NURS 503 Week 8 Population Health Intervention Project Final Paper Example

Offer It to Everyone, Follow Every Result: A Population Health Intervention for Routine HIV Screening and Linkage to Care in a Virginia Emergency Department

Introduction

An emergency department is often the only place where many adults meet the health care system in a given year. For people with undiagnosed HIV, it is also one of the few places where a test could be offered without anyone having to ask for one. The proposal that follows is written for one such department, at a 260-bed Virginia hospital, and it rests on two commitments: a routine, opt-out HIV test for every eligible patient aged 15 to 65, paired with a nurse navigator responsible for every reactive result until the patient is in HIV care. It describes the problem, the evidence, the intervention and its objectives, the plan for implementation and evaluation, and the barriers, costs and ethical questions the program raises.

The Problem

The National Indicator

Healthy People 2030 lists knowledge of HIV status as a leading health indicator, objective HIV-02. Five years of tracking moved the figure only from 85.8% to 87.2% between 2017 and 2022, leaving almost eight points to close before the 2030 goal of 95% (Office of Disease Prevention and Health Promotion [ODPHP], n.d.). Awareness is lowest among the young: CDC estimates put it at about 56 per 100 among people aged 13 to 24 in 2022 (Centers for Disease Control and Prevention [CDC], 2024).

Why It Matters

Undiagnosed infection is a personal and a population problem. A person who does not know cannot begin treatment, and modeling of 2016 transmissions attributed a little over a third of new infections to people who had not been diagnosed, while an even larger share came from diagnosed people who were not in care (Li et al., 2019). An intervention that diagnoses people without connecting them to treatment therefore addresses only part of the problem.

The Local Gap

The hospital's emergency department handles about 52,000 visits a year, of which roughly 30,000 involve patients who would be eligible for screening. At baseline, HIV tests are ordered only when a clinician suspects infection, and a chart review found tests offered in about 9% of eligible visits. The department has no defined process for reactive results, which are routed to the ordering clinician, often after that clinician's shift has ended.

Synthesis of the Evidence

Should Every Eligible Patient Be Offered a Test?

Federal guidance answers yes. CDC recommendations issued in 2006 called for routine opt-out screening of patients aged 13 to 64 in health care settings and removed separate written consent and counseling as conditions of routine testing (Branson et al., 2006). The Task Force's grade A recommendation extended screening to everyone from 15 to 65 (U.S. Preventive Services Task Force, 2019). Trial evidence supports offering the test broadly rather than selecting patients by risk. In a pragmatic trial that randomized 76,561 visits at four emergency departments, risk-based targeting did not identify new infections at a higher rate than offering screening to all, and the nontargeted arm completed the most tests (Haukoos et al., 2021).

How Should the Test Be Offered?

The wording and structure of the offer matter as much as the test. When one emergency department randomized patients to different offer formats, presenting the test as routine unless declined raised acceptance by roughly 24 percentage points compared with asking patients to opt in, a larger effect than cash payments of up to $10 (Montoy et al., 2018). The finding fits the behavioral economics principle that defaults shape choices, and it argues for building the test into triage and the standard order set.

What Does Screening Do to the Department?

Staff often fear that screening slows care. In the same multicenter trial, routine screening added on average about a minute and a half to waits, slightly increased departures before treatment was complete and did not lengthen stays for admitted patients (Jones et al., 2025). The effect is small but not zero, which is why the evaluation includes these measures as balancing measures.

What Does It Cost?

The trial's economic analysis estimated costs per new diagnosis of roughly $18,800 to $23,600 across the three screening strategies and found nontargeted screening reasonably cost-effective compared with traditional targeted testing, though results were sensitive to local HIV prevalence (Haukoos et al., 2024). A department with lower prevalence than the urban trial sites should expect a higher cost per diagnosis and should plan its budget accordingly.

What Happens After a Positive Result?

Studies of test result management show how easily results are lost when responsibility is unclear (Callen et al., 2012). Combined with the modeling showing that diagnosed people out of care drive a large share of transmission (Li et al., 2019), this evidence makes a defined linkage process an essential part of the intervention, not an optional addition.

Lessons From the Course's Earlier Work

The earlier assignments in this course shaped the design. The indicator overview showed that the national average hides a much lower rate among young people, which led to the separate reporting by age. The behavioral economics paper showed that the form of the offer matters more than the information in it, which led to the default and the script. The quality and safety paper showed that unfollowed results are a predictable system failure rather than an individual lapse, which led to the navigator queue and the registry. In that sense the final intervention is the course's argument in practical form: identify the gap in the population, design for how people actually decide, and build safety into the process rather than relying on memory.

Theoretical Basis

Two frameworks guide the program. Population health management, as described in the course text, treats the department's eligible patients as a defined population whose screening, results and linkage can be tracked over time, and it emphasizes measurement and continuous improvement (Nash et al., 2016). Behavioral economics explains why the design relies on defaults, routine framing and order sets rather than education alone: patients and clinicians both tend to follow the path the system makes easiest.

The Intervention

Component One: A Scripted, Routine Offer at Triage

The triage nurse will tell every eligible patient that the department tests everyone between 15 and 65 for HIV as part of routine blood work, that the test is free to the patient and confidential, and that the patient may decline. The script frames testing as universal, which reduces the sense of being singled out.

Component Two: An Order Set Default

The HIV antigen and antibody test will be added to the standard laboratory order set for eligible patients who have blood drawn. Clinicians may remove it, but they do not have to remember to add it.

Component Three: A Result Queue Owned by a Navigator

Every reactive result will route automatically to a navigator queue reviewed twice a day, including weekends, by a registered nurse trained in HIV disclosure and linkage. No positive result will ever again depend on whether the clinician who ordered the test happens to see it.

Component Four: Navigator-Led Linkage

The navigator will contact the patient within 72 hours, arrange confirmatory testing, schedule an appointment at the regional HIV clinic within 30 days and confirm attendance. When a patient cannot be reached, the navigator will work with the local health department's disease intervention specialists.

Objectives

• 1. Offer rate: from roughly 9% of eligible visits at baseline to 60% or more by the close of the sixth month.
• 2. Acceptance: seven in ten or more of the patients who hear the offer will agree to the test by that same point.
• 3. Linkage: nine in ten or more newly confirmed patients will be seen in HIV care no later than 30 days after their result, for every month of the project.

Implementation Plan

The project will run in three phases. In month one, the team will obtain approval from the emergency department, laboratory and quality leadership, build the order set and the navigator queue, hire or assign the navigator and train all triage nurses with a one-hour session that includes the script and practice with common patient questions. In month two, the program will launch in the main department, with daily huddles in the first two weeks to resolve problems. From month three, it will extend to the fast-track area, and the team will review data weekly and share a monthly run chart with staff. A project lead, an advanced practice nurse, will chair a working group of a triage nurse, an emergency physician, the navigator, a laboratory supervisor, an information technology analyst and a health department liaison.

Resources and Budget Estimate

The figures below are planning estimates for a six-month pilot, to be refined with the hospital's finance office.

Possible funding sources include state HIV testing funds administered by the health department, the hospital's community benefit budget and billing for the screening test, which most insurers cover without cost sharing under the Task Force recommendation.

Evaluation Plan

Evaluation will use RE-AIM, a framework built on the idea that an intervention's public health value depends on how widely it is delivered and how long it lasts, not just on whether it works under ideal conditions (Glasgow et al., 1999).

To make sure the program does not quietly harm the department's flow, the team will also watch two counterweights: the median wait and the proportion of patients who walk out before their care is finished. Data will be reviewed monthly, and a six-month report will go to hospital leadership with a recommendation to continue, change or stop the program.

Staff Preparation and Communication

Training will be brief but specific. Every triage nurse will complete a one-hour session covering why the department is screening, the wording of the offer, how to answer the five questions patients ask most often, what to do when a patient declines and how results reach the navigator. The session will use role-play, because the exact words matter: the behavioral evidence suggests that saying "we test everyone" produces different decisions than "would you like a test." Physicians and advanced practice providers will receive a shorter briefing on the order set and the navigator's role, emphasizing that they will not be asked to deliver positive results they did not expect.

Communication with patients will be planned as carefully as communication with staff. Signs in the waiting room and treatment rooms will state that the department offers HIV testing to all patients aged 15 to 65 as part of routine care, that the test is confidential and that patients may decline. A short written notice will explain how results are delivered, including that patients with a negative result may receive it through the patient portal and that anyone with a reactive result will be called by a nurse.

Disclosure and Linkage Protocol

The navigator will follow a written protocol for reactive results. The first step is to confirm the patient's identity and preferred contact method from the registration record. Disclosure will happen by phone only after confirming identity and privacy, with an offer to meet in person, and will include what a reactive screening result means, why confirmatory testing is needed and what treatment offers today. The navigator will then arrange confirmatory testing, ideally the same day, and schedule an appointment with the regional HIV clinic, which has agreed to hold two new-patient slots each week for referrals from the program. If the patient misses the appointment, the navigator will make three more contact attempts over two weeks before referring the case to the health department for field follow-up. Each step will be recorded in the registry with a date, so the time from result to contact and from contact to care can be measured.

Data Management and Privacy

The registry will contain only the information needed to follow each reactive result: a study number, contact details, dates of each step and the outcome. It will be stored in the hospital's secure system with access limited to the navigator, the project lead and the quality analyst. Reports to staff and leadership will use aggregate numbers only. Required reporting of new diagnoses to the health department will follow state law, and patients will be told during disclosure that the health department may contact them to offer support, which helps preserve trust when that contact occurs.

Barriers and Responses

Four barriers are expected. Staff may worry about workload; the order set and script keep the added task small, and the operations evidence can be shared to address concerns about flow. Some clinicians may be uncomfortable delivering a positive result; disclosure will rest with the navigator. Patients may decline because of stigma or fear of cost; the script addresses both. Patients without stable contact information may be hard to reach; the navigator will collect two contact methods and partner with the health department.

Community Partnerships

The emergency department cannot close the gap alone. The regional HIV clinic is the most important partner, because linkage depends on appointments being available quickly; its agreement to reserve new-patient slots will be confirmed in writing before launch. The local health department contributes disease intervention specialists who can locate patients the navigator cannot reach and state testing funds that may support the program. A community advisory group, including people living with HIV, a pastor from a local congregation active in health ministry and a representative of a community organization serving young adults, will review the script, signage and written materials before launch and meet quarterly to review results. Their review will help the program avoid language that sounds judgmental and identify reasons patients decline that staff might not hear. Faith communities in particular can reduce stigma by speaking openly about testing as an ordinary act of caring for one's health.

A Focus on Young Adults

Because awareness is lowest among people aged 13 to 24, the program will report every measure separately for patients aged 15 to 29. If young adults accept testing less often, the team will test changes aimed at them, such as having the offer made by younger staff, adding a line to the script about results being private from family members on the same insurance where the law allows, and offering results by text. The emergency department sees many young adults who have no primary care, so even modest gains in this group could make a meaningful contribution to the indicator in the hospital's service area.

Sustainability

For the program to outlast the pilot, testing must become part of the department's standard work, which the order set and triage script accomplish, and the navigator position must be funded permanently. The six-month report will present the cost per new diagnosis and the linkage rate so leaders can weigh the program against other uses of the same funds. Revenue from billable screening and grant funding from the health department can offset part of the navigator's cost.

Limitations

The plan has limits that the evaluation must keep in view. A six-month pilot in one department will produce few new diagnoses, so the effectiveness results will be imprecise, and the program will be judged more on process measures than on outcomes. Local HIV prevalence is likely lower than at the urban trial sites, which will raise the cost per diagnosis. The comparison with the pre-intervention period cannot exclude other changes in testing over the same months. Finally, the program reaches only people who come to the emergency department; it cannot by itself improve awareness among young people who rarely seek care, which will require community partners.

Ethical Considerations

Opt-out testing respects autonomy only if patients genuinely understand they can decline; the script states this plainly, and declining will not affect care. Results will be confidential and shared with the health department only as the law requires for disease control. The program's universal design is also a matter of justice, since targeting by appearance or assumption risks both missing infections and stigmatizing groups.

The Advanced Practice Nurse's Role

An advanced practice nurse is well suited to lead this program, combining clinical credibility with the staff who must use the script, knowledge of evidence and quality methods, and the ability to coordinate across the department, laboratory and health department. The project lead will also mentor the navigator, review data with staff and report to leadership.

A Christian Perspective

James warns believers against favoritism, against treating people differently by appearance (English Standard Version Bible, 2001/2016, James 2:1-4). Offering an HIV test to every eligible patient, rather than to those a clinician guesses are at risk, applies that teaching to a clinical decision. Following every result until the person is in care reflects the same commitment to the worth of each patient.

Conclusion

A test offered to every eligible patient by default, joined to a navigator who carries each reactive result through to treatment, answers both halves of the problem behind the Healthy People indicator: people who do not know their status and people who know but are not in care. The evidence supports offering the test to everyone, framing it as routine and protecting linkage with a defined process. With clear objectives, a modest budget and a RE-AIM evaluation, the program can show within six months whether it is reaching people and connecting them to treatment.

References

Branson, B. M., Handsfield, H. H., Lampe, M. A., Janssen, R. S., Taylor, A. W., Lyss, S. B., & Clark, J. E. (2006). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recommendations and Reports, 55(RR-14), 1-17.

Callen, J. L., Westbrook, J. I., Georgiou, A., & Li, J. (2012). Failure to follow-up test results for ambulatory patients: A systematic review. Journal of General Internal Medicine, 27(10), 1334-1348. https://doi.org/10.1007/s11606-011-1949-5

Centers for Disease Control and Prevention. (2024). Estimated HIV incidence and prevalence in the United States, 2018-2022 (HIV Surveillance Supplemental Report, Vol. 29, No. 1). https://www.cdc.gov/hiv-data/nhss/estimated-hiv-incidence-and-prevalence.html

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

Glasgow, R. E., Vogt, T. M., & Boles, S. M. (1999). Evaluating the public health impact of health promotion interventions: The RE-AIM framework. American Journal of Public Health, 89(9), 1322-1327. https://doi.org/10.2105/AJPH.89.9.1322

Haukoos, J., Hopkins, E., Campbell, J. D., Lyons, M. S., Rothman, R. E., Hsieh, Y. H., White, D. A. E., Trent, S., Al-Tayyib, A. A., Gardner, E. M., Sabel, A. L., & Rowan, S. E. (2024). Cost-effectiveness of HIV screening in emergency departments: Results from the pragmatic randomized HIV Testing Using Enhanced Screening Techniques in Emergency Departments trial. Annals of Emergency Medicine, 84(3), 234-243. https://doi.org/10.1016/j.annemergmed.2024.03.009

Haukoos, J. S., Lyons, M. S., Rothman, R. E., White, D. A. E., Hopkins, E., Bucossi, M., Ruffner, A. H., Ancona, R. M., Hsieh, Y. H., Peterson, S. C., Signer, D., Toerper, M. F., Saheed, M., Pfeil, S. K., Todorovic, T., Al-Tayyib, A. A., Bradley-Springer, L., Campbell, J. D., Gardner, E. M., . . . HIV TESTED Trial Investigators. (2021). Comparison of HIV screening strategies in the emergency department: A randomized clinical trial. JAMA Network Open, 4(7), Article e2117763. https://doi.org/10.1001/jamanetworkopen.2021.17763

Jones, A. T., Haukoos, J., Hopkins, E., Lyons, M. S., Rothman, R. E., White, D. A. E., Hsieh, Y. H., Joseph, K. M., Murray, E., & Rowan, S. E. (2025). Effect of routine opt-out HIV screening on emergency department operational metrics: Results from the pragmatic randomized HIV TESTED trial. Annals of Emergency Medicine, 86(3), 240-251. https://doi.org/10.1016/j.annemergmed.2025.04.011

Li, Z., Purcell, D. W., Sansom, S. L., Hayes, D., & Hall, H. I. (2019). Vital signs: HIV transmission along the continuum of care, United States, 2016. Morbidity and Mortality Weekly Report, 68(11), 267-272. https://doi.org/10.15585/mmwr.mm6811e1

Montoy, J. C. C., Dow, W. H., & Kaplan, B. C. (2018). Cash incentives versus defaults for HIV testing: A randomized clinical trial. PLOS ONE, 13(7), Article e0199833. https://doi.org/10.1371/journal.pone.0199833

Nash, D. B., Fabius, R. J., Skoufalos, A., Clarke, J. L., & Horowitz, M. R. (2016). Population health: Creating a culture of wellness (2nd ed.). Jones & Bartlett Learning.

Office of Disease Prevention and Health Promotion. (n.d.). Increase knowledge of HIV status: HIV-02. Healthy People 2030. U.S. Department of Health and Human Services. https://odphp.health.gov/healthypeople/objectives-and-data/browse-objectives/sexually-transmitted-infections/increase-knowledge-hiv-status-hiv-02

U.S. Preventive Services Task Force. (2019). Screening for HIV infection: US Preventive Services Task Force recommendation statement. JAMA, 321(23), 2326-2336. https://doi.org/10.1001/jama.2019.6587