Improving Linkage to Care in the Human Immunodeficiency Virus Clinic Setting

Abstract

Background At the end of 2015, an estimated 1.1 million individuals in the United States aged 13 and older were living with human immunodeficiency virus (HIV), including 162,500 (15%) of persons who are undiagnosed. The state of Maryland is currently ranked seventh among 50 states in HIV diagnoses. Linkage-to-care of people living with HIV is a major problem for health care providers. Linkage-to-care can be summarized as a completion of a visit with a primary care or HIV medical provider within 30 days of diagnosis. Linkage-to-care is currently below average at an estimated 66% in the United States with a national goal of 80%. Local Problem A linkage-to-care template inside the clinic patients’ electronic medical records ensures there is a standard of care when linking patients to a primary care provider after diagnosis. However, site staff may not be completing the template at discharge and closing the charts within three days according to protocol. The purpose of this DNP project is to raise linkage-to-care protocol adherence by implementing a pop-up point-of-care reminder in Outlook Calendar. Interventions A Quality improvement Project with pre-post intervention measurements was implemented at a Suburban HIV clinic in the United States. The project used a convenience sample consisting of five clinic case managers. Retrospective pre-intervention EMR audits (n = 20) were used to assess baseline rate of linkage-to-care closure within three days of opening. Records were randomly selected from all records discharged in April through August 2018. Pre-intervention surveys were given to clinic case managers to assess barriers to completing linkage-to-care templates within three days of opening and completing patient discharges. The intervention consisted of point-of-care electronic calendar reminders. Post-intervention surveys were given to assess satisfaction with the intervention and to seek recommendations on other ways the intervention can be utilized. Post-intervention records audits (n = 16) were used to assess whether linkage-to-care templates were closed within three days of opening at a higher rate than during pre-intervention. Results The pre-implementation survey revealed barriers in completing the discharge template, including complexity of the discharge, difficulty navigating through the record, template too wordy, too time consuming, and lack of patient cooperation. Pre-intervention audits indicated that 40% were not closed within three days. Five of 16 new records audited post-intervention were not closed within three days. A nine-percentage point increase in discharges completed within three days post-intervention was observed but was not statistically significant (p > 0.05). In the postimplementation survey, all subjects reported that reminders were important and helped with remembering to complete the discharge templates and other patient-related tasks. Conclusions This project suggests that there is a correlation between setting reminders in the outlook calendar and closing of linkage- to-care templates within 3 days. Closing of linkage-to-care templates within 3 days improved from 60% to 69% after the implementation of Outlook Calendar reminders. The results of this project further reinforce the notion that reminders at the point of care help staff complete patient-related tasks.