Engaging Hard-to-Reach
Populations: Empowering the
May 15, 2013
 Introduction
to SPNS Integrating HIV Innovative
Practices (IHIP) project
 Sarah
Cook-Raymond, Impact Marketing +
 Presentations
from SPNS grantees
Angulique Outlaw, Horizons Project
 Nikki Cockern, Horizons Project
 Margaret Hargreaves, Mathematica
 Brief
post-Webinar questionnaire
IHIP Resources on
TARGET Center Website
IHIP Resources:
Innovative Approaches to Engaging Hard-to-Reach Populations
Living with HIV/AIDS into Care
IHIP Tools on Engaging Hard-to-Reach Populations
Training Manual
Webinar Series
Outreach – April 18; see archive recording
Inreach – May 1; archive recording to be up soon!
Empowering the Patient - May 15
An Introduction to
Motivational Interviewing (MI)
Angulique Y. Outlaw, Ph.D.
Assistant Professor
Director of Prevention Services
Wayne State University School of Medicine
Horizons Project
• What Is MI?
• How Does MI Work?
• How Are We Using MI?
Why Is Change So Hard?
• Lack of motivation from within a person
People are not motivated by nagging or fear
Most people don’t change for another person
When pushed, people push back
Ambivalence (pros and cons)
• Lack of confidence (self-efficacy)
• Lack of social support, role models
• Life gets in the way!
What Do We Do To Try To
Make Other Change?
• Given them Insight – if you can just make
people see, then they will change
• Give them Knowledge – if people just know
enough, then they will change
• Give them Skills – if you can just teach
people how to change, then they will do it
• Give them Hell – if you can just make people
feel bad or afraid enough, they will change
What Is
Motivational Interviewing (MI)?
• Evidenced based intervention to promote
health behavior change
• *MI is
– Client-centered,
– Goal-oriented approach
– Focused on increasing intrinsic motivation
for change by:
• Resolving ambivalence about different
potential courses of action
• Increasing self-efficacy about change
*Miller & Rollnick (2002, 2007)
What Is MI?
• A method of communication
– Not a specific session by session
– Not a bag of tricks
• Good communication at a micro-level
• Making every word count
• Develop rapport, understand the
client’s view
• Elicit and reinforce any and every
communication about behavior change
Advantages Of MI
• Client-centered intervention
• Can be performed by a variety of
staff members
• Occurs in a natural setting
• Ambivalence is addressed
What Does The Conversation Look
Empathic and warm
Listening and understanding
Expressing optimism and hope
Reinforcing specific strengths
Emphasizing personal choice and
• Offering menu of options
• Discussing value-behavior incongruence
MI Elements
Change Talk
MI Principles
Express Empathy
Develop Discrepancy
Roll with Resistance
Support Self-Efficacy
The “RULE”s Of MI
• Resist the righting reflex
• Understand your client’s motivation
• Listen to your client
• Empower your client
Spirit of MI
• Collaborative (vs. Coercive)
– Working jointly together
• Evocative (vs. Educational)
– Elicit motivation, perceptions, goals, and
• Autonomy supportive (vs. Authoritative)
– Self-directing freedom (Choice)
MI Methods
Open-Ended Questions
Reflective Listening
Change Talk
• Disadvantages of doing what you are
• Advantages of change
• Optimism about change
• Intention to change
Horizons Project
• Dedicated to providing HIV prevention
services to at-risk youth and direct
care services to youth living with HIV
ages 13-24
• Is the only comprehensive HIV/AIDS
program in Michigan focusing on youth
Continuum Of Care
Other Medical Sites
Serving HIV+
Horizons Community
Horizons Field &
Internet Outreach
Horizons Peer
C&T Sites
Horizons C&T
Horizons Case Finding:
Agency/Field Outreach
Community Agencies
and Resources
Clinical Care
Primary Medical Care
Medical Specialty Care
Nursing Services
Health Education
Adherence Support
Social Work Services
Case Management
Ongoing Advocacy
Consumer Involvement
Therapeutic Activities
Psychological Services
Psychiatric Consultation
Education and Training
MI for Retention
Prevention Services
(MI and Group)
How We Use MI
• Single session (30 minutes)
– As part of field outreach to encourage HIV
• Single session (30 minutes)
– At initial appointment or first return to care
appointment focused on engagement and
retention in care
– Focused on adherence to antiretroviral
therapy (initiation and maintenance)
– Focused on risk reduction
MI Computer Applications
• *Motivational Enhancement System for
Sexual Risk & Adherence
– MISTI (Sexual Risk)(Feasibility study)
• Single session face-to-face or computer delivered
– MISTI-II (Sexual Risk)
• Two session computer delivered intervention (Baseline
and 3 months)
– MESA (Adherence)
• Two session computer-delivered intervention (Baseline
and 1 month)
*adapted by Ondersma et. al
To Sum Up
• Remember MI Elements
– Spirit
• Collaboration, Evocation, & Autonomy
– Principles
• Express Empathy, Develop Discrepancy, Roll
with Resistance, & Support Self-Efficacy
• Open-Ended Questions, Affirmations,
Reflective Listening, & Summaries
To Sum Up
• Remember MI Elements
– Change Talk
• Disadvantages of Staying the Same,
Advantages of Change, Positive Things
About Change, & Intention to Change
MI Resources
• Motivational Interviewing (2012,
2007, 2002) Miller and Rollnick
• Motivational Interviewing with
Adolescents and Young Adults (2010)
Naar-King & Suarez
• www.motivationalinterviewing.org
Thank You!!
Engaging & Retaining Youth in Care
Engaging Hard To Reach Populations – HRSA Webinar
Nikki Cockern, PhD
Assistant Professor
Clinical Care Manager
Wayne State University School of Medicine
Horizons Project
May 2013
Issues of Adolescence
• Trust
• Often not ready to change, not motivated
• Lack of impulse control
• Rebel against prescriptive approaches – educational, skills
building, traditional counseling
• Physical Changes (thanks to puberty)
• Peak of peer involvement and peer norms
• Heightened experimentation
What’s Unique about
 Environment-vitally important
 Separation/individuation
• Identity formation as separate from authority figures
• Translating personal goals into behavior within a
constrained environment
• Mood fluctuates
• Trying to figure out who they are and try different roles
 Communication skills are still developing
Horizons Project
• Dedicated to providing HIV prevention services to
at-risk youth and direct care services to
adolescents and young adults living with HIV
(ages 13-24)
• Has continued to grow as the only comprehensive
HIV/AIDS program in Michigan focusing on youth
• Wayne State University School of Medicine (WSU)
and the Detroit Medical Center (DMC) serve as
Engagement Strategies
 “One-stop shopping” & multidisciplinary approach to HIV care, that is youth sensitive &
culturally competent. Meeting youth “where they are” and focusing on building relationship
 Intensive Case Management Services
 Identification of needs (initial & ongoing)
 Development of comprehensive service plan, including strategies for implementation
 Coordination of care & services
 Mental Health/Psychosocial Services
 Client Advocacy
 Transportation
 Treatment Adherence Program
 Lost to Follow-Up (L2FU) Program
 Use of Multi-media tools
Horizons Project Enhancements
• Advocates assist youth in enrolling and remaining in care
• Rapid linkage into care
• Intake and medical appointments are provided within the first
week of contact
• Youth often receive resources prior to their med visit
• Direct linkage & support to ancillary care services and resources
• Motivational Interviewing is offered
• Multi-modal contact to youth in preferred medium (i.e. phone,
text, email, Facebook inboxes)
• Jam Sessions (support groups)
• Transportation to ‘life critical’ services (DHS)
• Provide a link to advocacy services if youth do not want to
enroll in medical care
• Actively Promote Consumer Involvement
Horizons Project Modifications
• Quickly establish and maintain rapport
Highlight and vitally protect confidentiality, while treating each with dignity and respect
Contact with youth is consistent, yet at varied times and amongst several staff
Staff is available outside of typical “working hours/days” and can be reached via cell and email daily
• Patient advocacy is vital to keeping youth connected and meeting their needs
Staff often accompany youth to other necessary medical and ancillary care appointments (i.e. DHS,
colposcopy, Dental, GYN, etc.)
Phone contacts for transportation to clinical and ancillary appointments, JAM sessions, other care
related activities
• Decrease barriers to access services
Increase frequency of medical clinics held, so more appointment slots are available (including separate day
youth can come in for treatment)
Reserved new patient and sick patient slots during each clinic session
Combined mom/baby or family clinic sessions to decrease the frequency of visits parents have to keep
Use of laptops in medical clinic in order to complete on-line applications for insurance and/or supplemental
coverage programs
• Provide incentives for improved adherence
i.e. keeping appointments, reducing drug use ,decreasing incidence of STIs, etc. (works with mental health
• Provide lost to follow-up outreach
i.e. phone calls, letters, and home visits (MI)
L2FU Program Protocol
MI @ point of
contact & @
clinic appt.
1. Maintain List
Identify youth who
missed clinic
appt. & not
to reschedule
Contact made w/
Client & clinic
visit scheduled
MI via
MI @ HV if
month after
missed clinic
visit. Advocate
Contact via phone/text
Home Visit
2nd month
Mail post
Card sent
Social Media Tools
General Information and linkage to Horizons Project and
Community Services
• Horizons Project Website:
Horizons specific information and events/activities
• FaceBook
• Twitter
Adherence to Appointments & ARV regimen
Text Messages (regular, timed texts for youth starting meds & those
w/sig adherence problems) (appointment reminders & check ins)
Email invites on the spot for upcoming med visits w/alarm
Private inbox message through Facebook
Suggestions for Programs Working
with Adolescents
• Empowerment: Give youth an
opportunity to be the “expert”;
demonstrate mutual respect &
• Address the ‘real affects’ of denial
and depression while increasing
hopefulness and opportunities for
• Instill responsibility, allowing for
choices when possible
• Be more of an advocate, than
parent or judge
• Be respectful of where youth is in • Listen first, focus on their
the moment & nonjudgmental
• Use open-ended questions
• Acknowledge safety issues
(community intolerance, bullying,
• Avoid power struggles and hidden
potential violence from others)
• Address stigma, assumptions,
judgmental behavior within the
care delivery system
• Provide integrated peer driven
medical and psychological support
• Develop cultural competence
• Patience, Patience, Patience
One stop shopping, multi-disciplinary team approach to care
• Clinical Services, including intensive case management
• Psychosocial Services
Engagement & Retention Strategies include:
• Rapid Linkage to Care
• Multiple clinic sessions options
• Practical and Concrete Support for accessing resources
• Peer Advocacy, access to support outside conventional time
• Transportation
• Treatment Adherence Program
• L2FU Program
• Use of social media tools
Staff Acknowledgement
Director of Medical Service and Research: Elizabeth Secord, MD
Director of Prevention Services: Angulique Outlaw, PhD
Consultant for Psychological Services and Research: Sylvie Naar-King, PhD
ATN Behavioral Research Coordinator: Monique Green Jones, MPH
ATN Clinical Research Coordinator: Charnell Cromer, MSN
Clinical Care Manager: Nikki Cockern, PhD
Clinical Nurse Practitioner: Debbie Richmond, NP
Clinical Social Worker: Tiffani Hollowell, CMSW
Care Coordinator/Case Manager: Keshaum Houston, BS
Adolescent Consultant: Jessica Daniel, MPH
MSM Prevention Coordinator: Jeremy Toney
MSM Outreach Workers: Bre’ Campbell, David Perrett
ATN C2P Coordinator: Emily Halden Brown, MPP
ATN Research Assistant: Cindy Chidi, BS
ATN Linkage to Care Specialist: Valentina Djelaj, LLMSW
ATN 110/117 Outreach Coordinator: Bryan Victor, MSW
Fisher HRH Prevention Coordinator: Te’Neice Dobbins, BS
Thank you!—
Nikki Cockern, PhD; 313.745.4892; [email protected]
Latino HIV Best Practices:
Improving Access, Engagement and
Retention in Care
May 15, 2013
Engaging Hard-to-Reach Populations – HRSA Webinar
Margaret Hargreaves, Ph.D., M.P.P.
Study Methods
Review of the literature
– Impact of HIV/AIDS epidemic on Latinos
– Evidence of effective practices for engaging and
retaining HIV-positive Latinos in HIV care
Site visits to 10 exemplary sites
– 6 States selected for study
– 10 sites selected across 6 states
– 1 to 1.5 day site visits by bilingual teams
Analysis of sites’ 2009 RDR and 2010 RSR data
– Racial/ethnic analysis of client characteristics,
service use, and clinical outcomes
Selected Sites
CARE Resource, Miami, FL
CommWell Health, Dunn, NC
Elmhurst Hospital Center – ID Clinic, Brooklyn, NY
Centro de Salud Familiar La Fe, El Paso, TX
Miami Beach Community Health Center – Immune
Support Program, Miami, FL
Mission Neighborhood Health Center – Clinica
Esperanza, San Francisco, CA
Montefiore AIDS Center, Bronx, NY
San Ysidro Health Center – CASA, San Ysidro, CA
Valley AIDS Council, Harlingen, TX
West Side Community Health Center – Clinic 7, St.
Paul, MN
Site Locations
Site Characteristics
7 Federally Qualified Health Centers (FQHCs),
2 hospital outpatient departments, 1 AIDS
service organization
RWHAP Funding: Parts A, B, C, D, F, MAI, SPNS
 Populations served: Mexico, Caribbean, Central
America, South America, Migrant farm workers
HIV clients served: 160 clients - 2665 clients
 Percentage Latino clients: 20 – 80 percent
Sites’ Quality of Latino HIV Care
9 providers prescribed HAART to Latino
clients at same or higher rate than non-Latinos
 4 providers conducted CD4 counts for over
90% of Latino clients in the last year; another 3
providers conducted CD4 counts for over 80%
of Latinos in the last year
3 providers conducted viral load tests for over
90% of Latino clients in the last year; another 4
providers conducted viral load tests for over
80% of Latinos in the last year
Barriers and Strategies
Barriers to Latino access, engagement, and
retention in HIV care identified at five levels
Total of 43 strategies were used by HIV
providers to address identified barriers to Latino
access, engagement, and retention in HIV care
Strategies to Address Individual-level Barriers
– Help completing applications and obtaining eligibility
documentation for Medicaid, Medicare, ADAP, SSA,
Ryan White, SNAP (n=10)
– Referrals for social services, including food and
housing assistance, domestic violence services,
legal aid, immigration services (n=10)
– Transportation assistance, including vans and
metro/bus cards (n=9)
– Targeted Latino support groups for MSM, women,
transgender, Spanish speakers, hepatitis C,
treatment adherence, substance abuse, domestic
violence, HIV education (n=8)
Individual-level Strategies, Cont.
– Peer health educators, peer counselors, buddies,
who provide health education, system navigation,
social support, and client advocacy (n=7)
– Reinforcement of treatment adherence messages
geared to client literacy levels, using reminder
calendars, pictures, symbols, color codes, pill boxes,
key chains, directly observed therapy, literacy
lessons (n=7)
– Home or clinic delivery of HIV medications by
pharmacy or clinic staff (n=3)
– Client social groups, knitting, arts, crafts (n=3)
Strategies to Address Clinician-level Barriers
– Knowledge of traditional home remedies, foods,
cultural values, religious beliefs, differences among
Latino subpopulations (n=10)
– Showing warmth, respect, friendship to clients and
their families; having a passion for the work (n=10)
– Fluent Spanish speakers, interpreter lines,
translation support from bilingual staff, certified
interpreters (n=10)
– Staff “willing to go the extra mile” for clients (n=7)
– Home visits, hospital visits, long-term follow-up
– Mostly Latino/Hispanic staff (n=5)
– Avoidance of culturally loaded terms such as gay,
mental health, and psychiatry (n=5)
– Training in cultural competency (n=3)
Strategies to Address Organization-level Barriers
– Comprehensive one-stop shop of HIV ambulatory
outpatient care and supportive services (n=10)
– Flexible scheduling, double-booking, walk-ins, open
slots for emergencies (n=10)
– Clinic materials in Spanish (signs, notices, videos,
website, brochures, medication labels, posters)
– Frequent appointment reminder calls, missed
appointment follow-up calls, free cell phones to
receive reminders (n=9)
– Close tracking of visits, labs, medications, and
contact information for treatment adherence and
retention purposes (n=9)
– Client confidentiality policies and practices (n=8)
Organization-level Strategies, Cont.
– Universal screenings for mental health and/or
substance abuse to reduce treatment stigma (n=7)
– Discreet name and location of clinic (n=6)
– Long appointment times for visits with clinicians,
case managers, and counselors (n=6)
– Multidisciplinary teams, team meetings, patient
briefings, case conferences (n=6)
– Expanded clinic hours, evening hours (n=5)
– Comfortable, home-like environment (n=3)
– Offices arranged to facilitate staff/client interaction
and communication (n=3)
– HIV clinician team includes specialists (i.e.,
dermatology, OB-GYN) (n=3)
Strategies to Address System-level Barriers
– Network of client referrals from Latino-serving
organizations; no wrong door entry into system
– Partnerships, consortia, and collaborations of
Latino-serving organizations (n=8)
– HIV care tracking and coordination across
inpatient/outpatient settings, agencies, states,
U.S./Mexican border (n=7)
– Latino representation on HIV prevention and
treatment planning councils (n=6)
– Health policy or funding advocacy for Latino HIV
services (n=5)
– Expedited, client hand-offs among testing, linkage,
bridge, and retention services staff (n=4)
Strategies to Address Community-level Barriers
– Targeted outreach to Latino subpopulations—MSM,
women, incarcerated, transgender, migrants,
undisclosed MSM (n=9)
– Discrete identity of outreach and linkage staff to
protect client privacy (n=7)
– Pride events and Latino celebrations to reduce
stigma (n=6)
– Regional HIV conferences and retreats to improve
HIV care (n=4)
– HIV talks to community groups, in churches, on
radio, TV (n=3)
– Latino theatre troops to increase awareness of HIV
Preliminary Conclusions
Some strategies are linguistically or culturally
specific to Latino populations
Some strategies address barriers common to
underserved populations
 Some strategies cost little or nothing to start
By addressing barriers, providers can reduce
or eliminate disparities in Latino access, use,
and retention in HIV care
For More Information
Please contact:
– Meg Hargreaves
• [email protected]
To be informed when these upcoming IHIP resources are ready,
keep an eye out for HRSA announcements or sign up for the IMC newsletter
email [email protected]
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Sarah Cook-Raymond, Managing Director |Impact Marketing + Communications |
Twitter: @impactmc1| Facebook: ImpactMarCom |www.impactmc.net | 202-588-0300

Empowering the Patient Webinar Slides