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


3 Department of Paediatrics, University of the Witwatersrand ... Lack of skills in paediatric management possibly used as a coping strategy ... – PowerPoint PPT presentation

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

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
  • 3 Department of Paediatrics, University of the
  • 4 Institute for Healthcare Improvement,
    University of North Carolina

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

Chronic Care Model
E Wagner
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
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
  • Need for data system to monitor outcomes led to
    this being an early priority
  • Baseline data collected
  • Multiple changes to clinic and care systems
  • 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

Development of Chronic Care Management Tool for
Paediatric ART
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
  • Poster MoPe.11.7.C14
  • Monitor systems and processes

Outcomes to be presented today
  • Efficiency
  • Patient centeredness
  • Scale-up
  • Viral load outcomes
  • Implementation in PHC setting

Efficiency (1)
Efficiency (2)
Efficiency (3)
  • Patient cycle time decreased from 3h12 to 2h06
  • 3rd available appointment for new bookings
    decreased from 13 weeks to 3 weeks

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
  • Down referral at patients request

Scaling-up ART
3 Month Viral Load Outcomes
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

  • 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

  • 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
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