Promoting Linkage to Care among HIV population: Utilizing ...



Promoting Linkage to Care among the HIV population: Utilizing the Same- Day Access Clinic for a Initiating Antiretroviral TherapyTest and Treat Initiative in Hillsborough CountyDigy PaulNGR 7974University of South FloridaAbstractPromoting Linkage to Care among the HIV population: Utilizing the Same Day Access Clinic for Initiating Antiretroviral Therapy AbstractIn an attempt to answer the question “Does implementation of a Same Day Access clinic with ART initiation improve access to care among newly diagnosed HIV Patients?”, I have endeavored to prove that tTreatment for Human Immunodeficiency Viral infection (HIV) through Same Day Access clinics, coupled with Same Day Antiretroviral Therapy (ART) has dramatically improved the quality of life and life expectancy of people living with HIVthe disease. Initiation of sameSame D day Antiretroviral Therapy ART is an evidence-based intervention that facilitates the care for HIV- positive patients. The guidelines published by the Centers for Disease Control and Prevention (CDC) have issued guidelines that emphasize a on “tTest and tTreat” initiative for HIV prevention, which . This approach emphasizes on universal HIV testing, followed by Antiretroviral treatment to improve linkage and retention in care. Improving patients’ access to care is very crucial in the HIV care continuum. The overriding concept of the Same D Day Access Clinic concept is that a change in practice that can be implemented in any HIV clinic for an early initiation of Antiretroviral Therapy (ART). This quality improvement project proposes that the initiation of same- day ART (Test & Treat Initiate) through a Same D Day Access Clinic will have a positive impact on accessibility to care.e.Promoting Linkage to Care among the HIV population: Utilizing the Same Day Access clinic for Initiating Same Day Antiretroviral Therapyfor Initiating Same Day Antiretroviral Therapy.Early initiation of an Antiretroviral Therapy (ART) reduces the morbidity and mortality of patients with HIV infection. As per the HIV/AIDS Clinical Care guidelines, the five key components to eliminate HIV transmission and related deaths are as follows: 1. Implement routine HIV screening in healthcare and non-healthcare settings. 2 Increase access to antiretroviral therapyART 3. Ensure retention in care. 4. Improve access to antiretroviral pre-exposure prophylaxis (PreP) 5. Increase the HIV awareness through community outreach programs (AIDS info, 2017). In 2010, the San Francisco Department of Public Health offered ART to all patients with human immunodeficiency virus (HIV) regardless of their CD4 count. In 2013, San Francisco General Hospital have launched a clinical health system intervention, the entitled Rapid ART Program Initiative for HIV Diagnoses (Rapid RAPID) ART program for HIV patients, by initiating same- day antiretroviral therapyART. The results of the program report reveal that repeated HIV testing, followed by immediate ART, could substantially decrease the incidence incidents of HIV (“SFGH Rapid RAPID ART program,””, 2013). The HIV Treatment Cascade recommends that same day ART initiation and early accessibility to care could reduce the prevalence of HIV infection (CDC, 2017). The primary objective of the Hillsborough County, FL, Department of Health in of implementing the Same Day Access Clinic in Hillsborough County Health Department is to increase the accessibility to of care among newly- diagnosed HIV patients.Description of the Problem (Background & Significance)According to the Centers for Disease Control and Prevention (CDC), as of 2016, more than 1.1 million people in the United States are were living with HIVV according to US government data as of 2016. . The year before that, In 2015, an estimated 38,500 new patients people were diagnosed with new HIV. infection in this country. While there was an overall eight percent decline in annual HIV infections in the United States from 2010 to 2015 (from 41,800 to 38,500), in 2016, 39,782 people were diagnosed with HIV (CDC, 2017). Despite impressive advances in antiretroviral therapy (ART) for HIV-infected individuals, only around one-third of the 1.1 million individuals who are eligible for treatment are currently receiving it. As perof the 2011 US Ccensus, it was estimated that only 21% of HIV- infected individuals in the United States are were aware of their HIV status. The data also shows that 31% of newly- diagnosed HIV patients delay the linkage to care for about six months or longer, (“Guide for HIV/AIDS,”, 2011). Missed appointments are often common and are associated with the delayed initiation of ART. According to the CDC’s (2011) data collection, 480,000 (40%) out of 1.2 million people with HIV in the US infection, 40% (480,000) were engaged in any form of HIV medical care. Only 92% (444,000) of tthose hose 480,000 were prescribed ART, and 82% (360,000) were withpresented a suppressed Viral Lload (VL) below 200 copies/ml. (CDC, 2011). In 2016, Florida was ranked ranked the third in the United States for HIV cases in 2016. As perThe Florida Department of Health reports that there were 4,972 people were diagnosed with HIV in that year. With 114,772 persons living with HIV in Florida, antiretroviral Antiretroviral (ARV) drug use is very essential in the treatment of HIV Florida’s population (114,772 people) living with HIV (CDC, 2016). The US Department of Health and Human Service (DHHS) guidelines recommend s universal ART to all patients with HIV as the early as possible. In 2016, DHHS identified the strategic directions to achieve this outcome, including are encouraging people to know their HIV status, accelerating the scale-up of HIV/AIDS treatment, maximizing the health sector’s contribution to HIV prevention, and investing in obtaining strategic information’s to guide the patient’s outcome (DHHS, 2016). ?One of the issues currently facing being faced today in the Hillsborough County Health Department’s (HCHD) , Specialty Care Clinic is the lack of accessibility to immediate HIV care among HIV- positive individuals. Initiating ART at the early stage of HIV diagnosis, as well asnd connecting patients to care, are necessary to keep the viral load under?control.?Patients were seen in this Specialty Care Clinic as an 80/20 mix of scheduled and walk-in patients?respectively. The current practice of initiating ART takes three to four3-4 months, to initiate an Antiretroviral Therapy, and the system was is currently not capable of accommodating the newly- diagnosed HIV patients. As a?result,This prompted the HCHD to initiate?a Same Day Access Clinic mModel was identified to initiatefor Antiretroviral?TherapyART therapy among this newly- diagnosed HIV population.Review of LiteratureReview of LiteratureIntroduction The review of literature provides the relevant information for validating the necessity of initiating ART at the early stages of HIV diagnosis. The HIV/AIDS tTreatment guidelines support the initiation of same day antiretroviralSame Day ART therapy on a newly diagnosed HIV patient. I have also reviewed Same Day ART initiation and its impact on linkage to care, along with and its effect on viral load suppression are reviewed. Furthermore, I have appraised a synopsis of related themes found in supportive literature. are appraised. Search StrategyA systematic literature search was done in theI have utilized the literature database PubMed, ; the search engine Google Scholar, and Research Gate for my systematic literature search. The search terms used are “Test and Treat initiative;”’’; “Same -Day Antiretroviral Therapy;”’’; “Early viral load suppression;””, and “linkage to care among the HIV population.””. Additionally, the eligibility criteria were set as follows: the publication period from January 1, 2013, to June 1, 2018;, however interventional, non-interventional; multiple design studies and randomized control trials were included. The grey literature, editorials, comments, congress abstracts, and letters were excluded. The search in PubMed revealed seventy suitable records; ten duplicates were removed, resulting in sixty records for screening. The first hundred hits for each of the search terms in Google Scholar were considered, resulting in two additional records after removing duplicates. Each title of the article was read and evaluated. Sixty-two non- duplicate citations were screened. Thirty-two articles were excluded after title/abstract screening, fifteen articles were excluded after full text screening, and ten articles were excluded during data extraction. After the entire search process were was completed, five were selected. For a depiction of the search, see the Prisma Diagram in Appendix A. PRISMA DIAGRAMPatient Problem, Intervention, Comparison, Outcome and Time (PICOT) and tThe Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) tools were used to develop the practice question, evidence and translation. After using PICOT to formulate the practice question, “Does implementation of a Same Day Access Clinic with ART initiation improve access to care among newly diagnosed HIV Patients?”, was determined, a search for an evidence was conducted on selected articles regarding the impact of same day ART on access to care among HIV population. As per the Poe & White (2010), I propose afollowing evidences, a practice change of implementing the Same Day Access Clinic model as a means of achieving virology suppression in newly-diagnosed patients. is proposed. (Poe &White, 2010).Literature Appraisal Research has shown that prioritizing immediate ART initiation can reduce the time needed to achieve virology suppression in newly- diagnosed patients. Pilcher, et al. (2015) performed a quantitative study (“Providing Same Day, Observed ART to newly diagnosed HIV+?out patients are associated with improved virology suppression” and published in the Journal of Acquired Deficiency Syndrome) in 86 patients, out of which; 39 were eligible. & 37 (94.9%) of those patients out of 39 began ART within 24 hours. VThe virology suppression was faster (within 1.8 months) in comparison to universal ART treatment in a standard clinic (within 4.3 months). This study agreed that same Same day Day ART shortens the time- to- virology suppression. One limitation of the study, however, identified that ART was begun without some baseline laboratory results, yet n. No safety or ART resistance issues were identified. As a result, there were intensified demands on clinical providers to consider early regimen modifications on follow- up visits were intensified. Furthermore, Aa second limitation of this study is that the RCT was performed with a small sample size; h. However, the data provided was substantial and evidence-based (Pilcher et al., 2015).A randomized control trial, performed by Rosen et al. (2016), shows There is an evidence that that offering single-visit -ART initiation to adult patients in South Africa increased the uptake of ART by 36% and viral suppression by 26 %. The trial A randomized control trial performed by Rosen et al. (2016) measured the outcome of viral suppression (<400 copies/ml) in 377 patients. In the rapid RAPID group, 119 out of /187patients (64%) initiated same daySame Day ART treatment and were virally suppressed at 10 months compared to 96/190 (51%) in the standard group. This study demonstrated a strong relationship between sameSame dDay ART initiation and early linkage to care. However, the long-term effect of reducing the number of clinic visits prior to ART initiation remains unclear. The results could not be generalized as the trialit was conducted only in two clinics (Rosen et al., 2016).A randomized control trial performed by Michael, et al (2012), concluded that higher rates of early retention in HIV care are associated with same same-dday ay initiation of ART, as well as helping . It also helps to attain early viral load suppression. The study identified that, aAmong 676 HIV patients that were included in the trial, the study identified that 63% achieved VL<50 copies/ml within three hundred and eight308 days. These findings validated the importance of same- day ART initiation on a newly diagnosed HIV patient (Michael et al., 2012). Same- –day HIV testing, and ART initiation is feasible, beneficial, and improves retention in care with virology suppression among patients with early clinical HIV disease. As per Serena et al. (2017), a randomized control trial in Haiti enrolled 762 patients, out of which ; a 356 standard group initiated ART (standard group) in 3 weeks after HIV testing vs 347 in the same- day ART group. In the standard group, the 156 (44 %) participants who were retained in care with 12-month HIV RNA <50 copies/ml; 184 (52%), had <1000 copies/ ml.? In the Same DSame Day ART group, 184 (53%) participants were retained with HIV RNA below 50 copies/ml, and 212 (61%) had <1,000 copies/ml (Serena et al., 2017).CASCADE trial, an RCT by Labhardt, et al. (2016), concluded that the same- day home-based ART initiation after a positive HIV test is a feasible approach to improve linkage to care, retention in care, and e & viral load suppression. The study points out that there was a significant increase in linkage to care at three months and viral suppression at twelve months (Labhardt et al., 2016). Among these evidences, five level- one high- quality quantitative control trials were appraised. All of these studies concluded that Same Day ARTnti-Retroviral Treatment improves access to care, retention in care, and faster viral load suppression among HIV-positive+ patients.Literature SynthesisThroughout the review of multiple literature,The multiple sources I have reviewed agree that Same day Day HIV testing and combined with ART initiation has been shown to improve the virology suppression among patients with an HIV. Pilcher, et.al., and disease (Pilcher et al.2015). Serena, et. al, agree that Same day Day ART will shorten the time to virology suppression and support the fact that . Hhigher rates of early retention in HIV care are associated with achieving VL suppression and lower VL burden (Serena et al. 2017). Labhardt, et. al., agree that Same day Day Anti-Retroviral Treatment improves access to care, ; retention in care, and faster HIV viral suppression among newly diagnosed HIV patients (Labhardt et al. 2016). Overall, the literature supported thatsupporting Same daySame Day ART initiation is rigorous, feasible, and beneficial. Patient, Implementation, Outcome, Time (PICOT)PICOT (Patient Problem, Intervention, Comparison, Outcome and Time) was utilized to develop a proper quality improvement question. The “P” addressed in thine PICOT represents the number of Adult HIV patients of all ethnicities and genders that could benefit from linkage to care in the Same Day Access Clinic. The “I,” for Intervention recommended, includes same- day ART initiation as per “Test & Treat” guidelines. The “C” “represents?comparison of access to care through a Same Day Clinic versus a Standard Clinic.?Outcome is measured by the number of?days it took to initiate?ART through au Same Day Clinic, while .?“T” represents time, which includesand represents a four- a four-month retrospective chart review. Utilizing the PICOT development tool, a formal PICOT question was established: “Does implementation of a Same Day Access clinic with ART initiation improve access to care among newly diagnosed HIV Patients?” (Poe & W white, 2010).Goals/ & ObjectivesThe primary objective of this quality improvement project is to increase the accessibility of care among the HIV population through a “Same Day Access Clinic” that minimizes the time to initiate an Anti-Retroviral Therapy on a newly diagnosed HIV+ patient.Theoretical or conceptual Conceptual models Models that guide Guide the project Project designDesignThe HIV Treatment Cascade (Appendix B) is a powerful model that represents a quantitative depiction of discrete steps in the HIV Care Continuumcontinuum. This model is consistent with the National HIV/AIDS Strategy and its specific national goals for testing, linkage, retention, and viral suppression (CDC, 2017). By applying this Eevidence-based Based practice Practice (EBP) model, a Same Day Access Clinic concept was introduced to initiate ART on newlyto newly- diagnosed HIV patients in order to promote early linkage to care. This concept was created specifically by using the latest research findings as well as incorporating the best practices in patient care. HIV Treatment Cascade {Retrieved from Clinical Infectious Diseases., 57(8), 2013.}Early initiation of ART will benefit individuals from in their pathophysiological progression to AIDS. In broad sense, ART initiation has various types of impact such as: It reducesimpacts, such as reducing the opportunity of secondary transmission by suppressing the viral load to an undetectable level. It impacts an individual’s life expectancy by reducing the risk of AIDs and AIDS- related death. The ultimate aim for an HIV treatment program is for people living with HIV to be virally suppressed. For this to happen, people living with HIV need to be diagnosed promptly, quickly receive antiretroviral treatment (ART), continuously engage with medical services, and adhere to medication. Their c, and the care also needs to be managed appropriately. If any of these steps are missed, the benefits of treatment for the individual and their sexual partners can be lost. ( HYPERLINK "javascript:;" Mugavero, etal. 2017). The Joint United Nations program on HIV/AIDS (UNAIDS) has introduced the concept of an HIV Treatment Cascade to fill the gaps in the continuum of services for testing, care and effective treatment (UNAID, 2018).Implementation PlanSetting The study will be conducted at Specialty Care Clinic, in Hillsborough County,; Florida. This clinic is operated by the Hillsborough County Health Department (HCHD) in , Tampa and. This clinic provides services to the local population of patients with HIV/AIDS population. An estimated of 2000 HIV patients were as established with this clinic, and & 2300 unduplicated services were provided in the year 2017. Six nurse practitioners and two physicians are provideing various services, including to this population. This clinic provides medical, ; dental, ; laboratory,; pharmaceutical, and ART assistance programs for all patients with HIV/AIDS. Target Population All newly- diagnosed HIV patients are included, irrespective of age, gender, or ethnicity. Patients who will be excluded from this project are: 1. Patients with HIV+ diagnosis for more than two years, 2. Patients who would not be safe to start therapy on the same day, 3. Patients transferring HIV care from other clinics or already on ART at the time of initial visit to Same Day Access Clinic. Procedure or InterventionThe HIV Treatment Cascade model will guide administrators who wish to facilitate a practice change at Specialty Care Clinic. The review of evidence-based literature supports that early initiation of ART on newly diagnosed HIV patients helps not only the accessibility to care but also helps to attain early viral load suppression. Same Day ART on newly diagnosed HIV patients will improve the linkage to care and will reduce the time span from diagnosis to the initiation of treatment. To achieve this outcome, the Same Day Access Clinic will be utilized to implement the Test & Treat Initiative. The Same Day Access clinic will see all newly diagnosed HIV patients who walk in any day (Monday to Friday) from 7 am to 3 pm. The purpose of this clinic is to offer same- day healthcare evaluation and treatment to three types of HIV infected patients on a walk-in basis. They include newly diagnosed HIV patients, previous patients that are being readmitted to the clinic who are fallen out of care for more than a year, and established patients who are sick and need to be seen before their next scheduled appointment. At the initial visit, prescribing provider offers mental health screening, risk assessment, discuss sexual health, education regarding HIV infection, and benefits of initiating antiretroviral therapyART. Options will be given to patients for declining the treatment or initiation of ART on the same day. To those who are willing to start the ART, all baseline laboratory tests (CD4 count, HIV RNA level, renal and liver function tests, hepatitis serology, HLA B 5701 testing and HIV resistance genotyping) will be obtained. Pre-approved ART regimen (Tivicay & Descovy or Prezista & Descovy or Genvoya) will be initiated and the patient will be given a 30-day supply of ART with a 2 two-weeks follow up appointment in a regular clinic. Also, Drug assistance Assistance program Program(ADAP) / Ryan White funding appointments for unfunded patients will be arranged on the same day so that these patients will be eligible to get free medication through these funding. The Same Day Access Clinic will increase the number of patients added to the practice and thereby access to care for newly diagnosed HIV patients as well as those who want to get re-established with the services. ?Measurement & Evaluation Plan Measures After the implementation of Same Day Access Clinic, the quantitative data will be collected related to patient metrics and no show rates. Also, the qualitative data pertaining to the referral process and clinic flow will be evaluated using a quality assessment questionnaire developed from the Agency for Healthcare Research and Quality (AHRQ, 2017). Data collection Procedure Upon IRB approval, the data will be collected for a period of four months after implementation of the project. Indicators are as follows :1. The percentage of newly diagnosed HIV patients who initiated ART through the Same Day Access Clinic for a period of four months 2. The time frame from the date of diagnosis to ART initiation in each individual cases. 3. Percentage of no-show rates will be assessed for a period of four months status post implementation of the project. To measure the no show rate, the total number of referrals will be collected from various referral units such as HIV screening, Disease Intervention Specialists (DIS) and the Health Department Business Center. Data will be compared with the number of patients who are not showing up for their initiation of ART. The student researcher will create a form and will answer six series of open-ended questions after analyzing the data and will record the results in narrative text format. The researcher will be using a series of tables and graphs to summarize the information gathered. To have an easy understanding of the process a flow chart will be developed that will guide other Health Department Clinics who would like to implement Test & Treat initiative in their practice settings. A minimum of thirty newly diagnosed HIV patients will be included for the study. However, sample size may vary according to the availability of new cases, plan is to include all the newly diagnosed HIV patients for a period of four months post implementation of the project.Data ManagementData analysis will be done on an Excel spreadsheet. A flow chart will be created to show the comparative analysis of patients who initiated ART on the same day versus those not initiated same day antiretroviral therapy. The researcher will collect the data by reviewing the patient chart from Electronic Health Record (EHR) for a period of four months upon IRB approval. The data will be stored in health department computer with a protected password. Once the project is completed, the hardcopy of files will be destroyed by shredding, and the researcher will delete the computer files permanently. Data Analysis PlanThe author will evaluate both quantitative and qualitative data from Same Day Access clinic to see if the goals and objectives of the project have been met and intervention is beneficial. It is assumed that initiation of?an?ART on the same day of HIV?diagnosis will not only increase the access to care but also improves the patient metrics of the?facility. The Researcher also will evaluate whether this Same Day Access Clinic process will reduce time frame to initiate ART on a newly diagnosed patient. In addition, it will serve as a practice model for other county health departments to?increase the accessibility of care for their HIV population. The process of referrals and barriers will be analyzed. Based on the results, the recommendations for a process improvement will be given. Measurement & Evaluation Plan Measures After the implementation of the Test & Treat Initiative through the Same Day Access Clinic, this researcher will evaluate the process of outcome by looking into four steps in the process (see Appendix C)Screening for HIVLinkage to careInitiating Same Day ART Transition to care. Data collection Procedure Upon IRB approval, the qualitative outcome pertaining to the Test and Treat initiative will be assessed by using a checklist, and the data will be collected every month for a period of four months after implementation of the project. The outcome will be evaluated are as follows:Percentage of patients who had screening and tested positive for HIVLinkage to care as measured by the percentage of patients who were registered at the Same Day Access Clinic, are seen by the provider on same day, and who were issued a prescription for Same Day ARTPercentage of patients who initiated Same Day ART and those who got their first dose of medication in the clinicTransition to care as measured by the percentage of patients who had shown up for follow-up appointments in two weeks. This researcher will utilize a series of tables and graphs to summarize the information gathered. To facilitate easy understanding of the process, a flow chart will be developed that will also serve as a guide for other Health Department Clinics that would like to implement the Test and Treat initiative in their practice settings. A minimum of thirty newly-diagnosed HIV patients will be included in the study; however, sample size may vary according to the availability of new cases. Data Management A checklist will be created in questionnaire format, and adherence to each step of the Test and Treat Initiative will be marked by answering “Yes” or “No.” The data will be collected each month, and the results of the analysis will be marked on an Excel? spreadsheet. There will also be a monthly comparative analysis of patients who initiated ART on the same day versus those who did not. This researcher will collect the data by a retrospective review of the patient chart from Electronic Health Record (EHR) for a period of four months upon IRB approval. The data will be stored in health department computer with a protected password. Once the project is completed, any hard copies of files will be destroyed by shredding, and this researcher will delete the computer files permanently. Data Analysis PlanThe author will evaluate quantitative as well as qualitative data from the Same Day Access Clinic to see if the goals and objectives of the project have been met and intervention is beneficial. It is assumed that the Test and Treat initiative through the Same Day Access clinic will increase the access to care, an early initiation of ART and the transition to care. A flow chart will be created to show the Same Day Access Clinic process of implementing the Test and Treat Initiative. In addition, it will serve as a practice model for other county health departments that wish to increase the accessibility of care for their HIV+ population, where the process and barriers can be analyzed and recommendations for process improvement can be made based on those results. Protection of Human SubjectsAs Because this study focuses on practice improvement, it will have pose a low risk for human subjects. There are no known or anticipated risks associated with participation in this study. Volunteers who agreed to participate in the practice improvement project will be provided an with all information pertaining to informed consent prior to the implementation of the project.. There is no compensation; cost or conflict of interest because of participation. Records and data will remain private and confidential. Outcomes from this study may be published,; in which case no information that would allow for patient identification will be includedpatient identification will be impossible. No names or patient identifiers will be included in the data collection process. A pPatient’s health information will remain private and their human rights will be protected. Project Approval approval was obtained from Mr. Carlos Mercado, the Director of Hillsborough County Health Department, Mr. Carlos Mercado. (See Appendix D.)The Same Day Access Clinic model will be submitted to the IRB for review and approval. Dissemination PlanMeetings will be held weeklyto keep to inform the Same Day Access Clinic staff (Registered registered Nursesnurses; Nursing nursing supervisors & Medical medical assistants) up to date on the process who are working in the Same Day Access Clinic will be held weeklyabout the process.D. The daily data regarding the number of newly diagnosed HIV patients who initiated ART through Same Day Access Clinic will be reported to the data analyzer. After implementation, the all data will be collected, analyzed, and compared by the researcher. The dissemination Dissemination Pplan involves the internal stakeholders, manuscript, poster, conferences and meetings. The final report will be submitted to the Program Manager of the Specialty Care Clinic Health Department, and the results will be shared with Dr. Catherine Ling, USF faculty supervisor. AThere will be a poster presentation will be made accessible to staff and students at the University of South Florida, while t. The data will also be shared with internal stakeholders, providers, nurse practitioners, and nurses who work in the Health Department. A manuscript will be submitted for publication to the peer- reviewed -journal of the Association of Nurses in AIDS Care. Conclusion The United States Centers for Disease Control and Prevention (CDC) estimates that HIV has not been diagnosed in about 13% of the people living with this virus (CDC 2017). Review of the literature shows that only 57% of patients are retained in care since the diagnosis of HIV. Among this group only 55% are virally suppressed because of poor linkage to care and retention in care (CDC, 2015). Implementation of Same Day Access Clinic is an evidenced-based intervention that aims to facilitate linkage to care. Previous quality improvement projects suggest that initiation of same daySame Day ART on newly diagnosed HIV patients improves early viral load suppression as well as keeps them in care. Implementing the proposed changes not only minimizes the days from HIV diagnosis to initiation of antiretroviral therapyART but is also proven to suppress the viral load at the earliest. This proposed project investigates the promoting factors and gaps in the literature, and uses that combined information to implement the Same Day Access Clinic in the Specialty Care Clinic setting at Hillsborough County Health Department. This will ultimately promote quality priorities of the FLDH, and improve healthcare outcomes for its HIV population.Appendix A.PRISMA DiagramAppendix BHIV Treatment CascadeRetrieved from Clinical Infectious Diseases., 57(8), 2013.Appendix CLetter from Mr. MercadoAppendix DSame Day Access Clinic Process in Initiating Same Day ART on Newly-diagnosed HIV+ Patients50165299699480034880559283700019462759702800046373096842200 References?Dearholt, S.L., & Dang, D. (2012). Johns Hopkins nursing evidence-based practice: Model and Guidelines (2nd ed.). Indianapolis, IN: Sigma Theta Tau International.FDOH HIV/ AIDS section Test and Treat Protocol. (Sep 2016) retrieved from h, B.M., & Fineout-Overholt, E. (2015). Evidence-based practice in nursing &?healthcare: A guide to best practice (3rd ed.). Philadelphia, PA: Wolters Kluwer Health.Mugavero, M.J., Amico, K.R. Westfall, A.O., Crane, H.M., Zincky, A. Willing, J.H., Dombrowski, J.C., Norton, W.E., Rapper, J.L, Kitahata, M.M.& Saag, M.S. (2012) Early retention in HIV care & Viral load suppression: Implications for a Test and Treat approach to HIV Prevention. Journal of Acquired Deficiency Syndrome,59(1), 86-93. Retrieved from doi:10.1097/qAI.0b013e318236f7d2.Pilcher, C.D., Ospina-Norvell, C., Dasgupta A., Jones, D., Hatrogenesis, W., Torres, S.,?Calderon, F., Demico, E., Geng, E., Gandhi, M., Havir, D.V., & Hatano, H (2015) Providing Same Day, Observed ART to newly diagnosed HIV+?out patients are associated with improved virology suppression. Journal of Acquired Deficiency Syndrome,59(1), 86-93.doi:10.1097/QAI.0000000000001134 Poe, S. S., & White, K. M. (2010). Johns Hopkins nursing evidence-based practice: Implementation and Transition. Indianapolis, IN: Sigma Theta Tau International.Koeing, S.?P., Dorvil, N. De?Vieaux,?J.?G.,?Hedtgautheir, BL, Riviera.?C.,?& Faustin;?M. (2017) same day HIV testing with initiation of antiretroviral therapy versus standard care for persons living with HIV. PLoSMed,14(7).10.1371/journal.pmed.10002357.Rosen, S., Maskew, M., Fox, M.P., Nyonic, C., Mallet, G., Sannel, L., Bokaba, D., Saul, C., & Long, L. (2016). Initiating Antiretroviral Therapy for HIV at a Patients First Clinical Visit: The Rapid IT Randomized Control Trial. PLoS Med. 13(5), e1002015.doi:10.1371.National Institutes of Health, U.S. Department of Health and Human Services. (2017). Retrieved July 2, 2018, from of resistance in subjects failing dolutegravir monotherapy (2017).CROI Conference, Retrieved from http:// HYPERLINK "" sessions/initiating-art-patient%C2%92s-first-clinic-visit-rapit-randomized-trial.World Health Organization. “Towards Universal Access: Scaling up Priority HIV/AIDS Interventions in the Health Sector. Progress Report (2008).” Retrieved June 30, 2018 from HYPERLINK "" universal access report 2008.pdf.Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents, AIDS info, (2017). Department of Health and Human Services. Retrieved July 2, 2018 from HYPERLINK "" . Appendix EEvaluation Questionnaires Developed as per Agency for Healthcare Research and Quality’s (AHRQ), 2017 ToolDoes the Same Day Access Clinic help to reduce the number of days to ART initiation on a newly diagnosed Patients?Once Implemented the process of Same Day Access Clinic Model, are we able to get zero percent no show rate.Does the process flow for referrals are executed smoothly and patients get to the provider within recommended time frame.?What are the benefits of implementing the project?What are the barriers for implementation of the process?Does Same Day Access Clinic will be a model for other health department clinics to follow in providing efficient care for HIV population?Center for Disease Control and Prevention, HYPERLINK "" \o "Guidelines for Using Antiretroviral Agents Among HIV-Infected Adults and Adolescents" Guidelines for Using Antiretroviral Agents Among HIV-Infected Adults and Adolescents, (2014). Atlanta, GA:US Department of Health and Human Services, CDC, (2014). Retrieved from HYPERLINK "" . HYPERLINK "javascript:;" Mugavero ,M.J., Amico, K. R., K., Horn, T., & Thompson, M.A. (2013).The State of Engagement in HIV Care in the United States: From Cascade to Continuum to Control.?Clinical Infectious Diseases, 53(8),1164-1171.Retrieved from HYPERLINK "" Francisco Program for Rapid ART Initiation and Linkage to Care, Standard Operating Procedures (2016). Retrieved June 28, 2018, from HYPERLINK "" citywide rapid protocolv2.pdf.Guide for HIV/AIDS Clinical Care. (2011). Retrieved June 30, 2018, from HYPERLINK "" , N.D., Ringera, I., ThaboI.Lejone, T.I., Klimkait, T., Muhairwe, J., Amstutz, A., & Glass, T.A. (2018). Effect of offering Same-Day ART VS Usual Health Facility Referral During Home Based HIV testing on Linkage to Care and Viral Suppression among Adults with HIV, The CASCADE Randomized Clinical Trial. JAMA,319(11),1103-1112. doi:10.1001/jama.2018.1818. Appendix AMission:To protect, promote & improve the health of all people in Florida through integrated state, county & community efforts.HEALTHHEALTH2994659-33021004771389-393710068389524129900Vision: To be the Healthiest State in the NationJune 6, 2018Rick ScottGovernorCeleste Philip, MD, MPHState Surgeon General and SecretDigy Paul, MSN, ARNP-cFlorida Department of Health in Hillsborough County 1105 E. Kennedy BoulevardTampa, FL 33602-3511Dear Ms. Paul:The purpose of this letter is to confirm administrative support and approval for implementation of the proposed quality improvement project, under protocol title "HIV Same Day Access Clinic Model Initiative & Implications on a Practice" at the Florida Department of Health in Hillsborough County in the Specialty Care Center facility. The goals of this quality improvement project are consistent with the Department's commitment to a culture of continuous quality improvement and of our agency's strategic goal to increase healthy life expectancy, including the reduction of health disparities by reducing the number of new HIV infections and fulfill our mission to promote, protect and improve the health of all people in Florida through integrated state, county & community efforts. We welcome this opportunity to support this endeavor and to further achieve our mutual goals and objectives.3459480952500,Director, Disease Control DivisionFlorida Department of Health - Hillsborough Countycc:Charurut Samboonvit, MD, Senior Medical Director, Florida Department of Health in Hillsborough CountyMichael Wagner, Health Center Administrator, Special Care Center, Florida Department of Health in Hillsborough CountyNadine Connor, DNP, MSN, ARNP-c, Administrative Director for HIV Services, Specialty Care Center, Florida Department of Health in Hillsborough County Maritza Acosta, Office Manager, Specialty Care Center, Florida Department of Health 70802521716900in Hillsborough County. 378523466230400 Florida Department of Health - Hillsborough CountyDivision of Disease Control; P. O Box 5135. Tampa, FL 33675-5135. Phone (813) 307-8008. Fax:813-272-6984.Appendix B Same Day Access Clinic Process in Initiating Same Day ART on Newly Diagnosed HIV+ Patients.35814091694000189738092456000538734092456000357378087122000Appendix CEvaluation Questionnaires Developed as per Agency for Healthcare Research and Quality’s (AHRQ), 2017 ToolDoes the Same Day Access Clinic help to reduce the number of days to ART initiation on a newly diagnosed Patients?Once Implemented the process of Same Day Access Clinic Model, are we able to get zero percent no show rate.Does the process flow for referrals are executed smoothly and patients get to the provider within recommended time frame.?What are the benefits of implementing the project?What are the barriers for implementation of the process?Does Same Day Access Clinic will be a model for other health department clinics to follow in providing efficient care for HIV population?ReferencesCenter for Disease Control and Prevention, Guidelines for Using Antiretroviral Agents Among HIV-Infected Adults and Adolescents, (2014). Atlanta, GA:US Department of Health and Human Services, CDC, (2014). Retrieved from Infectious Diseases (2013). Volume 57, Issue 8, 15 October 2013. , S.L., & Dang, D. (2012). Johns Hopkins nursing evidence-based practice: Model and Guidelines (2nd ed.). Indianapolis, IN: Sigma Theta Tau International.FDOH HIV/ AIDS section Test and Treat Protocol. (Sep 2016) retrieved from h for HIV/AIDS Clinical Care. (2011). Retrieved June 30, 2018, from for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents, AIDS info, (2017). Department of Health and Human Services. Retrieved July 2, 2018 from , S. P., Dorvil, N. De Vieaux, J. G., Hedtgautheir, BL, Riviera. C., & Faustin; M. (2017) same day HIV testing with initiation of antiretroviral therapy versus standard care for persons living with HIV. PLoSMed,14(7).10.1371/journal.pmed.10002357.Labhardt, N.D., Ringera, I., ThaboI.Lejone, T.I., Klimkait, T., Muhairwe, J., Amstutz, A., & Glass, T.A. (2018). Effect of offering Same-Day ART VS Usual Health Facility Referral During Home Based HIV testing on Linkage to Care and Viral Suppression among Adults with HIV, The CASCADE Randomized Clinical Trial. JAMA,319(11),1103-1112. doi:10.1001/jama.2018.1818. Mugavero ,M.J., Amico, K. R., K., Horn, T., & Thompson, M.A. (2013).The State of Engagement in HIV Care in the United States: From Cascade to Continuum to Control. Clinical Infectious Diseases, 53(8),1164-1171.Retrieved from , B.M., & Fineout-Overholt, E. (2015). Evidence-based practice in nursing &?healthcare: A guide to best practice (3rd ed.). Philadelphia, PA: Wolters Kluwer Health.Mugavero, M.J., Amico, K.R. Westfall, A.O., Crane, H.M., Zincky, A. Willing, J.H., Dombrowski, J.C., Norton, W.E., Rapper, J.L, Kitahata, M.M.& Saag, M.S. (2012) Early retention in HIV care & Viral load suppression: Implications for a Test and Treat approach to HIV Prevention. Journal of Acquired Deficiency Syndrome,59(1), 86-93. Retrieved from doi:10.1097/qAI.0b013e318236f7d2.National Institutes of Health, U.S. Department of Health and Human Services. (2017). Retrieved July 2, 2018, from of resistance in subjects failing dolutegravir monotherapy (2017).CROI Conference, Retrieved from , C.D., Ospina-Norvell, C., Dasgupta A., Jones, D., Hatrogenesis, W., Torres, S.,?Calderon, F., Demico, E., Geng, E., Gandhi, M., Havir, D.V., & Hatano, H (2015) Providing Same Day, Observed ART to newly diagnosed HIV+?out patients are associated with improved virology suppression. Journal of Acquired Deficiency Syndrome,59(1), 86-93.doi:10.1097/QAI.0000000000001134 Poe, S. S., & White, K. M. (2010). Johns Hopkins nursing evidence-based practice: Implementation and Transition. Indianapolis, IN: Sigma Theta Tau International.Rosen, S., Maskew, M., Fox, M.P., Nyonic, C., Mallet, G., Sannel, L., Bokaba, D., Saul, C., & Long, L. (2016). Initiating Antiretroviral Therapy for HIV at a Patients First Clinical Visit: The RAPID IT Randomized Control Trial. PLoS Med. 13(5), e1002015.doi:10.1371. San Francisco Program for RAPID ART Initiation and Linkage to Care, Standard Operating Procedures (2016). Retrieved June 28, 2018, from citywide rapid protocolv2.pdf.World Health Organization. “Towards Universal Access: Scaling up Priority HIV/AIDS Interventions in the Health Sector. Progress Report (2008).” Retrieved June 30, 2018 from HYPERLINK "" universal access report 2008.pdf. ................
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