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ART Set-up and Procurement

ART Set-up and Procurement

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ART Set-up and Procurement

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  1. ART Set-up and Procurement Unit 3 HIV Care and ART: A Course for Healthcare Providers

  2. Learning Objectives • Explain the continuum of HIV Care • Recognize the multidisciplinary (MD, RN, RP, CHCW) team approach to the chronic illness care model • Explain why the ART practice model requires patient flow and interventional definition at every clinic stop • Describe the clinical communication tools and forms required for effective multidisciplinary team practice

  3. Learning Objectives (2) • Describe ART practice setup • Identify the minimum requirements for ART practice • Describe the art of maximizing minimum resources • Identify the components of drug management

  4. Practice Care Model

  5. ART Practice • Family-centered without the exclusion of the individual • MD-led • RN-coordinated • Multidisciplinary (MD, RN, RP, Lab, CHCW) team practice

  6. Continuum of Care Model • Continuity of care provided at home to care or evaluation performed in any health care setting by specialists, generalists and primary care providers: • Home based care • Community care • Health facility based care

  7. ART Care Model • Multidisciplinary (Team) Effort: • Minimum Team Members: MD, RN, RP, CHCW Physician Social Worker Nurse Patient Pharmacist Community HC Worker TGK/ITECH/9.03

  8. Maximizing the Minimum 5% Patients with chronic illness’ care provider needs SP 35% MD Non-MD PA/ HO, MSW, RPh Nut, RN 60% “Workload could safely and legally be delegated to the appropriate level.” TGK/PSHCS, Primary Care

  9. ART Patient Flow

  10. Think About the Patient Experience • Safety: Communicable diseases, emergency • Comfort: Seats, shelter • Wait time • Distance between services • Unnecessary travel between stops

  11. Justify the Stops • Is it essential? • What would the patient lose if it was not there? • What would the organization lose if it were not there? • Is more than one stop necessary on the same visit?

  12. The Patient’s Route • Registration • Record room • OPD • HIV/ART clinic • Lab • Pharmacy

  13. Ideal Patient Flow Arrival area: RN triage: • the emergent • patients with cough x > 2 weeks • FU visits: scheduled, unscheduled Coughers: Exam room • RN further evaluation based on protocol • order sputum, x-ray • call in MD to examine Waiting area: • Patient ed: videos on nutrition, healthy living, etc • Patient ed live to answer patient questions on HIV care (dispel myths, etc) Emergent: Exam room • RN evaluate • call in MD after patient prepared for MD evaluation Registration desk/window: New • capture pertinent data • issue HIV care patient pocket book/passport New & enrolled • issue visit # • prepare medical chart • direct to the waiting area RN evaluation room • Hx (standard New/FU doc form) • VS, wt • intro to HIV care General exam room: • RN briefly summarizes ,patients issues • MD takes over RN counseling/disposition room: • Review MD instructions and go over them with patient • schedule patient • ART counseling • . Needs assessment, nutrition, etc Pharmacy: • ART counseling visit 1 • ART counseling visit 2 • ART adherence & safety review FU clinical servicesHome Case manager Health CenterCommunity Resources TGK 5/05

  14. ART Patient Flow ID, age, gender, married, # children, Support (family, friend), Dx date, ART date Intake Desk First visit Awareness score, mental status, Karnofsky's Score, Wt. HIV related Sx. Nutritional status Introduction to ARV Life style, habits, family or friend support Income, job ABC/prevention, disclosure RN visit MD visit Complete H&P, baseline labs, CXR, R/O or TX TB (Reminder) H&P, review past Tx, labs, CXR, R/O or TX TB, order missing MC referred Self or VCT referred Support Services • . Emotional support • . Counseling regarding ARVs & adherence, transmission risk reduction, general health maintenance, status disclosure • . Home-based Care • . PMTCT • . Family planning • . Other services Eligible ? NO YES TX OI, TmSx, FU ART protocol, TmSx RP : Regimen property Key side effects & measures Adherence counseling Invite & answer questions Hand out written instructions Hand out medications schedule 2-week FU RN : Adherence; review life style & counsel. Explain access to emergent FU. Discuss nutrition & healthy living. Check mental competence & level of understanding Hand out FU schedule Refer to support services if indicatedSchedule 4-week FU MD : Review lab, X-ray Determine regimen Discuss critical adverse effects Emphasize adherence Issue Rx Schedule 4-week FU 2nd visit TGK/ITECH/12/03

  15. Medical Evaluation - H & P 1. Screening visit - Eligibility ARV Evaluation visit - Lab, counsel 2. ARV initiation visit - Initiate, counsel ARV FU visit - 2, 4, 6, 8 weeks ARV Visits

  16. Visits Week Month Year Staff Lab Eval 1 0 MD, RN, RP HIV’ CBC, LFT, BUN, CR, UA, pregnancy, WHO stage LFT if NVP 2 0 MD, RN, RP FU:1 2 RP 2 4 MD, RN, RP CBC, LFT 3 6 RP 4 3 MD, RN, RP CBC, LFT 5 6 RN 6 9 MD, RN, RP CBC, LFT, BUN, CR 7 12  1 RN 8 18 MD, RN, RP 9 21 RN 24  2 MD Whatever is indicated 27 RN 30 MD 33 RN 36 3 MD Indicated 39 RN 42 MD 45 RN 48 4 MD Indicated ART Patient Visits

  17. ART Practice Setup

  18. ART Practice Setup Minimum Needs • Structure • Staff • Space • Tools • Process • Clinic stop interventions • Follow up • Monitoring System • Clinical • Safety • Efficacy • Operations/management • Outcome • Performance

  19. ART Practice • Multidisciplinary, generalist or specialist led • Family-centered primary care • Comprehensive • Continuous • Accountable (quality, cost) • To patients • To management • Teaching institutions should consider a stand alone HIV care clinic

  20. Management of Waiting List: • Establish HIV/AIDS committee • Committee will have to meet weekly • Set up an open access HIV clinic • Grandfather those on Tx • Mothers first priority • Gender equity • Prioritize anyone under 18 years old • Take family size and family earner into account • Priority of last resort= 1st come 1st served

  21. Coordinator Review ART DATA + waiting list status Report to Committee • Update list • Prepare action-plan • Take action • Report to management HIV/AIDS Committee Members: Director/Chair ART MD ART RN ART pharmacists ART Lab technician Coordinator staffs the meeting

  22. Pediatrics Priorities: • Age cut off <10 years (because children older than 10 can swallow pills, therefore are grouped with adults) • The sickest children must go first • Children <5 years tend to perish rapidly with HIV/AIDS

  23. Clinical Tools & Resources • Provider resources: • 3x5 cards: WHO staging, Karnofsky’s performance scale, etc • Ring Pocket books: Pathophysiology, medicine dosages, interactions, side-effects, OIs • Wall Posters: Flow charts & algorithms, etc • Patient resources: • Brochures • Patient instructions • Forms: • Provider documentation • Communication forms • Data capture and collection In major local languages

  24. Communication Forms • Inter-facility referral forms • Hospital Hospital • Hospital Health Center • Hospital Community • Intra-facility referral forms • ART Clinic Clinic • ART Clinic Lab • ART Clinic Pharmacy

  25. Primary Care Provider • Previous antiretrovirals: None  • Proposed regimen (discussed Y/N): AZT + 3TC + EFV • Concerns/problems anticipated: Not sure whether he has told me or RN all about his life style • Signature: GKMD Date: 07/25/05 • Provider: please give form to nursing staff, so appointments can be scheduled

  26. Pharmacy • Education Conducted: Introduction to HAART. Adherence & consequences of non-adherence. Introduction to healthy living. Need for drug Tx • Problems Identified: Binge drinker and intermittent drug user, gambler, marginal financial support • Comments/follow-up: Referred to MSW & ATP. Review for referral to adherence protocol group • __ Suggest HAART • X Suggest delay • Signature: JB Date: 07/25/05

  27. Clinical Documentation Forms

  28. Customer Requirements Quality Value • Patients • Providers • Managers • Facility • Regional • National • Donors • Capture all essential data elements • Legible • Simple • User friendly • Time saver • Comprehensive • Facilitates/reminds/prompts/ promotes practice model Customer Satisfaction Service

  29. Current Follow-up Form • Follow-up Form • Captures: • FU status • Sx: potential ARV complications + IRS • VS, weight, functional score • ARVs and labs • OIs, including TB and their status • Assessment, including adherence • Reasons for deferral of ART • Disposition

  30. Proposed Form Data Flow Sheet • Data flow sheet • Captures chronologically: • Dates • ARVs (1, 2, 3) • TB Status, OI Tx, OIP • Labs • Referrals • Designed to benefit MD, RN, Data manager • Simplifies continuity & record review

  31. Data Flow Chart

  32. Patient Medication Record . . In the past three days, how many days have you had missed doses? [ ] None [ ] One day [ ] Two days [ ]Three days Since last visit how has the patient taken his/her ARVs? [ ] About as prescribed [ ] Less often than prescribed [ ] More often than prescribed [ ] Not at all

  33. Clinical Tools • Standardize documentation • Save time • Facilitate continuity of care • Help during record review • Foundation for clinical research • Help in the delegation of clinical workload

  34. Systems Issues • M&E • Pharmacy MIS • Quota management system • Follow-up system

  35. Follow-up System • Structure • Appointment book • Patient passport • Clinic schedules • Confidential patient directory • Follow up coordinators • Process • Test your system to see if it works • Have patient repeat follow up schedules • Show patient that it is in his/her passport • Instruct patient to call you if he/she wants to reschedule or for any other question

  36. Follow up System No Show Tele # of patient or support No Yes Case manager (CHCW) Call until contact established Visit

  37. Drug Management System

  38. Drug Supply Management • Develop required infrastructure • Establish process • Assure an uninterrupted supply of standard drugs • Install information system

  39. Selection, Quantification, Procurement,Distribution and Use of ARV Drugs

  40. ARV Drugs Selection • The selection of ARV drugs is based on: • The purpose of use • ART (Adult, pediatrics) • PEP • PMTCT • The level of available health institution (hospitals, drug retail outlets) • Availability of authorized prescribers and dispensers • Guidelines for the use of ARV drugs in Ethiopia • National drug lists

  41. Quantification of ARV Drugs • Quantification of ARV drugs is impacted by a complex web of factors related to: • ARV product • ART • Demand (continuation and scaling up/rollout) • Supply

  42. Quantification of ARV Drugs (2) • Issues related to ARV Product: • Shelf Life • Short expiry date • Cost • Expensive • Handling Requirements • Require secure storage • Require refrigeration/temperature control

  43. Quantification of ARV Drugs (3) • Issues related to ART: • Rapidly evolving scientific field • Impact of stock out • Taken for life • ARVs used for prevention and treatment • Multiple drug therapy (3 or more and all must be available) • Multiple regimens • Resistance evolves quickly and is inevitable

  44. Quantification of ARV Drugs (4) • Issues related to demand: • Availability of historical consumption data • Efficient patient tracking (Up-to-date patient information): • Deaths • Lost for follow-up • Transfer out, transfer in • Treatment interruptions • Unpredictable scale up • Capacity to deliver services • Changes in regimen (Wt., pregnancy, Tx failure, ADR) • Pediatrics (change in regiment/dose, wastage of liquids)

  45. Quantification of ARV Drugs (5) • Issues related to supply: • Facility capacity to overcome handling costs of large stock • Delays in disbursement of funds by donors • Level of available funding • Very few suppliers • Rapidly changing market • Prequalification/regulatory approval • Special pricing/donation • Unpredictable and long lead time

  46. Quantification of ARV Drugs (6) • Issues to consider when quantifying ARV drug requirements: • Consumption data at each health facilities • Working and buffer stock kept at different levels • Quantity of stock on hand and on back order • Lead time (time it take from ordering to delivery) • Expected consumptions during the lead time

  47. Quantification of ARV Drugs (7) • Expected consumption is influenced by: • Number of current patients and their regimen • Anticipated scaling-up pattern • New patients on 1st line, 2nd line (adult and pediatrics) • Likely changes in prescribing patterns due to: • Revised STG, changes in registration status of ARV drugs, procurement constraints, varying composition of patient groups, non-naïve patients with non-standard regimen