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Improving HIV-TB referrals and care coordination in Thai Binh Province, Vietnam
07.01.2015
Thai Binh province is 120 km south-east of Hanoi, Vietnam’s capital city. The estimated number of people living with HIV in the province is more than 3000. Five adult outpatient clinics (OPCs) and one pediatric OPC in the province deliver HIV care & treatment. Vietnam’s national quality management program, HIVQUAL-Vietnam, has been implemented in Thai Binh OPCs since 2010 with technical support from the Ministry of Health, CDCVietnam, and the Harvard Medical School’s Partnership for Health Advancement in Vietnam (HAIVN). Prior to HQ-Vietnam implementation, all QI projects initiated in Thai Binh were focused on internal issues within the OPC, without attention to coordination of care between services and care at other facilities, such as HIV/TB. The Thai Binh provincial AIDS prevention and control center (PAC) and OPCs determined to focus on linkages between HIV related services and the perceived gap in coordination between those services, which included an identified need to improve the scope of guidance from PAC.
In August 2012, a qualitative survey was conducted to gain a better understanding of the main HIV related linkages in Thai Binh province (Figure 1). The survey was performed by interviewing medical staff from different hospitals and clinics in Thai Binh to gain insight into gaps in the referral processes between the various clinics. These gaps included a non-uniform use of the referral forms, lack of a formal notification procedure to the referred service, lack of a formal feedback procedure to the referring service, minimal coordination among the services (e.g. quarterly meetings or round table discussions), and lack of leadership or supervision for referral procedures.
Analysis of survey results demonstrated the need for an official referral procedure, which also requires formal approval by and support from the provincial Department of Health.
To put the procedure into practice and to apply additional quality improvement strategies, a quantitative assessment of specific linkage between the provincial adult OPC and TB clinics was completed. The rationale for focusing on this linkage was triggered by the high rate of HIV-TB coinfection and a request from the OPC. The provincial HIV OPC is the largest OPC in Thai Binh, with
nearly 400 currently active patients in care, among which, there are more than 300 patients on ARVs. This baseline assessment was developed with three indicators (Table 1) based on the definition of a successful referral from OPC to the TB clinic, which was defined in the referral procedure:
- Documentation of referrals from OPC to TB clinic should be recorded in the OPC referral logbook
- Referrals received at the TB clinic within 1 week should be documented in both HIV and TB referral logbooks
- Feedback should be documented in the OPC logbook within 2 weeks after referring the patient from OPC to TB clinic
A QI meeting was held with the participation of PAC, adult OPC and the TB clinic to discuss the assessment results and to develop a QI plan to improve the linkage. At the meeting, the group determined to focus improvement efforts on indicator number 2, % of referrals received at the TB clinic within 1 week and documented in both HIV and TB referral logbooks.
A fishbone diagram (Figure 2) and a flowchart (Figure 3) were developed to analyze the gap and root causes.
QI plan: For the two causes related to a lack of guidelines in OPC and the TB clinic, a referral procedure was developed and approved by the provincial Department of Health. This referral procedure provides instructions and specific referral forms for a variety of linkages such as: VCT-OPC, OPC-TB, etc.
For the other root causes, a QI plan was created identifying staff responsible for each intervention and an implementation timeline
Activities included:
- Assigning staff and a point of contact for referrals
- Developing instructions covering essential counseling information for referring patients
- Creating a telephone contact list
- Adding referrals to the agenda of daily morning meetings
- Calling the TB clinic every other Friday for follow-up
- Midterm and 6-month assessments
Indicator 3, % of patients referred to TB clinic, with referral result (feedback) documented in OPC logbook within 2 weeks increased from 50% at baseline to 100% at most recent follow-up where it has steadily remained.
Indicators 1 and 2 require continued attention; not all positive TB screens were referred, and of those referred, not all have arrived at the TB clinic. Follow-up will focus on ensuring uniformity and clarity of referral procedures for healthcare workers.
Despite continued challenges, this coordinated effort between Thai Binh OPC, the TB clinic and PAC resulted in dedicated focal people in charge of notification and feedback for referrals; availability of counseling materials; referral logbooks at TB facilities; a phone directory for the TB facility and OPC; regular dialogue; and summaries of evaluation results.
Barriers related to staff time, patient compliance and patients’ financial resources should be addressed, yet assessment of this intervention demonstrated several advantages.
Leadership involvement at both facilities and staff working for both clinics, increased capacity for application of improvement methods among medical staff, enhanced communication between facilities, and routine and clear documentation of referrals were all strengthened.
This initiative has encouraged expansion for other linkages, such as VCT and OPC, for which a baseline assessment is currently underway. In addition to providing a roadmap for expansion, this project underscores the importance of bilateral engagement from both clinics in improvement initiation.♦ Click here to download a PDF version of this story
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