Florida program offers new method of HIV care

Nurses will track HIV patients and their health care

The state of Florida has launched a novel state wide disease management program in order to provide patients with a better continuum of care and make the state’s Medicaid funding for HIV/AIDS more cost-effective.

The program, funded with about $9 million from the state, will track health care services for about 7,500 Floridians who have HIV and who qualify for the state’s Medicaid program. Called Positive Healthcare/Florida, the program was created by the AIDS Healthcare Foundation of Los Angeles, which has a contract with the state’s Agency for Health Care Administration.

AIDS Healthcare Foundation is a nonprofit, community-based provider of AIDS care in California. The organization has the first and largest Medicaid capitation demonstration project for AIDS. The foundation has established a managed care type of health services model for Florida.

HIV-infected enrollees receive health care coverage from the state’s Medicaid program. The program’s goal is to keep HIV patients healthier with fewer hospital admissions or emergency room visits.

"We’re applying a level of scrutiny and different interventions to HIV care under Medicaid, and we’re infusing them into the model to make them more streamlined for people with AIDS," says Peter Reis, director of business development at AIDS Healthcare Foundation.

Florida program provides doctor education

The program also entails holding educational forums for providers to bring them up to date on the latest medical advances in HIV treatment.

The educational component is especially important because 40% of the HIV patients in Florida are receiving their primary care from providers who have fewer than 20 HIV patients, Reis says. "Those providers really need our help.

"We have our own HIV protocols that are indexed, and we make those available to provi ders," Reis adds. "A lot of physicians don’t have the time or experience to navigate dense treatment guidelines."

After several years, the program will provide Florida officials with outcomes data, showing how well patients have done with maintaining their disease and how much money it has cost the state to pay for their health care services, says Fred Goldstein, president of Specialty Disease Management Services in Jacksonville, FL. Goldstein is in charge of implementing the program.

Here’s how the program works:

Enrolling clients. All Florida Medicaid-eligible HIV-infected patients are enrolled unless they choose not to be involved. The program has an opt-out model in which people receive a letter from the state telling them they’re eligible for Positive Healthcare/Florida, Goldstein says.

To protect clients’ privacy, the letters do not specifically refer to HIV or AIDS. Instead, the letters mention all the disease management programs the state has. People have 30 days in which to choose not to be in the program. They can disenroll by calling a state district office.

Locating clients is sometimes a challenge

One of the program’s earliest challenges was locating the clients. In the first month, they sent out 850 letters and enrolled 723 clients. Few people opted out of the program, but some could not be enrolled because the letters were returned with no forwarding addresses, Goldstein explains.

Initial assessments. The program, when fully implemented later this year, will have about 70 registered nurses and 10 support employees.

Nurses meet with each client to introduce the program and cover a detailed, six-page clinical assessment tool that helps them determine the status of the client and how well the client understands HIV disease, and helps them identify specific client needs. They also ask patients for the names of their treating physicians, which they later match with state information on patients’ listed primary care physicians. And they identify the client’s case manager and AIDS service organization.

"They get clients to sign medical information releases, and they determine which drugs they’re on, when they were infected, what their T-cell count is, what’s their viral load, and whether they use drugs or alcohol," Goldstein adds. "There is no actual hands-on clinical care."

One of the biggest obstacles the program has faced so far involves setting up that initial consultation with clients, says Judy White, RN, director of health operations for Specialty Disease Man agement Services. Patients sometimes didn’t have telephones and were difficult to reach.

Assigning risk. Using the patient’s CD4 cell count data, nurses assign patients to a risk category of low (CD4 cell count of 500 or above); medium (cell count between 200 and 500), and high (cell count of below 200). Those in the low-risk category are contacted once a month; clients in the medium-risk category are contacted at least twice a month; and people in the high-risk category are contacted at least weekly, White says.

Medical record review. Staff use the patient releases to obtain clients’ medical records to see what type of care has been provided. They pull out information on patients’ CD4 cell counts, types of antiretroviral medications prescribed, and whether patients were receiving prophylaxis drugs for certain opportunistic infections.

Then staff chart this information to identify trends among the entire group of clinicians serving the Medicaid HIV patients and to give individual physicians a look at how they are doing when compared to national and state data, Goldstein says.

Medical records prove difficult to obtain

The program initially had some difficulty in obtaining medical record information from clinicians and AIDS service organizations, White says.

"With any insurance coverage, when you ask for payment for a service, you give permission to that insurer to share information within a network, and we’re considered an agent of the state in providing this service," she explains. "We’ve even gone a step further and said, We’ll get a second permission form from the patient to submit to providers.’"

But even with all of these precautions, some organizations and clinicians were unwilling to release medical records until the program had the medical release forms rewritten in a way that met their own guidelines, she adds.

Meeting with physicians. Nurses meet with physicians or their staff to explain how the program works and what educational services are available. They also show doctors how their HIV treatment compares with state and national treatment guidelines and statistics.

Disease management officials have discovered that Florida’s health care services for HIV patients vary dramatically.

"You have sophisticated urban centers and state-of-the-art medical centers, and then you have rural backwater counties that may have physicians with one or two HIV patients in their practice," says Ged Kenslea, community relations director for AIDS Healthcare Foundation.

So physician education is a top priority of the program.

Experts educate physicians at seminars

For example, the program held a seminar in the fall at a private foundation’s Florida retreat called White Oaks Plantation, which is where President Clinton vacationed last year. The retreat, which is on an endangered species preserve, is not open to the public, and it is a very desirable place to visit, Goldstein says.

Physicians involved with the disease management program were invited to the seminar to hear HIV experts talk about the latest drugs and treatment.

The program also will soon have a variety of HIV educational materials, including a treatment magazine that has an upscale look and design. The magazine’s editorial board will include 50 to 60 HIV scientists, and the magazine’s focus will be on minorities with HIV. Called Thrive, the magazine is set to be launched in March, Reis says.

Cutting costs. Nurses will stay in close contact with clinicians to discuss outcomes and more efficient ways to provide care, Reis says.

For example, some physicians may be unaware of how often their HIV patients are admitted to the hospital. If they aren’t contacted while the patient is admitted, then they can’t supervise the inpatient stay to make sure the hospital is motivated to discharge the patient in a reasonable amount of time, Reis explains.

"We’re interested from a patient care perspective in taking a look at some of these issues and communicating information to physicians in an ongoing dialogue," he adds.