Systems Linkages and Access to Care for Populations at High Risk of HIV Infection Initiative

Ryan White HIV/AIDS Program Part BTechnical Assistance Webinar

March 18, 2015

HIV/AIDS BureauDivision of State HIV/AIDS Programs (DSHAP)

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DSHAP Mission

• To provide leadership and support to States/Territories for developing and ensuring access to quality HIV prevention, health care, and support services.

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Agenda

HAB Announcements Heather Hauck

Question & Answer

Introduction Harold Phillips

Systems Linkages Initiative Overview Adan Cajina

Multi-State Evaluation Overview, UCSF ETAC Stephen Morin

Demonstration States:

Virginia Steve Bailey Anne Rhodes

Wisconsin Casey Schumann

ETAC Lessons Learned Kim Koester Edwin Charlebois

Question & Answer

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Announcements

Heather Hauck, Director Division of State HIV/AIDS Programs

HIV/AIDS Bureau

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Question and Answer Session

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Harold J. Phillips, Director Division of Training and Capacity

DevelopmentHIV/AIDS Bureau

Systems Linkages and Access to Care for Populations at High Risk of HIV Infection Initiative

Special Projects of National Significance (SPNS) Program

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Overview Division of Training and Capacity

Development

• Mission: Strengthen and transform health care systems by supporting the development of leadership, evaluation, training and capacity development to assure the provision of high quality HIV/AIDS prevention, care and treatment services.

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Division of Training and Capacity Development (DTCD)

DirectorHarold Phillips

Deputy DirectorJose Rafi Morales

Special Projects of National

SignificanceChief – Adan Cajina

Pamela BeltonMelinda TinsleyJessica XavierChau Nguyen

Natalie SolomonRenetta Boyd

Global Health SystemsChief – George Tidwell

Susan BeckerJohn HannayRichard Poole

Philippe ChiliadeJanette Yu-Shears

Ellen CaldeiraJohn Oguntomilade

Christine LimDiana Palow

HIV Education BranchActing Chief – Jewel Bazilio-Bellegarde

Andrea KnoxDieunita GamlielMekeshia Bates

Senior Policy AdvisorsRaymond Goldstine (Acting)\

Jewel Bazilio-Bellegarde

Administrative

Support Bukeeia Goodson

Budget ManagementTerri Newman

Chief Medical OfficerPhilippe Chiliade/Rupali Doshi

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SPNS Program (Part-F)

• The SPNS Program supports the development of innovative models of HIV care to quickly respond to the emerging needs of clients served by the Ryan White HIV/ AIDS Program.

• Evaluation• Dissemination• Replication• Build and Improve IT capacity  

Chief, Special Projects of National Significance (SPNS), Division of Training and Capacity Development

Adan Cajina

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Systems Linkages Initiative

Initiative Overview4-year initiative (Sept 2011-August 2015)6 States (LA, MA, NC, NY, VA, WI) $1M/YR1 Evaluation and Technical Assistance Center (UCSF) $1.5M/YR

Address critical gaps along the Care Continuum

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Systems Linkages Initiative

Goal and Target PopulationGoal:

Improve access to and retention in high quality, competent HIV care and services for hard-to-reach populations of HIV-infected persons

Objectives:1. Test linkage interventions in six states2. Evaluate effectiveness of interventions and disseminate

findings

Target Population:At high risk for or infected with HIV but unawareAware but have never been referred to careAware but have refuse referral to careAware but have dropped out of care

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Systems Linkages Initiative

What are Systems Linkages?

Enhancement of existing – or implementation of new collaborative relationships or partnerships among Ryan White and other, non-traditional HIV organizations

IT/data systems linkage interventions • Data system integration (testing, surveillance, care)

Community linkage interventions• Disease Intervention Specialists• Navigation• Corrections• Enhanced testing• Social Networks

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Systems Linkages Initiative

Develop and pilot test innovative linkage interventions using the Collaborative Model

Host collaboration meetings/learning sessions with assistance from ETAC

• Introduce PDSA techniques and pilot linkage interventions• Review results of pilot tests• Identify linkage interventions for wider-scale implementation

Develop state-level evaluation plan

IHI Collaborative ModelYears 1 and 2

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Systems Linkages Initiative

Linkage Implementation and Evaluation Years 3 and 4

• Implement successful linkage interventions on wider scale

• Implement state-level evaluation plan

• Participate in cross-state evaluation with ETAC

• Disseminate project findings and lessons learned

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Systems Linkages Initiative

Role of the Evaluation and Technical Assistance Center (ETAC)

Regents of the University of California, San Francisco

• Design and implement a cross-state evaluation of systems linkage interventions

• TA on state local evaluations

• Data collection systems support

• Dissemination

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Systems Linkages Initiative

Key Research Questions

What characteristics of system linkage interventions most successfully lead to:

• Increases in identifying people living with HIV?• Increases in the proportion of newly diagnosed individuals

entering care within 3 months of first testing HIV positive?• Increases in the proportion of people living with HIV who are

continuously in care?• Increases in successful viral suppression among people

living with HIV?• What are the structural, policy, provider, and patient

characteristics that facilitate or hinder implementation of system linkage interventions?

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Systems Linkages Initiative

Adan Cajina, Branch Chief /acajina@hrsa.gov

Pamela Belton, Project Officer /pbelton@hrsa.gov

(UCSF-ETAC; Wisconsin & New York)

Melinda Tinsley, Project Officer /mtinsley1@hrsa.gov

(Massachusetts & Louisiana)

Jessica Xavier, Project Officer / jxavier@hrsa.gov

(North Carolina & Virginia)

SPNS Program Staff

OVERVIEW OF INTERVENTIONS

Stephen F. Morin, PhDEmeritus ProfessorEvaluation and Technical Assistance CenterUniversity of California, San Francisco

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Patient Navigation• Provider-mediated interventions

where health departments work with providers, e.g. “line lists” (MA, NC).

• Contracts with providers for services, e.g. patient navigation (VA, NY), peer navigation (NY), peer-nurse teams (MA) or Linkage to Care Specialists (WI).

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Direct Outreach

• Health Department Disease Investigation Specialists (DIS officers) are retrained to work with clients on linkage and re-engagement, e.g. State Bridge Counselors (NC); Active Referral (VA).

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Technology Approaches

• Technology-mediated interventions where surveillance data meet emergency department admissions e.g. public health information exchanges (LA) or systematic appointment reminders (NY).

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Special Populations

• Focused attention on corrections, e.g. video conferencing prior to release (LA), Care Coordination (VA) or mental health screening and treatment (VA).

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Increased Case Detection

• Expansion of existing or pilot HIV testing for increased case detection (LA, NC, WI).

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Policy Implications

• Increasingly states are using surveillance data to facilitate linkage and retention in care and to monitor viral suppression.

• Variations on patient navigation beyond traditional case management have emerged as key strategy.

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Policy Implications• Policy environments matter; in particular

states differ in access to care, e.g. ACA, Medicaid expansion, ADAP policies, state budgets, hiring freezes, etc.

• Without increased resources, states and cities need to redirect funds toward Ryan White early intervention services.

• Ryan White itself may need to be increasingly used with a goal to increase the proportion of HIV patients virally suppressed.

Virginia Special Projects of National Significance: Systems

Linkages Interventions

Steve BaileyAnne Rhodes

VA SYSTEMS LINKAGES STRATEGIES

Unaware of HIV status (never tested or never received results

Know HIV status but not in care

Infrequent use of HIV medical care

In some type of care but not receiving regular HIV medical care

Lost to HIV medical care or dropped out

Fully engaged in HIV medical care

Care Coordination (for DOC clients)

Patient Navigation

Active Referral

Mental Health

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Mental Health:• Standardized screening

and referral process to provide mental health (MH) services for clients with MH barriers for linking and retaining in care.

• Sites: Virginia Commonwealth University (VCU)

• Populations Targeted: HIV-positive persons with MH needs

• Outcomes: LINKAGE, RETENTION, SUPPRESSION

Care Coordination:Coordinated access to medical care and medications for inmates released from Virginia Department of Corrections (VADOC) and Virginia Local/Regional Jail (VLRJ) facilities.

Sites: Statewide coverage

Populations Targeted:Released from VDOCs and jails

Outcomes: LINKAGE, RETENTION, SUPPRESSION

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Active Referral:Referral process that requires Disease Intervention Specialists (DIS) to actively link patients directly to care via Patient Navigators (PNs) or medical providers.

• Sites: Statewide coverage• Populations Targeted: Newly

diagnosed• Outcomes: LINKAGE

Patient Navigation:A client-centered PN model• 90 days of services focused on

linking client to care and 12 month retention support

• Use Fidelity Monitoring (FM) to evaluate Motivational Interviewing (MI) skills

• Sites: VCU, Carilion, and Centra• Populations Targeted: Newly

diagnosed and lost to care• Outcomes: LINKAGE, RETENTION,

SUPPRESSION

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Care and Prevention in the United States (CAPUS) in Virginia

• CAPUS, awarded by CDC, through HIV Prevention, funds PN, expanded testing, housing pilot, and social media campaigns as well as enhanced use of surveillance data

• SPNS and CAPUS collaborated on protocol development for active referral and selection of PN sites

• SPNS and CAPUS PN sites were located in different geographical regions of the state to avoid cross contamination

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SPNS and CAPUS Sites in Virginia

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Successes• Increased referrals from DOC to health department and referrals for support services for inmates post-release

• Built communications between Care Coordinator and DOC and local jails

• Increased medication pick up rates post-release, and set up tracking for retention

• Coordination with other inmate programs (Comprehensive HIV/AIDS Linkages for Inmates – CHARLI)

Successes: Care Coordination

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Successes• Difficult to get information from DOC/jails prior to release, including consistent release dates

• Relationships with local jails often took a long time to build, medication provision not consistent in jails prior to release

• No consistent method for tracking medication pick up at local health departments

Challenges: Care Coordination

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Interim Outcomes

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Successes: Medication Pick Up

30 day supply picked up within 60 days of release

First ADAP Rx picked up within 90 days of release

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

45.0%50.0%

72.7%

62.8%

Prior to CC (estimate) CC (n=88)

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Successes : Continuum of Care

*Includes all clients served only by the CC intervention during the timeframe 1/1/2012-12/31/2014. **Includes all clients served by the CC intervention during the timeframe 1/1/2012-12/31/2014 and who also received CHARLI services during the timeframe 1/1/2014-12/31/2014

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%100.0%

78.3%

66.3% 67.5%

54.2%

85.7%

76.8% 77.4%

60.7%

92.9%87.1% 87.1%

67.1%

Overall Care Coordination (N=168) Care Coordination Only (N=83)

Care Coordination and CHARLI (N=85)

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Successes: Client Perspective

• Barriers• Unable to afford medications or medical visits copayments• Nearest clinic 2 hours away• Unemployed with unstable housing• Limited social support• Clients had ”given up”

• Intervention: Care Coordinator initiated client contact, noticing medical and medications had not been accessed

Complex care plan involving 3 different agencies• Facilitated medical transportation• Identified copayment assistance resources• Incorporating telemedicine once medically stable• Housing and employment assistance

• Successes• Employed• Sheltered• Adherent• Reduced isolation

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Lessons Learned

• Target population is difficult to track with many needs and barriers

• Centralized service is beneficial in areas that do not have many resources or a referral network; however, face to face involvement through collaboration with community partners is needed as well

• Access to medications/medical care not primary perceived need

• Territoriality can impede collaboration

• Referral systems from VADOC and VLRJ vary and require time intensive exploration

• Prescription authority and procedures are inconsistent across correctional facilities

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Sustainability Plan

Care Coordination has been added to the state ADAP model and will continue to be funded as a part of ADAP

PN will be funded through Ryan White, HIV Prevention and other ongoing sources

Mental Health providers are working to utilize third-party billing

Active Referral is part of standard Disease Intervention Specialist (DIS) protocol

Wisconsin Special Project of National Significance: Systems

Linkages Interventions

Casey SchumannMarch 18, 2015

Wisconsin Department of Health Services

• Community-based strategy utilizing peers to identify individuals at high risk for HIV and connect them with HIV testing services

• Testing agency enlists and coaches recruiters who have relationships with high-risk networks

• Recruiter identifies associates from their network and refers them to HIV testing

• Goal to standardize program across agencies (e.g. limit number of associates, provide minimum number of coaching sessions, standardize incentives across agencies)

Social Networks TestingOverview

• New patient navigation position located in ASOs, HIV clinics, and community-based organizations

• Employ ten full-time, non-medical professionals• Work with newly diagnosed, new to care, out of care,

post-incarcerated and at risk clients• Identify and address client barriers to medical care

over a period of nine months• Transition clients to case management or self-

management

Linkage to Care Specialist (LTCS) Overview

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Reported cases of HIV infection presumed to be alive by county, Wisconsin, as of 12/31/13

*Excludes 168 cases with the Wisconsin Department of Corrections as the last known address.

Number of Cases

1-20

21-40

41-100

101-200

201-3320

Dane County:AIDS Network UW HIV/AIDS Care Program

Milwaukee County:ARCWMCW ID Clinic16th Street CHCOutreach CHCMilwaukee Health Services

Linkage to Care Specialist Service Locations

• Similarities to Case Management:• Service provision via assessment, individualized service

plan development, and making referrals for needed services

• Differences from Case Management:• Specialist approach to barriers preventing linkage or

engagement in medical care• Smaller case loads (15 clients vs. 60 clients)• Use of motivational interviewing• More field work opportunities• Time limited

Linkage to Care Specialist Overview (continued)

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Challenges

• Initial role confusion between LTCS and case managers

• Initial resistance among some providers• Referrals to LTCS for out of care clients limited to on-

site LTCS• Client resistance to transition out of Linkage to Care

(LTC) Program• Limits of existing case management system to serve

high need clients

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Interim Outcomes

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Successes: Outcomes

HIV Care Outcomes Among Linkage to Care Specialist Clients and Control Subjects

Linkage to Care within 90 Days

Engagement in Care Viral Suppression0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

64.4%(199/309)

47%(126/268)

45.5%(122/268)

80.6%(75/93) 74.3%

(199/268) 66.0%(177/268)

Controls Linkage to Care Clients

Per

cen

tag

e o

f S

ub

ject

s

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Successes: Post LTC

Retention in Care ≥ 6 Months After LTC Intervention: Linkage to Care Specialist Clients and Control Subjects

Controls Linkage to Care Clients0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

62.5%15/24

83.3%20/24

Per

cen

tag

e o

f S

ub

ject

s

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Successes: Client Perspective

• Linkage to Care Specialists provided multiple forms of social support:• Mitigated negative feelings associated with HIV stigma• Increased motivation to adhere to medical care• Increased comfort with medical care• Caused reluctance to transition out of LTC

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Successes: Client Perspective

“When I had to make appointments she made sure I got there. She would come and pick me up all of the time, every time. She never missed a time...That made me feel more positive to go and do what I had to do…that is why I’m non-detectable right now...”

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Successes: Provider Perspective

“I can’t imagine now trying to function effectively in clinic without [our LTCS]... I have had numerous cases where [the LTCS] was instrumental in getting the patient in to clinic with me, [and] many more where she was instrumental in keeping the patient engaged in care…I can’t imagine how any of these people would have been successfully engaged in care without the intensive efforts of [the LTCS]...”

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Lessons Learned

• The collaborative process led to better integration of care and prevention services

• Setting client expectations up front was critical to success and eases transition out of the program

• Both LTCSs with formal social work education and those without can have success with clients

• Numerous best practices were identified that will be applied to case management

• All Ryan White funded services will be evaluated based on their impact on linkage, retention, and viral suppression

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Sustainability Plan

• Commit to funding LTCS until final evaluation results are available (ADAP rebate, Part B case management dollars, agency revenue)

• Incorporate lessons learned from the LTC Initiative into newly developed Medical Case Management Practice Standards• Motivational interviewing• Use of text messaging • More focus on behavior change rather than just referral to

other services

SYSTEMIC LINKAGES QUALITATIVE CROSS-SITE PRELIMINARY DATAKimberly Koester, MADirector of Qualitative Research Evaluation and Technical Assistance CenterUniversity of California, San Francisco

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Developing Interventions

• Over two years, State Health Departments convened multi-day “learning sessions” with stakeholders (45-80 people) from organizations and institutions serving people living with HIV.

• Meetings led to communication channels opened where they had not previously existed.

• Tremendous buy-in on the importance of linkage, retention and re-engagement efforts emerged as a priority.

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Navigation Interventions

• “Navigation” interventions resemble case management, but have unique elements:

• Intensive services offered to a select group of patients.

• Services are offered on a short-term basis.

• Caseloads are intentionally small.• Interventionists are encouraged to

leave the office to meet with patients in non-clinical environments.

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Implementation Observations

• Overall, patients are responding well to the interventions.

• Interventionists are spending more time with patients than any one else in the clinic.

• “Fieldwork” is a common feature and a necessary activity to reach out of care patients.

• Newly diagnosed patients have different (lesser) needs than those who are out of care.

• Goals to support newly diagnosed patients are clear: support to 1) cope with diagnosis and 2) link and remain in care.

SYSTEMIC LINKAGES QUANTITATIVE CROSS-SITE PRELIMINARY DATAEdwin D. Charlebois, III, MPH PhDProfessor of Medicine, Evaluation and Technical Assistance CenterUniversity of California, San Francisco

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Cross-Site Evaluation

The primary goal of the cross-site intervention outcomes evaluation is:

• To identify significant improvement across demonstration states in access to and retention in high quality HIV care for hard-to-reach populations of HIV-infected persons that are associated with innovative mechanisms which establish effective and sustainable linkages among Ryan White and other, community and non-traditional organizations that provide HIV-related services.

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• Large Population Size to be Touched by the Collective SPNS Interventions (N = 68,636)

• Significant Diversity in:• Geographic Settings

• Race/Ethnicity

• Risk Groups

• Insurance Status

• Client Types (new Dx, Out-of-Care, never linked)

SPNS Intervention Study Populations

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Patient Characteristics – New Diagnoses

Based on data reported to the ETAC as of 12/2/2014.

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Patient Characteristics – New Diagnoses

Newly diagnosed client type was diagnosed with HIV within one year of enrollment in the intervention.Other race/ethnicity includes Asian, Native Hawaiian/Pacific Islander, American Indian or Alaska Native, and multiracial.Excludes data from testing intervention clients submitted as a separate dataset.Based on data reported to the ETAC as of 12/2/2014. Preliminary Data – DO NOT CITE

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• Change analysis for: Navigation, Corrections, Testing• Minimum Dose for Success for: Linkage, Retention, Viral Load Suppression• Disparities Reduction Analysis: Race/Ethnicity, Risk Groups• Client Type Effects Analysis: Newly diagnosed versus re-engagement clients

Planned Cross-Site Analyses

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Cost Analysis

To better understand total resources needed to implement interventions:

• How do SPNS interventions leverage existing resource?

• What resources are needed to prepare for intervention implementation?

• What resources are needed to implement the intervention?

• What resources are targeted toward which intervention targets (linkage, re-engagement, retention)?

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Question and Answer Session

THANK YOU