Developing a Solution to Improve Linkage To And Retention In Care Through Proactive Tools And Hands-on Support
BACKGROUND
The University of Virginia (UVA) Health’s Ryan White Clinic serves approximately 900 patients with HIV over an area covering 52 counties in central and south-west Virginia. This area is mostly rural, and includes a few small towns and cities. Clients face multiple challenges including racial inequity, stigma, poverty, isolation, lack of social support, substance use disorder, and barriers to transportation or clinic access.¹ The clinic has received Ryan White funding from Health Resources and Services Administration (HRSA) since 1998. Funding from Ryan White Parts B, C and D is used to support on-site medical, gynecologic and mental health care, case management, dental services, community health and retention in care services, and funds for housing, transportation and food assistance for the clinic’s patients.
CHALLENGE
Prior to 2013, UVA’s Ryan White Clinic aimed to support all patients to engage with care, but reaching everyone was a challenge. Patients often did not answer phone calls, so case managers would drive up to 6 hours to connect with clients in person. Clients also had to travel just as far to visit the clinic. Geographic, structural and psychological barriers limited communication, connections, and attendance in clinic, and a new strategy was needed to provide clients and clinic staff with tools to help to engage clients consistently with care.
“PL supports patients when and where they need it most, and it has led to improved individual and clinic level outcomes. It is a key tool in my practice.”
SOLUTION
The UVA team aimed to develop a clinic-centered solution to improve linkage to and retention in care and communication with clients, focusing on connecting with those new to care, returning to care, or people who were not virally suppressed. After originally testing bi-directional texting programs, the team developed a digital health platform, PositiveLinks (PL), with a full-featured smartphone app and an online portal. When integrated into practice, the platform combines self-monitoring of medication adherence, mood, and stress levels, with coordination of care and access to anonymized social support. Input on design and features was obtained from clients and the clinic staff.
The PL program includes providing smartphones to clients that do not already have a phone, plus a monthly data credit for any client who responded to a predetermined percentage of daily check-ins in the preceding month.
““Getting data-driven insights from PL has been crucial. Being able to truly make informed decisions has made a real impact.””
After studies showed that PL was effective in helping people improve key outcomes such as retention in care and viral suppression, the PL program was implemented as a component of Usual Care at the UVA Ryan White clinic in 2017. This means it is an ‘opt out’ program. The platform is used by the full care team, including Medical providers, Mental health providers, Case managers, Community health workers, Substance use counselor, Nutritionist, Pharmacist and CHARLI case managers.
Ongoing research, development, and testing of upgrades to the PL platform continue at UVA and at partner universities. Numerous organizations provided funding support to the research and development of PL at different stages.
OUTCOMES
In the initial 2013 study, CD4 counts, viral load suppression, retention in care, and rates of visit constancy of PL clients all improved significantly. Qualitative analysis also found that PL’s community message board provided a sense of connection and social support. The data below shows outcome snapshots for different periods of time.
Since 2017, a total of 880+ clients have been enrolled, with 570+ clients currently active at the UVA Ryan White Clinic.
As of June 2023, the viral suppression rate of the UVA cohort is 93%, well above the national average for Ryan White Clinics, and the 1-year PL program retention rate is 61% (compared to the medical app industry average of 17%³). With funding and support from the Virginia Department of Health, UVA Health has supported PL implementations in other Virginia clinics.
References:
Dillingham, R., Ingersoll, K., Flickinger, T. E., Waldman, A. L., Grabowski, M., Laurence, C., Wispelwey, E., Reynolds, G., Conaway, M., & Cohn, W. F. (2018). PositiveLinks: A mobile health intervention for retention in HIV care and clinical outcomes with 12-month follow-up. AIDS Patient Care and STDs, 32(6), 241–250. https://doi.org/10.1089/apc.2017.0303
Canan, C.E., Waselewski, M.E., Waldman, A.L.D., Reynolds, G., Flickinger, T.E., Cohn, W.F., Ingersoll, K., & Dillingham, R. (2020). Long term impact of PositiveLinks: Clinic-deployed mobile technology to improve engagement with HIV care. PLoS One, 15(1):e0226870. https://doi.org/10.1371/journal.pone.0226870
https://www.alchemer.com/resources/blog/healthcare-apps-2021-engagement-benchmarks/