1

Project Consumer LINC Webinar

December 6, 2011

Emily Gantz McKayHarold Phillips

Hila Berl

Developing a Peer-Based Early Intervention Services

Program

Introductions

Sera Morganand

Emily Gantz McKay

3

Webinar Objectives

• To familiarize participants with the components of an Early Intervention Services Program, as described by the HIV/AIDS Bureau

• To summarize the benefits of using peers• To provide a step-by-step process for

developing a peer-based EIS program appropriate for your service area

4

Agenda

1. Components of an Early Intervention Services (EIS) Program

– Questions/Discussion

2. Benefits of the use of peers to help PLWH learn their status, enter or re-enter care, and remain closely linked to care

3. Steps and key questions for designing a peer-based EIS program

– Questions/Discussion

5

Components of an Early Intervention Services Program

Harold J. Phillips

HIV Testing:– Used to help the unaware learn their status and

receive either referral to prevention services or referral and linkage to HIV care services

– Cannot duplicate or supplant testing efforts paid for by other sources.

– Must be coordinated with other testing programs especially HIV prevention programs

Components of Early Intervention Services

Referral Services:Linkage Agreements (MOU/MOA) and referrals, working with key points of entry to create connections between services and funding streams, Routine X-Provider meetings, face to face contact, providing referral to additional services to meet immediate needs

Components of Early Intervention Services

Activity of Relationship/Trust building:

•Creating a bond of trust and safety with the client that extends to the other care givers in the HIV continuum.

•Instilling confidence in the client and in the system of care

Components of Early Intervention Services-

Referral Services

Assessment of immediate needs/attitude/knowledge/behaviors/beliefs regarding care/care system

•Assessment differs from case management and focuses on changing view and knowledge of HIV and care leading to care seeking behaviors

Components of Early Intervention Services –

Referral Services

Health Literacy/Health Education (counseling)

•Education on the HIV service delivery system

•How to work with your clinicians

•How to handle problems and issues

•Disease progression and managing life with HIV disease

Components of Early Intervention Services

Access and Linkage to Care:•Primary Medical Care (3-4 visits)

•Medical Case Management

•Entry into Substance Abuse Treatment

•Treatment Adherence

•Bringing others into care

•System for monitoring and tracking referrals (successful and unsuccessful)

Components of Early Intervention Services

1.Testing

2.Referral Services

3.Health Literacy/Health Education

4.Access and Linkage to Care

The Four Program Components of Early Intervention Services

• Early Intervention Services is a combination of all these service elements

• They must all be present and available to clients as an integral part of the program design

• They do not all have to be Ryan White Part A or B funded

The Four Service Elements Must be

Present

Early Intervention Services v. Outreach

EIS OUTREACH Core Service Support Service

Can include HIV Testing Does not include testing

Works with key points of entryTargets activities in areas with a high probability of finding individuals who are positive

Combination of services Only one service

Can assist in addressing unmet need and the unaware

Can assist in addressing unmet need and bring unaware to testing

Can use peers in paid staff positions

Can use peers in paid staff positions

Length of Service intervention a averages 3-6 months

Length of Service interventions are short term and often sporadic(1-3 months)

• Testing

• Referral Services–Linkage agreements to work with key points of entry

–Relationship/Trust Building

–Assessment of immediate need/ attitude /knowledge/behaviors/beliefs regarding care

–Information dissemination

• Health Literacy/Health Education (Counseling)

• Access and Linkage to Care

Components of Early Intervention Services

• EIS can be part of a strategy to address unmet need, and EIIHA

• EIS can focus on getting individuals in care who know their status

• Emphasis on working with points of entry

• Can resemble a models of case finding or patient navigation

Early Intervention Services & Unmet Need&

EIIHA

16

Questions and Comments

18

Benefits of the Use of Peers

Harold J. Phillips

19

Why Use Peers?

Letter from HAB/DTTA (2-10-10) said:

"Peers are uniquely positioned to effectively engage and help retain PLWH in care and treatment programs and, further, with appropriate training and supervision, they make remarkable contributions to the interdisciplinary team."

20

Why Use Peers?• Can develop a high level of trust with other PLWH• Ability to share their own experiences • Role models and proof that people can live

productive lives with HIV• Personal knowledge of system of care and

challenges associated with accessing care• Clinicians rarely able to spend significant time with

PLWH• Cost-effective • Particular value with HIV+/unaware and PLWH

with unmet need

21

Demonstrated Value of Peers

Demonstrated effectiveness with other diseases such as diabetes:– Bring people into care– Reduce missed appointments– Improve treatment adherence– Reduce complications– Reduce emergency room visits– Reduce hospitalizations– Reduce health care costs

22

Designing a Peer-Based Early Intervention Services Program

Emily Gantz McKay

23

Purpose of a Peer-based EIS Program

• To help people with HIV/AIDS enter and become fully linked to and engaged in HIV/AIDS care

• Focus typically on populations that are likely to be hardest to reach – – Individuals who feel marginalized and

disenfranchised– PLWH who have trouble navigating the HIV/AIDS

service system – often because they have never had a “medical home”

– PLWH who have had negative experiences with the care system

24

Key Questions/Decisions

1. What will be the focus of your EIS program?2. Should your EIS program pay for testing?3. What services will peers provide? What won’t

they do?4. What points of entry will be the focus for your

program? What about other relationships?5. What will be the job title for your peers – will

they be “peer community health workers”?6. How will you match peers with PLWH clients?

25

Key Questions/Decisions, cont.

7. What characteristics, knowledge, skills, and experience should be identified as required? Preferred?

8. What classroom and practical on-the-job training will you provide?

9. What will be the supervisory requirements?10. Will you use a central agency for training and

support?11. Will you allow both full- and part-time peers?

What about stipends?

26

1. Program Focus Options

• HIV+/unaware: Early Identification of Individuals with HIV/AIDS (EIIHA) – immediate linkage to care after testing

• Unmet need: Finding people who know they are HIV+ but have been out of care for at least 1 year and helping them enter/re-enter care

• Retention in care: Working with PLWH who are loosely connected to care or have missed medical appointments – including recently diagnosed PLWH

27

2. Use of Funds for Testing

Factors to consider:

• EIS is the only service category under Ryan White Parts A and B that can pay for testing

• Links to testing are essential• EIS funds should be used for testing only if

existing testing resources are insufficient• Peers can be trained to do counseling and

testing (even if you don't buy the test kits)

28

3. Services Peers will

ProvideConsider:

• Outreach

• Testing or testing support

• Trust building

• HIV literacy education: living with HIV

• Education about the system of care

• Intake support

• System navigation

• Coaching/mentoring and support

• Treatment adherence counseling

• Follow up

• Relationship building

• Support to the clinical team

29

4. Points of Entry and Other Relationships

• Assignment of peers based on:– Specific points of entry– Types of entities (e.g., homeless shelters, testing

sites, substance abuse treatment programs)– Location (e.g., county, neighborhood)

• Key importance of personal relationships:– Points of entry – to contact peer when a person

needing help is identified– Providers (especially clinics and case management

sites) – to inform peer when a client misses an appointment or seems to need peer support

30

5. Job Title

• Make it descriptive of full range of responsibilities

• Use a title that helps ensure respect for the peer's role

• Consider "community health worker" -- now a Bureau of Labor Statistics-recognized profession

• Explore titles and certification used in your state

31

6. Matching Peers with PLWH/Clients

• Matching factors:– Gender, race/ethnicity, sexual orientation, age– Location: specific community or neighborhood– Life experience– Use of a diverse peer team

• Other considerations: – Young men may relate well to an "older sister"– Stigma may mean peer should not be from the

same neighborhood or nationality group

32

7. Qualifications

Typical Requirements:• Peer status• Experience with local/regional system of care• No excludable criminal convictions – e.g., sex-

related felonies, serious violent crimes, recent convictions (within past X years)

• Education/literacy – can use demonstrated reading comprehension and writing skills needed for record keeping, etc. rather than diploma or degree requirement

33

Things to Look For

Characteristics• Commitment• Empathy• Interpersonal relations• Organization & multi-

tasking• Judgment

Decide what skills are required for selection, and which ones you can teach

Knowledge/Skills• PLWH population • Geographic area• How Ryan White programs

work• Strong, culturally

appropriate communications skills

• Mentoring, coaching• Boundaries• Computers/record keeping• Working with providers

34

8. Classroom & Practical Training

Consider 4 phases:1. Pre-service classroom training (community

college or project-developed and run)

2. On-the-job practicum combined with additional classroom training

3. Ongoing on-the-job training, with supervision

4. In-service sessions plus peer network meetings

35

Suggested Learning Topics

• Understanding HIV disease

• Ryan White programs – legislation, services, policies, guidelines

• Navigating the system of HIV care

• Multicultural awareness and competence

• Developing trust• Maintaining professional

boundaries

• Problem solving & crisis management

• Confidentiality & privacy, including HIPAA requirements

• Providing emotional support

• Self-management• Self-disclosure• Communication skills• Medications and

treatment adherence

36

9. Supervisory Requirements

• Specified level of supervision – e.g., hours per week

• Supervision must ensure:– Support for peer model– Understanding of EIS program components and

requirements– Consistently available supervision & support– Professional development opportunities– Help with relationship building– Links to testing

• Training for supervisors• Establishment of supervisors support network

37

10. Use of a Central Agency

Structure Options:1. Centralized: hiring, training, supervision,

monitoring and evaluation, with peers assignment to providers

2. Partially centralized: training, supervision, involvement in recruitment, assistance and evaluation; providers hire & supervise

3. Decentralized: multiple providers hire, train, supervise

38

Value of Centralized or Partially Centralized Structure

• Training quality – larger group for training, likely to be more structured, with consistent quality

• Consistent implementation of model – staff understand program model

• Cost effectiveness – only one agency develops and delivers training

• Flexibility – peers supervised day to day (and often hired) by multiple providers, allowing for variations based on population needs and organizational culture

• Evaluation – single evaluator

39

11. Full or Part Time Peers?

• Full time: Regular employee, easier to provide benefits, full caseload, good return on training investment

• Part time: May be needed to protect the health of the peer; allows smaller communities to hire several peers that match different populations or communities

• Limited Hours due to SSDI/SSI: Allows PLWH on disability to work 30-50% time and keep benefits; allows for a diverse peer team; but smaller individual caseloads

• Stipends: Peers tend to be hired away by other providers; level of work usually too great for stipends

40

Typical Challenges

• Training

• Boundaries

• Personal health issues

• Compensation

• Provider and partner attitudes

• Understanding of EIS

• Setting limits on work with a single client

41

Example: Positive Pathways Pilot Program

(DC)• Assists HIV-positive African Americans to participate in

HIV medical care; focus on women 

• Funded through Social Innovations Fund

• Central agency (CommonHealth Action) manages program for Washington AIDS Partnership

• Training includes formal community health worker certificate program at community college plus HIV-specific training and practical experience

• CHWs placed community and medical organizations  

• Peer support group

• Training and support for supervisors

42

Example: Design for New Washington, DC Part A

Program• Central agency to provide training, oversight,

assistance, & evaluation• Individual providers to hire and supervise peer

community health workers• 160 hours of classroom training plus 800 hours of

practicum over 6 months• Peer and supervisor support networks• Both full- and part-time employment• Focus on unmet need and PLWH loosely

connected to care

43

Other EIS & Related Programs

• People to People (P2P) – started by African American AIDS Task Force, Minneapolis/Saint Paul Part B Program

• Michigan Programs:– Youth Link Program of AIDS Partnership MI – Detroit– MI Patient Navigator Program of Sacred Heart

Rehabilitation Center – Saginaw– Wayne State Physician Group Peer Navigator Program

– Detroit

• Hand in Hand – New Orleans

• Christie’s Place – San Diego

• Linking to Care, Positive Connections – Charlotte (no longer operating)

44

Resources from Consumer LINC Project

• "Designing a Peer-Based Early Intervention Program: Components, Strategies, and Key Decisions"

• Other Consumer LINC project materials

• Links to other materials

• See http://www.mosaica.org/Resources/ HIVAIDS/ProjectConsumerLINC.aspx

45

Other Resources

• Community Health Workers National Workforce Study - http://bhpr.hrsa.gov/healthworkforce/chw/

• Building Blocks to Peer Success - 2 toolkits - PEER Center, Boston University -http://www.hdwg.org/peer_center/training_toolkit

• Integrating Peers into Multidisciplinary Teams: 2 toolkits - Cicatelli Associates - http://careacttarget.org/

library/peers/ToolkitForPeerAdvocateSupervisors.pdf • “The Utilization and Role of Peers in HIV

Interdisciplinary Teams” - HRSA/HAB Consultation - http://hab.hrsa.gov/newspublications/peersmeeting summary.pdf

Questions and Comments