Evidence of Success - New York/New Jersey AETC Service Area: New Jersey and New York

New Jersey Local Performance Site

Illustration: Evaluation of Clinical Training Outcomes and Quality Improvement

The University of Medicine and Dentistry of New Jersey (UMDNJ) serves as the New Jersey LPS for the New York/New Jersey AETC. Working in conjunction with the City of Newark, Department of Health and Human Services, the UMDNJ team has been contracted to complete chart reviews for primary care providers in the Newark Eligible Metropolitan Area (EMA) as part of the EMA's overall quality management plan. The HIV epidemic in the EMA has historically been and continues to be driven by substance use. As part of the chart review process, a substance abuse treatment clinic was identified as an organization that would benefit from longitudinal training.

UMDNJ's initial assessment of the clinic's RWCA client charts for March 2002-February 2003 revealed multiple deficiencies in the quality of primary medical care provided to patients. For example, 61% of patients had less than 200 CD4+ Tcells/mm3, and 18% had less than 50 CD4+ T cells/ mm3, putting them clearly at risk for opportunistic infections. Only 71% of the patients who were eligible for Pneumocystis juroveci pneumonia (PCP) prophylaxis received therapy and only 55% of patients who were eligible for prophylaxis against Mycobacterium avium complex (MAC) received therapy.

UMDNJ faculty and staff have met with key leaders at the clinic to review the results of the chart review. Clinic staff reach and treat a population living in a syndemic of HIV, poverty, homelessness, and substance use. The clinic provides a valuable resource for clients who would not be able to access primary care were it not co-located in a substance abuse treatment center. The staff realizes that limited resources and overstretched schedules may not have provided opportunities to stay current with the complexities of HIV treatment and management, nor to ensure that systems were in place to support an optimal level of care.

The clinic staff worked with the NJ LPS to develop a clinical training plan with didactic and clinical training that will span a five month period. Outcomes will be evaluated by measuring documented changes in the clinical status of patients through chart reviews before and after the training plan is implemented.

Outcomes

Immediate/Short-term:

	Established interactions between AETC and substance use treatment center.
	Identified deficiencies and need for education in specific HIV-related areas.
	Established training plan.

Mid-term/Long-term:

	Developed system to evaluate the site's ability to meet and exceed NEMA standards of care for HIV Primary Care.

New York Local Performance Site

Illustration: Longitudinal Training

St. Vincent's Catholic Medical Center-Manhattan Comprehensive HIV Center is an LPS for the NY/NJ AETC. In May 2003, St. Vincent's Catholic Medical Center developed an HIV resistance workshop at the request of mid- to low-volume community health care providers. The three-part workshop focused on educating providers about interpretation of genotype and phenotype resistance assays with each session building on previous learning. The first program centered on explaining various resistance tests. The second reviewed primary and secondary mutations and how each related to viral fitness; this case-based presentation was very well attended. The third program provided a unique opportunity for participants to present their own cases in a moderated setting and for group discussions to enhance the learning points of the case. The goal of the program was to develop skills so that participants would have the confidence needed to interpret resistance tests in their own patients. Improved patient outcomes were noted over time.

The program was designed to address needs identified by community providers. The programs helped health care professionals develop abilities to use and interpret resistance tests. Providers who attended the training stated, "I have a much better understanding of the use of resistance testing," and "I can better speak to my patients about genotyping and phenotyping. It was an excellent program."

Outcomes

Immediate/Short-term:

	Demonstrated applicability of resistance testing in HIV practice.
	Developed a process of shared learning with cases from individual practices.
	Increased knowledge about the interpretation of resistance tests through the presentation of individual cases.
	Enhanced clinician confidence in interpreting laboratory results.

Mid-term/Long-term:

	Established more effective patient management as noted by improved clinical outcomes.
	Developed ongoing relationships between the LPS and the community health providers.