scholarly journals 1314. HOME CARE: Reaching Our Lost to Follow-up Patients and Overcoming Barriers to Care Utilizing Nontraditional Care Models

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S474-S475
Author(s):  
Erin Goldman ◽  
Sheronda Union ◽  
Tammie McClendon ◽  
Jennifer Veltman
Keyword(s):  
Healthcare Delivery ◽  
Care Program ◽  
Outpatient Setting ◽  
Standards Of Care ◽  
People Living With Hiv ◽  
Virologic Suppression ◽  
Healthcare Delivery System ◽  
Mental Health Barriers ◽  
Care Models

Abstract Background Of the 11098 people living with HIV in southeast Michigan, over 30% are out of care, with transportation being the most commonly identified barriers. To address this barrier and re-engage patients into care, we introduced an HIV homecare program. The objective of this study was to describe the implementation of the homecare program and document the outcomes of patients enrolled. Methods In 2016, WSUPG ID clinic saw 1990 patients and had additional 95 clients who were virally unsuppressed and lost to care for 12 months. We called all 95 of these clients and offered homecare. We also advertised our program internally, to the Detroit Public Health Departments’ Data to Care Program (Link up Detroit), and to community-based organizations. Referred patients were seen by a NP/MA team supervised by an infectious disease attending. HIV medical care delivered in home utilized same standards of care as for outpatient setting, including lab draws and counseling. Patients also had the ability to text/call provider directly on the program cell phone. This project was funding through a Part A Ryan White MAI grant. Results Of the 95 clients out-of-care, 38 (40%) were unreachable, 41 (43%) were reachable and 16 (17%) did not qualify (relocation, incarcerated, deceased, in-care at the time of call). 5 (5%) enrolled in homecare and additional 29 patients were referred to our program. A total of 34 patients enrolled from September 20, 2017 to September 20, 2018. Among the 34 clients, mental health barriers were the most frequently reported (depression in 20, schizophrenia or bipolar in 7, anxiety in 23, and history of trauma in 11). Of the 34 clients, 24 have achieved virologic suppression at least once during their enrollment. Among the 26 clients with 6+ months of follow-up, 17 have achieved virologic suppression. Conclusion Homecare offers a new, innovative healthcare delivery system which is effective at achieving viral suppression in a challenging patient population and is a successful strategy to re-engage patients in care. Disclosures All authors: No reported disclosures.

Abstract TMP100: Outpatient Statin Adherence is Associated with Reduced Recurrent Stroke Risk in Patients with or without Atrial Fibrillation

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Alexander C Flint ◽  
Carol Conell ◽  
Xiushui Ren ◽  
Sheila L Chan ◽  
Vivek A Rao ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Recurrent Stroke ◽  
Healthcare Delivery ◽  
Survival Models ◽  
Healthcare Delivery System ◽  
Race Ethnicity ◽  
Statin Adherence ◽  
The Relationship

Outpatient statin use is known to reduce the risk of recurrent ischemic stroke of atherothrombotic etiology, but it is not known whether statins have similar effects in ischemic stroke associated with atrial fibrillation (AF). We examined the relationship between outpatient statin adherence and the risk of recurrent ischemic stroke in patients with or without AF in a large integrated healthcare delivery system. Among 6,283 patients with ischemic stroke discharged on a statin over a 5 year period, 1,486 (23.7%) had a diagnosis of AF at discharge. Statin adherence rates, measured as percentage of days covered (PDC), averaged 85% (88% for AF patients and 84% for non-AF patients). We observed up to three years after the initial stroke, with an average of two years follow up. In multivariable survival models, after controlling for age, gender, race/ethnicity, and key medical comorbidities, higher statin adherence was found to strongly predict a reduced risk of recurrent ischemic stroke (Figure). In the second year post-stroke, the hazard ratio (HR) associated with a 10% increase in PDC was 0.93 (95% C.I. 0.89-097). The relationship between statin adherence and reduced stroke rates was similar in AF patients (HR 0.94, 95% C.I. 0.84-0.98) and non-AF patients (HR 0.93, 95% C.I. 0.88-0.98). These findings support the use of outpatient statins in all ischemic stroke patients, irrespective of stroke etiology (atherothrombotic vs. atrial fibrillation).

scholarly journals 1325. Inpatient Initiation of ART Improves Short-Term Mortality in People Living with HIV

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S479-S479
Author(s):  
Jamie Campbell ◽  
Christopher Polk ◽  
Danya Roshdy ◽  
Michael Leonard
Keyword(s):  
Hospice Care ◽  
Intervention Group ◽  
People Living With Hiv ◽  
Virologic Suppression ◽  
Short Term ◽  
Patient Admissions ◽  
Short Term Mortality ◽  
Living With Hiv ◽  
The Impact

Abstract Background Treatment of HIV is recommended as soon as possible and early initiation of combined antiretroviral therapy (cART) is associated with improved engagement in care; however, treatment with cART is often deferred in hospitalized patients despite being correlated with improved outcomes. We implemented an institutional intervention to ensure all people living with HIV (PLwH) were on cART during hospitalization to improve patient outcomes. Methods We prospectively identified all PLwH hospitalized at our institution and had ID physicians and pharmacists ensure they were on appropriate cART and linked to outpatient care. We retrospectively collected clinical and lab data to assess the impact of our intervention on inpatient mortality, 30-day mortality, 30-day readmission rate, and frequency of outpatient follow-up. Patients were excluded from analysis if they were admitted for hospice care. Results We identified 389 patient admissions in 275 unique patients, of which 304 admissions were already on cART at admission. After ID physician assessment, 37 of the 85 not on cART at admission were initiated on therapy. We assessed the impact of this intervention on short-term outcomes as listed in Table 1. Despite the intervention group having similar immunologic and virologic baseline characteristics to those not initiated on cART, their inpatient and 30-day mortality was similar to those already on cART. Readmission rates also decreased in the intervention group. Thirteen of 24 patients in the intervention group who could be tracked for long-term follow-up within our system achieved virologic suppression by 90 days after hospital discharge. Conclusion Inpatient treatment with cART during hospitalization improves short-term mortality outcomes. This study also demonstrates the value of inpatient cART treatment as most patients achieved virologic suppression at subsequent outpatient follow-up. Disclosures All authors: No reported disclosures.

scholarly journals The Heart Failure Readmission Intervention by Variable Early Follow-up (THRIVE) Study

2020 ◽  
Vol 13 (10) ◽  
Author(s):  
Keane K. Lee ◽  
Rachel C. Thomas ◽  
Thida C. Tan ◽  
Thomas K. Leong ◽  
Anthony Steimle ◽  
...  
Keyword(s):  
Heart Failure ◽  
Primary Care Physicians ◽  
Care Delivery ◽  
Healthcare Delivery ◽  
Clinic Visit ◽  
Heart Failure Hospitalization ◽  
Healthcare Delivery System ◽  
Unique Identifier ◽  
Clinic Visits

Background: In-person clinic follow-up within 7 days after discharge from a heart failure hospitalization is associated with lower 30-day readmission. However, health systems and patients may find it difficult to complete an early postdischarge clinic visit, especially during the current pandemic. We evaluated the effect on 30-day readmission and death of follow-up within 7 days postdischarge guided by an initial structured nonphysician telephone visit compared with follow-up guided by an initial clinic visit with a physician. Methods and Results: We conducted a pragmatic randomized trial in a large integrated healthcare delivery system. Adults being discharged home after hospitalization for heart failure were randomly assigned to either an initial telephone visit with a nurse or pharmacist to guide follow-up or an initial in-person clinic appointment with primary care physicians providing usual care within the first 7 days postdischarge. Telephone appointments included a structured protocol enabling medication titration, laboratory ordering, and booking urgent clinic visits as needed under physician supervision. Outcomes included 30-day readmissions and death and frequency and type of completed follow-up within 7 days of discharge. Among 2091 participants (mean age 78 years, 44% women), there were no significant differences in 30-day heart failure readmission (8.6% telephone, 10.6% clinic, P =0.11), all-cause readmission (18.8% telephone, 20.6% clinic, P =0.30), and all-cause death (4.0% telephone, 4.6% clinic, P =0.49). Completed 7-day follow-up was higher in 1027 patients randomized to telephone follow-up (92%) compared with 1064 patients assigned to physician clinic follow-up (79%, P <0.001). Overall frequency of clinic visits during the first 7 days postdischarge was lower in participants assigned to nonphysician telephone guided follow-up (48%) compared with physician clinic-guided follow-up (77%, P <0.001). Conclusions: Early, structured telephone follow-up after hospitalization for heart failure can increase 7-day follow-up and reduce in-person visits with comparable 30-day clinical outcomes within an integrated care delivery framework. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03524534.

scholarly journals 1313. Complementary Effects of Medical Follow-up and Virologic Suppression for Reincarcerated Inmates Living with HIV

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S474-S474
Author(s):  
Melissa E Badowski ◽  
R Kane Stafford ◽  
Brian W Drummond ◽  
Thomas D Chiampas ◽  
Sarah M Michienzi ◽  
...  
Keyword(s):  
Hiv Care ◽  
People Living With Hiv ◽  
Virologic Suppression ◽  
Management Support ◽  
Chi Square ◽  
History Of ◽  
Secondary Endpoints ◽  
Living With Hiv ◽  
Hiv 1

Abstract Background Although prison presents an opportunity to achieve virologic suppression (VS) among people living with HIV, continued success is not guaranteed upon release. Methods A retrospective cohort study was performed in reincarcerated Illinois prisoners from January 1, 2016 to July 31, 2018. Patients were included if they were age ≥18 years, carried a diagnosis of HIV/AIDS, on antiretroviral therapy (ART) at the time of release, and had CD4 and HIV-1 RNA labs drawn within 6 months of release and reincarceration. Potential subjects were excluded if reincarcerated within 30 days due to a technical violation and not receiving ART at the time of prison release. Primary and secondary endpoints were percent of patients achieving VS upon reincarceration and percent of patients following at an HIV clinic while released. Statistical analysis included descriptive statistics, chi-square, and paired t-tests. Results Among 505 patients released during the study period, 95 patients were reincarcerated and 80 were included (Figure 1). Demographic information can be found in Table 1. Fifty-one patients (64%) reported follow-up at an HIV clinic while released, whereas 29 (36%) did not. Patients who had VS at the time of prison release were more likely to make their follow-up appointment (90%) compared with those who did not (69%) (P < 0.001). In addition, patients making their follow-up appointment were also more likely to have VS at the time of reincarceration (86% vs. 10%, P < 0.001). Recidivist patients adherent to ART were less likely to experience decreases in mean CD4 count (P = 0.03) (Table 2). Subjects reporting a history of substance use were more likely not to re-engage in post-release HIV care (P = 0.001), but no difference was noted in patients with a documented psychiatric history (P = 0.2). Conclusion Patients failing to meet VS at the time of prison release should be targeted for more intensive re-entry medical and case management support to ensure adherence to follow-up and maintenance of immunologic function. Disclosures All authors: No reported disclosures.

scholarly journals Emergency Telepsychiatry and the Acute Care Continuum: Creating Value Through Improved Patient Accessibility and Follow-up

2018 ◽  
Vol 2 (4) ◽  
Author(s):  
Prentice A. Tom
Keyword(s):  
Medical Care ◽  
Human Resource ◽  
Acute Care ◽  
Medical Information ◽  
Healthcare Delivery ◽  
Healthcare Practitioner ◽  
Healthcare Delivery System ◽  
Ready Access ◽  
Access To Medical Care

I few years ago, I coined the term, “Medicine Without Walls”1 to describe our future healthcare delivery system—an environment where patient and healthcare practitioner are unencumbered by physical location or limitations in access points due to human resource restrictions, where medical information is transferred not only between patient and clinician but also between any number of care practitioners and healthcare institutions—a world where patients have open and ready access to medical care when and where needed.

Universal hepatitis B screening and management in patients with cancer who received immunosuppressive chemotherapy

2019 ◽  
Vol 26 (5) ◽  
pp. 1141-1146
Author(s):  
Lisa A Thompson ◽  
Lauren J Heath ◽  
Heather Freml ◽  
Thomas Delate
Keyword(s):  
Hepatitis B Virus ◽  
Hepatitis B ◽  
Healthcare Delivery ◽  
Hbv Reactivation ◽  
Healthcare Delivery System ◽  
Patients With Cancer ◽  
Management Protocol ◽  
B Virus ◽  
Hepatitis B Screening

Background Clinical data to guide management of patients with cancer and hepatitis B virus (HBV) infection who are treated with immunosuppressive chemotherapy are lacking. The purpose of this study was to describe HBV+ rates in a population of patients with cancer and evaluate a risk-stratified management protocol for the prevention of HBV reactivation (HBVr). Methods This was a descriptive study conducted in an integrated healthcare delivery system. Patients with cancer and hepatitis B virus infection who received immunosuppressive chemotherapy between 1 January 2014 and 31 January 2016 were included. A risk-stratified management protocol that continued for six months after chemotherapy completion or 12 months after completion of B-cell targeted chemotherapy was assessed. Outcomes included the proportion of patients who were HBV+ and amongst patients who initiated immunosuppressive therapy, proportions who received hepatitis B virus monitoring or anti-hepatitis B virus prophylaxis, or experienced HBVr or hepatitis B virus-related complications. Results There were 2463 patients with cancer screened for hepatitis B virus with 114 (4.6%) HBV+ of whom 59 (51.8%) initiated chemotherapy. Included patients were primarily older, male, and white with gastrointestinal or hematologic cancers and initiated intermediate/low-risk cytotoxic chemotherapy. During follow-up, 41 (69.5%) received hepatitis B virus DNA monitoring and 17 (28.8%) initiated anti-hepatitis B virus prophylaxis. No HBVr was observed. ALT and AST abnormalities were common but mostly Grade 1 and primarily related to the patient’s malignancy or medications. Conclusions Universal hepatitis B virus screening coupled with a risk-stratified management strategy utilizing HBVr monitoring and anti-hepatitis B virus prophylaxis in HBV+ patients receiving immunosuppressive chemotherapy for cancer may prevent HBVr.

scholarly journals HOSPITAL FOLLOW-UP FOR HEART FAILURE IN AN INTEGRATED HEALTHCARE DELIVERY SYSTEM

2014 ◽  
Vol 63 (12) ◽  
pp. A538
Author(s):  
Ali R. Rahimi ◽  
Elizabeth Neeley ◽  
Sherry Bowen ◽  
Carla Leto ◽  
Binwei Song
Keyword(s):  
Heart Failure ◽  
Delivery System ◽  
Healthcare Delivery ◽  
Healthcare Delivery System ◽  
Integrated Healthcare

scholarly journals Outcomes along the HIV continuum of care for Men who have Sex with Men in Haiti

2020 ◽  
Vol 30 (Supplement_5) ◽  
Author(s):  
W Dunbar ◽  
N Sohler ◽  
Y Coppieters
Keyword(s):  
Viral Suppression ◽  
Continuum Of Care ◽  
Hiv Care ◽  
People Living With Hiv ◽  
Virologic Suppression ◽  
Care Clinic ◽  
Effective Interventions ◽  
Sex With Men ◽  
Living With Hiv

Abstract Background The HIV epidemic in Haiti continues, with an estimated 160,000 people living with HIV at the end of 2018. Although HIV prevalence in the general population is estimated to be 2.0%, certain groups are at a higher risk of HIV infection. The prevalence of HIV among men who have sex with men (MSM) is estimated to be 12.9%. As previous data have found gaps in HIV care for this population, we explored the steps in the continuum of care to determine outcomes at each step. Methods We used an observational retrospective cohort study design to follow up MSM diagnosed with HIV in the largest HIV care clinic in Port-au-Prince, Haiti. Estimates were calculated of proportions of participants reached, tested, linked to care, commencing treatment, adherent to treatment, and who achieved virologic suppression. We identified factors associated with loss to follow-up at each step using multivariable analysis. Results Data were collected between January 1, 2015, and December 31, 2018. 5009 MSM were reached for prevention services. Of those reached, 2499 (49.8%, 95% CI 48.5-51.3) were tested for HIV, 222 (8.8%, 95% CI 7.8-10.0) had a positive test result for HIV, and 172 (77,47%, 95% CI 71.4-82.8) were linked to HIV care. Among participants who started care, 54 (44.6 95% CI 24.5-38.9) were retained and 98 (78.4%, 95% CI 49.2-64.5) achieve a suppressed viral load. Fifty-nine (44.8%, 95% CI 27.2-41.9) were lost to follow-up. Participants who had been younger, with lower educational and economic level were significantly less likely to achieve retention and viral suppression (p = 0.001). Conclusions HIV cascade data among MSM in Haiti show very poor rates of retention in treatment although those retained had good virologic outcome. Characteristics associated with LTFU suggest an urgent need to develop and implement effective interventions to support patients in achieving retention and viral suppression among MSM living with HIV. Key messages Poor HIV outcomes for men who have sex with men in Haiti. Effective interventions to improve HIV outcomes for men who have sex with men in Haiti are urgently needed.

scholarly journals Treatment outcomes in HIV infected patients older than 50 years attending an HIV clinic in Harare, Zimbabwe: A cohort study

PLoS ONE ◽  
2021 ◽  
Vol 16 (6) ◽  
pp. e0253000
Author(s):  
Tinei Shamu ◽  
Cleophas Chimbetete ◽  
Matthias Egger ◽  
Tinashe Mudzviti
Keyword(s):  
Risk Factors ◽  
Cohort Study ◽  
Significant Proportion ◽  
Cox Proportional Hazards ◽  
Sub Saharan Africa ◽  
People Living With Hiv ◽  
Virologic Suppression ◽  
Viral Loads ◽  
Cell Counts

There is a growing number of older people living with HIV (OPLHIV). While a significant proportion of this population are adults growing into old age with HIV, there are also new infections among OPLHIV. There is a lack of data describing the outcomes of OPLHIV who commenced antiretroviral therapy (ART) after the age of 50 years in sub-Saharan Africa. We conducted a cohort study of patients who enrolled in care at Newlands Clinic in Harare, Zimbabwe, at ages ≥50 years between February 2004 and March 2020. We examined demographic characteristics, attrition, viral suppression, immunological and clinical outcomes. Specifically, we described prevalent and incident HIV-related communicable and non-communicable comorbidities. We calculated frequencies, medians, interquartile ranges (IQR), and proportions; and used Cox proportional hazards models to identify risk factors associated with death. We included 420 (57% female) who commenced ART and were followed up for a median of 5.6 years (IQR 2.4–9.9). Most of the men were married (n = 152/179, 85%) whereas women were mostly widowed (n = 125/241, 51.9%). Forty per cent (n = 167) had WHO stage 3 or 4 conditions at ART baseline. Hypertension prevalence was 15% (n = 61) at baseline, and a further 27% (n = 112) had incident hypertension during follow-up. During follow-up, 300 (71%) were retained in care, 88 (21%) died, 17 (4%) were lost to follow-up, and 15 (4%) were transferred out. Of those in care, 283 (94%) had viral loads <50 copies/ml, and 10 had viral loads >1000 copies/ml. Seven patients (1.7%) were switched to second line ART during follow-up and none were switched to third-line. Higher baseline CD4 T-cell counts were protective against mortality (p = 0.001) while male sex (aHR: 2.29, 95%CI: 1.21–4.33), being unmarried (aHR: 2.06, 95%CI: 1.13–3.78), and being unemployed (aHR: 2.01, 95%CI: 1.2–3.37) were independent independent risk factors of mortality. There was high retention in care and virologic suppression in this cohort of OPLHIV. Hypertension was a common comorbidity. Being unmarried or unemployed were significant predictors of mortality highlighting the importance of sociologic factors among OPLHIV, while better immune competence at ART commencement was protective against mortality.

Abstract 339: Insights into Readmission Rates of Atrial Fibrillation Patients

2014 ◽  
Vol 7 (suppl_1) ◽  
Author(s):  
Thomas Vasko ◽  
Rachel Sylvester ◽  
William Froehlich ◽  
Meghana Subramanian ◽  
Alison Wiles ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Transitional Care ◽  
Care Program ◽  
Post Discharge ◽  
Readmission Rates ◽  
Bridge Program ◽  
Coronary Syndrome ◽  
Significant Difference ◽  
Care Models

Purpose and Background: Bridging the Discharge Gap Effectively (BRIDGE) is an NP-driven transitional care program for cardiovascular patients. It has demonstrated lower rates of readmission for patients with acute coronary syndrome who participated, but a similar benefit was not seen for atrial fibrillation (AF) patients. We sought to assess differences between AF patients who participated in the BRIDGE program and those who did not. Methods: Retrospective review of all patients referred to BRIDGE with a primary discharge diagnosis of AF was conducted (n=148). An equal number of BRIDGE attendees was randomly matched to non-attendees (n=36). Univariate techniques were used to compare groups. Results: Of 148 AF patients referred to BRIDGE, 84 (56.8%) attended BRIDGE, 36 (24.3%) saw cardiologists or PCPs for their first post-discharge follow-up, and 28 (18.9%) saw other providers or had unknown follow up. There was no significant difference in median time to follow up (12.5 days for attendees vs 9.0 days for non-attendees, p=0.503). Of the 72 patients reviewed, 17 (23.6%) were readmitted within 30 days (Table 1). Non-attendees were more likely (85.7% vs 40% p=0.134) to be readmitted with AF/related diagnoses as compared to attendees. More than half of 30-day readmissions for BRIDGE attendees were unrelated to AF (n=6, 60.0%). There was a trend toward greater incidence of comorbid CAD, HTN, CHF, or vascular disease among BRIDGE attendees, compared to non-attendees. Conclusion: Readmission patterns vary in AF patients; comorbid conditions play a role in early 30-day readmissions for AF patients despite adequate transitional care. NP-driven transitional care models, compared to traditional follow-up with a physician provider, may help identify additional issues related to comorbidities, leading to readmission. A larger sample is needed to better understand this dichotomy and to determine what measures can be taken to enhance the BRIDGE program for AF patients.

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