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The American Journal of Managed Care June 2019
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Enhanced Care Coordination Improves HIV Viral Load Suppression Rates
Ross G. Hewitt, MD; Debra Williams, EdD; Richard Adule; Ira Feldman, MPS; and Moe Alsumidaie, MBA, MSF
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Enhanced Care Coordination Improves HIV Viral Load Suppression Rates

Ross G. Hewitt, MD; Debra Williams, EdD; Richard Adule; Ira Feldman, MPS; and Moe Alsumidaie, MBA, MSF
Enhanced care coordination in New York City that leveraged surveillance data with a health plan’s Medicaid managed care roster improved its HIV viral load suppression rate.

Study Interventions

MetroPlus, a participant plan in the pilot, established 2 interventions: street outreach, designed to target members who were not engaged in care; and peer care connection, designed to target members who were engaged in care but had an unsuppressed viral load.

Inclusion criteria for the street outreach intervention were (1) actively enrolled, (2) no viral load test or primary care provider visit in the prior 9 months, and/or (3) no ART refill in the prior 6 months. Exclusion criteria were (1) the discovery of a negative HIV antibody test or (2) disenrollment from the plan after only 1 month of enrollment. MetroPlus partnered with the Alliance for Positive Change, an AIDS service organization, to conduct street-based outreach using trained peers to seek out these lost-to-care members either by telephone or through face-to-face interaction. When contact was made, the peers discussed returning to care with the member and, with member consent, helped to make an appointment and escort the member to an HIV-related primary care appointment. Some of these visits occurred on the same day the contact was made.

Inclusion criteria for the peer care connection intervention were (1) included in the target population, (2) actively enrolled and engaged in care, and (3) with an unsuppressed viral load, defined as 200 copies/mL or greater, at last available result. Exclusion criteria were (1) the discovery of a negative HIV antibody test after program initiation or (2) disenrollment from the plan after only 1 month of enrollment. Once a member in the street outreach intervention group became engaged in care, they were also included in the peer care connection intervention. Care coordinators, working together with trained peer educators and peer counselors, sought to contact these members through telephone and/or face-to-face interactions at the clinics or hospitals that the members attended. Comprehensive psychosocial assessments were conducted whenever possible. Activities within this intervention included educational workshops, creative arts workshops, individual adherence counseling, referrals to community programs and other supportive services, and individual navigation to appointments.

Study Population

MetroPlus received a cross-referenced list in August 2015. NYS purposely sent names of individuals who were enrolled with MetroPlus at any time in the prior 4 years because members may return to the plan (beneficiaries have the right to switch Medicaid managed care plans once every 12 months). Monthly, MetroPlus reconciled the list with its active enrollment roster.

Viral Load Data Handling and Collection

For listed members with surveillance viral load results, baseline values were as recent as July 2015. To maintain some measure of confidentiality, NYS chose not to share exact numeric values and dates for viral load results but instead reported them with month/year only and in predefined logarithmic ranges categorized as suppressed (<200 copies/mL) and unsuppressed (200-999, 1000-9999, 10,000-99,999, and ≥100,000 copies/mL). MetroPlus reconciled the list with its internal care coordination database, which included available viral load results collected from provider medical records. If the internal database contained a quantified viral load value that matched the range, month, and year of the surveillance viral load value, the quantified value was kept. When there was a range value for which MetroPlus was unable to obtain a corresponding quantified value, the range value was assigned a quantified value for statistical analysis as follows: 999.99, 9999.99, 99,999.99, or 100,000.99. Using the “.99” within the value allowed for clear recognition by staff working with the members that the result was an approximation and originated from the state list. Throughout the 2-year study interval, quantified viral load values were collected and recorded from available medical records.

Data Collection

Collected data included demographics, program contact type and frequency, ART usage (refill pattern), CD4 cell counts and dates, and HIV viral load values and dates over 2 years. A successful program contact was defined as direct contact with a member who agreed to speak with the person attempting the contact either by telephone or face-to-face.

Statistical Methods

Not all members in the program had viral load data. Hence, the sample selection methodology required that eligible members for analysis had at least 2 viral load data points to measure the change in viral load from baseline. The closest viral load value to the program initiation date (+/– 90 days) was labeled the baseline viral load value. The current viral load value was selected based on the viral load available at last observation. Finally, the viral load values were categorized into suppressed or unsuppressed logarithmic ranges.

This study analyzed 2 groups: one including the derived sample of members with comparable viral loads and a subset who had an unsuppressed viral load at baseline. Because of the participation overlap of the outreach and peer care connection interventions, as well as the small number of members referred to the street outreach intervention, members from both interventions were combined for analysis.

The null hypothesis was that the program had no impact on lowering viral load values from program initiation to termination. We conducted a retrospective statistical analysis on viral load values to evaluate the change of member viral loads in each logarithmic range at baseline compared with current viral load. We visualized the change from baseline to current viral load using a kernel density estimation (KDE) plot. A χ2 analysis was performed with a P value α of .05 as a cutoff for significance for the above comparisons. Additionally, an odds ratio (OR) analysis was conducted on variables of program contact and viral load suppression, with a P value α of .05 as the cutoff for significance.

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