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August 07, 2007
Moving ahead with the actual "adolescent transition clinic and peer support program"
The research study assessing the needs of adolescents has been a core part of my work this summer, laying the groundwork for creation of the adolescent transition clinic and peer support program by ascertaining whether it is even needed, why it is needed, and in what ways such a program should and can feasibly be structured/organized to best meet the unique characteristic needs of the IDI’s adolescent/young adult patients.
Yet this has only been part of my work---what about the very adolescent/young adult transition clinic and peer support system itself? Even while we have conducted the study, we have begun and moved forward with the process of looking into what the actual clinic would look like and how it would function---an exploratory phase in which we have focused on the complex finance, resource, logistical aspects.
Let me start with the numbers. At the very beginning of the project, we had to find out just how many of our target patients there were. If we found out there none, then there wouldn’t be much of a project! Now granted we knew there were quite a few. But we were quite surprised to find such a large number of almost 400 patients! This is a lot because the IDI healthcare providers never seemed to notice anywhere near that many. But it indicated that this was an even bigger need than we had initially thought because there were so many. And the surprise at the number (the lack of awareness at just how many of the patients there were in this subset at the IDI) revealed just how lost in the fold these patients currently were in the adult-dominated clinic based on an adult-oriented mode of care. Further information for these young adults like contact information, age, antiretroviral status, most recent and next scheduled visits, etc was elusive, but with the data management team we eventually found it!
Considering potential days and times for a separate period of time (young adult clinic) when just young adults would be seen was a most critical step. After all, one can’t determine the resources required and the logistics without determining when this could and perhaps might take place… if all the stars are aligned down the line! To start, the IDI clinic is already extraordinarily over-congested and struggling to manage the load given its capacity- which is really high! It is attempting to start encouraging patients to move to satellite clinics in their local clinics (and it is helping build the capacity of those clinics), not just to decongest the IDI but to have patients receive care in their home communities and reduce general dependency of the city’s population on the IDI. In any case, isolating a separate time for adolescent/young adults would not be easy given the congestion.
The IDI clinic operates Monday-Friday with the exception of Wednesdays in which the clinic does not operate (“special Wednesdays”). Despite the decision to keep Wednesday free for other activities, this seemed initially like a golden possibility to open the IDI clinic for part of the day with certain staff operating who could make the time available because of the flexibility of their activities.. However, this idea proved to be more of a rotten egg! On the whole, there are just too many activities to free up enough staff. The mornings are reserved for outreach to satellite clinics (KCC, or Kampala City Clinics) for HIV-related care provision (they are general practice clinics) but especially to help build capacity in clinical care, management, other areas etc. Half of the IDI clinical staff would travel to these clinics, alternating each week with the other half of the clinic staff. Those not traveling to the outreach clinics were involved research meetings, working on the research studies they were involved in. In the afternoons, there were departmental meetings, department leadership meetings, general staff meetings, and a host of other activities. Plus, having a break from direct clinical work on Wednesdays is something I quickly came to learn is treasured by the staff, who would be quite unhappy to give it up (I wouldn’t either from the load I see them carry the other four days of the week!). So the combination of a hectic schedule of activities for all clinic staff and a desire to keep “special Wednesdays” effectively eliminated the possibility of having a separate clinic on Wednesdays.
What about an evening clinic that operated after the normal adult clinic closed at 4? Having it in the late afternoon/into the evening (say 4:30-8 PM) outside normal clinic hours in of itself could signify that this is a different clinic with a the true intention of being really “youth friendly.” It would also be easy to coordinate the Creativity Initiative with this time block. It might also help those who are in school. On the other side of the coin, the late time could make it more difficult for younger Friends to come, and they may not have the energy to make the trek from often far away distances. A much more significant issue would be staffing a clinic operating in this evening time period. Could current clinical staff work 8 AM- 9 PM one day a week? 8 AM- 4 PM is already exhausting, and even if they were devoted to the cause of providing specialized young adults care (and receiving overtime pay), is it reasonable (even sane?) to expect them to work and effectively so for that many hours consecutively? Also, the success of a ‘young adult clinic’--- in its fundamental mission to provide specialized, personalized care for adolescents--- would be compromised if clinic staff were so exhausted and worn down that they would be unable to put in more effort and energy than would be required in even the normal clinic! So other possibilities in this evening model include bringing in part-time staff to operate this ‘young adults clinic’. Bringing in new staff seems to be undesirable. A creative yet challenging idea put forth by the IDI Director himself was that of “shift splitting”, an idea not that amenable to staff anywhere perhaps but an important possibility as a solution to staffing problems of this sort that is being utilized more and more in Europe. What is “shift splitting“? Let’s say that the ‘young adults clinic’ will operate on Tuesday nights. Let’s divide Tuesday’s working day into three blocks: morning (8-12 AM), afternoon (12-4 PM), and evening (4-8 PM). Looking at nursing as an example, they work the morning and afternoon periods in the normal system. In this structure, there would be three periods instead of two, and a reduced number staffing each four hour shift. Some staff would work the morning and evening shifts, but have the afternoon shifts off. Others would work the afternoon and evening shifts. This would maintain the 8 hour day and prevent additional funding from a budget very-much overstretched. It might not, however, be desirable for staff who don’t want to work at night or have a big gap of time in the afternoon where they cannot go home and have nothing to otherwise do with their valuable time. Additionally, in the resource allocation survey and analysis I did (discussed below), the heads of all the departments said that they couldn’t afford to have reduced number of staff in the morning or afternoon periods given the high patient load. Literature has indicated initial hesitation at this type of scheme, but often acceptance over time. So a possible solution yet complicated issue no doubt….
There is one other option for when to operate this clinic, which is how we may start the “young adults clinic” as sort of a trial particularly because it is feasible given current resourcing limitations (described below). This would be during an afternoon of the regular clinic, moving adult patients from that time to other periods and shifting the adolescent/young adult patient appointments to this time. We have explored this, and such a process of shifting patients in this manner would take possibly two months since appointments are made on a monthly basis only when each patient visits. But you may be wondering how this is possible when I just cited how congested the IDI already is. The adolescent/young adults are already active patients receiving care at the IDI and there are enough to saturate a clinic afternoon, so our thinking is that it is just a shifting of patients-- unless more are added (which is not in the immediate plan).
Let me describe what was a fun process to obtain estimates for the human resources needed to run a model young adults’ clinic. The estimates are based on the once-a-week evening clinic model. Interestingly it is the most complicated of all the options I outlined, but that’s what made it particularly fun and challenging. This key step in developing the clinical component of our program was one of the most enjoyable endeavors of my work this summer. It involved running around and tracking down (I love doing that type of thing) the heads of each clinical department---nursing, reception, doctors/clinicians, counselors, records, data management, laboratory, pharmacy, and even cleaning services. I had to ask around repeatedly to get the names of those in charge and upon locating them, it took a few minutes for them to figure out who this random person was they had not yet met!, and what I was inquiring about (I was looking for the number of staff needed in their department for a proposed young adults clinic operating on one night a week for 3.5 hours). I explained what the transition clinic project is and that we were in an initial exploratory phase (I later found that I had not been clear enough- some thought we were starting this right now!!).
The allocation estimates were as I said for a potential evening clinic happening once a week, let’s use Tuesday evening as an example. In this allocation estimate we used the assumption of 400 patients in total, and since they all are supposed to visit monthly, we also assumed that there would be 100 each Tuesday (they would divided up evenly per week. We deemed 3.5 hours a good enough time for the 100 patients to be treated on a Tuesday night. Using these guidelines, I sought from each department an estimate of how many staff they thought would be needed to operate a clinic---just like a normal clinic---for 3.5 hours treating 100 patients. The numbers are in this document: “Human Resource Allocation Estimates”.
The estimates are straightforward for doctors, counselors, nurses, data entrants, receptionists, and records persons. For nurses, I learned that there were three types- those who saw patients just as doctors do (nurse visits), those working in the clinic doing the initial screening with history and vital signs, and those working in triage (stationed at reception). For laboratory (CD4, CBC testing etc), the deadline for blood sample submissions would need to be extended, which can be tricky since the current deadline requires lab personnel to work late into the night and it is important that CBC tests be analyzed the same day (and desirable for all to be analyzed the same day). Cleaning is done by a contracted company, but it appears possible to move forward their time period to accommodate an evening clinic. Perhaps most complicated is the operation of the pharmacy, because it ends up operating at least an hour after the last patient is seen at the normal clinic (so if last patient seen at 4 PM, its load won’t end until 5 PM- I call this the “pharmacy lag”). Exacerbating this is the fact that the normal clinic often runs up to 1-2 hours beyond its end time. Naturally patient load would have to be managed carefully on the ‘young adults clinic’ day so patient overflow beyond the end of the clinic time will be minimized, especially for the sake of pharmacy operations within and between the two clinics. My idea for a solution to the pharmacy lag problem was to have the pharmacy begin operation for the young adults center an hour after the clinic starts (allowing for the adult lag), and then give it some extra time at the very end of the evening clinic for its inevitable lag. So my thought was that if the clinic would operate from 4:30-8:00 PM (patients being seen), the pharmacy would operate from 5:30-8:30 PM, allowing for both the previous clinic lag and the evening clinic lag.
One of the reasons I loved the human resource allocation project was that it gave me a crash course on the ins and outs of how a high-level HIV-specialized clinic in a resource-limited setting operates. I also get a sense of how complex things can be and how easy it is for a variety of problems to crop up every single day, but also how carefully thought through the entire process is. For things to go right and for reasonable time to be kept, records must locate and bring the correct file to reception, which in turn must process the file and according to the patient’s appointment card send them to the nursing or clinical wings. The nurses must be able to easily access the patients’ files amongst many, take history and vitals, and ensure that they go to the right room for their clinical appointment. Following that, the patient must be directed to a counselor if they are seeing one in this particular visit, to the laboratory to get necessary tests done, and/or to the pharmacy to receive their meds.
The resource allocation estimates that I did are critical to moving forward the process of establishing the beginnings of the clinic itself. The IDI clinical budget is stretched thin, and it took some creative maneuvering just to fund the research study. The plan all along, given the unlikelihood of internal financing, is to present a proposal for the Adolescent Transition Clinic and Support Program (with the study report as the foundation) for external funding. In the meantime, we hope to start by having the clinic during an afternoon when the clinic would normally be operating with its regular cohort of patients (majority adults maybe mixed in with some of our young adult Friends). This would involve as described moving patients around such that during this particular afternoon every week, the clinic would serve just young adults. Then the unique initiatives would be gradually integrated once the young adults are set into this time period. The thought is that this would be more cost-effective to start because the clinic infrastructure is in place, the young adults are already IDI patients with comprehensive care covered like all the other patients, and shifting patients would be relatively straightforward and require minimal time. Providing the resource allocation estimates and the initial concept paper (describing the type of clinic we envision/conceptualize), we have requested from Finance to create a budget for a clinic. This initial budget would assume just the physical infrastructure and budget for every cost a clinic would require from overhead to drugs. From there we will then, depending on the model we use, narrow the budget down based upon what it is already in place or can be provided for in other ways.
One other thing we have also had to think about is the process of keeping the clinic staff informed about the needs we have observed, the study, and the interventions we have conceptualized (clinic and support program). It is not just about informing them and trying to bring them on board with the project, but listening to their experiences working with IDI adolescent/young adult patients, assessing what they think about the importance of adolescent/young adult care at the IDI, what needs of adolescent patients they see and believe are most pressing to address, and their opinions and ideas about the suggested intervention. Monthly general staff meetings (GSMs), departmental meetings, inter-departmental leader meetings provide the chance for informal discussion. In the near future, I would like to administer more of a formal staff survey/assessment asking the aforementioned questions. We would be sure to provide the results and conclusions that we have drawn to date in the surveys.
Posted by Vijay Narayan at August 7, 2007 11:56 PM
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