in+care Campaign Meet the Author August 6, 2013 1 Ground Rules for Webinar Participation Actively participate and write your questions into the chat area during the presentation(s) Do not put us on hold Mute your line if you are not speaking (press *6, to unmute your line press #6) Slides and other resources are available on our website at incareCampaign.org All webinars are being recorded 2 Welcome & Introductions Welcome & Introductions, 5min NYC Care Coordination Program, 30min Q & A Session, 20min Updates, Reminders & Evaluation, 5min Michael Hager, MPH MA NQC Manager, in+care Campaign Manager New York, NY 3 In the chat room, Enter your: 1. name, 2. agency, 3. city/state, and 4. professional role at agency August 6, 2013 PATIENT NAVIGATION: A Network Perspective from the NYC HIV Care Coordination Program New York City Depar tment of Health and Mental Hygiene Argus Community, Inc. Beth Israel Medical Center PRESENTERS Beau J. Mitts, MPH Director, Ryan White Technical Assistance NYC Department of Health and Mental Hygiene Stephanie Chamberlin, MPH, MIA Evaluation Specialist, Research and Evaluation NYC Department of Health and Mental Hygiene Maria Rodriguez, MPA Program Director, Care Coordination Argus Community, Inc. Vanessa Haney, MFA Program Director, Care Coordination Beth Israel Medical Center 5 AGENDA DOHMH Care Coordination Program (CCP) Model Background Development Implementation Argus Community Experience Beth Israel Medical Center Experience Evaluation Take-Home Messages 6 BACKGROUND: The CCP Model Benefits and Services Coordination Navigation Treatment Adherence Health Promotion Outreach BACKGROUND: Target Population Persons at high risk for suboptimal health care outcomes: newly diagnosed previously lost to care/never in care irregularly in care with recent adherence issues (e.g., viral rebound, resistance) 8 BACKGROUND: Patient Navigation Patient Navigators are key players on the Care team Most interaction with the clients Community Health Workers Bridge the gap between the clinic and the community Reflect the community they serve Services provided (often in client’s home) include: Health promotion Accompaniment Treatment adherence Modified DOT Caseloads Patient Navigators: 14 to 20 clients DOT Specialists: 7 clients Required clinical supervision 9 DEVELOPMENT: Research and Timeline Models reviewed: Medical Home, Patient Navigation, Chronic Care, Community Health Worker Prevention and Access to Care and Treatment (PACT) Project Partnership between Partners in Health (PIH) and Brigham and Women’s Hospital in Boston, MA Requests for Proposals (RFP) 2004: Treatment Adherence Program (TAP) 2006: Maintenance in Care (MIC) 2009: Care Coordination Program (CCP) Bradford et al. HIV System Navigation: An Emerging Model to Improve HIV Care Access. AIDS Patient Care and STDs. 2007;21:S49–S58. 10 DEVELOPMENT: Tools Program Manual Version 4.0 released May 29, 2013 Each version evolved and adapted Recommended staffing plan Staff roles and responsibilities Guidance on program processes Standardized forms Excel adherence calculator eSHARE data reporting system 11 DEVELOPMENT: Training and TA Trainings 10-day Care Coordination training National Development and Research Institutes (NDRI) HIV 101, case management skills, program forms, etc. Four-day Health Promotion Training of Trainers (TOT) PACT trainers along with NYC DOHMH Project Officers Two trainers at each Care Coordination program One-day trainings Care Coordination Refresher Cultural Sensitivity Co-occurring Disorders (HIV, MH, and SA) Technical Assistance NYC DOHMH Project Officers Bi-annual Provider Meetings Site visits and webinars 12 IMPLEMENTATION: Funded Programs 28 agencies providing CCP in New York City (NYC) 16 hospital-based agencies 12 community-based agencies Caseloads: Agency caseloads: 52 to 230 active clients 9 small programs 12 medium programs 7 large programs ~3,300 PLWH in the active portfolio caseload at any given time 4,986 unique PLWH served from March 2012 – February 2013 13 IMPLEMENTATION: Client Demographics Grant Year (GY) 2012, Care Coordination Program (All Agencies), N = 4,986 AGE GROUP <25 % GENDER 6.9% 25-44 38.4% 45-64 50% 65+ 4.7% RACE/ETHNICITY % Female 37.3% Male 60.9% Transgender % BOROUGH 1.8% % Hispanic 37.1% Manhattan 21.0% Black 52.6% Brooklyn 32.8% Bronx 31.1% RISK MSM IDU Heterosexual % 28.3% 7.8% 58.6% INSURANCE Public Insurance Uninsured % 80.2% 9.7% 14 ARGUS COMMUNITY, INC. 760 East 160 th Street Bronx, NY 10456 718-401-5700 www.arguscommunity.org Maria Rodriguez, MPA BACKGROUND: Argus Community, Inc. Founded in South Bronx in 1968 Began as substance abuse treatment provider Expanded to address homelessness, AIDS/HIV, welfare reform Received national and international recognition Programs replicated in Washington, DC; San Francisco; Albany; Des Moines; and Belfast, Northern Ireland. Program created in response to community needs and continues to respond to new emerging needs 16 PROGRAMS: Argus Community, Inc. ACCESS I Care Management ACCESS II Care Coordination Argus Career Training Institute Argus Client Money Management Argus Community Re-Entry Initiative ARU Outpatient Center DWI Screening and Assessment Elizabeth L. Sturz Outpatient Center Harbor House & Harbor House II MEDAL Program Prometheus I and II RESTART GED Program Striver House Youth Intervention and Development 17 The 3 P’s In Care Coordination Treatment Adherence Patients Linkage To Care Coordination of Medical Services Providers Community Maintain a Stable Health Status Become SelfSufficient Program Staff Coordination of Social Services Support and Coach Home Based Navigation 18 PATIENTS: Argus Community, Inc. Total Census as of June 2013: 125 Active Patients Referred by 3 medical facilities, self -referrals, and/or our Health Home program. Patients By Track Enrollment as of June 2013: Track Enrollment A (Quarterly, no ART) 5 B (Quarterly, with ART) 18 C1 (Monthly) 47 C2 (Weekly) 36 D (Daily Directly Observed Therapy) 19 19 IMPLEMENTATION: Client Demographics GY 2012, Argus Community, N = 208 AGE GROUP <25 All CCP 6.9% Argus 25-44 38.4% 2.6% 26.3% 45-64 50% 66.5% 65+ 4.7% 4.6% RACE/ETHNICITY All CCP Argus GENDER All CCP Argus Female 37.3% 44.3% Male 60.9% 55.6% Transgender 1.8% 1.0% BOROUGH All CCP Argus Hispanic 37.1% 49.5% Manhattan 21.0% 9.3% Black 52.6% 45.4% Brooklyn 32.8% 2.1% Bronx 31.1% 86.6% RISK MSM IDU Heterosexual All CCP Argus 28.3% 16.1% INSURANCE 7.8% 10.7% Public Insurance 58.6% 62.4% Uninsured All CCP Argus 80.2% 88.7% 9.7% 7.2% 20 ACCESS II CCP STAFF PROGRAM STAFF Data Manager Medical Center Liaison Patient Navigator Patient Navigator Care Coordinator Patient Navigator Program Director DOT Field Specialist Patient Navigator Patient Navigator Care Coordinator Patient Navigator DOT Field Specialist 22 PROVIDERS 1. Montefiore Medical Group (MMG) – CICERO Program/Bronx Community Health Network 11 Clinics from the Montefiore Medical Group CICERO Program 2. All Med and Rehabilitation of New York 3. The George and Eva Neil Barbee Family Health Center 4. The 151 st Medical Center 23 THE MODEL: Referral Process Walkin/Word of Mouth Provider Referral Linkage to Care Referrals Argus ACCESS II CCP Health Home Referrals New York City 311 24 THE MODEL: Building Provider Buy -in 1. Provider Website 2. Social Work Luncheon/Program Presentations 3. Clinical Rounds/Conferences 4. CCP Patient Report for Providers 5. Consumer Advisory Board Meetings 25 THE MODEL: Services Provided Accompaniment Assistance with Entitlements and Benefits, Health Care, Housing, and Social Services Care Plan Case Conference Directly Observed Therapy (DOT) Health Promotions Home Visits Intake/ Re-Assessment Outreach for Patient for Reengagement Treatment Adherence/Pill Box Count 26 CASE STUDY: Lisa Lisa was referred by her PCP on 7/15/11 Initial enrollment track was C2-weekly CD4 at the time of enrollment was 219 and VL was 29,492 She began DOT services on 11/16/2011. Her CD4 was 214 and VL 30,494 CCP staff provided daily DOT services, weekly Health Promotion, and case management until 3/23/2012 when patients lab reported her CD4 was 350 and VL undetectable. On 9/17/2012 her CD4 was 375 and VL remained undetectable On 1/18/2013 her CD4 was 465 and VL remained undetectable. Her last lab report indicates that her CD4 is 397 and VL remains undetectable. 27 BETH ISRAEL MEDICAL CENTER PETER KRUEGER CENTER FOR IMMUNOLOGICAL DISORDERS www.wehealny.org/services/bi_aidsservices 10 Nathan D Perlman Pl, New York, NY 10003 212-420-2620 Vanessa Haney, MFA BIMC’S AIDS CENTER TIMELINE Donna Mildvan, MD (Chief of Infectious Disease) notices enlarged 1978-1979 lymph nodes in gay men studied for sexually transmitted intestinal infections 1980 Beth Israel sees its first AIDS patient, a 33-year old West German man 1981 Beth Israel’s Infectious Disease Clinic opens 1988 BIMC is given Designated AIDS Center status 1989 Beth Israel’s Infectious Disease Clinic is renamed The Peter Krueger Center for Immunological Disorders 1993 The Robert Mapplethorpe Residential Treatment Facility is founded by the Robert Mapplethorpe Foundation 29 BACKGROUND: BIMC Inpatient 1,083 certified beds Emergency Department Visits (Excluding Admissions) in 2011: 107,178 Admissions in 2011: 35,376 Methadone Maintenance Treatment Program Visits: 1,079,514 Ambulatory/Outpatient The Peter Krueger Center Number of Unique Patients: 1,200 HIV Primary Healthcare Specialty Healthcare (Dermatology, Gynecology, Pain Management) Dental Mental Health (Psychiatry/Psychology/Counseling) Transgender Health Care Services Care Coordination Social Work and Case Management Harm Reduction: Project S.H.a.R.E. Nutrition Visits: 371,083 30 PATIENTS: BIMC Since 2010, 298 people have been enrolled into BI’s CC Program Total Census as of June 2013: 186 Active Patients Patients By Track Enrollment as of June 2013: Track Enrollment A (Quarterly, no ART) 0 B (Quarterly, with ART) 15 C1 (Monthly) 102 C2 (Weekly) 64 D (Daily Directly Observed Therapy) 5 31 IMPLEMENTATION: Client Demographics GY 2012, Beth Israel, N = 223 AGE GROUP <25 All CCP Beth Israel GENDER All CCP 6.9% Female 37.3% 41.3% Male 60.9% 56.1% Transgender 1.8% 2.7% Beth Israel 25-44 38.4% 3.1% 21.1% 45-64 50% 70.0% 65+ 4.7% 5.8% All CCP Beth Israel Hispanic 37.1% 43.5% Manhattan 21.0% 39.0% Black 52.6% 44.8% Brooklyn 32.8% 30.9% Bronx 31.1% 18.8% RACE/ETHNICITY RISK MSM IDU Heterosexual BOROUGH All CCP Beth Israel 28.3% 21.5% INSURANCE 7.8% 29.1% Public Insurance 58.6% 65.0% Uninsured All CCP All CCP Beth Israel Beth Israel 80.2% 89.2% 9.7% 1.8% 32 THE MODEL: Referral Process 33 CARE COORDINATION: Our Team! 34 PROGRAM STAFF Data Entry Care Coordinator Patient Navigator Patient Navigator Patient Navigator Patient Navigator Program Manager Patient Navigator Patient Navigator Care Coordinator Patient Navigator Patient Navigator Patient Navigator EVALUATION: Outcomes CCP Quarterly Viral Loads: N=50 Percent Undetectable 90 82.05 80 72.93 70 60 50 Percent Detectable 69.23 65.85 52.08 47.92 40 34.15 30.77 27.07 30 17.95 20 10 0 Prior to Enrollment QTR 1 (Jan-Mar 2011) QTR 2 (Apr-Jun 2011) QTR 3 (Jul-Sep 2011) QTR 4 (Oct-Dec 2011) 36 CASE STUDY: Brenda Brenda is a 44 year -old woman test HIV positive in 2004 History of trauma, depression, and substance use Enrolled in CCP April 2011 Viral Load of 100,000 copies and CD4 was 113 Throughout 2011 and 2012 Remained difficult to engage but kept on a weekly track Did not agree to pill boxing and self-reported 100% adherence March 2013 Viral Load had risen to 659,892 copies and her CD4 dropped to 11 April 2013 Agrees to DOT during her PCP appointment July 201 3 Viral Load is <75 and her CD4 have risen to 43 Significant improvement in herpes lesions 37 CARE COORDINATION PROGRAM EVALUATION NYC Depar tment of Health and Mental Hygiene Stephanie Chamberlin, MPH, MIA EVALUATION: Process and Outcomes Cross-agency evaluation utilizing standard metrics, based on the well-defined CCP protocol Fidelity to Program Model Process Barriers Facilitators Quality Management Outcomes Cross-sectional (2010 – Present) Pre- and Post-CCP Enrollment (2012-Present) Short-Term Long-Term 39 EVALUATION: Time And Effort Study Hours Worked per Day (7.37 Average ) 100% 80% 2.67 Direct Client Services 60% 1.99 1.22 0% Program Activities N/A 40% 20% Indirect Client Services Background Method Sample of six (6) Agencies Administrative Blank, Illegible, 0.78 Missing 0.49 0.22 Patient Navigators n = 35 40 EVALUATION: Time And Effort Study All Client Services (Direct and Indirect): Average Hours per Day Travel Time to/from Client Encounters 1.18 Health Promotion 0.59 All Assistance w/ Activities 0.47 Outreach for Reengagement 0.25 All Adherence Logs 0.16 DOT Field 0.16 All Accompaniment 0.11 All Case Conferences 0.10 Intake and Reassessment 0.04 Care Plan 0.01 0 0.2 0.4 0.6 0.8 1 Patient Navigators n = 35 1.2 1.4 41 EVALUATION: Engagement In Care n/a 42 EVALUATION: Viral Load Suppression n/a 43 NYC DOHMH Care Coordination Evaluation Team TAKE HOME MESSAGES Patient Navigators do more than just navigation Health promotion, treatment adherence, modified DOT, etc. Diverse Community Health Worker staff Cultural sensitivity and competency Field safety training and protocol Means of communication Clinical supervision Technical assistance Provider meetings Peer to peer learning Best practices Incorporate data collection and evaluation 45 QUESTIONS Beau J. Mitts, MPH NYC Department of Health and Mental Hygiene bmitts@health.nyc.gov Stephanie Chamberlin, MPH, MIA NYC Department of Health and Mental Hygiene schamberlin@health.nyc.gov Maria Rodriguez, MPA Argus Community, Inc. marodriguez@arguscommunity.org Vanessa Haney, MFA Beth Israel Medical Center vhaney@chpnet.org To find Care Coordination tools online visit: www.nyc.gov SEARCH: Care Coordination 46 Announcements 47 Upcoming Events and Deadlines Upcoming Webinars: ― Stay Tuned! Campaign staff is hard at work for you Data Collection Submission Deadline: October 1, 2013 Improvement Update Submission Deadline: August 15, 2013 Upcoming Monthly Topics ― August – Transitory Populations and Retention ― September – Women and Retention 48 ― October – Sex Work and Retention Campaign Headquarters: National Quality Center (NQC) 90 Church Street, 13th floor New York, NY 10007 Phone 212-417-4730 incare@NationalQualityCenter.org incareCampaign.org youtube.com/incareCampaign 49