Data can be used to educate agency leaders and other decision-makers in order to lead efforts toward changes and enhancement of HIV care and public health approaches to ending the HIV epidemic and curing hepatitis C. Data utilization can be applied in the design of agency services, community planning, integration of data systems, and identification of cluster outbreaks.
Best Practices
- Center for Innovation and EngagementCollection of implementation guides on evidence-informed best practices in HIV care delivery.
- HRSA Bureau of Primary Health Care (BPHC), Centers for Disease Control and Prevention (CDC)Toolkit to help Health Centers expand the provision of HIV services.
- Center for Innovation and EngagementThe Clinic-Based Surveillance-Informed (CBSI) intervention combines clinic and health department surveillance data to identify people with HIV who are out of care and re-engage and retain them in HIV care.
- Best Practices CompilationThis medical-community partnership worked to link clients to care and decrease missed appointments and used peer navigators to successfully re-engage clients in care.
- Best Practices CompilationThe intervention integrated supportive employment services, housing services, and HIV care for clients receiving case management services and with unmet housing and employment needs. Evaluation of the program showed improvements in employment rates, participant confidence in being able to hold onto a job, household median income, participants’ living situations, and self-perception of homelessness status.
- Best Practices CompilationCoRECT was a data to care project to identify and reengage people with HIV who were newly out of care. It included a clinic and health department data reconciliation process to identify missed laboratory results or appointments and create the out-of-care list, case discussions via telephone to review the combined list, and field epidemiologist outreach to assist clients with making appointments, securing transportation, and arranging referrals. The intervention employed strengths-based case management techniques and motivational interviewing to contact identified people within 30 days, reengage them in care, and reduce time to viral suppression.
- Best Practices CompilationThe Michigan Department of Health and Human Services was one of seven health departments funded by Leveraging a Data to Care Approach to Cure Hepatitis C Virus (HCV) Within the RWHAP Part F SPNS initiative implemented from 2020–2022. With the support of the Yale University School of Medicine, which served as the Technical Assistance Provider, MDHHS matched RWHAP and HIV and HCV surveillance data, calculated HCV viral clearance cascades for coinfected populations, and worked with three RWHAP clinics to generate clinic-based lists of coinfected clients and conduct outreach and linkage to HCV treatment.
- Best Practices CompilationThe goals of the Emergency Department and Hospital-Based Data Exchange for Real-Time Data to Care (ED Alert) intervention are to reengage people with HIV in care and to improve viral suppression rates. This is achieved using a real-time data exchange system that connects clients presenting to the emergency department with health department linkage specialists. ED Alert increased viral load testing and viral suppression over six months following a provider visit in the post-intervention period.
- Best Practices CompilationThis referral-based oral health model used dental navigators to connect clients to a large network of dentists, which facilitated scheduling of appointments.
- Best Practices CompilationExpanded housing and employment opportunities for people with HIV contributed to positive housing, earned income, and viral suppression outcomes for clients.
- Best Practices CompilationLA Links is a combined data-to-care and client navigation approach that cross-references routinely collected HIV surveillance data with other secondary data sources to identify and locate people with HIV who are not in care, as well as those who are in care, but with high viral loads. Originally implemented in 2013 as part of the Care and Prevention in the United States Demonstration Project, LA Links improved linkage to care, reengagement in care, and viral suppression. Louisiana expanded the program statewide in 2016.
- Best Practices CompilationGay Men’s Health Crisis updated its data management process to better document housing and employment service outcomes. Enhancements to the Electronic Health Record contributed to positive housing, employment, and viral suppression outcomes for clients.
- Best Practices CompilationLink-Up Rx is a pharmacy-data-based Data to Care program implemented by the Detroit Health Department in partnership with the Michigan Department of Health and Human Services and a specialty pharmacy. Using pharmacy data to identify clients in need of follow-up greatly reduced the amount of time for clients to appear on “not in care” lists compared to traditional D2C approaches. Protocols for a three-tiered outreach and reengagement approach were developed to connect clients back to antiretroviral therapy and HIV care following a missed pharmacy pick-up. Nearly half of identified clients were linked back to their pharmacy or other HIV medical services.
- Best Practices CompilationThis data-to-care (D2C) initiative, implemented by the San Francisco Department of Public Health and its affiliated clinics from 2015–2017, used three sources of data to identify people not in care: HIV surveillance data, healthcare provider referrals, and electronic health record (EHR) data. LINCS navigators then used disease intervention searching tools and EHR data to locate clients and connect them to an HIV care provider. LINCS navigators followed up with clients for 90 days to support engagement in care. LINCS participants were more likely to be retained in care and virally suppressed after the intervention than before.
- Best Practices CompilationThe Louisiana Public Health Information Exchange is a bidirectional exchange that connects hospital system electronic health records with state surveillance data. Providers use the exchange to identify and relink people with HIV who are out of care to clinical and supportive services. Since LaPHIE was implemented in 2009, thousands of people with HIV who were out of care have been identified, with a significant number being successfully linked to care.
- Best Practices CompilationThe Utah Department of Health and Human Services collaborated with RWHAP Part B-funded medical case managers to improve care and outcomes for clients following Franklin Covey’s 4 Disciplines of Execution: 1) focus on the wildly important goal; 2) act on the lead measures; 3) keep a compelling scoreboard; and 4) create a cadence of accountability. Through intensive case management, regular monitoring, and feedback sessions, the state's RWHAP Part B program's overall viral suppression rate increased from 88.9% in 2020 to 90.4% by December 2021.
- Best Practices CompilationFenway Health, Fenway AIDS Action Committee, and MassHire Downtown Boston provided housing and employment supports to clients who were unstably housed and were un- or under-employed, in order to improve health outcomes as part of the RWHAP Part F SPNS initiative Improving HIV Health Outcomes through the Coordination of Supportive Employment and Housing Services. Almost 70 percent of clients who participated in this intervention and received medical care at Fenway Health were virally suppressed, despite facing considerable barriers to care.
- Best Practices CompilationSoutheast Mississippi Rural Health Initiative, Inc., a network of community health centers serving Southern Mississippi, uses data-driven quality improvement techniques to identify youth who are not virally suppressed or have missed appointments. Medical case managers use a client checklist to identify and address barriers to antiretroviral therapy (ART) and medical care adherence. They also use a health literacy visual illustration tool to help youth understand the effects of ART on viral suppression. The intervention strategy was successful in improving viral suppression rates for youth.
- Best Practices CompilationThe Arizona Department of Health Services partnered with three clinics to identify people with a dual diagnosis of HIV and HCV, determine their care needs, and link them to HCV treatment.
- Best Practices CompilationMacGregor Infectious Diseases, a hospital-based clinic affiliated with the Hospital of the University of Pennsylvania, implemented a multidisciplinary approach to strengthen outreach to clients and improve care retention. As compared to clients in standard care, clients served with the multidisciplinary approach had higher rates of retention in care, particularly among clients who were not virally suppressed.
- Center for Innovation and EngagementClinical Decision Support System (CDSS) that generates alerts in electronic medical records to notify HIV outpatient providers of suboptimal follow-up, virologic failure, and laboratory toxicity.
Resources
- Data Integration, Systems and Quality (DISQ) TeamSessions for RWHAP agencies to talk with their peers about technical challenges and solutions.
- SPNS HIV/HCV Data-to-Care Initiative
Jurisdictions and their partner clinics used different approaches to implement Hepatitis C Virus (HCV) Data to Care project activities based on their previous experience, data management infrastructure, ability to share data, and staffing resources.
- HRSA HIV/AIDS Bureau (HAB)
Update to the Unmet Need Methodology for RWHAP Part A and B recipients.
- HRSA HIV/AIDS Bureau (HAB)Questions and answers about using the Compass Dashboard.
Training Modules
- HRSA HIV/AIDS Bureau (HAB)
Data visualization tool for use by RWHAP agencies to make use of data in decision-making in order to improve outcomes along the HIV care continuum.
Webinars
- Data Integration, Systems and Quality (DISQ) Team, HRSA HIV/AIDS Bureau (HAB), Ryan White Data SupportFirst of two trainings to support Ryan White HIV/AIDS Program Part F (AETC) Programs
- Data Integration, Systems and Quality (DISQ) TeamReview of 2021 RSR data and data quality issues.
- IHIPWebinar series featuring HIV care innovations developed under HRSA SPNS projects.
- Data Integration, Systems and Quality (DISQ) Team
DISQ “Office Hours” are technical assistance opportunities that allow Ryan White HIV/AIDS Program (RWHAP) recipient and provider staff to talk with their
- Data Integration, Systems and Quality (DISQ) Team, Ryan White Data SupportFeedback session for RWHAP recipients to discuss challenges or issues experienced during the 2022 RSR submission process.
- RWHAP Data SupportStep-by-step instructions for recipients on accessing and completing the 2023 RWHAP Part A PTR.
- IHIPBest practices and tools for telling persuasive stories with your data.
- Technical Assistance Provider Innovation Network (TAP-in)Recordings of the TAP-in webinars on topics critical to the Ending the HIV Epidemic Initiative.