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									Practical Solutions from HIV Programs to Improve the Effectiveness of ARV Management
1. Documentation in Medical Record                                                     4. Provider Education
     Routine specific documentation of stable/unstable status.                             Provide ARV management education to frontline clinicians
     Stamp for progress note that includes ARV management criteria and                     Updates in HIV care at monthly provider meetings
       stable/unstable status for use at every encounter                                      Weekly clinical conference for providers to discuss complicated ARV
     Improve documentation of decision process about ARV management                           decisions
     Modify medical history and physical forms to improve documentation about                Sponsor Grand Rounds by respected speakers
       ARV management                                                                         Discuss with medical providers when ARV should not be given
     Have patients sign form if they choose not to take ARV (can reverse decision)           Train case workers about ARV management and importance of routine
     Progress note developed to prompt providers at each visit to address & review            monitoring
       CD4, VL, treatment plans, and to document rationale for ARV decisions and              Tighten resident supervision
       unstable status                                                                        Review of fellows’ management decisions by attending
     Case management interventions integrated in medical record                              Case presentations and seminars by HIV experts
     Reorganize medical records to better identify information about ARV                     Preceptorships
       management                                                                             Attendance at IAS conferences
     Documentation of side-effects                                                           Case Conferencing:
     Accelerate return of lab and other results to chart                                       Focus on difficult cases
     Create or modify existing flow sheets:                                                    Routine quarterly adherence discussions
        Include all key components of HIV care                                                 Include as part of monthly provider meeting in clinic
        Develop standardized forms covering the following areas:
                o CD4 and viral load monitoring with trends
                o Triggers for action when VL>1000                                     5. Medical Director Involvement
                o Adherence referrals                                                       Feedback to frontline practitioners
                o Defined follow-up intervals
                                                                                            Letter to medical staff about guidelines for managing patients not responding to
                o Specific ARV management parameters
                                                                                               ARV therapy
        Utilize medication flow sheet with documentation about adherence                   Act as backup for complex cases
                                                                                            Designate clinician lead for HIV care at each site
2. Reminder Strategies                                                                      Random HIV chart review and follow up on findings
       Call patients to remind them about upcoming appointments
       Tickler file to send reminder cards out for appointments
       Follow-up calls by case manager or nurse for no-shows                          6. Self Management - Patient Education/Empowerment
       Letters and/or calls to no-shows                                                    Availability of treatment readiness program, (including importance of keeping
       Enhance outreach program                                                                appointments)
       Comprehensive no-show program-including patient input into process for              Side effects education
        follow-up & checking in after visit                                                 Incentives
                                                                                            Patient diary to track labs, treatment, provide tips about adherence and other
3. Tracking Systems                                                                             educational materials
    Create list of unstable patients, update and use for tracking, referrals to            Enhance role of CAB in reviewing data
       multidisciplinary team
    Routine updating of list of visits and missed appointments with direct feedback
       to medical providers
    Develop systems to accelerate identification and contact of no-shows

NYSDOH AIDS Institute – December 2003                                                                                                                    Page 1 of 2
Practical Solutions from HIV Programs to Improve the Effectiveness of ARV Management
7. Information Systems
     Use EMR data to monitor essential elements of HIV care                          10. Adherence
     Develop system to easily track kept/missed appointments                              Promote enrollment into adherence program
     Develop automated reminder system                                                    Make comprehensive treatment adherence services available
     Database to track follow-up appointments and clinical outcomes                       Increase referrals by physicians to adherence counselors
                                                                                           Increase appointment-keeping for labs
8. QI Plans                                                                                Routine monitoring by case manager
     Implement specific ARV QI Plan                                                       Patients who miss appointments meet with Medical Director or administrator
     Implement plan to address management of patients not responding to ARV               Adherence counseling
             o Review case with clinical coordinator
             o Involve case manager                                                   11. Performance Measurement
             o Use adherence information form                                              Random ARV management reviews: monthly, quarterly
             o Flag for resistance test or repeat VL                                       Specific reviews of patients >1000 copies to determine if clinically unstable;
             o Case conference                                                                flag for special review
     Unstable Patients Plan                                                               Review of charts by Medical Director
             o Review of medical record                                                    Modify indicators to incorporate criteria from AI guidelines
             o Team review                                                                 Develop new indicators to measure care of unstable patients on ARV
             o Tracking of unstable patients                                               Review treatment plan for all patients
             o Increase HIV Specialist involvement                                         Multidisciplinary QOC review teams
             o Focused plans to facilitate adherence, expedite & enhance access to
                 multidisciplinary team services
     Monitor timeliness of viral load tests                                          12. Staff and Visits
                                                                                           Increase number of HIV Specialists
9. Lab Issues                                                                              Hire new case managers
     Simplify review of lab results                                                       Special medication visit for unstable patients
     Shorten turnaround time for reporting of results                                     Utilize community resources
     Post results to computerized lab system, including resistance tests                      Document referral processes to CBOs
     Coordinate blood drawing with visit                                                  Conduct home visits for patients unstable on ARV therapy
     Staff drawing blood will ensure f/u clinic visit scheduled in two weeks                  COBRA
     Loosen lab restrictions for processing of specimens                                      Nursing staff
     Lab Error Plan                                                                           VNS
            o Identify when blood not drawn or picked up
                                                                                               Adherence - DOT
            o Flag missing results for follow up
            o Nurse communicates routinely with lab staff
                                                                                      13. Pharmacy Involvement
            o Lab log to track when labs were completed for checking results within
                                                                                           Onsite delivery of medications to clinic to ensure pickup of refills
               14 days of draw
            o Immediate rescheduling if labs not obtained                                  Onsite pharmacist in clinic to discuss changes in regimen
            o CM and outreach staff to bring patient for labs                              Incorporate pharmacy provider into adherence form
            o Coordinate with lab staff/address IS issues
            o Ongoing performance measurement

NYSDOH AIDS Institute – December 2003                                                                                                                    Page 2 of 2

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