Model mechanics

ART refills

Clinical consultations

Individual/group approach

Group

Individual, all on the same day

Who attends?

Client or client-appointed representative

Client

Client recruitment

Where

At facility

By whom

Lay health care worker in facility waiting rooms
Posters/pamphlets in facility waiting room advertising model
Clinician offering enrolment to eligible clients

Eligibility assessment

By clinician during consultation

Group formation

By lay health care worker or nurse at the facility

HIV disclosure

Does it happen?

Yes

If yes, where?

Within the group

Annual health care visit schedule for client

  1. ART refill  
  2. ART refill + VL
  3. ART refill + clinical review + script 
  4. ART refill
  5. ART refill
  6. ART refill + rescript 

Please note: This visit schedule is based on 6-monthly rescripting and annual clinical consultations.

Alignment of ART refill and blood draw visit

Does it happen?

Yes

Aligment of ART refill and clinical visits

Does it happen?

Yes

Strategy and timing for actioning high VL/other red-flag results

Strategy

Immediate recall of client and/or reviewed by clinician who sees all group members for clinical review at next club visit after blood draw

Minimum period for action/action failure risk

Immediately after result received at facility/high risk

Maximum period for action/action failure risk

2 months/low risk 

Clinical outreach from facility potential

Does it happen?

Yes

If yes, by whom?

Nurse can take blood and complete clinical review off site 

ART refill preparation

Is ART pre-packed?

Yes

If yes, by whom?

Facility pharmacy or pharmacy assistant 

ART refill provision to group meeting location

How

Box with pre-packed ART supply is collected from the facility pharmacy and taken to the group meeting location at facility (or off site, which is within a short walking distance) 

By

Lay health care worker

Clinical referral mechanism

Criteria

Client complaining of being unwell, client losing weight, client reporting symptoms during symptom screen

By

Lay health care worker facilitating the group

To

Nurse (allocated to see any unwell group clients)

When

Immediately after group

Up referral (return to standard of care)

Criteria

Client did not attend group visit and was more than 5 days late
Nurse assesses client to be clinically unstable requiring regular clinical follow up, including:

  • Develops TB
  • Serious OI
  • ART regimen is switched
  • Uncontrolled hypertension/diabetes
  • Other co-morbidity requiring regular follow-up

Nurse identifies client with:

  • High VL (>400 copies/ml)
Communicated by

Lay health care worker/club nurse/club manager

Client records

Facility clinical folder

Not pulled or completed other than once a year at clinical review

Client ART card

Presented at each group meeting for return date completion

Monitoring system

At group meeting venue

Paper register for each group, managed by lay health care worker

At health care facility

Client visits captured for group paper register into facility electronic monitoring system (where available)

Staffing

In these models, every client continues to interact with a health care worker at each health care visit, but as part of a group rather than as an individual. These group interactions have been task shifted to a lay health care worker, reducing individual time spent with a professionally trained lay health care worker. This will result in an increase in the need for a lay health care worker cadre and staff to manage the model. All other staff resource needs are based on those needed to service a growing cohort of ART clients despite optimization of such resources.

Lay health care worker

Approx. 1 full time equivalent (FTE) per 25-30 groups (750-900 clients)

Prepares for and runs each client group
Follows up clients who have not come to group visit

Nurse

Approx. 1 FTE per 100 groups (3,000 clients)

Assesses eligibility for group model
Blood taking once a year for each group member
Clinical review once a year for each group member
Script all group members twice a year
On day of group visit session – allocated to prioritize seeing any unwell clients
Provide clinical oversight of group visit

Facility manager

Approx. 0.5 FTE per 100 groups (3,000 clients)

Manages group system within facility, including:
Ensuring model implementation in facility
Allocation/rostering of lay health care workers and nurses
Quality control and training new staff
Reporting to health authorities on model outcomes

Pharmacist/pharmacy assistant

Approx. 1 FTE per 100 groups (3,000 clients)

Pre-packs ART supply for group members prior to group meeting

Data clerk

Approx. 1 FTE per 100 groups (3,000 clients)

Captures group members attendances from client register into electronic monitoring register (where available)

Training

Client training

Limited 
Only required for individual client understanding of model participation 

These groups are not set up or run by clients. Training is limited to client education on the model offered and how participation works. It can be done briefly by the clinician offering participation and in more detail at the first group session by the lay health care worker

Facility staff training

Intensive initially
Mentoring for 6-12 months is recommended, and refresher training is recommended to train new staff and maintain overall quality

Facility teams have to be trained to set up and run the model at their facility (the full model mechanics), including:
·      Model promotion
·      Setting up groups
·      Scheduling group visits
·      Preparation of pre-packed drug supply
·      Availability of staff to facilitate and carry out blood draws/clinical reviews/rescripting
Mentoring for 6-12 months to support the model set up and functioning is recommended. See the approach taken to training (5, 6)

 

Considerations

Client considerations

Group formation and size

Groups are allocated by the health system and likely larger than client’s direct relationship network

Risks

Reduced participation due to confidentiality concerns
Client pressure to disclose status to access efficiency benefits of model

Opportunities

Increasing client relationship to network for peer support and empowerment to demand health system accountability

Health system considerations

Requires health system management structures

This model is health system led, requiring forward planning and management of staffing, visit scheduling, ART refill pre-packing, rescripting and provision of clinical care

Risks

Increased demand for management system. Reactive health systems may not have the capacity to adapt to forward planning required

Opportunities

A pro-active management system can ensure model benefits, significantly improving patient outcomes and optimize facility resources for other patients
Clinical care (blood draws and clinical review) can be carried out off site supporting community outreach systems

Requires additional and dedicated lay health worker cadre

Lay health care worker cadre prepares for, facilitates and follows up on group members

Risks

Insufficient, sustainable funding
Poor-quality lay health care worker may reduce benefits of model if unprepared or unmotivated

Opportunities

Dedicated lay health care worker can improve client’s experience of health care system

Resources

Published evidence