Gregory Pappas, MD, PhD Senior Deputy Director HAHSTA Department of Health District of Columbia

1. Convergence of the National HIV/AIDS Strategy and the Affordable Care Act: implication for HIV care delivery system in Metro Washington DC Gregory Pappas, MD, PhD Senior Deputy Director HAHSTA Department of Health District of Columbia

2. DC Department of HealthMission • to promote healthy lifestyles, prevent illness, protect the public from threats to their health, and provide equal access to quality healthcare services for all in the District of Columbia.

3. Overview of this presentation • The convergence of HIV care and health reform • Current issues for care for HIV, review the Gardner Continuum for DC • Begin to explain why DC has problems suppressing viral load • Patient Centered Medical Home • Accountable Community Care and redesign of the care delivery system • The way forward

4. Where are we? (1) • Convergence of two great movements • National AIDS Strategy which emphasizes suppression of viral load • Treatment is prevention • Health reform is moving towards establishment of patient centered medical homes for better care of chronic disease • This is happening regardless of whether insurance mandates continue. • One point of convergence is an “HIV medical home”

5. Where are we? (2) • National leader in fight against HIV and AIDS • Second highest health insurance coverage in the nation after Massachusetts • 93% of adults are covered in DC • 96% of children are covered, number one in the nation!

6. Where are we? (3) • As an early adopter of Affordable Care Act, DC can move on to issue of improving the design of the health care delivery system • DC has shifted over 1000 people off of ADAP onto Medicaid to achieve “treatment on demand” • Medicaid Expansion • Extends Medicaid eligibility to every U.S. Citizen with income at or below 133% (tax rate of 138%) of the federal poverty level (FPL)

7. The National HIV/AIDS Strategy • Great contribution that has helped focus the field • The four pillars of the strategy • Reducing HIV incidence • Increasing access to care and optimizing health outcomes • Reducing HIV-related health disparities • Achieving a More Coordinated National Response to the HIV Epidemic DC is actively scaling up the National Strategy

8. District of Columbia Continuum of HIV Care*, 2010 *This includes HIV/AIDS cases diagnosed in DC between 2005 and 2009 and living as of December 31, 2010.†Continuous care is defined as having 2 viral load or CD4 test results reported to the DCDOH at least 2-4 months apart. ‡Cases are considered virally suppressed if their last viral load test reported in 2010 was ≤400 copies/mL.

9. Factors Associated Challenges to Care, NYC Less Likely to Regular Care* Compared Adj Odds to Ratio Blacks Non-Blacks 2.0 Ages 13-24 Age 50 + 3.0 IDU History Non IDU History 2.7 * Regular care ≥1 visit every 6 months Torian, LV and Wiewel, EW. Continuity of HIV-Related Medical Care, New York City, 2005-2009: Do Patients Who Initiate Care Stay in Care? 2011. AIDS Patient Care and STDS. 25(2):79-88.

10. Factors Associated Challenges to Care, NYC More Likely to be Lost to Care* Compared Adj Odds to Ratio Ages 13-24 Age 50 + 1.9 Diagnosed at Diagnosed at 1.4 Early Stages Later Stages Non-Hospital Designated AIDS 1.4 Settings Centers *last visit >6 months before close of analysis Torian, LV and Wiewel, EW. Continuity of HIV-Related Medical Care, New York City, 2005-2009: Do Patients Who Initiate Care Stay in Care? 2011. AIDS Patient Care and STDS. 25(2):79-88.

11. Preliminary data in DC on continuous care • Blacks and persons 13-19 less likely to be in continuous care • Black (AOR=1.4, 95%CI: 1.0-2.0 versus White) are less likely to be continuous in care than whites in DC. People age 20-29 years (AOR=0.5, 95%CI:0.2-0.9 versus 13-19 yrs) and 50-59 years (AOR=0.5, 95%CI: 0.2-1.0 versus 13-19 yrs) were more likely to be in continuous care than persons aged 13-19.

12. District of Columbia Continuum of HIV Care*, 2010 *This includes HIV/AIDS cases diagnosed in DC between 2005 and 2009 and living as of December 31, 2010.†Continuous care is defined as having 2 viral load or CD4 test results reported to the DCDOH at least 2-4 months apart. ‡Cases are considered virally suppressed if their last viral load test reported in 2010 was ≤400 copies/mL.

13. Average: 86% Percentage of clients on ART, aged 13 years and older, with a diagnosis of HIV/AIDS with a viral load <200 copies/ml at last test between September 2010 and August 2011. Denominator includes clients that had at least two medical visits during the measurement year with at least 60 days between each visit; were prescribed antiretroviral therapy for at least 6 months; and had a viral load test during the measurement year.

14. Patient Centered Medical Home • Long history traced back to Altamy Declaration • Barbara Starfield a pioneer • Emerging as a key strategy in health reform to address chronic disease quality and cost of care

15. Elements of Patient Centered Medical Home • There are four core functions • Accessible • Comprehensive • Longitudinal, and • Coordinated care in the context of families and community.” (National Academy of Sciences, 1996)

16. Appropriate coordinated care • The increases in complexity may overwhelm informal coordinating functions requiring a care team that can explicitly provide coordinated care and assume responsibility for the coordination of a particular patient’s care (National Academy of Sciences, 1996). “When you have a home and you don’t make it home to dinner some one calls you.”

17. CMS Definition CMS definition of the medical home 17 criteria for medical homes emphasizing written care plans, written protocols to ensure appointments, electronic medical records, referral networks and much more. http://www.acponline.org/running_practice/pcmh/demonstrations/two_tier.pdf.

18. Work in DC is proceeding to better define an HIV medical home • Building on the basic model • Needs to be clinical expertise in HIV • Need support services with HIV expertise • Needs community outreach customized to HIV infection populations • Places with low prevalence may need medical home with HIV emphasis versus an HIV medical home A debate in the medical home literature involves the role of specialty care. Rittenhouse, Shortell, and Fisher. N Engl J Med 2009

19. Ryan White: An Unintentional Home Builder • Convergence with long standing work by HRSA (Ryan White) to improve quality of HIV care and the medical home • HIV has a lot to contribute to medical home particularly related to patients role Saag, AIDS Reader. 2009;19:166-168

20. Redesign Needs Investment • Payment systems driving redesign alone may not be enough to get it right • Investments to help clinics and CBOs come together may be need • Local tax dollars in DC “Effi Barry Program” will be used to encourage this redesign Berensen et. al Health Affairs 2008

21. What CBOs need to consider • Strategic alliances with clinics • Mergers • Performance measures that demonstrate contribution to care • Participation in care teams • Contractual agreements that provide money for services rendered to clinical centers

22. Medical Home is not a panacea • Risk of becoming a fad and cannot solve health care’s cost and quality challenges. • Accountable Care Organizations also being discussed, redesign of larger units than the home. • Substantial payment redesign, overall health system reorganization, and much more also needed. • More research on medical home needed • team-based care, • full patient engagement, • optimal use of electronic records • Best way to implement Kilo and Wasson, Health Affairs 2010 Redesign of the health system an important role for the future of public health.

23. Three kinds of people* *This is my common sense understanding of different types of patients and levels of care they need.

24. …Accountable Care Communities: the missing link? • Contribution to health reform literature out of University of Akron • White paper emphasizes need for community based organizations to play role in improving health care quality • http://www.faegrebdc.com/webfiles/accwhitepaper12012v5final.pdf

25. Indicators of Adherence to Antiretroviral Therapy Treatment • Clinical supervision of community based programs increases adherence and viral load suppression • Without clinical supervision, no improvement Indicators of Adherence to Antiretroviral Therapy Treatment Among HIV/AIDS Patients in 5 African Countries. Etienne et. al Journal of the International Association of Physicians in AIDS Care, 2010

26. The mission of the JACQUES Initiative (J.I.) program is to provide a holistic care delivery model that provides long-term treatment success for urban populations infected with HIV. Our focus is to decrease the morbidity and mortality associated with HIV illness through care delivery while providing early intervention services through activities such as testing, outreach and linkage to care. We are committed to providing a “safe place” for our clients through delivered services and providing access to clinical research for all. We accomplish this mission through theJourney To Wellness.

27. Summary • To reach the potential of “treatment as prevention” we must improve the care delivery system in coordination with community support. • The medical home provides a useful model to achieve continuity and comprehensive care. • Redesign of the health care delivery system should be a top priority for research in DC.