya program, a combination of the mothers2mothers peer-mentoring program and a culturally adapted cognitive-behavioral intervention (CBI) from the USA. Pregnant women attending two maternity clinics offering PMTCT in Gugulethu and Vanguard Townships, Cape Town, South Africa, were invited to participate in the study. Women at the intervention site (Gugulethu) received the support of a mentor mother and also attended an eight-session Mamekhaya CBI. At the control site (Vanguard), women received standard services provided by midwives and counselors. Baseline assessments were completed by all participants at enrollment (n=160), and follow-ups were completed six months later by 44% of participants. Self-reports of adherence to PMTCT practices were high across both sites (90% or more engaging in the core practices). Women at the Mamekhaya site showed significantly greater improvement in establishing social support and reducing depression scores than women at the control site. Mamekhaya participants also showed trends for better attendance at follow-up medical visits, and greater improvements in positive coping. The greatest effect of the Mamekhaya program was to increase HIV knowledge scores, particularly with regard to understanding the meaning and importance of viral load and CD4 test results. Results from this pilot study show promise that augmenting basic PMTCT services with mentor mothers and a culturally adapted CBI can be effective in conveying information and in improving the emotional outlook and hopefulness of HIV-positive pregnant women in South Africa.