Scalingup Paediatric ART and Improving Care Through the Implementation of a Chronic Care Model

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Scaling-up Paediatric ART and Improving Care
Through the Implementation of a Chronic Care Model

• Harry Moultrie1,2, Claire Egbers1, Tammy
  Meyers1,3 and Pierre Barker4
• 1Wits Paediatric HIV Working Unit
• 2 School of Public Health, University of the
  Witwatersrand
• 3 Department of Paediatrics, University of the
  Witwatersrand
• 4 Institute for Healthcare Improvement,
  University of North Carolina

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Estimation of need for ART in Johannesburg
Total children 730 000 HIV positive children
-22 000 Children needing ART -5000-11000
Harriet Shezi Clinic
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Children on ART in Johannesburg (n1133)
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Project aims

• Phase 1
• Scale-up ART provision
• 1300 children by 31st December 2005 at Harriet
  Shezi Childrens Clinic
• Improve quality of care
• Safety, effectiveness, patient-centeredness,
  timeliness, efficiency and equity
• Chronic care approach to paediatric ART
• Phase 2
• Pilot methodology in a Primary Health Care ART
  site

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Chronic Care Model
E Wagner
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Systems Change Framework

• Key Questions
• What are we trying to accomplish?
• How will we know that a change is an improvement?
• What changes can we test?

• Theoretical Framework
• Non-normative model with implementation of
  evidence driven changes to systems
• Avoids top-down implementation
• Allows clinicians at ART sites to determine their
  own specific priorities
• Small scale tests of change
• IHI Scale-up Model
• District based learning collaborations
• Share successful strategies
• Work on district wide systems eg. up and down
  referral mechanisms

Nolan et al
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Implementation process

• Phase 1 Harriet Shezi Childrens Clinic
  October 04
• Quality improvement team formed
• Goals and specific targets set
• Initial focus on improving efficiency to free up
  capacity
• Need for data system to monitor outcomes led to
  this being an early priority
• Baseline data collected
• Multiple changes to clinic and care systems
  tested
• Phase 2 Primary Healthcare Level ART Site
  December 04
• Weekly visits by team consisting of a doctor,
  primary health care sister and counsellor to
  provide case-based training and assist with
  systems change model

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Development of Chronic Care Management Tool for
Paediatric ART
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Chronic Care Management Tool

• Flexible and can be adapted to meet specific
  needs and resources of a clinic
• Facilitates patient stratification and flow
  through the clinic
• Provides clinician with the necessary information
  to manage a child on ART
• Provides triggers to healthcare workers eg.
  positive family members, TB, IRIS etc
• Delineates roles and responsibilities
• 1331 children (744 on ART)
• 5820 clinical visits captured
• Data to
• Manage individual children
• Monitor clinic population
• Tracking of priority outcome indicators
• Tracking defaulters and children with high viral
  loads
• Poster MoPe.11.7.C14
• Monitor systems and processes

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Outcomes to be presented today

• Efficiency
• Patient centeredness
• Scale-up
• Viral load outcomes
• Implementation in PHC setting

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Efficiency (1)
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Efficiency (2)
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Efficiency (3)

• Patient cycle time decreased from 3h12 to 2h06
• 3rd available appointment for new bookings
  decreased from 13 weeks to 3 weeks

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Patient centeredness

• Parents involved in team
• Identification of care-givers needing ART
• Fewer visits before initiation
• Decreased waiting times
• Adherence self-management
• 2 months supply at pharmacy for stable patients
  to decrease financial burden and free pharmacy
  capacity
• Down referral at patients request

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Scaling-up ART
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3 Month Viral Load Outcomes
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Phase 2 primary level site

• Collaborating primary clinics experienced some
  difficulties in implementing the model
• Staff in the primary clinics were overwhelmed by
  adult patients and battled to make time to see
  children together with the outreach team
• Lack of skills in paediatric management possibly
  used as a coping strategy
• Systems change model requires intensive support
  by a project manager
• Implementation of the Chronic Care Management
  tool hindered by policies concerning data
  management in the ART programme

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Conclusion

• Rate of ART provision more than doubled in the
  Harriet Shezi Childrens Clinic
• Safety, patient-centeredness, timeliness,
  efficiency and equity have all been improved
  within the clinic
• Further analysis of viral load outcomes over a
  longer duration on treatment together with
  comparison with other ART sites is required
• Dedicated family focused ART days are required in
  primary health care ARV sites in order to
  facilitate onsite training, systems changes and
  paediatric ART provision
• Implementation challenges in primary clinics are
  being addressed and a district wide collaboration
  involving 9 ARV sites in Johannesburg is to start
  in September

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Acknowledgments

• Sponsors
• Gauteng Department of Health
• Rockefeller Brothers Fund
• Elizabeth Glaser Pediatric Aids Foundation

• Team members
• Hermien Gous
• Yvonne Mahlangu
• Nomawonga Mtshizana
• Sandra Mbaqa
• Lungi Tenza
• Gail Ashford
• Princess Mbatha
• Zanele Ngwenya
• Nadia Patrick
• Khetiwe Nkhosa
• Pearl Hlangwane
• John Matshoga
• Peter Ngubane
• Parents and Care-givers