Notes
from
the Field
Editors Note: Submissions to Notes from the Field (500 to 1000 words, preferabl without references, tables, orfigwrs) should be sent to Hugh H. Tilson, MD, Editor, AMPH Notes from the Fiel" ESP Dl io, Burroughs Weakome Co, 3030 Comwallis Road, Research Tnangle Pa,* NC 27709. Ths colwnpresents infonnation on newsworthy public health progams and project experiences at the commnwiy leveL Furter infonnation should be soughtfrom the author(s) listed at the end of each article.
Fails Among the Elderly: A Community Prevention Program Falls are common among the elderly, affecting up to one third of communityresiding older persons annually. Falls represent the leading cause of unintentional injury (e.g., fractures, head trauma) and often lead to associated complications (e.g., organ system failure, mobility dysfunction). It is therefore important that fall prevention programs be initiated. To succeed, however, programs must be designed to eliminate the factors that contribute to falls. Because falls in older people involve an interaction of several factors-medical conditions (e.g., acute and chronic diseases, medication effects) and environmental hazards (e.g., inadequate lighting, slippery or uneven floor surfaces)-prevention requires a mixture of countermeasures or interventions to be effective. In June of 1989, we developed a fall prevention program at the Community General Hospital in Sullivan County, New York. This is a rural upstate community; 15% of its population of 70 000 is 65 years of age or older. Our approach consisted of 892 American Journal of Public Health
identifying a population of older persons who had had falls or related injuries and describing the extent of the problem; deternining the circumstances and conditions under which these people had fallen; developing preventive interventions aimed at eliminating or ameliorating the factors identified; and, finally, evaluating
the effectiveness of the program.
Identfication To identify a population of fallers, we retrospectively reviewed the emergency room records of all people aged 65 and olderwho had visited the hospital for nonfatal injuries during the previous 17 consecutive months (in 1988 and 1989). We used ICD-9-CM codes for fracture, dislocation, sprains, and stains of joints and adjacent muscles. Each person was then contacted to determine whether the injuries were fall-related. To determine the contributing fac-
tors, we asked each person to describe the circumstances surrounding the fall (e.g., location, time of day, activity engaged in, and symptoms). We also took a history for the 3 months prior to injury to discover whether the individual had fallen before.
EAt and Crumswnes of Falls Our significant findings were as follows: * Fall-related injury was the most common cause of emergency room visits for this population with these diagnoses. The ratio of fall to nonfall injuryvisits was 3:1. * Fractures accounted for 84% of the
injuries. 0 Ninety-five percent of the injuries occurred in and around the home, primarily in the bedroom and bathroom.
* Nearly two thirds of the injuries occunred during transfers (moving to or from
chairs, beds, and toflets, and in and out of
bathtubs) when the person slipped on a wet or unstable surface (rugs, waxed floors, leaves) or tripped over an uneven surface (rug edges, doorsills, cracked walkways). * Finally, 49% of the population reported having fallen one or more times previously.
Approximately 30% of these people reported having neurological and musculoskeletal diseases and taking medications such as psychotropics or antihypertensives, which may have affected their gait
and balance. The information we collected led us to the following conclusions. First, in the community context surveyed, for a large number of older people falls ending in injury are neither isolated occurrences nor
"accidental" events; they are to a large degree predictable and, therefore, amenable to preventive interventions. Second, environmental factors in the home may contribute to falls and injury. Chronic diseases leading to diminished functional capacity, in conjunction with environmental hazards, may make it difficult for older people to function safely.
Preventive Interventions On the basis of and with reference to the community survey, we designed a multifaceted fall prevention program to (1) educate health care professionals and the community's elderly about falls; (2) identify those older persons who had suffered falls or who were at risk for falls and evaluate opportunities for prevention; and (3) develop community services to make modifications to older persons' homes to promote safe functioning. June 1992, Vol. 82, No. 6
Notes from the Fild
A device bank was initiated to collect (from the community), store, and dispense unused or discarded devices (e.g., grab bars, toilet risers, bath seats) for people unable to afford them. A service was set up in which volunteers from community organizations helped older people make any necessary environmental modifications (e.g., installation of devices such as grab bars and elimination of hazardous conditions) in their homes.
perceived that identfying persons with falls and correcting the underlying factors responsible decreased fall risk and enhanced mobility. A review of 28 persons who had been evaluated for multiple fails verified this impression. Many suffered from several underlying medical problems (e.g., uncontrolled hypertension, electrolyte imbalance, parkinsonism, adverse drug effects), and many cited environmental hazards that were responsible for their falling episodes. Once these problems were addressed and corrected, falls were reduced. We have followed this group over a 2-year period, interviewing them on a monthly basis. To date, 75% have experienced no additional falling episodes. The response from the broader community of older persons has been equally positive. Approximately 1500 persons have been reached at the senior centers. They generally report that the lectures have given them greater knowledge about falls and ability to identify potential fall hazards in their home environments. Although the device bank and home modification program are still in an early stage, people have appreciated the availability of devices and assistance in their installation. This project can serve as a model of an effective low-cost fall prevention program. With the exception ofone-time only grant support ($20 000) for a gerontologist to help develop the program, the costs were absorbed by the hospital (e.g., the educational slide program at a cost of $100) or were negligible. Existing resources (health professionals, community services) were used to develop prevention interventions. Currently, the program is being managed by the health educator, who has replaced the gerontologist. The health educator's salary is paid by thirdparty reimbursement fees generated from patient evaluations. The acceptance and usefulness of the program are clearly demonstrated by the fact that community health professionals and oWnizations (e.g., Public Health Department, Visiting Nurse Service, Area Agency of Aging) have embraced it as a fall prevention measure. The hospital has incorporated the program into its ongoing budget and mainstream services offered. [] Rein 7-deikaar., PhD
Evaaiion
Acknowledgments
After 1 year, we evaluated the program's effectiveness. Both physicians and nurses in the community stated that they had a greater understanding of falls. They
Grant C-003792. The author thanks Martin Richman, Executive Director; Marc Mendelsohn, Director of Planning; Barbara Hallenbeck, Administrator of the Geriatric Program;
Education Physician education consisted of a grand round lecture covering the causes, evaluation, and management of falls. Community nurses were given a similar lecture emphasizing how to perform regular assessments for fall hazards in the home and recommend appropriate environmental modifications. The thrust of our lay education was to generate awareness about falls, the importance of reporting them to appropriate health care professionals, and making home environments safer. We published articles in the community newspaper on falls and prevention. A health educator from the hospital was trained to lecture at senior centers throughout the county; a set of slides showing common hazards in the home accompanied the talks. These sessions incorporated a discussion period that allowed older people to ask for further information on falls and advice on how to make their homes safer.
Identification To help identify fallers and those at risk, physicians and nurseswere trained to question patients about falls during routine examinations. Hospital emergency room personnel were encouraged to use E codes, a subset of the ICD-9-CM codes specifically developed to identify the external cause of fall injuries, and to refer persons for physician or nurse follow-up. During community lectures at senior centers, the health educator routinely asked whether any older persons in the audience had fallen in the past few months, took names of those people who responded affirmatively, and referred fallers to their primary providers for evaluation.
Comnuwity Senices
June 1992, Vol. 82, No. 6
This project was supported by New York State Department of Health Rural Diversification
Peter Notarstefano, Coordinator of the Geriatric Program, Community General Hospital, Sullivan County, New York; and Judith Howe, Administrator, Ritter Department of Geriatrics and Adult Deveklopent, Mount Sinai Medical Center, New York, for their assistance in this project.
Requests for reprints should be sent to Rein T-ideiksaar, PhD, Falls and Imnobility Program, Ritter Departmnt of Geriatrics and Adult Development, Mount Sinai Medical Center, One Gustave Levy Place, New York, NY 10029. Copies of materials, including the baseline and follow-up instruments, and information
about the educational materials can be obtained from the author. Editor's Note. See related editorial on p 785 of this issue.
Community-Based Case Management of liIV Disease Fairfax County, Virginia, with a population of more than 800 000, is the most populous political subdivision of the Washington, DC, area. Although metropolitan Washington has consistently ranked fifth nationally in the cumulative incidence of AIDS cases, Fairfax County's share of the total has been only slightly more than 5%, over 80% ofwhom have been classified as belonging to the gay-bisexual transmission group. To monitor the incidence of human immunodeficiency virus (HIV) infection in its clinic populations, the Fairfax County Health Department began an expanded program of voluntary testing for antibody during 1986. In June 1987 the county implemented the HIV Case Management Program for residents asymptomatically infected with HIV. The program was designed primarily to serve the low-income, high-risk heterosexual populations, especially those who have engaged in intravenous drug use, and their sexual partners. These individuals are difficult to reach and may pose the greatest danger for continued spread ofthe virus in the general population. The program is open to the gay-bisexual community as well, but because most have access to other care providers through insurance or special community resources, many opt for care through other sources. The county's human services agencies-Departnent of Health, FairfaxFails Church Community Services Board, and the Department of Human Development-operate this program jointly. During the pastyear, bycontractual arrangement, a group practice speialiig in infectious diseases (Infectious Diseases Physicians, Inc. Or LDP) has provided a prgam for early American Journal of Public Health 893
Notes frm the FEldd
Zidovudine therapy for asymptomatic HIV patients. The county health departnent collaborates with IDP in monitoring these patients unti they become symptomatic or require prophylaxis against Pnewwncystis cam infection. At that stage in the disease, patients are no longer followed in the case management program. Fairfax Hospital, under a contract with the county health department, assumes medical and case management responsibility for our patients when their disease becomes symptomatic or their CD4 count falls below 200. The case management program holds clinics at two geographic sites within the county; the clinics are staffed by personnel from the three participating agencies. The management of patients with HIV infection includes lifestyle counseling to slow the progression of the infection and to prevent its spread to others. A special patient consent form enables members of the interagency team to share patient information with each other, thus facilitating the development of a coordinated plan for the patient's medical care and mental health and social needs. This systematic plan reduces the need for crisis management. Patients enter the case management program voluntarily. They are referred to the program through the health department's HI-V screening and case-finding activities and by private physicians, local hospitals, and HIV/AIDS information services. Before the first clinic visit, the patient provides a detailed medical and social history and blood and urine specimens for routine laboratoxy examination. At the initial and subsequent routine visits the patient's histoxy is updated and a thorough clinical examination is performed. Routine laboratoxy tests include complete blood cell count and differential, urinalysis, serologictests for syphilis, HIVantigen test, ,B-2microglobulin assay, and ahelperTlymphocyte (CD4) count. Tests for hepatitis B
894 Amencan Journal of Public Health
core antibody and surface antigen are done on the inital visit and subsequently if indi-
cated. Pap smears are done annually on female patients. Chestx-rays are obtained for the initial visit and annually thereafter. Reactivity to purified protein derivative (tuberculin), mumps, and candida antigens is determined by skin test at the initial visit. Patients are seen every 6 months unless a shorter interval is indicated; those receiving early Zidovudine therapy are seen at intervals set by IDP. At each routine visit the patient is evaluated and counseled by the mental health counselor and, if indicated, the substance abuse counselor. Arrangements are made for separate individual or group counseling sessions as desired. The Human Development team member reviews with the patients their current and future financial requirements and needs for support. Case management program team members meet jointly once a month to review the status of the patients seen during the month and to make recommendations for their future care. A total of 81 patients entered the case management program between June 1987 and June 1991. Demographic attributes of the patients are as follows: * Age: Range, 21 to 62 years; median, 30 years * Sex: Male 51, female 30 * Ethnicgroup: White, 38; Black, 39; Hispanic, 3; Asian, 1 * Risk group: Male homosexual, 27; intravenous drugs, 34; heterosexual, 20 The characteristics of the 14 patients lost to follow-up were similar to those of the total group. Only one patient, an elderly person with chronic alcoholism, is known to have died. The cause of death was liver failure and HIV was not considered a contributory cause. Program costs rose only slightly from 1989 to 1990, whereas costs per visit de-
clined (Table 1). The total cost per visit in 1989 was $1285; in 1990, it was $1100. The average for the 2yearswas $1179 pervisit. The health department's cost for routine clinic services in 1990 was approximately $400 per visit, which included $200 for laboratory services. The remainder of the staff costs were devoted to intake, patient follow-up, and case review. The increase in laboratoxy costs in 1990 reflects the greater use of CD4 counts for patients receiving early Zidovudine therapy. Most clinics operated at considerably less than optimum patient load; the operating costs per visit should decline appreciably with increasing numbers of patients per clinic. The collaborative program with IDP for early therapy with Zidovudine entails additional annual costs of $400 per patient for physicians' fees. At present the state of Virginia is supplying the Zidovudine if the patient is unable to pay for the drug; thus this cost is not included in the direct costs of the program. Although the future course ofthe HIV epidemic in the United States is still uncertain, current evidence suggests that the virus has begun to spread in the young heterosexual population in many areas of the country. There will be an increased need for adaptive programs at the community level that will combine expanded casefinding activities with case-management programs smiilar to the one descnbed here. As the next step in this program, we are exploring new methods of outreach to intravenous drug users and to the young sexually active heterosexual population. Improved methods will be required if there is to be effective intervention in this epidemic. Programs like this can provide a useful community focus for these broader efforts. [ Fred J. Payne, MD Card S. Shane#4 MD
Donald N. Pontz MD Lawrence J. Eron, MD Thoma Stage, MD Roalyn For,obar RNV, AU Chestef Bowman, BS Ricart K. Miler, MD
Fred J. Payne, Carol S. Sharrett, Rosalyn Foroobar, Chester Bowman, and Richard K Miller are with the Fairfax County Health Department, Fairfax, Va. Donald N. Poretz and Lawrence J. Eron are with the Infectious Disease Section, Department of Medicine, Fairfax Hospital, Fairfax, Va. Thomas Stage iswith the Community Services Board, Fairfax, Va. Requests for reprints should be sent to Fred J. Payne, MD, Director, HIV Case Management Program, 10777 Main Street, Suite 203, Fairfax, VA 22030.
June 1992, Vol. 82, No. 6
from
the Field
Editors Note: Submissions to Notes from the Field (500 to 1000 words, preferabl without references, tables, orfigwrs) should be sent to Hugh H. Tilson, MD, Editor, AMPH Notes from the Fiel" ESP Dl io, Burroughs Weakome Co, 3030 Comwallis Road, Research Tnangle Pa,* NC 27709. Ths colwnpresents infonnation on newsworthy public health progams and project experiences at the commnwiy leveL Furter infonnation should be soughtfrom the author(s) listed at the end of each article.
Fails Among the Elderly: A Community Prevention Program Falls are common among the elderly, affecting up to one third of communityresiding older persons annually. Falls represent the leading cause of unintentional injury (e.g., fractures, head trauma) and often lead to associated complications (e.g., organ system failure, mobility dysfunction). It is therefore important that fall prevention programs be initiated. To succeed, however, programs must be designed to eliminate the factors that contribute to falls. Because falls in older people involve an interaction of several factors-medical conditions (e.g., acute and chronic diseases, medication effects) and environmental hazards (e.g., inadequate lighting, slippery or uneven floor surfaces)-prevention requires a mixture of countermeasures or interventions to be effective. In June of 1989, we developed a fall prevention program at the Community General Hospital in Sullivan County, New York. This is a rural upstate community; 15% of its population of 70 000 is 65 years of age or older. Our approach consisted of 892 American Journal of Public Health
identifying a population of older persons who had had falls or related injuries and describing the extent of the problem; deternining the circumstances and conditions under which these people had fallen; developing preventive interventions aimed at eliminating or ameliorating the factors identified; and, finally, evaluating
the effectiveness of the program.
Identfication To identify a population of fallers, we retrospectively reviewed the emergency room records of all people aged 65 and olderwho had visited the hospital for nonfatal injuries during the previous 17 consecutive months (in 1988 and 1989). We used ICD-9-CM codes for fracture, dislocation, sprains, and stains of joints and adjacent muscles. Each person was then contacted to determine whether the injuries were fall-related. To determine the contributing fac-
tors, we asked each person to describe the circumstances surrounding the fall (e.g., location, time of day, activity engaged in, and symptoms). We also took a history for the 3 months prior to injury to discover whether the individual had fallen before.
EAt and Crumswnes of Falls Our significant findings were as follows: * Fall-related injury was the most common cause of emergency room visits for this population with these diagnoses. The ratio of fall to nonfall injuryvisits was 3:1. * Fractures accounted for 84% of the
injuries. 0 Ninety-five percent of the injuries occurred in and around the home, primarily in the bedroom and bathroom.
* Nearly two thirds of the injuries occunred during transfers (moving to or from
chairs, beds, and toflets, and in and out of
bathtubs) when the person slipped on a wet or unstable surface (rugs, waxed floors, leaves) or tripped over an uneven surface (rug edges, doorsills, cracked walkways). * Finally, 49% of the population reported having fallen one or more times previously.
Approximately 30% of these people reported having neurological and musculoskeletal diseases and taking medications such as psychotropics or antihypertensives, which may have affected their gait
and balance. The information we collected led us to the following conclusions. First, in the community context surveyed, for a large number of older people falls ending in injury are neither isolated occurrences nor
"accidental" events; they are to a large degree predictable and, therefore, amenable to preventive interventions. Second, environmental factors in the home may contribute to falls and injury. Chronic diseases leading to diminished functional capacity, in conjunction with environmental hazards, may make it difficult for older people to function safely.
Preventive Interventions On the basis of and with reference to the community survey, we designed a multifaceted fall prevention program to (1) educate health care professionals and the community's elderly about falls; (2) identify those older persons who had suffered falls or who were at risk for falls and evaluate opportunities for prevention; and (3) develop community services to make modifications to older persons' homes to promote safe functioning. June 1992, Vol. 82, No. 6
Notes from the Fild
A device bank was initiated to collect (from the community), store, and dispense unused or discarded devices (e.g., grab bars, toilet risers, bath seats) for people unable to afford them. A service was set up in which volunteers from community organizations helped older people make any necessary environmental modifications (e.g., installation of devices such as grab bars and elimination of hazardous conditions) in their homes.
perceived that identfying persons with falls and correcting the underlying factors responsible decreased fall risk and enhanced mobility. A review of 28 persons who had been evaluated for multiple fails verified this impression. Many suffered from several underlying medical problems (e.g., uncontrolled hypertension, electrolyte imbalance, parkinsonism, adverse drug effects), and many cited environmental hazards that were responsible for their falling episodes. Once these problems were addressed and corrected, falls were reduced. We have followed this group over a 2-year period, interviewing them on a monthly basis. To date, 75% have experienced no additional falling episodes. The response from the broader community of older persons has been equally positive. Approximately 1500 persons have been reached at the senior centers. They generally report that the lectures have given them greater knowledge about falls and ability to identify potential fall hazards in their home environments. Although the device bank and home modification program are still in an early stage, people have appreciated the availability of devices and assistance in their installation. This project can serve as a model of an effective low-cost fall prevention program. With the exception ofone-time only grant support ($20 000) for a gerontologist to help develop the program, the costs were absorbed by the hospital (e.g., the educational slide program at a cost of $100) or were negligible. Existing resources (health professionals, community services) were used to develop prevention interventions. Currently, the program is being managed by the health educator, who has replaced the gerontologist. The health educator's salary is paid by thirdparty reimbursement fees generated from patient evaluations. The acceptance and usefulness of the program are clearly demonstrated by the fact that community health professionals and oWnizations (e.g., Public Health Department, Visiting Nurse Service, Area Agency of Aging) have embraced it as a fall prevention measure. The hospital has incorporated the program into its ongoing budget and mainstream services offered. [] Rein 7-deikaar., PhD
Evaaiion
Acknowledgments
After 1 year, we evaluated the program's effectiveness. Both physicians and nurses in the community stated that they had a greater understanding of falls. They
Grant C-003792. The author thanks Martin Richman, Executive Director; Marc Mendelsohn, Director of Planning; Barbara Hallenbeck, Administrator of the Geriatric Program;
Education Physician education consisted of a grand round lecture covering the causes, evaluation, and management of falls. Community nurses were given a similar lecture emphasizing how to perform regular assessments for fall hazards in the home and recommend appropriate environmental modifications. The thrust of our lay education was to generate awareness about falls, the importance of reporting them to appropriate health care professionals, and making home environments safer. We published articles in the community newspaper on falls and prevention. A health educator from the hospital was trained to lecture at senior centers throughout the county; a set of slides showing common hazards in the home accompanied the talks. These sessions incorporated a discussion period that allowed older people to ask for further information on falls and advice on how to make their homes safer.
Identification To help identify fallers and those at risk, physicians and nurseswere trained to question patients about falls during routine examinations. Hospital emergency room personnel were encouraged to use E codes, a subset of the ICD-9-CM codes specifically developed to identify the external cause of fall injuries, and to refer persons for physician or nurse follow-up. During community lectures at senior centers, the health educator routinely asked whether any older persons in the audience had fallen in the past few months, took names of those people who responded affirmatively, and referred fallers to their primary providers for evaluation.
Comnuwity Senices
June 1992, Vol. 82, No. 6
This project was supported by New York State Department of Health Rural Diversification
Peter Notarstefano, Coordinator of the Geriatric Program, Community General Hospital, Sullivan County, New York; and Judith Howe, Administrator, Ritter Department of Geriatrics and Adult Deveklopent, Mount Sinai Medical Center, New York, for their assistance in this project.
Requests for reprints should be sent to Rein T-ideiksaar, PhD, Falls and Imnobility Program, Ritter Departmnt of Geriatrics and Adult Development, Mount Sinai Medical Center, One Gustave Levy Place, New York, NY 10029. Copies of materials, including the baseline and follow-up instruments, and information
about the educational materials can be obtained from the author. Editor's Note. See related editorial on p 785 of this issue.
Community-Based Case Management of liIV Disease Fairfax County, Virginia, with a population of more than 800 000, is the most populous political subdivision of the Washington, DC, area. Although metropolitan Washington has consistently ranked fifth nationally in the cumulative incidence of AIDS cases, Fairfax County's share of the total has been only slightly more than 5%, over 80% ofwhom have been classified as belonging to the gay-bisexual transmission group. To monitor the incidence of human immunodeficiency virus (HIV) infection in its clinic populations, the Fairfax County Health Department began an expanded program of voluntary testing for antibody during 1986. In June 1987 the county implemented the HIV Case Management Program for residents asymptomatically infected with HIV. The program was designed primarily to serve the low-income, high-risk heterosexual populations, especially those who have engaged in intravenous drug use, and their sexual partners. These individuals are difficult to reach and may pose the greatest danger for continued spread ofthe virus in the general population. The program is open to the gay-bisexual community as well, but because most have access to other care providers through insurance or special community resources, many opt for care through other sources. The county's human services agencies-Departnent of Health, FairfaxFails Church Community Services Board, and the Department of Human Development-operate this program jointly. During the pastyear, bycontractual arrangement, a group practice speialiig in infectious diseases (Infectious Diseases Physicians, Inc. Or LDP) has provided a prgam for early American Journal of Public Health 893
Notes frm the FEldd
Zidovudine therapy for asymptomatic HIV patients. The county health departnent collaborates with IDP in monitoring these patients unti they become symptomatic or require prophylaxis against Pnewwncystis cam infection. At that stage in the disease, patients are no longer followed in the case management program. Fairfax Hospital, under a contract with the county health department, assumes medical and case management responsibility for our patients when their disease becomes symptomatic or their CD4 count falls below 200. The case management program holds clinics at two geographic sites within the county; the clinics are staffed by personnel from the three participating agencies. The management of patients with HIV infection includes lifestyle counseling to slow the progression of the infection and to prevent its spread to others. A special patient consent form enables members of the interagency team to share patient information with each other, thus facilitating the development of a coordinated plan for the patient's medical care and mental health and social needs. This systematic plan reduces the need for crisis management. Patients enter the case management program voluntarily. They are referred to the program through the health department's HI-V screening and case-finding activities and by private physicians, local hospitals, and HIV/AIDS information services. Before the first clinic visit, the patient provides a detailed medical and social history and blood and urine specimens for routine laboratoxy examination. At the initial and subsequent routine visits the patient's histoxy is updated and a thorough clinical examination is performed. Routine laboratoxy tests include complete blood cell count and differential, urinalysis, serologictests for syphilis, HIVantigen test, ,B-2microglobulin assay, and ahelperTlymphocyte (CD4) count. Tests for hepatitis B
894 Amencan Journal of Public Health
core antibody and surface antigen are done on the inital visit and subsequently if indi-
cated. Pap smears are done annually on female patients. Chestx-rays are obtained for the initial visit and annually thereafter. Reactivity to purified protein derivative (tuberculin), mumps, and candida antigens is determined by skin test at the initial visit. Patients are seen every 6 months unless a shorter interval is indicated; those receiving early Zidovudine therapy are seen at intervals set by IDP. At each routine visit the patient is evaluated and counseled by the mental health counselor and, if indicated, the substance abuse counselor. Arrangements are made for separate individual or group counseling sessions as desired. The Human Development team member reviews with the patients their current and future financial requirements and needs for support. Case management program team members meet jointly once a month to review the status of the patients seen during the month and to make recommendations for their future care. A total of 81 patients entered the case management program between June 1987 and June 1991. Demographic attributes of the patients are as follows: * Age: Range, 21 to 62 years; median, 30 years * Sex: Male 51, female 30 * Ethnicgroup: White, 38; Black, 39; Hispanic, 3; Asian, 1 * Risk group: Male homosexual, 27; intravenous drugs, 34; heterosexual, 20 The characteristics of the 14 patients lost to follow-up were similar to those of the total group. Only one patient, an elderly person with chronic alcoholism, is known to have died. The cause of death was liver failure and HIV was not considered a contributory cause. Program costs rose only slightly from 1989 to 1990, whereas costs per visit de-
clined (Table 1). The total cost per visit in 1989 was $1285; in 1990, it was $1100. The average for the 2yearswas $1179 pervisit. The health department's cost for routine clinic services in 1990 was approximately $400 per visit, which included $200 for laboratory services. The remainder of the staff costs were devoted to intake, patient follow-up, and case review. The increase in laboratoxy costs in 1990 reflects the greater use of CD4 counts for patients receiving early Zidovudine therapy. Most clinics operated at considerably less than optimum patient load; the operating costs per visit should decline appreciably with increasing numbers of patients per clinic. The collaborative program with IDP for early therapy with Zidovudine entails additional annual costs of $400 per patient for physicians' fees. At present the state of Virginia is supplying the Zidovudine if the patient is unable to pay for the drug; thus this cost is not included in the direct costs of the program. Although the future course ofthe HIV epidemic in the United States is still uncertain, current evidence suggests that the virus has begun to spread in the young heterosexual population in many areas of the country. There will be an increased need for adaptive programs at the community level that will combine expanded casefinding activities with case-management programs smiilar to the one descnbed here. As the next step in this program, we are exploring new methods of outreach to intravenous drug users and to the young sexually active heterosexual population. Improved methods will be required if there is to be effective intervention in this epidemic. Programs like this can provide a useful community focus for these broader efforts. [ Fred J. Payne, MD Card S. Shane#4 MD
Donald N. Pontz MD Lawrence J. Eron, MD Thoma Stage, MD Roalyn For,obar RNV, AU Chestef Bowman, BS Ricart K. Miler, MD
Fred J. Payne, Carol S. Sharrett, Rosalyn Foroobar, Chester Bowman, and Richard K Miller are with the Fairfax County Health Department, Fairfax, Va. Donald N. Poretz and Lawrence J. Eron are with the Infectious Disease Section, Department of Medicine, Fairfax Hospital, Fairfax, Va. Thomas Stage iswith the Community Services Board, Fairfax, Va. Requests for reprints should be sent to Fred J. Payne, MD, Director, HIV Case Management Program, 10777 Main Street, Suite 203, Fairfax, VA 22030.
June 1992, Vol. 82, No. 6
