Nicaragua | Antiretroviral Therapy (ART) Improvement Collaborative

Date improvement activities began: 
January, 2009
Date of end of collaborative: 
August, 2010
Aims/objectives: 
The collaborative aimed to provide early and opportune anti-retroviral therapy (ART) who fall under the treatment initiation criteria, as well as improve the clinical state for 100% of patients on ART over 18 months. An improved clinical state was defined as stabilized weight with patients not losing more than 2 kilos between visits, maintaining the ability to work and engage in social activities, and prevention of new opportunistic infections. Additionally, the collaborative aimed to achieve the following for 100% of patients on ART in participating sites: - Improve management of patient files to assure data quality and thus improved follow-up and treatment - Assure a psycho-social component to treatment - Promote retention and treatment adherence - Compliance with treatment protocols, including TB testing, PMTCT services as necessary, and laboratory testing
 
Implementation package/interventions: 

HCI led workshops and trainings for participants on quality voluntary counseling and testing procedures, biosecurity, use of HIV rapid tests, and a human rights approach for persons living with HIV according the WHO’s clinical eligibility criteria. Each hospital held trainings to ensure all providers were capable of following MINSA protocols related to HIV and ART, and completed patient charts correctly to promote follow-up and quality care for patients. Additionally, a 6 session workshop on stigma and discrimination was held for all participants, and additional hospital and facility staff were able to attend this workshop.

Participating facilities formed a multi-disciplinary quality improvement (QI) team, which included HIV program managers, general medicine doctors, specialists, nurses, psychologists, social workers, pharmacists, patient file managers, and dentists. The teams met monthly to discuss implementation of changes and evaluate progress based on data collected. Team members attended learning sessions, where HCI staff led meetings that included opportunities for teams to share lessons learned and progress, clinical content, best practices, and other HIV topics of general interest. Program managers from SILAIS also participated in learning sessions and were responsible for ensuring participating facilities had the necessary medicines, inputs and supplies to carry out changes. Teams designed, implemented and tested changes during rapid improvement cycles. Within their facilities, teams implemented the following changes:

- Actively search for lost patients through phone calls and home visits;
- Design organizational changes in the hospital to promote better inter-disciplinary care and improve the patient experience;
- Form self-support groups for patients and their family members to promote self-care, the importance of staying in treatment and maintaining appointments, disclosing status, and to foster community and family support;
- Use patient flow sheets in charts to track active infections, weight, and laboratory results;
- Hold regular multi-disciplinary team meetings to identify patient needs, analyze progress and identify areas for improvement; and
- Have a psycho-social approach that includes patient counseling to truly address patients’ needs and prevent treatment abandonment by involving psychologists and social workers.

Some hospitals used “peer counselors” to assist patients, with the same aims as the self-support groups. Others extended clinic hours to better accommodate patients’ schedules. At the regional SILAIS level, anti-retroviral therapy was de-centralized to enable facilities to better address the specific needs of their patients.

QI coaches provided follow-up visits to assist the teams in implementation of changes, support organizational changes, discuss further strategies for decreasing abandonment and increasing access to treatment, and help teams analyze progress to date to identify gaps for improvement.

Measurement: 

Participating facilities monitored and analyzed the following indicators to address quality improvement:
- % retention of ART patients
- % of HIV patients who had good clinical status during last consult
- % of HIV patients who have initiated ART according to established criteria
- % of HIV patients who receive ART and regularly receive consults for care and follow-up
- % of HIV patients who receive prophylaxis for opportunistic infections, according to MINSA protocols
- % of HIV patients tested for TB
- % of men and women with HIV, who use a FP method

Spread strategy: 

MINSA and SILAIS representatives were involved in the collaborative from the beginning to promote learning and uptake of practices for future expansion. For example, a SILAIS program coordinator participated in each learning session not only to support participating hospitals, but also to spread knowledge and practices to other hospitals within the SILAIS. 10 new hospitals and the manager of the national MINSA program participated in the third learning session, representing 10 new SILAIS and the central ministry.

The collaborative was designed in consideration of MINSA priorities to facilitate adoption of the practices, protocols and tools, especially related to monitoring & evaluation. When the collaborative began, ART was not available at the national level. By the end of the collaborative, ART was available in 16 of 17 SILAIS, and all SILAIS had multi-disciplinary HIV teams. Today, ART is available through Nicaragua, and MINSA recently adopted the indicators used in this collaborative for surveillance at all hospitals.

Number of sites/coverage: 

7 hospitals and 2 health centers from 6 SILAIS participated in this collaborative: Chinandega, Rivas, Masaya, Granada, Leon, and RAAS. In the country, there are 21 hospitals and 10 health center that provide ART.

Coaching: 

As previously described, teams received monthly support visits from QI coaches, who helped teams implement best practices, analyze progress, and institutionalize organizational changes. Teams in RAAS received quarterly coaching visits due to their distance from Managua.

Learning sessions & communication among teams: 

HCI led three learning sessions for this collaborative. The third session included participants from hospitals in 10 new SILAIS, as well as the national program manager for MINSA. At all learning sessions, teams shared the changes they had implemented during the previous rapid cycle, successes achieved, and lessons learned to facilitate communication and sharing of ideas between teams and facilities.

Results: 

Results from the collaborative are available from 7 of the 9 participating hospitals. Through the improvement collaborative and learning sessions, hospitals were able to achieve the following:

- 99% of HIV patients received ART according to MINSA protocols
- 90% of HIV patients received prophylaxis for opportunistic infections according to MINSA protocols
- 90% of HIV patients received a TB diagnostic test
- 98% of HIV patients had a good clinical status during their last appointment
- 100% of HIV patients have begun ART according to established protocols

Best practices/conclusions: 

The experience of this collaborative highlights the importance of a multi-disciplinary approach. Care is not provided by one person, and HIV providers often suffer from burnout. By sharing decisions and working together, providers on these teams did not suffer from burnout and thus were able to provider higher quality of care for their patients.

Often, HIV providers paid costs from their own pockets, especially for transport to find lost patients and to provide food for patients. While providers did not hesitate to do this, it was generally not recognized by the institutions, which is a need that should be addressed in the future.

An important area for future work is strengthening laboratory processes. While patients do complete CD4 and viral load testing every 3 months, the results must be sent to a central location in Managua, which is often delayed in returning test results to facilities. As a result, it is more difficult for doctors to make clinical decisions for patients as they are no sure how the patients are responding to their drug regimen. This should be addressed to achieve further improvements in the quality of care.

 

Report Author(s): 
Danilo Nunez, Indira Moreno
Organization(s): 
USAID Health Care Improvement Project (HCI), Ministry of Health of Nicaragua (MINSA)
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