Increasing Access to Care (ATC) for
Homeless Individuals
Living with HIV/AIDS:
Harlem Model Implementation
Stephen Crowe, ATC Managing Director
Liza Kasmara, Director of Program Evaluation
Harlem United Community AIDS Center, Inc.
HRC Conference 2012, Portland, OR
Learning Objectives
By the end of the session, participants will be able to:
 Identify barriers to linking and retaining patients in care
 List essential elements in a patient navigation system to increase
access to and retention in care
 Understand the importance of care coordination
Agency Overview
Founded at height of first phase of AIDS epidemic:
1988.
• Specifically to serve people living with HIV/AIDS (PLWH/As) who
were homeless and/or suffering from mental illness and/or
substance use.
Agency of last resort for medically-underserved
communities of color in Harlem.
• Part of community-based movement to care for PLWH/As
• Founded to address lack of response from established providers;
• Responding to the unique personal, social, and institutional
barriers to care in Harlem
Organizational Structure
INTEGRATED HIV SERVICES
Adult Day Health Centers
Food & Nutrition
Supportive Housing
(Women’s Housing,
Transitional Housing,
Congregate, etc. )
Health Homes (COBRA)
Case Management
Family Support
COMMUNITY HEALTH SERVICES
Community-Based
HIV/STI/HCV Testing
Holistic Provider-Led,
Patient-Centered
Primary Care and
Dental Services
Behavioral Health
Services
Patient
Navigation/Case
Management Support
Access to Care & Support Services
Drug User Health Services
(Syringe Access, Harm Reduction,
Recovery Support)
Black Men’s Initiative –
integrated interventions for
YMSM, YTG of color
New Business Development
& Outreach Services
Access to Care (ATC) & Support Services
ATC Program Development
 National HIV/AIDS Strategy
 Reduce New HIV Infections
 Increase Access to Care and Improve Health Outcomes for
People Living with HIV
 Reduce HIV-Related Health Disparities
 Achieve a More Coordinated National Response to the HIV
Epidemic in the U.S.
 Access to Care (ATC) Model
 Ensure access to and retention in medical care
 Provide support services needed to achieve optimal health
outcomes
 Facilitate re-entry into care and support services
ATC Program Development
• Testing team
identified needs
for Linkage to
care (LTC)
services for
clients who
tested positive
• LTC “ninja” was
created
2007
2010
• Conducted study
to determine
factors that
predict retention
in care
• Found that LTC is
one of the factors
that predict
retention in care
• Integration of
similar
programs to
reduce
duplication of
services
• ATC program
was established
2011
ATC Program Development
Access to Care (ATC) &
Support Services
Case
Management
Services
Patient
Navigation
Services
Supportive
Services
(Entitlements,
Housing
Support, Tx
Adherence,
Mental
Health)
Outreach &
Engagement
Activities
ATC Client Characteristics
 75% Male, 24% Female, >1% Transgender
 95% Black and Hispanic
 Primarily 35-54 years old
 65-75% Homeless/Unstably Housed
 40% HIV+, 15-20% AIDS diagnosis
ATC Program Overview
GOALS:
SERVICES:
• To locate and engage
out-of-care individuals into
care and support services
•
Supportive Case Management Services
•
Patient Navigation & Reengagement Activities
•
Support Groups (in English, Spanish & French)
•
Connection to Medical Care & Support Services
•
Psychosocial Assessments and Counseling (individual and group)
•
Health Education/Risk Reduction Counseling
•
Treatment Adherence Counseling (individual and group)
•
Housing Placement Assistance (individual and group)
•
Enrollment into ADAP/ADAP-Plus/APIC/Health Coverage
•
Entitlements Assistance
• To ensure access and
retention to medical care
and support services
• To provide support
services needed to achieve
optimal health outcomes
• To navigate through
initial medical care and
connect to comprehensive
case management
ATC Program
Current Model - Structure
Managing Director
AA/Data Entry
Specialist
LCSW
Program Director
Program Coordinator, Case
Management Services
Program Coordinator, Patient
Navigation Services
Program Coordinator,
Support Services
CM I
CM II
PN I
PN II
Sr. Program Enroller
Housing Specialist I
CM III
CM IV
PN III
PN IV
Treatment Adherence
Specialist
Housing Specialist II
CM V
CM VI
PN V
PN VI
Outreach Specialist
ATC Program Overview
Target Population(s):
• HIV-Positive and High
Risk HIV-Negative
Homeless Individuals
• High utilizers of
emergency rooms and
detox facilities
• Undocumented
Immigrants
Program Flow
1. PATIENT NAVIGATION SERVICES
CLIENT
IDENTIFICATION:
Referrals, Out-ofCare individuals,
Community
Outreach, Internal
Referrals


Conduct record
search: ePaces;
correctional
databases; eCW;
HASA, AIRS, etc.
REENGAGEMENT:
Conduct home-
visit, canvassing;
phone calls; letters;
outreach to
providers
SERVICE
ORIENTATION:
If located, a service
orientation is
completed and
reconnection begins
2. SUPPORTIVE CASE MANAGEMENT
SCREENING:
Service
Orientation;
Screening for
Insurance &
Program
Eligibility
Target Area(s):
• Harlem
• South Bronx
CLIENT SEARCH:
INTAKE &
ASSESSMENT:
Service Plan
Development
SERVICE PLAN
Referrals;
Verification of
medical
appointment
and services
SERVICE PLAN
UPDATE:
2 Medical
Appts; PCSM;
Reassessment;
SP Update
CASE
CLOSURE:
Connection to
CM; Case
Closure
Summary
2A. PSYCHOLOGICAL ASSESSMENT
ASSESSMENT:
Completion of
Psychosocial assessment
by LCSW
CASE CONFERENCE:
CM staff and LCSW; in
service plan; engage
client in short-term
counseling
INIDIVIDUAL COUNSELING:
3 - 5 sessions with LCSW
with connection to
psychiatry services where
applicable
ATC Program Overview
2B. ENTITLEMENTS
SCREENING:
If HIV+: Screen for
ADAP/ADAP Plus
If HIV-: Screen for
Medicaid
APPLICATION:
Verification of
inactive Medicaid;
Collect
documentation for
ADAP and Medicaid.
APPLICATION
SUBMISSION:
Submit Completed
Application;
Verification of
Application
CASE CLOSURE:
Ensure entitlement
cards: Case Closure
Summary
3. SUPPORTIVE SERVICES
HOUSING ASSISTANCE
•Housing Assessment
•Housing Service Plan
Development
•Individual Engagements
•Access to Educational and
Support groups
TREATMENT ADHERENCE
EDUCATION
•Tx Adherence Assessment
•Development of Tx
Adherence Service Plan
•Case Conference with
Medical providers
•Individual Education
•Access to Educational and
Support groups
SUPPORTIVE COUNSELING &
RISK REDUCTION PLANNING
•Minimum of 2 Risk Reduction
Counseling Sessions
•Interim supportive
counseling; minimum of two
sessions
•Access to Educational and
Support groups
ATC Program: Outcomes
 Retention in care
 ART Status
ART status among engaged ATC and
non-ATC clients
Retention rate among ATC and nonATC clients
88%
90%
80%
74%
80%
70%
70%
61%
60%
60%
50%
50%
Not Retained
40%
Retained
30%
71%
26%
39%
20%
10%
10%
0%
Non-ATC (n=78)
ATC (n=78)
0%
Non-ATC (n=58)
Not on ART
On ART
29%
30%
12%
20%
40%
ATC (n=69)
ATC Program: Outcomes
Viral load at baseline - ATC
Viral load at follow up - ATC
Undetectable viral load(<400)
Undetectable viral load(<400)
Detectable viral load (>=400)
Detectable viral load (>=400)
15%
42%
58%
85%
Viral load at baseline - Non-ATC
Undetectable viral load(<400)
Detectable viral load (>=400)
Viral load at follow up - NonATC
Undetectable viral load(<400)
Detectable viral load (>=400)
33%
67%
42%
58%
ATC and Primary Care
Care Coordination
 Team meetings/daily rounds
 Electronic Reports
 Daily communication between outreach and office managers
 PN/Provider Protocols
 E-mails with daily reminders of appointment availability
 Patient Navigation/Escorts
 Case Management and Providers
 Communication via electronic health record
Care Coordination
Utilizing HU’s Electronic Medical Records,
e-ClinicalWorks (eCW), to coordinate care:
No show list
Monthly
review
• Extraction of no show list (i.e. list of clients who consistently do not
show up) from eCW
• Submit no-show list to ATC program coordinators monthly
• List is reviewed to determine clients in need of re-engagement
activities
• Patient Navigators conduct re-engagement activities for clients on no
show list (e.g. phone calls, home visits, letters, etc)
• Patient Navigators connect clients to care (i.e. escorts, checking
Reengagement
provider availability on eCW, tickler system)
Care coordination
Tickler system in
eCW:
• Action items in
“Review Actions”
feature
• Serve as
communication tool
between PN and clinic
• Useful for clients
who have chronic noshow issues
Challenges
 Difficulty locating clients who are transient or homeless
 Staff training & development, buy-in, resistance to change
 Paperwork integration (difficulty in minimizing duplication)
 Program funded by 6 contracts (city and state) is challenging
to manage since funders have different core requirements,
deliverables, expectations, and constraints
 Multiple points of entry
 Multiple databases
 Ensuring effective communication happens among all staff
during process of program development
 Data entry issues (timeliness, not enough data entry support)
Best practices & Lessons learned
 Employing Harm Reduction model
 Client-centered Approach
 Using Motivational Interviewing techniques to engage clients
 Low threshold services
 Using Daily Rounds to case conference clients
 Collaborations with internal programs and external agencies
to recruit clients
 Ongoing staff training and development
 Minimizing duplication of intake and paperwork
throughout entire process
Contact Info
 Stephen Crowe, ATC Managing Director
scrowe@harlemunited.org
 Liza Kasmara, Director of Program Evaluation
lkasmara@harlemunited.org
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