Improving client appointment-keeping at Hoima Regional Referral Hospital (RRH)

Effective HIV care requires clients to adhere to regular appointments for drug refills, clinical and laboratory, as well as ART adherence monitoring. But all too frequently, clients fail to observe their scheduled appointments, often due to the time, cost and inconvenience of travelling to and waiting at the clinic. Furthermore, service provider teams often have difficulties following up clients because of inaccuracies in client contact information captured at registration. This makes it hard to determine if clients who do not keep appointments have, on their own, transferred to another healthcare facility or truly defaulted on treatment. Clients who default on treatment are at risk of developing treatment failure, frequently leading to drug resistance and loss of future treatment options.

In July 2013, through a performance review exercise, the Hoima RRH ART Clinic team found out that only 64% of the clinic’s total clients returned for routine scheduled clinical reviews, drug refills, CD4 testing and counselling. This was below the recommended Uganda Ministry of Health target of 100%. The team made a decision to close this gap by implementing a quality improvement (QI) project focused on increasing the rate of client appointment keeping.
Following a problem analysis exercise, various interventions were identified and implemented (beginning July 2013) to close the identified gap:Appointment keeping at Hoima RRH ART clinic

  • Harmonizing appointments for clients from the same family, and assigning them same return dates to reduce transport costs, and encourage family support as well  

    Clients at the Hoima RRH ART Clinic wait to see clinicians.@URC 2014 USAID/SUSTAIN project /Julian Natukunda

  • Opening the clinic earlier each day and ensuring that client files are transferred from triage, consultation or counsellors’ rooms to the pharmacy on behalf of clients to reduce movement and congestion. This was aimed at reducing client waiting time.
  • Updating client contact information, including information for family members or other treatment supporters.

Other strategies included referring clients who live far from Hoima RRH to nearby healthcare facilities; establishing a phlebotomy section at the ART Clinic for easy collection of CD4 samples; educating and counselling clients further about the importance of appointment-keeping during general and individual health education sessions;  and issuing  two-month supplies of ARV drugs to stable clients.

We announce during health education sessions that clients who have their family members attending the same clinic for to share this information with clinicians so that the clients can be assigned appointments on the same day,” said Prisca Nyamaizi, Clinical Officer at Hoima’s ART Clinic.

I am happy that the clinic changed me from receiving one-month to two-month drug supplies. I have been struggling to raise money for transport to come here every month, but now I will comfortably save money to bring me to the clinic every two months,” a client expressed.

By end of June 2014, the percentage of clients honoring scheduled appointments had improved to 95%. The interventions also reduced client waiting time within the clinic; by 3:00pm of each day, on average, all clinical consultations are completed, including drug dispensing from pharmacy—two hours earlier than in the past.

 

Written by; Julian Natukunda, Communications Specialist; Dr. Hillary Alima, HIV Care and Treatment Technical Advisor,  with contributions from Dr. Prisca Nyamaizi, Clinical Officer at Hoima Regional Referral Hospital and Jessica Ziegler, Knowledge Management Specialist at URC