Background
Methods
Study design and settings
Site characteristics | Innovator site | FQHC | Testing site |
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Clinic type | Academic HIV clinic in safety-net hospital system | Federally Qualified Health Center | Sexual health clinic and testing site |
RAPID patient source | Combination of patients diagnosed w/in hospital system & off site | Combination of patients diagnosed on and off site | Majority of patients diagnosed on site |
RAPID visit structure | By appointment & drop-in | By appointment & drop-in | By appointment & drop-in |
RAPID Team | Prescriber (MD, NP) + RN + MSW | Health Educator (HE), RN or MA + Prescriber (MD, DO, NP, PA, APN) + Linkage to Care Coordinator (LTC) + Pharmacist | Prescriber (NP) + Health Navigator |
Composition of RAPID Visit | Typically, patient seen by whole RAPID team at once | Typically, patient seen by RN, HE, or MA, then LTC, then Prescriber | Typically, patient seen by Health Navigator and NP only |
Linkage to HIV Primary Care | HIV primary care on-site (no external linkage) | Within FQHC system (linkage to internal primary care at one of 10 clinics) | Off-site (linkage to external primary care) |
# of RAPID 2019 Encounters | 41 | 198 | 70 |
# of Patients w/HIV | 2800 | 4942 | n/a |
# of HIV Providers | 38 | 54 | 7 |
# of Patients/clients | n/a | 30,013 | 9600 |
# of Providers | n/a | 63 | 7 |
Sampling, recruitment and data collection procedures
Data analysis
Findings
N = 27 | N (%) |
---|---|
Gender | |
Male | 10 (37%) |
Female | 15 (56%) |
Trans/non-binary | 2 (7%) |
Race/ethnicity | |
White | 19 (70%) |
Latinx | 6 (22%) |
Asian | 1 (4%) |
Black | 1 (4%) |
Years in HIV | |
< 5 | 9 (33%) |
5 to 15 | 10 (37%) |
> 15 | 8 (30%) |
Role within RAPID program | |
Prescribing provider (MD, NP, PharmD) | 8 (29%) |
RN | 4 (15%) |
Social work/navigator/linkage specialist | 11 (41%) |
Leadership + prescribing provider | 4 (15%) |
Innovator site | Testing site | FQHC | |
---|---|---|---|
Comfort and competence prescribing ART | MDs/NPs prescribing HIV primary care team w expertise in HIV care Select cadre of RAPID providers from broader pool of primary care providers | NPs prescribing (recent addition for other prescribing services at site) All providers available to participate in RAPID as any other sexual health service | MDs/NPs/DOs/PAs/APNs prescribing HIV primary care team w expertise in HIV care All providers available to participate in RAPID as any other sexual health service |
Expedited access to ART | Starter packs + Rx for ongoing ART to be filled by patient | Starter packs + Rx Proximity to pharmacy for immediate prescription fulfillment (same-day Rx fulfillment so successful, starter packs rendered unnecessary) | Prescription that could be filled immediately or next-day at the on-site pharmacy Proximity to pharmacy for immediate prescription fulfillment Medication sample packs |
Benefits, linkage, and care navigation | Access to patient drug assistance programs (same day ADAP) Clinic receives warm hand-offs from referrals; on-site HIV primary care, occasional external linkage necessary Social worker as part of RAPID team to assess and connect pt to wraparound services Navigation of pt through RAPID process (“red carpet” treatment) | Access to patient drug assistance programs (ADAP) Ability to assess eligibility and enroll patients in benefits programs same-day Assess for additional needs (housing, mental health, etc.), psychosocial support on site Off-site linkage to external HIV PC provider (includes assessments of benefits and needs to find appropriate match, coordinating transition) | Access to patient drug assistance programs (ADAP) Insurance and patient assistance program knowledge for patients to access free meds Clinic receives referrals as warm hand-offs and self-referrals; on-site HIV primary care, no external linkage necessary Assess for additional needs (housing, mental health, etc.), psychosocial support on site Navigation of pt through RAPID process, ensuring warm hand-off to internal HIV PC provider |
Flexibility and adaptive capacity | Appointment & Drop-in Interdisciplinary Team Prescribing clinicians flexible in accommodating RAPIDs in the schedule Iterative program development and improvement | Appointment & Drop-in Interdisciplinary Team Iterative program development and improvement (i.e., cross-training benefits navigators and health navigators; expanding physical space for RAPID; opening access to mental health services at RAPID visit when needed) | Appointment & Drop-in Interdisciplinary Team Iterative program development and improvement (i.e., adding Uber account, adding on-site linkage coordinator to clinic) |
Patient-centered approach | Services for patients experiencing homelessness, substance use RAPID as a red-carpet event to provide patient support Warm hand offs between RAPID team members | LGBTQ + community focus, including transgender and gender nonbinary services Community outreach and site-specific access (for patients experiencing homelessness), mobile testing units Meet with as few people as possible during encounter Attitude of doing whatever it takes to meet the patient’s need | LGBTQ + community focus, including transgender and gender nonbinary services Services for patients experiencing homelessness, mental health needs, substance use Community outreach and testing Meet with as few people as possible during encounter, stays in same exam room throughout process, (when possible/desirable) has prescription brought to them Attitude of doing whatever it takes to meet the patient’s need Accessing all needs for patients (i.e., clothing, food, transportation vouchers) In-house linkage to minimize time patient spends alone |
Communication methods and culture | Interdisciplinary team, team members present and together for some parts of the RAPID encounter Central pager system | Small team communicates informally throughout daily activities | Centralized “linkage to care phone” Repeated check-ins among RAPID team throughout RAPID process, and continued in-person and EMR-based communication throughout full linkage to care process (first 6–12 months of patient’s care) RAPID team members use EMR to read patient notes during RAPID encounter |
Essential elements for RAPID program implementation
“[I]t wasn’t a proposal. It was an order. … When [Champion’s name] came and said, ‘We're going to launch a new initiative and we're actually going to try to start people on the day of diagnosis,’ we actually thought she was crazy. …. We thought it was just impossible that the barriers - the ability to get a patient to start medication could not be merged in the disclosure of a new diagnosis. … [But the were] the boss … and so we said, ‘Okay. We'll try it,’ but we weren't very confident that it could work. Within the third day or fourth day of the launch of RAPID, we had done, probably maybe three or four RAPID cases. Our team just - at the end of the day, informally, all found ourselves in the same room and was sharing the experiences that we'd had with these new diagnoses and were all completely blown away.” (Innov KI01)
“[Champion’s name] is the biggest visionary in this field, and it's simply down to him. He was the one who initiated this, and that's the end of it... He was so motivated to do this. … And initially, obviously, it was a little confusing as to what bloods to order, what are the different scenario, et cetera, but now everything is built into the template. … [Champion] is the biggest force behind this, to me.” (Test KI06)
“I knew some providers would say no to a RAPID appointment because we can't ever plan for them…. We have to sort of drop everything we're doing … and we knew specific providers that were open and willing and excited to do that. ..we would just have a mental list of people who were willing and open to doing those appointments. So, I think that it as a practice and as a protocol was accepted, but not every practitioner felt comfortable doing them.” (Innov KI05)
“I’d rather err on the side - ‘cause worst case scenario, you get them the pills, they take one, and then you never see them again—they don’t take anymore. And like, they’re not going to cause themselves that much harm from it. I would be horrified, horrified if I did not give a treatment to somebody who would’ve successfully done it. I’d rather … err, whatever else, giv[e] someone the opportunity who maybe wasn’t ready than to remotely risk someone not getting care.” (Test KI04)
“They leave with five days of meds. So, it's not just like, "Okay, here's this prescription," because there's still 1,000 things that can go wrong between, like, handing them a prescription and picking up that prescription from your, you know, local, unfriendly Walgreens, and so …Yeah, starter packs are amazing.” (Innov KI04)
“We [had] been doing PrEP. We got really, really good at being able to get any med for anyone, like super easy. … We were already doing that, so we already had the access to getting meds part down pat.” (Test KI04)
“Having the nurses, well trained in sexual health and HIV treatment is definitely one of the most [important] things that made this program successful, and also having a dedicated benefits team. Without that you can have the best nurse that's well versed in all aspects of HIV treatment, but if they're not well versed in how to get the patient the medications…. It's just gonna end right there. Yes, you have great care, but can you afford your medication when you leave the clinic? No.” (Test KI09)
“… the number one question I usually get from people when I talk to them, is how much is this all going to cost me? So being able to say confidently that we have the resources to get you all of this for free, I think is a big relief for patients, and a big relief in why they're able to initiate that.” (FQHC KI05)
“Sitting with the client to me is one of the most important things, and establishing some rapport so that they can become increasingly comfortable to work with me and share some information that helps me figure out what's an appropriate medical home for them. … So having someone start on RAPID is invaluable because it gives us that breathing room. We don't have to, like, oh, my God, oh, my God, oh, my God, they have to start on medication, they have to, you know, get into care yesterday. But they're still sitting there shaking. We haven't even started the intake process, let alone, you know they don't have medical insurance and, you know, just all these variables. So it's just invaluable.” (Test KI03)
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(5) RAPID team member flexibility and organizations’ adaptive capacity.
“I’d say more than half of our appointments are drop-in. It's like an open-access model, and that’s where you get to squeeze in, you know, PrEPs, the PEPs [Post-exposure prophylaxis], the iARTs [ART re-engagement], the RAPIDs.” (Test KI08)
“We’re building out staffing to be able to see more folks as they drop in—so having more nurse practitioners. [Also] we're expanding to the third floor to use one of the counseling rooms. I think we've already started using one of the counseling rooms up here for an additional like blood draw station. We're renovating our clinic to add another exam room on the second floor. So, there are like staffing and space needs that are being addressed to ideally build out that capacity.” (Test KI11)
“We have UberHealth, which has been very helpful. Like we got one guy who we brought him up from San Jose. We brought him all the way up here. … He must’ve been acutely infected, so that means like they left here. Like in three days they get a positive viral load, and I’m like, he has no ride up here. Like what do you do? And so it’s a barrier, so then you solve it.” (Test KI04)
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(6) Patient-centered approach.
“I think with managing any kind of chronic illness, you can be nervous for your patient. You're just hopeful that they're able to follow directions or keep track of their meds or keep coming to their scheduled appointments. So, for me, yes, I definitely had reservations, and you still move forward and try and support people the best you can. Because if they say they want to start meds, it would feel so inappropriate to deny them medication… I think that it's important to just respect what a patient wants after they're given non-biased, nonjudgmental information and support. They get to decide the next step. And then you help create a care plan that makes it as easy as possible.” (Innov KI05)
“Are we pressuring patients to do this? How is it really going to help them? I think fairly quickly we kind of got that from the patients…they really saw that as an opportunity to like take control over this virus that they thought was like out of control in their body. So, it was actually, actually pleasantly surprising. It was really a nice surprise because I was kind of worried.” (Innov KI03)
“One of the very special things about this clinic but definitely the … RAPID team is how interdisciplinary it is and how none of it would work if anybody was missing. Like, that there needs to be a nurse, and there needs to be social workers, and there needs to be eligibility, and there needs to be providers, and, like, it's such a beautiful example of the power of interdisciplinary work.” (Innov KI04)“We practice as a group here. That means if someone tests positive, uh, it has to be done by an NP. . . And the - the clinic pretty much steps up and kind of creates that space for that NP to spend the amount of time that they need with that person.” (Test KI04)
“They get that it needs to be a red-carpet event, so the RAPID patient will meet every single member of the team. Like the provider, the social worker, the nurse. Even if they're not necessarily working with that person that day. It's just like, "Hey! I am the RAPID nurse," or, "I am the RAPID social worker and I am - we're not going to meet today, but we can meet next week, if you want." We're part of the same team, here to support you. We're happy that you're here. It's just reinforcing that they have a lot of people behind them. … That they do a really good job.” (Innov KI09)
“So, instead of somebody finding out their diagnosis and me meeting with them right away, they'll meet with a provider first, and then they'll meet with like a [partner] service person, and then they'll meet with me. So, it's just the structure is a little bit different depending on like which clinic the person is diagnosed at.” (FQHC KI03)
“I don't have capacity to sit in the room for 30 minutes while we wait for someone to come. Our nursing team doesn't have that capacity. So a lot of times for a substantial amount of that period, the patient is sitting alone in an office exam room, living with that diagnosis. And I always thought that that was not ideal. A lot can happen in your head in 30 minutes in a room alone.” (FQHC KI05)
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(7) Strong communication methods and culture.
“[Some of the] team actually wasn't even aware that we were trying to launch [RAPID], because they weren't really present [on-site]. They were primarily at the [other] site. And I think there was just bad communication happening at that time.” (Test KI11)
“They change things, and then they really don't give us directions on the next steps. They changed [to a new pharmacy software] and then didn't really train us on how to [use it]. … It's little things like that that kind of happen frequently, with other examples. So, let's see. They changed ADAP on us. They just tell us things at the very, very, very last minute, and like the transparency is just like – by the time it gets to us, like we're already with a patient. And then it's just like, okay. And then you just have to figure it out as you go…” (FQHC KI01)
Challenges to implementation with implications for sustainability
“For me as a clinician, [RAPID ART] was very easy, and it was a wonderful thing that we were able to offer it. So, for me, it was easy, logical, organic.” (Test KI05)“I think as time goes on, it's easier to manage and kind of predict, but in the beginning, that was a pretty tough transition.” (FQHC KI03)
Transitional tension
“And then while [the cross-training] process is happening, managing the folks who are holding the work at that same time. You know, like we're still having to do benefits, we're still having to do, um, medication acquisition while the other team is being trained.” (Test KI11)
“Assuming they're interested [in cross-training], um, then it becomes, are they going to be able to do the work? [There are] different learning curves that come with [new skills]. So, are people going to be able to do the work that we're kind of tasking them with…?” (Test KI11)
“Right now it’s painful with all these transition periods, as we build out staff and training the staff. But the idea is that we’ll be able to see folks without kind of derailing the clinic flow as much as it currently is and whenever certain situations pop up. So, that definitely seems like it’s painful for now, but we’re able to get through it.” (Test KI11)
Burnout/provider strain
“This is just the same-day start in general. Like when they implement these programs, they should talk to the people who are going to be doing it for more input, because these people are getting burnt out really quickly. … they're just burnt out, like tired. And then not only are they doing same-day start, but they have a full caseload of 40 individuals that are newly positive that they have to retain and engage in care. So, it's not just a same-day start, and then that's it. Your job is not done. You have to maintain contact with these people, schedule their monthly or bimonthly medical appointments, meet them at their appointment, try to get them to come to support groups, be their sometimes sole supporter, make sure they have their medication, check in on them, see how they're doing, make sure they're taking their medication. If they're not taking their medication, see what the problem is. Like it's way more.” (FQHC KI01)
Volume
“Originally I thought we were going to be doing 12 a year. …. So, that was my initial proposal for it. And then when all these people came in, I think we did like 65 last year. I’m like, that’s more than 12.” (Test KI04)“During the next year, 2017–2018, it became increasingly less manageable. The numbers were growing, our staff was not.” (Test KI03)
“[The RAPID program we implemented] was just meant to be for our folks. And then what was happening is people were testing positive at other locations, and that location couldn’t take care of them, so they were funneling them to us. You know, so we kind of became this referral center.” (Test KI04)“One of the difficult things we're now facing is that [our site] and same-day start is growing so rapidly that like just follow-up appointments are really difficult. So, in the beginning, you were supposed to have a follow-up appointment one to two weeks out from diagnosis. But now, it's like a month to a month and a half just because all of the providers are so booked, and a lot of them don't even have open panels [and] scheduling that initial follow-up is so difficult. And then if somebody misses that follow-up appointment, we're not seeing them for like three months after their initial diagnosis just because scheduling is so hard.” (FQHC KI03)