Campaign Webinar
Los Angeles County Linkage
and Re-engagement Programs
March 5, 2014
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
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unmute your line press #6)
• Slides and other resources are available on our
website at incareCampaign.org
• All webinars are being recorded
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Agenda
1.
2.
3.
4.
Welcome & Introductions, 5min
Campaign Update, 10min
LA DPH, 35min
Question and Answer, 10min
Michael Hager, MPH MA
NQC Manager,
in+care Campaign Manager
New York, NY
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In the chat room,
Enter your:
1. name,
2. agency,
3. city/state, and
4. professional
role at agency
Campaign Update
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in+care Campaign in 2014
•
•
•
•
•
•
•
Campaign database running through 2018!
Campaign website running through 2018!
Partners in+care Facebook maintained indefinitely
Campaign Newsletter moves to quarterly
Campaign Webinars move to quarterly
Partners in+care Webinars move to quarterly
Campaign Coaching integrates into NQC
Continuous TA Portfolios
• Local Retention Groups that wish to continue
meeting should do so – NQC will support where
possible
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Disseminating Improvement Work
Lightning Rounds!
• 1 or 2 slides that contain the most salient points of your
retention projects
• Include information on patient target, rationale for target selection and
baseline data from your measures (including the date)
• Include information on each improvement cycle (what was tried, what
was the result per the data) – for early cycles short measures of change
are not necessary, but add value!
• What are your conclusions? How are you sustaining improvement
• Simplicity and clarity are the idea!
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in+care Retention Improvement Strategies
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in+care Retention Improvement Strategies
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Data Collection Submission Deadline:
April 1, 2014
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Gap Measure Results (12/11 – 2/14)
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Visit Frequency Measure Results (12/11 – 2/14)
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New Patients Measure Results (12/11 – 2/14)
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Viral Load Suppression Measure Results (12/11 – 2/14)
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Los Angeles County HIV Linkage-to-Care
and Re-Engagement Programs: Preliminary
Results and Lessons Learned
Amy Rock Wohl MPH PhD
Division of HIV and STD Programs
Los Angeles County Department of Public Health
March 5, 2014
Navigation Program
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Navigation Program
 Background:
 Goal is to re-engage lost HIV clinic patients in HIV
care using enhanced locator techniques and
modified strengths-based cm intervention (ARTAS)
 Participants to-date are out of care (OOC) patients
from 4 LAC publicly-funded HIV clinics
 Eligibility includes HIV+ patients who have not had a
primary care visit in the past 6 mos and last vl >200
copies/ml; or no HIV primary care visits in 12 mos;
or newly-diagnosed and never in care
 Current status:
 Ongoing enrollment
Modified ARTAS Intervention
• Based on ARTAS model
• Consists of:
• 4-phases administered over a 90-day period
instead of ARTAS 5-sessions
• Increase in the number of visits per phase to
add flexibility (up to 10)
• Like ARTAS, sessions are 60-90 minutes
Intervention Phase
Title/Content
Number of
Sessions
Maximum
Timeframe
Phase 1
Building the Relationship
1-2
1 week
Phase 2
Assessment
1-2
1-2 weeks
Phase 3
Linking to Resources/Enhancing Strengths
2-4
1-8 weeks
Phase 4
Disengagement
1-2
1-2 weeks
Preliminary Data
• Disposition of 499/6361 Lost Clinic Patients
12%
In Care Elsewhere
23%
No Longer LAC Resident
2%
Returned to Clinic Independently
Patient is Deceased
17%
4%
Patient is not available/left message
Number is Wrong/Disconnected
11%
26%
1
5%
Patient Declined Enrollment
Patient Located/Interested in NAV;
appt. scheduled
137 lost clinic patients were found ineligible due to VL/last appointment date
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Most Effective Data Source1 for Contact
Information (n=499)
Series 1
HIV Surveillance
2
39%
Clinic Medical Record
36%
Ryan White Client Database
Lexis-Nexis
Other 3
17%
5%
2%
1 Patient
contact data searches were hierarchical starting with clinical medical records, followed by Ryan White Patient
database, HIV surveillance, Lexis-Nexis, and Other until patient was successfully contacted
2 HIV Surveillance breakdown: iHARS-LAC=24%, eHARS-CA=15%
3 Includes LAC Inmate locator, CA Prison Locator, STD surveillance database
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Demographics (n=61)
 Race: 13% African American, 77% Latino, 5% White,
2% Asian, 4% Other
 Gender : 26% female, 70% male, 4% transgender
 Age: 45% <40 yrs, 55% >40 yrs
 Insurance Status: 61% Uninsured, 36% Public
Insurance, 3% Unsure
 Substance Use (past 6 months): 5% IDU; 23% any
drugs
 Current Housing: 90% stable, 8% temporary, 2%
homeless
 Education: 70% <High School, 30% High School/GED
 Employment: 38% employed, 13%
disability/SSI/public assistance, 41% unemployed,
8% other
 Yearly Income: 52% <$5,000, 22% $5,000-$15,000,
26% >$15,000
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Main Barrier to HIV Care at Time of
Enrollment in NAV Intervention (n=61)
40
38%
35
30
25
20
15
10
7%
5
7%
5%
2%
2%
0
Other Life
Priorities
(childcare,
work)
Didn't Complete
No
Homelessness Drinking/Using
Application Transportation
Drugs
Process
Didn't think
Needed HIV
Care
Needed Services1 at Time of Enrollment
in NAV Intervention (n=61)
70
60
67%
50
40
44%
30
18%
36%
20%
27%
20
22%
10
0
1
Dental Care
Food & Other Basic
Needs
Benefits
Housing/Shelter
Mental Health
HIV-Related Medical Medications/Pharmacy
Participants listed multiple needs
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HIV Testing, Care and Clinical History at
Time of Enrollment (n=551)
Variable
Time Since Positive Result
Time Since Last Medical Appt.
Last Viral Load Prior To Enrollment
(copies/ml)
1
Data pending for 6 patients
Min
Max
Median
Mean
9 months
17 yrs
6.4 yrs
7 yrs
21 days
3 yrs
308 days
358 days
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1,011,623
2,221
58,046
Intervention, Linkage and
Engagement in Care (n=551)
• Avg # of NAV visits = 7 (range 3-10)
• Avg # of hours spent with NAV = 15 (range 2-44)
• 98% (n=54/55) linked to care (attended 1 HIV medical
visit) following intervention enrollment
• 20 of 34(48%) patients who were enrolled in NAV for
at least 6 months engaged in care; (i.e. attended 2 or
more medical visits and were referred for
long-term case management and retention)
• NAV patient referrals: housing, substance abuse
treatment, mental health, nutrition, transportation,
assistance w health insurance and ADAP enrollment
1
Data pending for 6 patients
Lessons Learned and Next Steps
• Preliminary Lessons Learned
– More efficient to start with surveillance rather than
clinic data to identify OOC patients
– HIV surveillance and clinic data provided most useful
contact information for finding OOC patients
– OOC patients vary in the intensity of intervention
needed; NAV needs to work with OOC patients
longer to promote long-term engagement in care
– Structural roadblocks
• LACDPH legal concerns with sharing surveillance
information
• Clinic administrative requirements
• Next Steps
– Incorporate lessons learned into
county-based LTC program
Navigation Program Version 2.0
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Navigation Program Flow Chart
Confirm
eligibility with
clinic staff
Clinic/Surveillance
list of out of care
individuals
Referral to
navigator
(NAV)
Initial attempt
to contact using
clinic contact
info
Located
?
No
1) Utilize HARS/
Casewatch to
gather contact
info/status
2) Coordinate
with MCC &
prioritize
Intervention
Low
(Resources)
Not Linked
Moderate
(MI)
-consent
-survey
Not Linked
ARTAS
-intervention
intensity
assignment
(Low, Mod,
ARTAS)
Transitional Retention
Linked to care
(medical, case
management)
-
Yes
Initial
appointment
with NAV:
3) Utilize
MMP/PHI
investigative
methods to locate
NAV contacts
patient to
schedule initial
appointment and
enroll in
Navigation
Program
Yes
Contacted!
Patient
Agreed
No
Unable to
find, case
closed
Case closed
In care
elsewhere,
case closed
NAV follow-up for 6 months
after linkage
additional NAV visits as
needed
Clinic staff
updated info
in Casewatch
IN CONSISTENT CARE
(Intervention Ends)
Project Engage
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Project Engage
 Background:
 Goal is to identify OOC HIV+ persons and link them
to HIV care
 OOC HIV+ persons (alters) are identified through
social network referrals from seeds or direct
recruitment by staff; alters may recruit OOC
persons
 Incentives: $40 for baseline survey for seed/alter;
additional $40 for seed/alter when alter links to care
 Seeds identified from:
1. HE/RR programs at CBOs for at-risk MSM (eg crystal
meth support group)
2. HIV clinic patient populations
3. Flyer/pocket card recruitment
 Current status:
 Ongoing Enrollment
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Flyer
Pocket Card
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Preliminary Results
Study Screening and Recruitment
 Screened
 Seeds: 99
 HIV+ Alters: 1041
 Enrolled
 Seeds: 56
 HIV+ Out of Care Alters: 29
 8 (28%) have enrolled as recruiters
 21 (72%) have linked to care
 Site Specific Enrollment:




1
APLA: 8 seeds and 20 alters (12 linked)
OASIS Clinic: 12 seeds and 3 alters (all linked)
GLC Clinic: 30 seeds and 3 alters (all linked)
Direct Recruitment: 6 seeds 3 alters (all linked)
62% were ineligible/not HIV infected per HIV surveillance
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Demographics
 Out-of-Care Alters (n=29)








Race: 41% African American, 10% Latino, 28% White, 21% Other
HIV Status: 100% HIV-positive
76% MSM; 24% heterosexual
Insurance Status: 38% Insured, 62% Uninsured
Reported Sex Work: 24%
Incarceration History: 86% lifetime, 55% past 12 months
Recent/Current Homelessness: 79%
Illicit Substance Use:
 IDU: 48% lifetime, 21% past 3 months
 Non-IDU: 62% lifetime, 41% past 3 months
 Seeds (n=56)







Race: 42% African American, 22% Latino, 25% White, 11% Other
HIV Status: 75% HIV-positive
96% MSM; 4% heterosexual
Insurance Status: 89% Insured, 11% Uninsured
Incarceration History: 51% lifetime, 4% past 12 months
Reported Sex Work: 7%
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Recent/Current Homelessness:16%
Out-of-Care Alters (n=29)
 Testing and Care History
 Time since 1st HIV+ test: Avg=10.8 years (range: 3
mos-29 yrs)
 Time between 1st HIV+ test and 1st HIV doctor visit:
Avg=12.8 months (range: 1d-6yrs)
 Number of clinics attended: Avg=2.6 (range: 1-20)
 ART use: Ever taken= 72%, Currently taking=17%
 Readiness to Engage in Care Scale1
 11 “contemplative” about starting care
 18 “ready for action” about starting care
 Sexual Behaviors (last 6 mos)
 # of sexual partners (n=20): Avg=6.5 (range: 1-40)
 31% report UAI
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1
Scoring based on Transtheoretical model of behavior change
Characteristics of Out-of-Care Alters
 Linkage, Care, VL
 Linkage and Care
• Avg time out of care (n=21): 9.7 mos (range: 0-26)
• Avg time to link to care (n=21): 12.4 days (range: 0-97)
• Avg staff time dedicated to link to care (n=28): 373.9 min/6.2
hours (range: 140-840 min)
 Viral Load
 Last reported vl before enrollment (n=27): Avg=50,184
copies/ml (range: 48-370,660)
 Acceptability Survey
 Out-of-care alters who linked to care (n=16) stated:
• Project Engage helped get them into care: 16
• Were satisfied with the help they received: 16
• Would recommend PE to friends who were out of care: 15
 11/16 (79%) stated that without PE,
they would not have entered care themselves
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Unmet Needs and Barriers to Care for
Out-of-Care Alters
 Unmet needs (social & medical services)
 Number of unmet needs: Avg=7.7 (range: 1-14)
 Most reported not being able to obtain:
 Regular HIV care (n=25)
 Dental care (n=22)
 Medical Case Management/Mental Health
Counseling (n=21)
 Barriers to Care
 Did not know where to obtain services
 Experienced disrespect from HIV clinic staff
 Challenges completing needed paperwork
36
Case Study #1
Case 1 is an older homeless minority MSM who tested HIV positive in
2006. He has been out of care for 26 months. He is a crystal meth user
and prostitutes for survival and sleeps in parks and alleys. He reported 5
sex partners in the last 6 mos and was the insertive partner for UAI with
all 5 partners. He has been incarcerated several times due to his drug
use and prostitution. His physical appearance suggested he was feeling
the effects of both his medical and social situation (several lesions on
his face and arms, frail body and missing teeth).
After enrolling him into Project Engage, he was linked into care in one
day (4 hrs PE staff time). He was very excited and happy that someone
took such an interest in his situation. After his first treatment
appointment, he went back to the park where he hangs out and told his
friends about his positive experience. One week later his physical
appearance had improved dramatically and he stated that he is on the
medication and feeling much better.
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Case Study #2
Case 2 is a 29 year old homeless minority MSM who tested positive
anonymously in June 2013 but had never linked to care. His mother
gave him and his two sisters up for adoption when he was a child. He
became homeless at the age of 18 after his adopted parents passed
away and he moved from the midwest to California. He is currently
homeless and lives on the streets in Los Angeles.
He is a crystal meth user but does not currently engage in prostitution.
He has spent time in jail for stealing, drug possession and prostitution.
He reported 5 sex partners in the last 6 months and was the insertive
partner for UAI for all 5 and also receptive partner with 1 of the 5
partners. He was very well-spoken and was appreciative that a program
was in place like Project Engage to help people with HIV link into care.
After enrolling into Project Engage, he was linked into care within two
days by Project Engage staff (6 hours PE staff time). He is currently
working with the HIV clinic staff to secure housing and other needed
social services.
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 Preliminary Lessons Learned:
 Agency-based recruitment more effective than
clinic-based recruitment
 A few productive seeds is critical to success
 Labor intensive to identify OOC persons
 Labor intensive to link OOC persons to HIV care
 Capacity needed to help OOC alters obtain photo ID
to enroll in medical care/ADAP
 LTC intervention needed for some
 Next Steps:
 Scale up staff (currently 1 FTE); increase incentives?
 Expand direct field recruitment at parks/street
corners; enhanced recruitment at more CBOs, atrisk youth agency, mobile testing vans, skid row
clinic
 Add 3-tiered intervention option in next phase
 Incorporate into county-based
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LTC program
Acknowledgments
Saloniki James
Rhodri Dierst-Davies
Alla Victoroff
Sonali Kulkarni
Heather Northover
Jeff Bailey
Brian Risley
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Question & Answer
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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
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