Achieving Program Targets: A n HIV Care Cascade Approach

1. Achieving Program Targets: An HIV Care Cascade Approach Molly McNairy and Bill Reidy, ICAP-NY March 28, 2013

2. Webinar Overview • Background • Examples of low target performance • Dimensions of the problem: M&E & Clinical • Introduce a cascade approach • A case study • Toolkit inventory

3. Webinar Overview • Background • Examples of low target performance • Dimensions of the problem: M&E & Clinical • Introduce a cascade approach • A case example • Toolkit inventory

4. Background • There are many reasons why a program may face challenges reaching key targets • Even the highest-functioning program can have low target performance • It is important that we address these challenges on an ongoing basis • Country teams have various methods for monitoring progress to targets (e.g., ongoing DQA, reports to funders, slide sets, URS)

5. URS Targets Dashboardhttps://urs2.icap.columbia.edu/#dashboard Filter by country and time period

6. URS Targets Dashboard Export data to Excel sheet

7. Webinar Overview • Background • Examples of low target performance • Dimensions of the problem: M&E & Clinical • Introduce a Cascade approach • A case example • Toolkit inventory

8. ART Initiation: Swaziland

9. Retention on ART: Mozambique Target = 85% retained 59% * 50% *Excludes patients who transferred out

10. Pediatric TB screeningOne OPD facility: Tanzania Target = 100% screened 32% 25% 8%

11. Webinar Overview • Background • Examples of low target performance • Dimensions of the problem: M&E & Clinical • Introduce a Cascade approach • A case example • Toolkit inventory

12. Low performance may have multiple and overlapping M&E-Clinical components • Data quality • Data availability • M&E system issues • Structural barriers • Staffing issues • Health system issues Solution = must include both components

13. Webinar Overview • Background • Examples of low target performance • Dimensions of the problem: M&E & Clinical • Introduce a cascade approach • A case study • Toolkit inventory

14. A Cascade Approach: Why? • A care cascade outlines the multiple steps in a clinical pathway needed to achieve optimal health outcomes. • The target of interest is part of a larger cascade of care in which the previous steps affect the target • Improving the entire cascade will lead to improvements in the target as well as other targets simultaneously • Improving the entire cascade will lead to more sustainable improvements

15. Steps in the Cascade Approach • Identify steps in the cascade that relate to target • Identify baseline data to operationalize the cascade • Choose priority sites • Choose interventions and prioritize them • Use a cohort methodology to monitor progress

16. 1. Identify steps in the cascade that relate to target • The cascade’s steps are specific to the disease (i.e. HIV, TB) and the patient population (i.e. adults, children, pregnant women/infants).

17. Adult Care & Treatment ART Eligible Link McNairy, El-Sadr AIDS 2012

18. Tuberculosis TB Suspect TB Treatment TB Treatment Success TB Disease Prevent recurrence, ongoing screening Retain, counsel monitor and support Screen Evaluate for TB disease Fayorsey, Howard 2013

19. 2. Identify Baseline Data to Operationalize Cascade • Where to get baseline data for a cascade? • Routinely-reported M&E data, e.g.: • Country aggregate databases • URS • Original data collection from clinics

20. What source to use for baseline data? • Routinely-reported M&E data • Advantages: • historical data is readily available • data available for many facilities • collection requires no additional efforts • Disadvantages: • indicators not flexible (may not measure what you need) • data may have quality issues • Particular danger when target shortfall is in part due to M&E system issues

21. What source to use for baseline data? • Original data collection from clinic • Advantages: • have access to all data collected • high level of flexibility in defining set of indicators • can use highest-quality data available • may be used to compare to reported M&E data • Disadvantages: • burden of data collection • lack of a large amount of historical data for comparison • If at all possible, advisable to collect original data to supplement routine M&E data

22. 3. Determining & Prioritizing Interventions • Root cause Analysis/Driver Diagram • Focusing Matrix

23. Driver Diagram • A tool to facilitate root cause analysis • Articulates the aim of the campaign • Organizes primary categories for reasons contributing to low performance • Subdivides categories into specific reasons • Facilitates a specific intervention tied to each reason An example…

24. Secondary Drivers Interventions Primary Drivers Aim

25. Driver Diagram • Step 1: Aim • Target • Numerical goal for improvement • Time frame • Location (place or # of clinics)

26. Secondary Drivers Interventions Primary Drivers Aim

27. Driver Diagram • Step 1: Aim • Time frame • Location • Step 2: Primary Drivers • Make a list of broad categories of factors that must be addressed to achieve aim

28. Secondary Drivers Interventions Primary Drivers Aim

29. Driver Diagram • Step 1: Aim • Time frame • Location • Step 2: Primary Drivers • Make a list of factors that must be addressed to achieve aim • Step 3: Secondary Drivers • Specific problems under each category • Step 4: Match specific interventions to each driver

30. Secondary Drivers Interventions Primary Drivers Aim Continue to fill in and complete boxes for all secondary drivers and interventions

31. Focusing Matrix • Tool to aid in prioritizing interventions • Uses both importance and ease of implementation to rank priority An example…

32. Focusing Matrix Ease of Implementation

33. Focusing Matrix Ease of Implementation # 2 priority most important and easiest to implement – #1 priority

34. Prioritizing InterventionsExample: Low ART Initiations (adult) EASE of IMPLEMENTATION Interventions B and A should be first priority

35. 4. Choosing Priority Sites Highest Volume Lowest Performance 65% 80% 42% 55% 30% 75% 20% 85% 66% 40% 35% 80%

36. 5. Cohort Methodology to measure change in performance towards target • Goal is to assess impact of approach on relevant target and cascade indicators • Impact must be sustainable • A cohort methodology: • Define cohorts of patients • Collect cascade data for cohort from source documents • Summarize graphically • Review data and revisit intervention plans • Repeat process 2-4 periodically (e.g., every month)

37. Define Cohorts of Patients • A cohort is a group of people sharing a common trait, usually defined by a point in time (e.g., birth cohort of people born in 1981) • For this cascade approach, define cohort as any patient who entered the cascade during a specified time period, e.g.: • Patients testing HIV-positive at Kagera Regional Hospital during January 2013 • Patients enrolling in HIV care at RFM Hospital during 2011

38. Collect cascade data for cohort from source documents • Operationalize the steps in relevant cascade • # enrolling in HIV care • # with ART eligibility assessed via CD4/WHO stage • # ART eligible • # initiating ART • # retained on ART (e.g., at 6 months, 12 months) • Specify the best source of data for each step • Design simple tools (paper, Excel) for abstracting and summarizing this data • Plan for periodic data collection • Measuring retrospective improvements • Measuring improvements moving foward

39. Summarize cohort in a graph Intervention begins 58% 71% 36% 36% 20

40. Summarize cohort in a graph Intervention begins 73% 58% 58% 36% 36%

41. Summarize cohort in a graph Intervention begins 79% 73% 58% 70% 58% 36%

42. Summarize cohort in a graph Intervention begins 79% 95% 73% 58% 88% 70% 58% 36%

43. Summarize cohort in a graph Intervention begins 99% 79% 95% 73% 58% 91% 88% 70% 58%

44. Review data and revisit intervention plan • Review pre- and post-intervention cohort data • Identify successes and ongoing challenges • Take inventory of factors enabling program improvement • Outline likely barriers to improvement • Consider revising intervention plan • Identify activities to keep in place, those to drop, and any new activities to begin • Keep in mind sustainability of activities and improvements • Repeat this process as new cohort data becomes available

45. Webinar Overview • Background • Examples of low target performance • Dimensions of the problem: M&E & Clinical • Introduce a cascade approach • A case study • Toolkit inventory

46. Case Study: ART Initiations • ICAP Swaziland at end of Q3 reported reaching 50% of annual target for ART initiations • Dimensions: M&E, Clinical • The Cascade approach was implemented with the following steps and results • Identify steps in the cascade that relate to target • Identify baseline data to operationalize cascade • Choose priority sites • Choose interventions and prioritize them • Use a cohort methodology

47. 1. Identify steps in the Cascade • # persons test HIV + (not reliable) • # persons enroll in HIV care • # persons assessed for ART eligibility (WHO, CD4) • # persons eligible for ART • # persons initiated ART

48. 2. Identify baseline data to operationalize cascade

49. 3. Choose priority sites • 10 largest volume clinics in 3 regions = 30 sites • Volume was defined as # of patients enrolling in HIV care in the past quarter

50. Choose interventions and prioritize them • Identify patients with known ART eligibility but no ART initiation and put them in a “expectant” patient box for expert clients to call to return to care • Introduce WHO Staging job aid to assist providers to assess patients for ART eligibility given reports of CD4 stock outs • Transfer reported CD4 results from lab registers to patient charts