Ask, Screen, Intervene
4 Cities Project
Training Exchange
June 20, 2013
For Audio dial: 1-800-591-2259 Passcode: 959325
Please remember to mute your speakers
Training Exchange Objectives
• Discuss updates to the Ask, Screen, Intervene
(ASI) curriculum
• Review the ASI Four Cities Project
• Identify lessons learned from the
implementation of the ASI framework in
community health clinics
• Describe preliminary results from the
evaluation of the project
Agenda
▫ Welcome and Call Purpose --- Joanne Phillips
▫ Ask, Screen, Intervene (ASI) Curriculum Updates
2013 --- Helen Burnside
▫ Ask, Screen, Intervene Four Cities Project --Joanne Phillips
Introduction of the project
Collaborators
Timeline
Agenda
• Four Cities Updates
▫ Needs Assessment: process
and findings
▫ Training Design
▫ Training Evaluation Data:
barriers and anticipated
practice changes
▫ Lessons Learned
▫ Clinic Experience
▫ Plans for Sustainability
•
•
•
•
Baltimore
Chicago
Miami
Los Angeles
Agenda
▫ Evaluations of the curriculum implementation --AETC NEC
Evaluation Design
Data Collection
Data Analysis
Results
▫ Summary of the Project --- Helen Burnside
▫ Question and Answer --- Joanne Phillips
ASI Curriculum Updates
• 2012 4 modules→ 3 modules
▫ Risk assessment & screening for STDs
▫ Prevention Interventions
▫ Partner Services
• 2012-2013 Revisions completed from DHAP and
DSTDP Clearance
• Contact National Resource Centers for access to
DRAFT curriculum
http://www.cdc.gov/hiv/prevention/programs/pwp/index.html
Project Overview
• MAI-funded project through HRSA HAB
▫ Supports National HIV/AIDS Strategy goals
• Began Fall 2011
▫ 2 year project
• Project activities
▫ Planning and implementation
▫ Training and on-going technical assistance
▫ Program assessment and evaluation
Project Objectives
• Enhance clinician ability to conduct effective
risk screening, conduct prevention counseling,
and refer for services
• Increase the number of HIV-positive persons
who receive information about transmission
risks and regularly receive risk reduction
counseling
• Increase the number of HIV-positive persons
who are screened for STDs
• Assist in strengthening linkages to referral
services
Collaborators
•
•
•
•
•
•
•
HRSA HAB
CDC
4 regional AETCs and 4 PTCs
National Resource Center for NNPTCs
AETC National Resource Center
AETC National Evaluation Center
8 Ryan White Part C clinics/FQHCs in 4 cities
4 Cities and Clinics
• Baltimore
▫ Chase Brexton Health Services (3 sites)
▫ Total Health Care, Inc. (10 sites)
• Chicago
▫ Access Community Health Network
▫ Erie Family Health Center, Inc.
▫ Heartland Health Outreach, Inc.
Selected based
on ECHPP
designation
and
application
review
4 Cities and Clinics
• Los Angeles
▫ Alta Med Health Services Corporation
• Miami
▫ Jessie Trice Community Health Center, Inc.
▫ Miami Beach Community Health Center
Project Activities
• Planning & Implementation (Fall 2011 - Winter
2012)
Kick off calls with
collaborators
(HRSA HAB)
Planning and
Implementation
Meeting
1/2012
Baltimore, MD
Introductory
meetings and
needs
assessments with
clinics
(AETCs & PTCs)
Project Activities
• Training (Spring 2012- Summer 2012)
▫ Tailor to clinic needs
▫ Clinic project coordinator help facilitate and
monitor
• Assessment & Evaluation (Spring 2012 –
Summer 2012)
▫ Training Data
FTCC PIF
▫ Training Evaluation Summaries
NRC for the NNPTCs
Project Activities
• Ongoing Training and Technical Assistance (Fall
2012-June 2013)
Booster
trainings
need
assessment
Booster
training
delivery
Methods for
sustainability
Providing
clinic specific
TA
• Program level (feasibility, fidelity, impact)
▫ AETC National Evaluation Center
AETCs and PTC updates on: needs assessment process, training
design, training evaluation data, lessons learned, clinic
experience, and plans for sustainability
Chicago
Ricardo Rivero: Midwest AETC
Deyanira Flores: ACCESS Clinic
Chicago: Needs Assessment
• Meeting with clinic leadership and key staff
• Specific needs related to 3 ASI modules:
What’s in place already
Who would be involved
EMR
What needs to be covered from ASI curriculum
• Plans for sustainability
Chicago: Training Design
• All 3 training modules were tailored …
Audience
Local information
Time
• Training / TA beyond ASI:
STI: Overview & What’s New
Motivational Interviewing Bootcamp
Filling Your Prevention Tool Box
Risk screeners
Chicago: Practice Changes
• Risk screening (e.g., paper and iPad tools, etc.)
• Screening of STDs
• Delivering prevention messages
• Use of behavioral counseling
• Referral to more intense prevention interventions
Chicago: Barriers
• Time (per encounter and for training)
• Lack of confidence in skills
• Competing priorities
• Changes in leadership
• Staff turnover
Chicago: Lessons Learned
• Clinic leadership and providers buy-in
• Needs assessment
• Single contact at the clinic
• Clinic-centered trainings and TA
• Periodic site visits
• Partner services … the weakest link?
Chicago: Clinic Experience
Deyanira Flores, Project Coordinator
ACCESS Community Health:
• Overall experience
• Major accomplishments
• Barriers worth mentioning
Chicago: Plans for Sustainability
All 3 sites will continue implementation at
different levels:
ACCESS Community Health will expand to another
site as of July 1, 2013
Erie Family Health Center and ACCESS will continue
working with the PTC to conduct risk assessments
with iPads
Heartland Health Outreach … new leadership and
programmatic staff
Los Angeles
Tom Donohoe, UCLA Pacific AETC
Linda Creegan, CA HIV/STD Prevention Training Center
Ardis Moe, UCLA Pacific AETC
Alberto Perez, CA HIV/STD Prevention Training Center
HIV Clinic in Los Angeles, California
Main HIV Clinic, Commerce, California
Los Angeles: Needs Assessments/ Training
Design
• Initial Assessments: Winter-Spring
2012
• Scheduling: Spring 2012
• ‘Overview’ session
• Modules I, II, III delivered May-June
2012
• ‘Implementation’ session June 2012
• “Wrap up” in-person session May 2013
Los Angeles: ASI Training Design
All ASI modules delivered at clinic and utilized
Turning Technologies ARS
Overview session was important to review what ASI
implementation project was/wasn’t (i.e., exit interviews)
Draft clinic signage was used to facilitate training
experience and discussion of clinic specific implementation
of ASI
Bilingual signs for HIV waiting room
Bilingual HIV Waiting
Room Signage
Pin: “Ask me about
Sexual Health”
Los Angeles: Training Evaluation
• Barriers
▫ Existing Secondary Prevention Programs
▫ Existing ideas of ideal clinic flow for prevention
▫ EMR implementation/trainings during project
• Practice changes
▫ Increased STD testing/partner services referral
▫ Increased sharing of patient risk information
▫ Enhanced discussion of hard-to-reach patients
Los Angeles: Lessons Learned
• Important not to make patients feel like they are public
health hazards---that assessing sexual health and
prevention needs is part of high-quality HIV care
• Combine ASI questions and protocols with existing
prevention and STI screening procedures to enhance
patient experience (without repeating sensitive questions)
• Clinicians and support staff need to share prevention
information and screening information, ideally through
the EMR
• Changing clinician/staff ‘routines’/beliefs may be harder
than changing the EMR
Los Angeles: Sustainability of ASI
• PAETC/PTC will work with clinic to assist with
future ASI-related training needs, including
options for dealing with ‘condom refusers.’
• The clinic now doing six month RA screening,
with some staff more frequently
• Partner Services always offered as standard of
care (not always accepted, but increased)
• Increased rectal and pharyngeal testing
Los Angeles: Sustainability of ASI
• Increase interactions within HIV staff groups
(front office/back office, clinicians, mental
health, case managers)
• EMR key for future sustainability (billing)
• More specific questions about prevention needs
helped change exam room interaction but this is
long term process
• Might be helpful to have level III observational
experience for each discipline
Los Angeles: ASI-related trainings needs
PAETC, PTC or other (PS ATTC) will offer:
• PrEP
• Brief Mental Health Screenings for non-mental
health clinicians
• Billing for Prevention in the ACA Era
• SBIRTS
• Medical Marijuana and HIV
• Crack Cocaine and HIV
• Meth and HIV
• Alcohol and HIV
Baltimore
Terry Hogan: Johns Hopkins PTC
Abby Plusen: Pennsylvania/Mid-Atlantic
AETC
Jennifer Kunkel: Total Health Care
Baltimore: ASI Collaboration
▫
Introductory Meetings
▫
Training Centers’ Responsibilities
▫
Technical Assistance Training
Clinics Operations
▫
Training Centers’ Staffers
Clinics’ Staffers
Total Health Care, Inc.
Chase Brexton Health Services
Needs Assessments
Baltimore: Needs Assessment
▫
Conducted face-to-face meetings with key
stakeholders at each clinical setting
Collected needs assessment data with stakeholders
▫
▫
Used format developed in partnership with full ASI, 4Cities Project Group
Prepared full report
Shared with clinic partners
Sent reports to ASI, 4-Cities Project
Baltimore: ASI Trainings
▫
Scheduled trainings based on clinic schedules
▫
▫
Chase Brexton – held trainings on several different
dates to accommodate all staff
Total Health Care – held one training to coincide with
full clinic meeting
Collaborated with BCHD faculty for Module 4
Assured sustainability through TOT for selected
staff
Recognized that traditional TOT not best for staff
resource
Baltimore:
▫
Clinic Perspective Implementation
Key components
What clients need to know
Am I at risk
What puts me at risk
What can I do to prevent risk
What providers and support staff need to know
How can I implement ASI in a high volume primary care
setting
What does it take to document ASI activities
How to evaluate the impact of ASI on affected population
Baltimore: Barriers & Lessons Learned
▫
Primary Care Settings
Not offering exclusive HIV services
Diverse clinic census
Electronic medical records
▫
Already established
ASI risk questions
HIV Care Patients
Total Health Care – separate clinic visits
Many HIV-specific visits
Some chose to stay with primary care providers
Chase Brexton – incorporated into clinic
Baltimore: Clinic Perspective/Outcomes
▫
Primary Care Side and Meaningful Use Questions
Brief ASI intervention
Incorporate ASI intervention into Electronic Medical
Record is ideal
Coordinate HIV Medical Services with Primary Care
▫
Imperative in high volume setting
Clinic Accomplishments
Total Health Care, Inc.
Chase Brexton Health Services
398 HIV-positive clients screened/documented – 2012
933 Clients screened/documented – 09.2012-05.2013
Ongoing collaboration between clinics
Baltimore: Sustainability
▫
▫
TOT model
TA
▫
Linkage
Reverse Preceptor?
AETC + PTC as a resource
Collaboration between two large service providers
Miami
Yvette Rivero: Florida/Caribbean AETC
Richard Meriwether: AL/NC PTC
Ruth Duval: Jesse Trice Clinic
Coordinator
Clinics in Miami, Florida
• Jessie Trice Community Health Center (JTCHC)
5361 NW 22nd Avenue, Miami, FL 33142
• Miami Beach Community Health Center (MBCHC)
710 Alton Road, Miami Beach, FL 33139
Miami: Needs Assessments
• Initial Assessment
▫ March 2012
• 2nd Assessment
▫ October 2012 (sites requested training on HPV, Mental Health
•
in HIV, STD, Substance Abuse, and Cultural Sensitivity)
3rd Assessment
▫ April 2013 (Sexual Health survey has been implemented as part of
Primary Care and updates on STD will be provided yearly)
• Last assessment pending June 2013
Miami: ASI Training Design
Modules delivered monthly in a previously
scheduled training slot
Training slot was 3-5:00pm to avoid overtime pay
and cutting into clinic hours
Training conducted in conference rooms at clinics
All clinic staff attended trainings
Miami: Training Evaluation Practices
• Barriers
▫ Time constraints of clinic visit
▫ Client refusal to take Sexual Health survey
• Practice changes
▫ Allocating more time to provider
▫ Allowing a Medical Assistant (MA) to assist
provider
▫ Providing education to clients that refuse to take
Sexual Health survey
Miami: Supplemental Trainings
• Cultural Sensitivity –
▫ MBCHC, May 22, 2013
▫ JTCHC, tentative for June
• HPV and HPV Vaccines –
▫ JTCHC, May 3, 2013
• STD updates –
▫ MBCHC, Feb. 21, 2013
▫ JTCHC, May 17, 2013
▫ Mental Health and HIV – (pending) June 2013
Miami: Additional trainings
• Module I training provided on March 29, 2013,
to:
▫ Community Health Centers of South Florida, Inc.
▫ Borinquen Medical Centers of Miami
Clinic posters for waiting area,
provider’s office
Miami: Lessons Learned
• Provider administered Sexual Health survey is more likely
to be more comprehensive and/or complete than selfadministered survey
• Patients were more willing to discuss sexual history
because they knew that the sexual survey would be
administered
• Implementation of the Sexual Health survey has helped
staff to facilitate sexual health discussions
• Local involvement is crucial to program implementation
• Prior to training, clinic involvement is crucial to program
implementation
Miami: Sustainability of ASI
• F/C AETC Coordinator has committed to
provide STD training updates to staff at both
clinics yearly.
• The clinics have established the Sexual Health
survey as part of their Primary Care visit, which
can be accessed in the EMR.
• The clinics have already made changes to have
every patient screened at every visit for sexual
history in order to reduce HIV transmission.
Tim Buisker, Julia James, Andres Maiorana, and Janet Myers:
AETC National Evaluation Center
Overview
• Evaluation Design Overview
▫
▫
▫
▫
Risk Screener Data
Patient Exit Survey Data
Ryan White Services Report/Client Level Data
Qualitative Interviews
• Preliminary Results
Evaluation Design Overview
Feasibility
Integration
Impact
Evaluation Design Overview
Risk Screener Data
N=5673
Qualitative Interviews
ASI Trainers (8)
Providers (27)
Patient Exit Surveys
N=589
RSR Data
Triangulate
Quantitative Methods
• Patient Exit Surveys
▫ Min 30 patients every other month in 400+ patient
clinics
▫ Min 12 patients every other month in <400 patients
▫ Procedures tailored to clinic
• Clinical Record Risk Data
▫ ½ from EMR, ½ extracted using paper form
• RSR Data
▫ Was HIV risk reduction screening/counseling
conducted?
▫ Syphilis, Hep C, Hep B screening over time.
Qualitative Interview Methods
• Study Participants:
▫ At least one ASI trainer per clinic
▫ Planned for at least 4 providers per clinic
• Methods:
▫ Semi-structured Interviews
▫ 30-60 minutes conducted over the phone
▫ Interviews were audio-recorded and transcribed
using a transcription service
▫ Transcripts were coded iteratively by two
independent researchers using an open-coding
process (Strauss and Corbin 1998)
Preliminary Results
Patient Exit Survey
Age:
18-24
25-34
35-44
45+
(missing)
Racial/ethnic background:
African-American or black
White
Hispanic/Latino
Asian or Pacific Islander
Native American
Mixed Race
Other
(missing)
7.1%
20.5%
26.8%
45.0%
0.5%
53.5%
9.7%
33.3%
0.5%
0.2%
2.0%
0.2%
0.7%
Demographics
Gender:
Male
Female
MtF
FtM
Other
Sexual orientation:
Heterosexual
Homosexual
Bisexual
Other
66.7%
32.4%
0.3%
0.0%
0.2%
53.8%
37.7%
5.9%
1.2%
Demographics
Age:
18-24
25-34
35-44
45+
(missing)
Education:
Less than 8th grade
8th-11th grade
12th grade or high school graduate
or GED
Some college or AA degree
College graduate
Graduate education or graduate
degree
7.1%
20.5%
26.8%
45.0%
0.5%
10.7%
30.4%
27.5%
17.3%
9.7%
1.5%
Demographics
Risk discussion topics
In this visit, did your provider discuss…
HIV/sexual behavior:
How to choose sex partners?
Choosing HIV+ sex partners (serosorting)?
Telling partners HIV status?
Asking partners about HIV status?
Talking to partners about safe sex?
Having less unprotected anal sex?
Having less unprotected vaginal sex?
Getting help to disclose HIV status?
Condom use:
How often you carry condoms?
Using condoms more often?
62.7%
57.7%
67.8%
60.9%
68.8%
63.1%
51.6%
52.1%
64.8%
72.1%
Risk discussion topics
In this visit, did your provider discuss…
Injection drug use:
Sharing needles, works, cotton or water?
Using needle exchanges?
Using clean needles, works, cotton, H2O?
Using drugs while having sex
STI screening:
Getting screened for any STI?
Gonorrhea?
Syphilis?
Hepatitis C?
HPV?
Chlamydia?
Disclosing STIs to partners?
38.4%
34.8%
31.9%
39.0%
73.8%
64.2%
68.4%
66.8%
51.6%
62.0%
46.8%
Overall…
On a scale of 1 to 10, how
important is it to you that
your provider discuss HIV risks
this visit?
Mean:
8.48
Preliminary Results
Provider Interviews
Interview Guide – Selected Questions
• How has the way you talk to patients about
prevention changed after using ASI
compared to before using ASI?
• How did the ASI training prepare you to talk
to your patients about STD screening and
HIV prevention with their partners?
• How integrated do you think ASI has become
to clinic procedures or protocols?
Feasibility
• ASI provided a formal structure for discussing
PwP with patients
• Clinic procedure: EMR adapted to include
questions from ASI
• ASI led to discussions about capacity for
screening at the clinic
• Medical providers and other staff were involved
in implementing ASI
Feasibility
“I guess that what I would say about it is that it is
a good reminder of something that, for the most
part, we’re doing.”
-- Medical Provider
Integration
• ASI served as a reminder for providers on the
importance of PwP
• ASI raised awareness of oral and anal swab
testing in STI screening for gonorrhea
• The Risk Screener facilitated conversations
between patients and providers
• Improved communication among team
members helped medical providers learn more
about their patients
Integration
“I would say doing [ASI] has been pretty seamless
because I couldn’t even differentiate. It’s not like
we fill out a form that says, ‘Fill out this form that
you’ve completed ASI.’ We have to do more. It’s
just part of what you do with every patient.”
-- Medical Provider
Barriers
•
•
•
•
Time
Knowledge transfer to new hires
Need for ongoing training
Need for special services for high risk patients
and for those with comorbidities
Impact
“What this project did was make us talk about
[STD screening] and just figure out how to make it
available. Because our last lab wasn’t able to
process everything correctly, we changed labs. It
made us really figure out the process. From that,
we’ve been able to do more. It just got everyone on
the same page in the clinic about doing routine
screening.”
-- Medical Provider
“Now, as part of the HIV care team, we're not
going to pull back on discussing people's risks and
how to intervene for a particular patient. We have
those conversations weekly and we're going to
continue that. We will also develop new tools and
approaches for helping people.”
-- Medical Provider
Evaluation Team
•
•
•
•
•
Faye Malitz, HRSA
Janet Myers, AETC NEC at UCSF
Andre Maiorana, AETC NEC at UCSF
Tim Buisker, AETC NEC at UCSF
Julia James, Fellow, UCSF
Helen Burnside: NNPTC NRC
ASI Training Considerations
• Patients want to discuss sexual health/Patient
reluctance as a provider barrier
• Needs assessment with clinic prior to training
▫ Lab needs
▫ Clinic flow/process and responsibilities of staff
▫ Documentation: use of EMR, risk screener integration,
partner service protocol, & data sharing
▫ Clinic and provider buy-in
Project Summary: Keys to Success
• Multidisciplinary approach/medical home
model
• Sustainability: increase implementation success
▫ Booster trainings
▫ Clinic champion
▫ Referral process
▫ Incorporate ASI framework into clinic routine
“Changing clinician behavior is harder then changing
an EMR”
ASI Resources and Materials
• Contact your AETC
or NNPTC NRC for
the ASI curriculum
• Clinic posters are
under development
by NRCs
• ASI provider guide
Joanne Philips: AETC NRC
