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Making it Routine – HIV Screening at Family First Health

Promising Practices for Putting the "Routine" into HIV Testing at Health Centers on-demand webinar with panelists from Family First Health

Family First Health logoIn 2007, fewer than 200 of Family First Health's 14,295 medical patients received HIV tests. 

The Centers for Disease Control and Prevention (CDC) guidelines had just shifted from recommending “risk-based” HIV testing to routine screening of all patients older than 13 years. 

Pennsylvania law, too was changing. A separate opt-in consent and extensive pre- and post-test counseling for HIV testing was soon to be a thing of the past.  

Health center staff also began to see a pattern. Patients who tested positive tended to be later in the course of the disease, delaying their entry into treatment for the disease and denying clinicians the opportunity to counsel the patient about changing behaviors that put others at risk.

Clearly, more aggressive screening across the patient base was needed. 

The problem was how.  

“The test really has to fit into the primary care visit and cannot disrupt the patient flow in the health center,” said Karen McCraw, chief program officer at Family First Health. “Because we have patients coming and going all day … I would say that was the single most important variable in making this work.”

Start Small

McCraw understood that in primary care, you can’t rush change. To meet the challenge of integrating routine HIV screening into the primary care appointment, Family First Health first conducted a self-evaluation and addressed staff concerns.

  1. Assess staff capacity. Workflow already had medical assistants and licensed practical nurses taking patients to exam rooms and were a logical choice to conduct the HIV screening at that time, with providers delivering results.
  2. Determine when and what type of test patients should receive. Family First Health selected a rapid HIV test so it could be completed in a typical 20-minute from waiting room to exit visit. Blood based testing also was available for patients and used to confirm reactive rapid tests.
  3. Remove judgment from the process. Risk assessment questions were eliminated unless germane to some other part of the visit.
  4. Conduct an honest financial assessment of both cost and revenue. Cost was an issue for patients, so the test had to be provided at no additional expense. At the same time, fixed rates per visit from Medicare and Medicaid meant the health center would have to find a way to absorb the additional costs of routine testing uninsured, Medicaid and Medicare patients. Family First Health negotiated a lower test price with their supplier and successfully competed for HHS Office of Population Affairs funding that supports routine screening in family planning programs. For privately insured patients, Family First Health is currently reimbursed $18 to $21 per test.

Thus equipped, Family First Health initiated a routine HIV screening pilot among family planning patients. 

Build on Success

The pilot convinced even skeptics, including Health First medical director Asceline Go, MD, who quickly became a champion of the program and started calling HIV screening "the fifth vital sign."

Next step: expand testing to all patients 13 years of age and older, across all five service delivery sites, in accordance with Centers forClinician Disease Control revised guidelines for routine HIV screening.

To help cover the additional costs, McCraw turned to the Pennsylvania Department of Health, which agreed to support the routine screening program. “Health care providers who need financial support for a routine HIV screening program should explore a variety of options, including HIV pharmaceutical company grant programs, existing publicly funded HIV testing programs, or foundation funds," she said.

Today, every patient age 13 or older is offered the opportunity to be screened for HIV – in a non-judgmental way that has proven successful. Typically, it is explained that "Dr. X believes it is important for all of her patients to be tested for HIV. We would like to do the test today.”

HIV testing training is part of new clinical employee orientation. Electronic health records, adopted in 2011, include reminders for HIV screening. 

Longstanding patients who had never been tested under the "risk" model have been found to be HIV positive and engaged in care, giving them "an opportunity to be treated and to live a longer and healthier life," according to McCraw.

One of the most important lessons learned, and the primary reason routine HIV screening is essential: Even seasoned medical providers cannot predict who will test positive

More Screening, More Treatment

Patients at Family First Health are starting to think about HIV testing in the same way they think about cholesterol or diabetes testing. Since 2009, 64 percent of patients offered the HIV test have taken it, with higher acceptance rates of 71 percent among Hispanic/Latino patients and 68 percent among young people. 

The most common reason for refusal remains: “I don’t think I am at risk.” Family First Health believes that continued vigilance will reduce that belief.

“Key to our success was presenting HIV testing as routine, and that required a culture change in our organization," said Dr. Go. "The result has been that we have identified people as being HIV positive and have gotten them the care they need; but just as importantly, we have given our patients the message that everyone should know their HIV status. Once someone knows they are HIV negative, we can work with them as their primary care provider to help them stay that way.”

If offering routine HIV testing to patients is the first step in realizing an AIDS-free generation, linking patients who test positive to HIV care and treatment is the second.

Family First Health receives Ryan White HIV/AIDS program funding that supports services for 550 patients living with HIV, making it easier to move patients who test positive seamlessly into care. 

McCraw advises health centers that do not already offer in-house HIV care to form partnerships with their local Ryan White providers. “As a Ryan White provider, one of the expectations of our funder is that we facilitate the transition of HIV positive people into medical care," she said. "I believe that Ryan White programs would be very willing to work out arrangements with health care providers for HIV care referrals.” Health Center Program guidelines encourage health centers to expand HIV service delivery by establishing formal referrals with other providers in their service area, in addition to building internal capacity.

For more information: Karen McCraw, chief program officer, Family First Health

More Grantee Spotlights

Why Routine Screening?

Nearly 1 in 5 people infected with HIV in the U.S. is unaware of their HIV-positive status.

High-risk patients do not always tell their doctors about their high risk behaviors.

Patients may not know what behaviors can put them at risk.

Early detection and entry into care can improve health outcomes and prevent the spread of HIV. 

CDC Recommends routine testing: Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings

Health Centers are encouraged to implement routine testing: HIV Testing in Health Care Settings: PAL 2010-13

About Family First Health

Founded in 1970, first Federal funding in 1975

Located in Susquehanna Valley farmlands 110 miles west of Philadelphia

Five clinical locations, some open 12 hours per day

19,759 patients – 10 percent school-based

35 percent of patients are children, 18 years old or younger

One-third of all patients uninsured

Half covered by Medicaid/CHIP

One in ten covered by Medicare

Half of all patients are minorities; one-third Hispanic or Latino

Go to Family First Health