Health at Home – The AMPATH Evolution

Sonak Pastakia, PharmD, MPH, BCPS Assistant Professor

Purdue University College of PharmacyCollaborator, Chronic Disease Management Program

Objectives

Provide a brief overview of AMPATH Discuss AMPATH’s transition Describe the structure and design of

comprehensive care in Western Kenya Analyze key early results from the

diabetes care program Describe areas of care focused research

Academic Model for Prevention And

Treatment of HIV/AIDS

Academic Model Providing Access To

Healthcare

Development of the Program

Initiated in November 2001 55 care sites in western Kenya

Catchment population ~ 2.2 million HIV prevalence 2 – 30% >130,000 patients enrolled; 75,000 active patients with 40,000 on cART

Academic Model Providing AccessTo Healthcare

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Cumulative Patients Enrolled: Nov ’01 – Mar ’08

80% of Chronic Disease Deaths Occur in Low & Middle Income Countries

Home Based Screening

Village based screening at innovation sites

Targeted Diagnostic Testing

Referral to clinic for enhanced careLinked to care by community worker

Perpetual door to door screening for chronic diseases

Community Screening

AMPATH Approach to Screening

Health at Home

Adults Children Total Pregnant Women

Number Tested 317,172 38,376 355,548 8,977

Number and Percent Positive

9,731 (3.1%)

702 (1.8%) 10,433 (2.9%)

396 (4.4%)

Number Newly Identified HIV positive

8039 (83%) 1028 (83.3%)

8641 (83%)

310(78%)

Number of Orphaned and Vulnerable Dependents Identified

36,593 51,066 87,659

Preliminary Screening Data from Webuye

ParameterParameter ResultResultNumber Screened 350Number with random blood sugar > 7.0 mmol/L (128 mg/dL)

47

Total number returning for a confirmatory testing/diagnosis at the health center

19

Total number confirmed with diabetes 4Estimated prevalence of diabetes 1.1**60% of patients did not return for follow-up

MTRH Center

of Excellence

Port Victoria Mosoriot

Turbo

Chulaimbo

Teso

Primary Health Care and Chronic Disease Innovation Sites

Webuye

CHRONIC DISEASE MANAGEMENT

CASE FINDING (EARLY DIAGNOSIS) & LINKAGE TO CARE:

PHCT: HIV, BP & RBS

CASE FINDING (EARLY DIAGNOSIS) & LINKAGE TO CARE:

PHCT: HIV, BP & RBS

PATIENT CARE AND REFERRAL SYSTEM PATIENT CARE AND REFERRAL SYSTEM

AMPATH-MTRH Centers of Excellence AMPATH-MTRH Centers of Excellence

CVPD Onc DM Psych Others

HEALTH CENTER/AMPATH CHRONIC DISEASE CLINIC

Patient received and initiated to care using CDM protocols

HEALTH CENTER/AMPATH CHRONIC DISEASE CLINIC

Patient received and initiated to care using CDM protocols

DISPENSARY (RN): Triage, prevention, monitoring (BP and RBS rechecks; foot exam etc.) and dispensing role through decision support

COMMUNITY CARE AND SELF MANAGEMENT: CHEWS, CHWS, AND COUNSELORS Decision support/training on referral protocols

DISPENSARY (RN): Triage, prevention, monitoring (BP and RBS rechecks; foot exam etc.) and dispensing role through decision support

COMMUNITY CARE AND SELF MANAGEMENT: CHEWS, CHWS, AND COUNSELORS Decision support/training on referral protocols

REGIONAL/DISTRICT REFERRAL CENTERS

Patient can be admitted or treated and referred down for follow up at lower levels

Patient referred up based on defined thresholds

Patient sent home for dispensary/community/self care

Patient referred to dispensary

C. CHW performs basic assessment based on decision

support in the phone based EMR

A. Community health workers (CHWs) make home visits or client visits local dispensary

Web –based Network ServerEventually connectivity to all areas within our

catchment areaB. CHW Scans Patients Medical

ID card

D. Data entered directly into the

phone

E. Data from previous visits available for decision support

Preliminary Descriptive Data from the Clinics

Number of Active Patients at Each SiteSite Number of

Active PatientsEldoret – Moi Teaching and Referral Hospital

On insulin

On oral agents or diet control

1343

604 (45%)

739(55%)

Kitale – Kitale District Hospital

On insulin

On oral agents or diet control

1122

359 (32%)

763(68%)Webuye – Webuye District Hospital

On insulin

On oral agents or diet control

383

76(20%)

307 (80%)

Demographic Data (N=1348)

Characteristic Average or Frequency

Range

Age 52 1-92

% With Food Insecurity 35%

% With Outpatient Health Insurance

<1%

% With History of Smoking 2%

% With a History of Alcohol Use 7%

% With Caretaker Assistance 68%

5.60% 3.00%

11.50%

8.20%

5.80%64.30%

no exercise

1 time/week

2 times/week

3 times/week

4 times/week

>5 times/week

Frequency of Exercise Per Week (N=637)

1.10%

9.58%

30.61%

31.24%

20.41%

4.71% 2.35%<16

16 - 19

20-24

25-29

30-34

35-39

>40

BMI of the Diabetes Population (N=637)BMI

Home Glucose Monitoring Program Results

Patients with at least 3 months of follow up HbA1c data

101

Active patients 135

Mean HbA1c at enrolment 13.2 13.2 95%CI (12.8-13.6)95%CI (12.8-13.6)

Mean HbA1c after at least 3 months 10.2 10.2 95%CI (9.7-10.9)*95%CI (9.7-10.9)*

Mean HbA1c after at least 6 months 9.8 9.8 95% CI (9.2-10.5)*95% CI (9.2-10.5)*

% of patients with an improvement in HbA1c after at least 3 months 95%95%

*P<0.01 via t-test comparison with Mean HbA1c at enrollment

Preliminary Results from Home Glucose Monitoring

Preliminary Results from Home Glucometer Pilot-Webuye

14

13

12

11

10

9

8

7

6

5

Months of enrollment

0 3 6 9 12 15 18 21

Future Steps

• Innovative Partnerships• Price Reductions on Supplies• Development of Sustainable Models of Care• Incorporation of co-pays • Greater dependency on patients• Integrated Partnership with Kenyan

Government/ Ministry of Health