HIV Service Delivery in New Mexico

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HIV Service Delivery in New Mexico

• Health Management Alliances
• Bruce Williams, MD, MPH
• University of New Mexico

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HIV Service Delivery in New Mexico

• Geographic and Sociodemographic Context
• HIV Epidemic in New Mexico
• HIV Service Delivery (1981-1997)
• HIV Service Delivery (1997-present)
• Rural Access to HIV care

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Geographic Sociodemographic Contexts
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Large Rural State

• 5th in geographic size (121,598 sq. mi)
• Total population 1,739,884 (1999 estimate)
• 45th in population density (14.3/sq. mi)

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343 miles
370 miles
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Ethnically Culturally Heterogeneous
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Poor Access to Health Care

• Highest uninsured rate in the country (25.8)
• 30th in number of active physicians (190/100,000)
• 30/33 (91) counties designated Medically
  Underserved Area (MUA)
• 12/33 (36) counties designated Health
  Professional Shortage Areas (HPSA)

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HIV Epidemic in New Mexico
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New Mexico HIV/AIDS Cases1Living (as of June 30,
2006)

• Number Rate (/100,000)
• HIV 1213 62.9
• AIDS 1958 101.5
• Total 3171 164.3
• HMA 1 Region 1196 (37.7)
• (at diagnosis)

1HIV Hepatitis Epidemiology Program,
(www.health.state.nm.us/hiv-aids.html), NM Dept.
of Health, July, 2006.
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HIV/AIDS Cases in New MexicoAs of June 30, 2006
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HIV Service Delivery in New Mexico

• 1981-1997

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NM Dept. of Health HIV/AIDS Service Grants

• Programs distributed across several NMDOH
  agencies and grantee organizations
• No unified supervision or planning
• Duplication of services common
• clients accessing same services in several
  locations
• overlapping programs managed by different
  agencies
• Differential access to care
• Rural access limited by availability of local
  resources

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NM Dept. of Health HIV/AIDS Service Grants

• Services reorganized in 1993
• HIV/AIDS Bureau created
• Single Point of Entry(ACCESS) implemented in
  1994
• single application for all HIV service programs
  in state
• demographic, financial, and clinical information
• updated annually
• statewide database administered by NMDOH planned
  but never implemented
• Direct grant mechanism maintained

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Problems With HIV Delivery System

• Decentralized service delivery by multiple
  autonomous agencies
• Variable access to ancillary services, especially
  in rural areas
• Quality of services variable, especially case
  management

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Problems With HIV Delivery System

• Central planning and supervision weak
• Grants management difficult due to distance and
  poor NMDOH staffing

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HIV Service Delivery in New Mexico

• 1997-Present

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Health Management Alliances

• Organized and funded by NMDOH in 1997
• Single grantee within each of four regions
• single point of regional entry
• one-stop service delivery
• Each serving as RW-funded Center of Excellence
  for HIV Care
• Native American HMA serves statewide clientele
• culturally competent case management

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NM Dept. of Health Direct HIV/AIDS Services

• Centralized medication program (ADAP)
• mail-order
• next-day delivery standard
• same-day delivery available in emergencies
• comprehensive formulary
• all antiretrovirals available immediately upon
  FDA approval
• extensive inclusion of other HIV-related
  medications
• prior approval generally not required
• no waiting list

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Health Management Alliances

• Capitation from NMDOH using state and RW Title II
  funding
• to provide continuum of HIV care previously
  funded through separate grants
• excludes inpatient care and medications
• amount negotiated separately for each HMA (mean
  361/pt/month range 352-380/pt/month)
• Capitates primary care and wrap-around services

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Health Management Alliances

• Partial capitation recognizes existence of
  other funding streams
• Grantee may subcontract services to ensure
  geographic coverage, but responsible for ensuring
  that care provided meets best practice
  guidelines

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HIV Funding in New MexicoFY 2006

• Source Amount Purpose
• RW Title II 3,349,677 case mgmt, ADAP,
  ancillary services
• RW Title III 1,539,423 primary care
• RW Title IV 337,186 women, pediatric,
  youth, access to clinical trials
• RW AETC 234,753 provider education
• CDC 2,347,531 testing counseling,
  prevention
• NMDOH 11,200,000 primary care, dental, case
  mgmt, ancillary, ADAP
• Private unknown discretionary

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Integration

• All major categorical funding streams integrated
  within HMA structure
• NMDOH responsible for statewide
• external quality assurance
• provider education
• single point of entry application (ACCESS)

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RW Title IV

• University of New Mexico Health Sciences Center
  sole grantee in New Mexico
• statewide HIV pediatric care through UNMHSC
  Pediatric Division of Infectious Diseases
• statewide access to high risk obstetric care
  through local UNMHSC outreach clinics.
• Some Title IV services localized to HMA 1
• routine and high risk gynecologic care
• support services for youth, affected families
• outreach to high-risk Title IV populations
• clinical trials screening and referral

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Rural Access to CareHealth Management Alliance,
District 1
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HMA 1 Map
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HMA 1 Structure

• HMA 1 Center of Excellence
• Medical
• University of New Mexico Health Sciences Center
• Division of Infectious Diseases/Dept. of Internal
  Medicine
• Social and Ancillary Services
• NM AIDS Services
• Co-located in community setting

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HMA 1 Structure

• Funding
• UNMHSC
• RW Title III
• RW Title IV
• NMDOH
• NMAS
• NMDOH
• RW Title II
• State
• CDC
• Private

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Rural Services

• Medical
• Two subcontractors (ID, General IM)
• Farmington
• Gallup
• UNMHSC supervision, including quality assurance
• Social Services
• NMAS case manager (Farmington)
• NMDOH Infectious Diseases RN (Farmington)
• Coordination of Care
• Regular case conferences between physician,
  nurse, case manager and NMDOH Infectious Diseases
  RN
• Encounter data transmitted to UNMHSC HIV Program
  Manager

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Rural Access to Specialty Care

• Medical
• Regional Hospitals
• UNMHSC
• Tertiary Care
• Subspecialties not locally available
• Telephone Consultation
• UNMHSC Physician Access Line (PALS)
• HMA 1 Medical Director
• Video Case Conferences (proposed)

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Rural Access to Specialty Care

• Dental
• NMDOH-funded contractors
• Behavioral Health
• Referral
• UNMHSC
• NMAS
• Value Options
• Statewide Single Point of Entry for Behavioral
  Health
• Available only to Medicaid patients

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Quality Assurance

• Standards of care established by Medical Director
  in consultation with Medical Advisory Board given
  to all providers
• Adult
• Womens Health
• Pediatrics

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Quality Assurance

• Annual on-site chart review
• selected indicators of compliance with standards
• perinatal assessment and triage
• charts requiring immediate attention are flagged

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Quality Assurance

• Annual on-site chart review
• exit interview with local providers and staff
• performance scores sent to each provider along
  with recommendations for improvement
• composite scores reviewed annually with Medical
  Advisory Board

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Provider Education

• Case consultation
• Annual statewide HIV clinical update
• On-site, case-based CME during annual chart audit
• E-mail alerts

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Challenges

• Access to services
• behavioral health
• dental
• nutrition
• Coordination of care
• subspecialty
• tertiary inpatient care
• Consumer involvement
• Confidentiality