FOCUS PROPOSAL MARICOPA JAIL HCV_ 3-27-2017.PDF

FOCUS
Frontlines of Communities in the United States
Maricopa County Jail
Clinical Partnerships – HCV Screening
Is a smart EMR algorithm proposed? Smart EMR algorithms support more automated processes for
determining eligibility for testing, populating lab orders to facilitate screening and reduce human error,
and getting to greater scale in testing
Are continuous quality improvement (CQI) practices proposed? CQI enables ongoing data sharing
and feedback that leads to improvement in testing outcomes
Does the proposal demonstrate sustainability? Efficiency? Cost-effectiveness?
Does the proposal demonstrate a strong commitment to dissemination with clear goals and
multiple deliverables that reach key audiences?
Does the model demonstrate the potential for replication, development of a best practice, an
innovative approach, and/or systemic change?
Proposal Checklist
Please carefully review the entire proposal and complete fully; refer to the following checklist:
Have all the questions and sections been completed with specific details and responses requested
(please refrain from generalities)?
Does timeline reflect goals and activities that are Specific, Measurable, Achievable, Relevant and
Timely (SMART)?
Have the following attachments been included (please do not submit any additional attachments
such as newsletters, brochures, or reports):
Budget and Budget Justification
Timeline
Testing Flowchart
Linkage to Care Flowchart
Completed W-9 Form
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Part I
Proposal Cover & Overview
• Name of applicant organization: Maricopa County Correctional Health Services
• Legal name of applicant organization: Maricopa County
• Name of Project Director / Key Contact: Jeff Alvarez, MD
• Telephone: 602-527-6458
• E-mail: j.alvarez@mail.maricopa.gov
• Project Title: Hepatitis C Opt-Out Screening of a Jail Population
• Application date: 3-27-2017
• Total Budget Requested: $339,377
Background
Maricopa County is the 4th largest county by population (approximately 4 million residents) in the United States
containing the city of Phoenix metropolitan area. The Maricopa jail system houses an average daily population
of 8500 detainees in six jails all located in Phoenix, Arizona. By gender, this population breaks down to 76%
male and 24% female. Ethnic and racial distribution of the jail population is as follows: 60% white, 18%
African American, 16% Hispanic, 4% Native American, and 1% Asian.
Correctional Health Services (CHS), a separate county department, provides all healthcare to this large jail
population. This places the healthcare of the correctional population under the direct supervision of the Board
of Supervisors instead of the Sheriff’s Department. CHS does not have any external clinics outside of the jail
system. Its sole purpose is to provide health care to people booked into the custody of the Maricopa County
Sheriff’s Office jails. This arrangement allows for a separate budget to be retained by CHS to provide
healthcare as opposed to combined use with custody staff.
The Maricopa County jail system is the 2nd largest county jail system in the country fully accredited by the
National Commission on Correctional Health Care (NCCHC). The jail system received the NCCHC’s Facility of
the Year award in 2015. In addition to full accreditation for its health care, the system has four accredited
Opioid Treatment Programs (OTP’s) allowing access to OTP services to the full population as medically
indicated and for continuity of care with the community. These OTP’s provide new starts of methadone to
pregnant females booked into the jail system with opioid addiction, maintenance of methadone for both males
and females booked in the system with verified community dosing, and new starts for referrals from drug court
and probation. Currently there are 54 individuals in the system on methadone treatment. All new starts are
referred to a community provider after being seen by that community provider while still in custody to provide a
“warm hand-off”.
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Proposal Narrative & Proposed Reach
Executive summary.
The FOCUS Project at Maricopa County Jail intends to build on the current infectious disease
screening activities occurring in our clinical settings by including Hepatitis C as a test provided according to
USPSTF guidelines. In our clinical care model, CHS currently offers opt-out HIV and TB screening for the
entire population between days 5-7 of booking. If screening is provided after day 5, in our experience, many
individuals screened do not receive results, treatment, or linkage to follow up care in a timely manner. After
discussion with our Public Health Department, it was decided that using the day 5-7 testing range had the best
outcomes for our jail population and the community as a whole. The recent successful implementation of a
permanent electronic interface (funded by CHS) between the Maricopa County Public Health Department lab
and the CHS Electronic Health Record (EHR) will now allow us to add Gonorrhea, Chlamydia, and Syphilis
testing to our current HIV and TB screenings by mid-April of this year. CHS determined that given the current
epidemiology of infectious disease in our incarcerated population, it was important to routinely screen for all of
these infections in a timely manner. In addition, individuals move through the detention system rapidly
(approximately 70-80% of all individuals detained are released within the first week) and by linking HIV,
Sexually transmitted infections (STI’s) and TB tests together, we are able to more rapidly notify patients of their
diagnosis, treat for acute STI’s, and begin the process to link chronically infected patients with treatment in
and/or out of custody. This integrated approach for HIV and TB screening was implemented in 2014. During
this time, CHS successfully identified 70 new HIV diagnoses and screened approximately 40,000 individuals
with a blood based HIV test.
An additional strength of this screening standard was developing a close working relationship with the
Maricopa County Public Health Department. The two agencies were able to build a process by which CHS
collects blood samples for testing and the public health lab processes all of the infectious disease tests for the
correctional health system. When the lab identifies a new HIV positive patient, the lab staff quickly contacts
correctional health care staff of the new diagnosis. The new interface also directly reports the lab results into
the patient’s medical record for the clinical staff to review. Clinical staff are then able to immediately begin
treating or linking the individual to care. This need became more evident when CHS determined through
targeted testing in the female jail population that 10-12% (ADP 900-1000) of individuals were infected with
Chlamydia and Gonorrhea infections. Given this information, there is a tremendous need and opportunity to
impact the health of our population by routinely screening for multiple infectious diseases.
In order to provide inmates a robust infectious disease screening panel, CHS is proposing to add routine HCV
screening to our current and planned STI screening exams. This will be implemented for all 6 Maricopa
County Jail Facilities covering all males and females in the jail system. Currently, all patients who request HCV
screening are provided a test. In the current model CHS screens approximately 1,000 inmates annually. Under
a routine testing model it is possible to screen approximately 15,000 individuals and notify them of their result.
In addition to testing these individuals, CHS is committed to linking individuals to care either during their stay in
the jail system or upon release from the facility to the community or transfer to the state prison system. These
efforts are likely to have a significant impact on the epidemiology of HCV in the Phoenix community.
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Our leadership staff is committed to this project. We have been very successful in our efforts in identifying HIV
in our population, along with linking them with care while in and/or out of custody. We have already committed
resources to this identification and linkage with care for the last 3 years. Adding Hepatitis C screening long
term will not present any new logistical challenges. Training on how to offer an opt-out screening program has
already been completed. Electronic forms for ordering all of the needed lab tests have already been
developed in our EHR. The interface for electronic lab result reporting is already in place. Staff resources are
already in place for education of patients at the time of lab draw on preventive practices. Finally, our EHR
reporting system allows us to continuously monitor our progress in screening our population in a timely
manner, along with compiling the needed data to support its continued success. We just need financial
assistance in starting this new Hepatitis C screening addition to our program. We hope to show the true
number of individuals in the system affected by this chronic disease. This will allow us to better plan for future
utilization and treatment.
BASELINE Variables (Annual for previous Maricopa
Total A+B+C
year- Month/Year to Month/Year) Jail
HCV (Must be completed if HCV screening is being proposed)-These numbers are based on values
obtained by patient requested Hepatitis C tests last year and not via a larger opt out or CDC guideline
driven testing method.
Unique # of Patients served in prior year 91,473 Maricopa
Unique # Patients eligible for HCV Screening 13,263 Maricopa
# HCV Tests Conducted 996 Maricopa
#/% HCV AB+ 360/36% Maricopa
#/% HCV RNA + # Not Maricopa
available
# /% Linked to Medical Care (first medical # Not Maricopa
appointment kept) available
PROPOSED REACH (reach for proposed Organization Maricopa
project period) Total Jail
HCV (Must be completed if HCV screening is being proposed)
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Unique # Patients eligible for HCV testing –opt out 10,000 Maricopa
for all patients at day 5-7 of booking
# HCV tests to be conducted/ % of eligible to be 10,000/100% Maricopa
reached
# HCV AB+ 900/9% Maricopa
685 (approx.
#/% HCV RNA + 80% will be Maricopa
chronic
carrier)/76%
# /% Linked to Medical Care (first medical 615/90% Maricopa
appointment kept)
Part III
Project Framework
Pillar I: Testing integrated into normal clinic or work flow -
1. Please attach a proposed flow chart of how the test will be offered as part of an
integrated clinic flow (see Appendix C1 and C2 is an example of best practice
automated flow).
a. STI screening is already part of the daily flow. Adding Hepatitis C
testing will not alter this flow. Patients are identified as day 5 of
booking by our EHR (see screenshot below). CHS staff use this list in
the EHR to pull patients, offer opt-out screenings, and draw labs along
with applying TB skin tests Monday-Friday (which is why we say day
5-7). Hepatitis C screening would be included at the same time with
all other opt-out STI screenings.
Pillar II: Electronic Medical Record (EMR) modification -
1. What EMR system does your institution currently use?
a. TechCare (sold by NaphCare)
2. What EMR modifications are you proposing that align with Pillar II?
a. EHR already has Infectious Disease (ID) screening queue to identify
those patients within the 5-7 day timeframe for TB skin testing and ID
screening tests.
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b. EHR already has forms built into it to guide nursing staff on opt-out
screening patient presentation, consent/refusal forms, and processing
of lab work. Hepatitis C will be added to this form. No alteration to
work flow is needed. No provider order is necessary as the system
automatically orders labs via standing orders built into the system.
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c. Lab results already flow into the EHR from the Public Health lab
interface. No new modifications are needed to receive the Hepatitis C
results.
d. Current reports on STI’s will be enhanced to pull needed data for
Hepatitis C reporting to include positivity rates, provider visit for
notification of results, and linkage to care in and/or out of custody.
3. How long do you project that it will it take to operationalize EMR changes?
a. 1 month or less since only simple wording modifications are needed to
forms. No new interfaces or major technology development is
needed.
4. Is your institution in the process of changing EMR?
Yes X No If yes, what is the new system?
5. If your institution does not yet have an EMR system, what is the timeline for EMR
implementation? In the interim, what processes, systems or technologies will
you use to improve and monitor testing?
a. N/A
6. What type of test technology will you use? (i.e., 4th Gen Lab-Based –onsite, 4th
Gen Lab Based-commercial lab)
a. 4th Gen Lab Based-commercial lab
7. If latest generation test technology is not currently in place, when does your
organization expect to add?
a. N/A
8. For HCV screening, will all ab+ tests automatically reflex to an HCV RNA test?
a. Yes
9. For HBV screening, describe how you will update your EMR to identify eligible
patients. For example, will the EMR be modified to identify eligible patients by
country of origin? Provide a second language alert? Or will there be a change in
protocol because disproportionate amount of patients are at risk for HBV? Please
describe.
a. N/A
Pillar III: Systemic Policy Change -
1. Please list by name and title, key leaders within your organization
a. Dr. Jeffrey Alvarez, CHS Medical Director
b. Dr. Grant Phillips, CHS Assistant Medical Director
c. Dr. Robert England, Maricopa County Public Health Director
d. Vincent Gales, RN, CHS Infectious Disease Coordinator
Pillar IV: Training, Feedback and Quality Improvement -
1. Which evidence-based quality improvement methods will your organization use?
a. The evidence based quality improvement methods used are the steps
of the Continuous Quality Improvement (CQI) process. A problem is
identified, a threshold is determined (if appropriate), a baseline study
is completed which consists of data collection and interpretation,
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implementation of improvement actions, and monitoring for results of
the improvement actions. The steps are repeated until desired
outcomes are achieved. All jail sites have CQI teams consisting of
representatives from nursing, medical providers, and mental health
staff. The individual teams report up to a centralized Quality
Department who oversees the programs for all facilities. This is in
accordance with National Commission on Correctional Health Care
Standards for site specific CQI teams.
2. How frequently will data be shared with team and leadership to drive
improvement and compliance?
a. The data will be shared as appropriate depending on the stage of the
study but not less than monthly with the study/clinic team (and
monthly health staff meetings) and quarterly with the Continuous
Quality Improvement Council (leadership). Since the CQI teams
consist of local jail staff, data is continuously shared with all line staff
at every site.
A. Brief summary of potential challenges and proposed solutions in implementing any of the
Pillars outlined above:
• CHS does not foresee any major clinical or IT challenges to this project. The
largest hurdle will be processing the agreement with the county board of
supervisors, including the legal department. All contract language must be
approved by the elected board of Maricopa County. The vetting process for new
contracts can take 2-3 months, as long as the contract language is acceptable to
the attorneys.
B. Linkage to Care
• CHS currently receives all lab results via an interface with our laboratory
vendors. These results are received directly into a queue for immediate review
by CHS staffed medical providers. Visits with a nurse will be scheduled as a
priority for the next day after review by a provider. The nurse will educate the
patient on Hepatitis C, ensure that the viral load verification is pending, and
schedule the patient for a visit with the provider to answer any follow up
questions. For those released prior to receiving results, education will be given at
the time of the lab draw informing the patient on how to obtain their results after
release. Information on the importance of follow up for treatment with community
providers will be emphasized. CHS currently has a strong relationship with a
community HIV clinic run by the local health district. This health district has
several federally qualified health care clinics (FQHC’s or lookalike’s). We would
like to engage the health district for direct hand-offs at release. However, without
better estimates on true numbers of clients, it is currently difficult to solidify a
community partner. Our current partnership has led to a very successful linkage
for our patients releasing to the community with the diagnosis of HIV. CHS also
has a strong relationship with the Regional Behavioral Health provider. All of the
seriously mentally ill patients are directly connected to their community case
managers at release.
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D. Data Monitoring, Submission and Evaluation Plan
• The CHS EMR, TechCare, has a reporting mechanism that can track any
identified data point. CHS will have all FOCUS reporting points added to current
STI reports in order to provide all needed reporting requirements.
• Current CHS Quality Improvement meetings include STI reports by our Infectious
Disease Coordinator. Data has been collected for reporting on our HIV opt-out
testing program for the last 3 years. Hepatitis C values on current testing are
already also being reported based on current tests being conducted upon patient
request. This number obviously is expected to increase with opt-out testing. The
screen shot below shows a data pull of all patients reporting heroin use on their
receiving screen in the last month.
• CHS has used this reporting to enhance our ability to collect information
on our own population for treatment and budgetary planning. It also
assisted us in our submission and selection for a National Association of
Counties (NACo) award in 2016. See link to abstract below.
http://www.uscounties.org/cffiles_web/awards/program.cfm?SEARCHID=20
16heal04
E. Dissemination Plan
TABLE 1: Planned Conferences, Presentations, and Publications
Local or Regional
Presentation Title/
Opportunities to Share Submission Timeline
Content area
Best Practices
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National Association of
NACo awards for Health Spring/Summer of 2018
Counties
Conference or Publication Abstract or Manuscript
Timeline
Name Title /content area
Opt-out Hepatitis C
NCCHC Spring or Fall
screening in a large Winter 2017 or Spring 2018 for application period.
Conference 2018
county jail
Other Funding.
The State Department of Health Services has funded an opt-out HIV screening for our patients since
2014. The funding is not received by CHS. The state reimburses the lab of the public health
department for all HIV screening lab tests conducted on the jail population. No funds are received by
CHS for staff positions for the screening process.
Part IV
Goals, Sustainability Plan & Timeline
A. Plans for sustainability.
• Since this activity only enhances our current STI screening, sustainability is not a
concern. CHS has been able to continue to offer HIV opt-out screening for over 3
years now with no funds for staffing. This includes having patients see a medical
provider for all positive results. Since CHS has no external face in the community,
continued linkage to care will be dependent on identifying a strong community
partner as we did with our HIV linkage to care. We feel strongly that we will be
successful in developing this as we achieve true numbers on the quantity of referrals
generated.
B. Goals & Activities Timeline.
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Part V
Proposal Budget
Organization Name Maricopa County Correctional Health Services
July 2017 to
Budget Period: June 2018
Name of Program Opt-Out Hepatitis C Screening
BUDGET ITEM Item Description Gilead Program Budget Non-Gilead In-Kind
Funding Support Support
PERSONNEL include % FTE and # months on
project
Medical Assistant, 20% FTE, 12 months, Full Salary $ 6,570 80% FTE, 12
$32,851.20, jail site M-F for lab months,
Durango, I draws $26,281
Medical Assistant, 20% FTE, 12 months, Full Salary $ 6,570 80% FTE, 12
$32,851.20, jail site M-F for lab months,
Estrella, 2
draws $26,281
Medical Assistant, 20% FTE, 12 months, Full Salary $ 6,570 80% FTE, 12
Towers, 3 $32,851.20, jail site M-F for lab months,
draws $26,281
Medical Assistant, 20% FTE, 12 months, Full Salary $ 6,570 80% FTE, 12
$32,851.20, jail site M-F for lab months,
Lower Buckeye, 4 draws $26,281
Medical Assistant, 4th 20% FTE, 12 months, Full Salary $ 6,570 80% FTE, 12
Avenue, 5 $32,851.20, jail site M-F for lab months,
draws $26,281
Office Assistant, Lower 100% FTE for reporting assistance $ 28,367
for all jail sites, 12 Months, Full 0
Buckeye Salary $ 28,366.58
80% FTE for supervision and
oversight of program for all jail $ 60,955
RN sites, 12 months, Salary 0
$76,194.56
Sub-total Salaries $ 122,172 $131,405
19.13% Variable Benefits ($
Fringe Benefits
25,030.09) $11,400 Fixed $ 55,292 $ 70,738
(%)
Benefits per FTE x3 ($34,200)
Subtotal Personnel $177,465 $ 202,143
OTHER DIRECT
PROJECT COSTS
Hepatitis C Ab test 10,000 tests/ year @ $11 per test $110,000 $0
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Hepatitis C RNA 900 tests/year @ $36 per test $32,400 0
Subtotal Other Direct $ 142,400 $0 $0
Costs
PURCHASED SERVICES
Subtotal Purchased $0 $0 $0
Services
Indirect Rate Not to exceed 10% $19,512 $0 $0
TOTAL PROGRAM BUDGET $ 339,377 $0 $202,143
REQUEST
Budget Justification
FTE Analysis
RN .80 FTE
Description of Task(s) Hours Per Month
(160 hours per FTE)
Meet with each patient at each jail site with 64 hours
positive results daily M-F to discuss initial results
and enroll in chronic care clinic
Obtain provider order, vaccinate, and document 16 hours
vaccination of all newly diagnosed patients
Prepare daily Public Health notification of all 16 hours
patients with positive results including
demographics needed by Public Health
Department
Assures that Office Assistant prepares and sends 16 hours
all negative result patient notifications and other
quality assurance measures of program are met
Prepare and review all statistics for monthly 8 hours
administrative meeting
Prepare and review all reports for quarterly CQI 8 hours
meeting and quarterly Infectious Disease meeting
Total Hours 128 hours
Total FTE (Hours divided by 160 hour work 80% FTE
month)
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Office Assistant 1 FTE
Description of Task(s) Hours Per Month
(160 hours per FTE)
Prepare daily notification of normal/negative results to 80 hours
all patients for all jail sites
Enter all Hepatitis A/B vaccinations into patient 40 hours
electronic health record and state immunization
database
Collects data from electronic health record for RN to 30 hours
prepare monthly administrative reports
Collects data for quarterly CQI meetings for RN 10 hours
Total Hours 160 hours
Total FTE (Hours divided by 160 hour work 1 FTE
month)
Medical Assistant (5 of these at 20%FTE)
Description of Task(s) Hours Per Month
(160 hours per FTE)
Prepare daily list of patients to be pulled for lab 32 hours
draws, offer opt out testing, draw the labs, and
prepare labs to be sent to lab
Total Hours 32 hours
Total FTE (Hours divided by 160 hour work 20% FTE
month)
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APPENDIX A
Project Data
Organization will submit the following Project Data to Gilead or Gilead’s designee (which may include ICFI,
Inc.), on a quarterly basis:
Aggregate Summary Variables (where applicable)
All Tests
• Clinic/Site Name
• Month and Year of Project Data
• Data Reporting Quarter
• Unique Number of Patients(clinical settings)
HCV Tests
• Unique Number of Clients/Patients Eligible for HCV Testing (clinical settings)
• Number of Clients Born Between 1945-1965 (Birth Cohort) Tested for HCV Ab
• Number of Clients Born Outside of the Birth Cohort Tested for HCV Ab
• HCV Ab Test Results of Clients Tested (positive, negative, invalid/indeterminate/no result)
• HCV RNA Test Results of Clients Tested (positive, negative, invalid/indeterminate/no result)
• Number of Individuals Testing HCV RNA Positive Linked to Care
Test-Level Variables for Positive Clients/Patients Only (where applicable)
All HIV, HCV ab, or HBsAg Positive Clients/Patients
• Client ID (de-identified in accordance with HIPAA)
• Clinic/Site Name
• Data Reporting Quarter
• Year of Birth of Positive Client/Patients
HCV Antibody Positive Clients (tested or not tested; where applicable)
• Ever Injected Drugs (only for clients not in birth cohort)
• Previous HCV Ab Test Result
• HCV Ab Test Result
• HCV RNA Test Conducted by Partner
• HCV RNA Test Result
• HCV RNA Positive Client/Patient Newly Identified
• HCV RNA Positive Clients/Patients Linked to Medical Care: First Appointment Kept (Y/N)
• Reason First Medical Appointment Not Kept
• HCV Positive (Ab or RNA)/HIV Co-Infection? (Y/N)
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Monthly Top Line Estimate Data
HCV
HCV Ab Tests Performed
HCV Ab Positive Patients Identified Through Testing
HCV RNA Tests Performed
HCV RNA Positive Patients Identified Through Testing
HCV RNA Positive Patients (identified through testing) Attended First Appointment
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APPENDIX B - TIMELINE TEMPLATE (Please populate activities that are specific to your project and organization)
Month Month Month Month Month Month Month Month Month Month Month Month
GOALS AND ACTIVITIES 1 2 3 4 5 6 7 8 9 10 11 12
Testing, Linkage and Tracking /Person Responsible
Update current P&P’s for STI screening X
Train nursing and provider staff on enhanced screening X
Begin Testing for Hepatitis C with our current screening X
Continue testing for 1 year X X X X X X X X X x
EMR modification
Add Hepatitis C to our screening forms in EMR X
Enhance STI reports in EMR to include Hepatitis C X
Dissemination
Apply for NCCHC presentation at Spring Conference 2018 X
Monitoring & Evaluation
Report on STI screening results at quarterly CQI meeting X X X
Report on STI screening results at monthly Sheriff’s meeting X X X X X X X X X X
Program Administration
FOCUS Quarterly Data Report Submission X X X
FOCUS Interim Report Submission X
FOCUS Final Report Submission X
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