Developing a Peer-Based Early
Intervention Services Program
Project Consumer LINC
Webinar
December 6, 2011
Emily Gantz McKay
Harold Phillips
Hila Berl
1
Introductions
Sera Morgan
and
Emily Gantz McKay
Webinar Objectives
• To familiarize participants with the
components of an Early Intervention
Services Program, as described by the
HIV/AIDS Bureau
• To summarize the benefits of using peers
• To provide a step-by-step process for
developing a peer-based EIS program
appropriate for your service area
3
Agenda
1.
Components of an Early Intervention
Services (EIS) Program
–
2.
Questions/Discussion
Benefits of the use of peers to help
PLWH learn their status, enter or reenter care, and remain closely linked to
care
Steps and key questions for designing a
peer-based EIS program
3.
–
Questions/Discussion
4
Components of an
Early Intervention
Services Program
Harold J. Phillips
5
Components of Early
Intervention Services
HIV Testing:
– Used to help the unaware learn their status
and receive either referral to prevention
services or referral and linkage to HIV care
services
– Cannot duplicate or supplant testing efforts
paid for by other sources.
– Must be coordinated with other testing
programs especially HIV prevention programs
Components of Early
Intervention Services
Referral Services:
Linkage Agreements (MOU/MOA) and referrals,
working with key points of entry to create
connections between services and funding
streams, Routine X-Provider meetings, face to face
contact, providing referral to additional services to
meet immediate needs
Components of Early
Intervention ServicesReferral Services
Activity of Relationship/Trust building:
•Creating a bond of trust and safety with the
client that extends to the other care givers in the
HIV continuum.
•Instilling confidence in the client and in the
system of care
Components of Early
Intervention Services –
Referral Services
Assessment of immediate
needs/attitude/knowledge/behaviors/belief
s regarding care/care system
•Assessment differs from case management
and focuses on changing view and knowledge of
HIV and care leading to care seeking behaviors
Components of Early
Intervention Services
Health Literacy/Health Education
(counseling)
•Education on the HIV service delivery system
•How to work with your clinicians
•How to handle problems and issues
•Disease progression and managing life with HIV
disease
Components of Early
Intervention Services
Access and Linkage to Care:
•Primary Medical Care (3-4 visits)
•Medical Case Management
•Entry into Substance Abuse Treatment
•Treatment Adherence
•Bringing others into care
•System for monitoring and tracking referrals
(successful and unsuccessful)
The Four Program
Components of Early
Intervention Services
1.Testing
2.Referral Services
3.Health Literacy/Health Education
4.Access and Linkage to Care
The Four Service Elements
Must be Present
• Early Intervention Services is a combination
of all these service elements
• They must all be present and available to
clients as an integral part of the program
design
• They do not all have to be Ryan White Part A
or B funded
Early Intervention Services v.
Outreach
EIS
OUTREACH
Core Service
Support Service
Can include HIV Testing
Does not include testing
Works with key points of entry
Targets activities in areas with a
high probability of finding
individuals who are positive
Combination of services
Only one service
Can assist in addressing unmet
need and the unaware
Can assist in addressing unmet
need and bring unaware to testing
Can use peers in paid staff
positions
Can use peers in paid staff
positions
Length of Service intervention a
averages 3-6 months
Length of Service interventions are
short term and often sporadic
(1-3 months)
Components of Early
Intervention Services
• Testing
• Referral Services
–Linkage agreements to work with key points of entry
–Relationship/Trust Building
–Assessment of immediate need/ attitude
/knowledge/behaviors/beliefs regarding care
–Information dissemination
• Health Literacy/Health Education (Counseling)
• Access and Linkage to Care
Early Intervention Services
& Unmet Need& EIIHA
• EIS can be part of a strategy to address
unmet need, and EIIHA
• EIS can focus on getting individuals in care
who know their status
• Emphasis on working with points of entry
• Can resemble a models of case finding or
patient navigation
16
Questions and Comments
Benefits of the
Use of Peers
Harold J. Phillips
18
Why Use Peers?
Letter from HAB/DTTA (2-10-10) said:
"Peers are uniquely positioned to
effectively engage and help retain
PLWH in care and treatment programs
and, further, with appropriate training
and supervision, they make remarkable
contributions to the interdisciplinary
team."
19
Why Use Peers?
• Can develop a high level of trust with other
PLWH
• Ability to share their own experiences
• Role models and proof that people can live
productive lives with HIV
• Personal knowledge of system of care and
challenges associated with accessing care
• Clinicians rarely able to spend significant time
with PLWH
• Cost-effective
• Particular value with HIV+/unaware and
PLWH with unmet need
20
Demonstrated Value of Peers
Demonstrated effectiveness with other
diseases such as diabetes:
– Bring people into care
– Reduce missed appointments
– Improve treatment adherence
– Reduce complications
– Reduce emergency room visits
– Reduce hospitalizations
– Reduce health care costs
21
Designing a Peer-Based
Early Intervention Services
Program
Emily Gantz McKay
22
Purpose of a Peer-based EIS
Program
• To help people with HIV/AIDS enter and
become fully linked to and engaged in
HIV/AIDS care
• Focus typically on populations that are likely
to be hardest to reach –
– Individuals who feel marginalized and
disenfranchised
– PLWH who have trouble navigating the HIV/AIDS
service system – often because they have never
had a “medical home”
– PLWH who have had negative experiences with
the care system
23
Key Questions/Decisions
1. What will be the focus of your EIS program?
2. Should your EIS program pay for testing?
3. What services will peers provide? What won’t
they do?
4. What points of entry will be the focus for your
program? What about other relationships?
5. What will be the job title for your peers – will
they be “peer community health workers”?
6. How will you match peers with PLWH clients?
24
Key Questions/Decisions, cont.
7.
What characteristics, knowledge, skills, and
experience should be identified as required?
Preferred?
8. What classroom and practical on-the-job
training will you provide?
9. What will be the supervisory requirements?
10. Will you use a central agency for training and
support?
11. Will you allow both full- and part-time peers?
What about stipends?
25
1. Program Focus Options
• HIV+/unaware: Early Identification of
Individuals with HIV/AIDS (EIIHA) –
immediate linkage to care after testing
• Unmet need: Finding people who know
they are HIV+ but have been out of care for
at least 1 year and helping them enter/reenter care
• Retention in care: Working with PLWH
who are loosely connected to care or have
missed medical appointments – including
recently diagnosed PLWH
26
2. Use of Funds for Testing
Factors to consider:
•
•
•
•
EIS is the only service category under
Ryan White Parts A and B that can pay for
testing
Links to testing are essential
EIS funds should be used for testing only if
existing testing resources are insufficient
Peers can be trained to do counseling and
testing (even if you don't buy the test kits)
27
3. Services Peers will Provide
Consider:
• Outreach
• Testing or testing
support
• Trust building
• HIV literacy education:
living with HIV
• Education about the
system of care
• Intake support
• System navigation
• Coaching/mentoring
and support
• Treatment adherence
counseling
• Follow up
• Relationship building
• Support to the clinical
team
28
4. Points of Entry and Other
Relationships
• Assignment of peers based on:
– Specific points of entry
– Types of entities (e.g., homeless shelters, testing
sites, substance abuse treatment programs)
– Location (e.g., county, neighborhood)
• Key importance of personal relationships:
– Points of entry – to contact peer when a person
needing help is identified
– Providers (especially clinics and case management
sites) – to inform peer when a client misses an
appointment or seems to need peer support
29
5. Job Title
• Make it descriptive of full range of
responsibilities
• Use a title that helps ensure respect for
the peer's role
• Consider "community health worker" -now a Bureau of Labor Statisticsrecognized profession
• Explore titles and certification used in
your state
30
6. Matching Peers with
PLWH/Clients
• Matching factors:
–
–
–
–
Gender, race/ethnicity, sexual orientation, age
Location: specific community or neighborhood
Life experience
Use of a diverse peer team
• Other considerations:
– Young men may relate well to an "older sister"
– Stigma may mean peer should not be from the
same neighborhood or nationality group
31
7. Qualifications
Typical Requirements:
• Peer status
• Experience with local/regional system of care
• No excludable criminal convictions – e.g., sexrelated felonies, serious violent crimes, recent
convictions (within past X years)
• Education/literacy – can use demonstrated
reading comprehension and writing skills needed
for record keeping, etc. rather than diploma or
degree requirement
32
Things to Look For
Characteristics
• Commitment
• Empathy
• Interpersonal relations
• Organization & multitasking
• Judgment
Decide what skills
are required for
selection, and
which ones you
can teach
Knowledge/Skills
• PLWH population
• Geographic area
• How Ryan White
programs work
• Strong, culturally
appropriate
communications skills
• Mentoring, coaching
• Boundaries
• Computers/record
keeping
• Working with providers
33
8. Classroom & Practical
Training
Consider 4 phases:
1. Pre-service classroom training (community
college or project-developed and run)
2. On-the-job practicum combined with additional
classroom training
3. Ongoing on-the-job training, with supervision
4. In-service sessions plus peer network
meetings
34
Suggested Learning Topics
• Understanding HIV
disease
• Ryan White programs –
legislation, services,
policies, guidelines
• Navigating the system
of HIV care
• Multicultural awareness
and competence
• Developing trust
• Maintaining
professional boundaries
• Problem solving & crisis
management
• Confidentiality &
privacy, including
HIPAA requirements
• Providing emotional
support
• Self-management
• Self-disclosure
• Communication skills
• Medications and
treatment adherence
35
9. Supervisory Requirements
• Specified level of supervision – e.g., hours per
week
• Supervision must ensure:
– Support for peer model
– Understanding of EIS program components and
requirements
– Consistently available supervision & support
– Professional development opportunities
– Help with relationship building
– Links to testing
• Training for supervisors
• Establishment of supervisors support network
36
10. Use of a Central Agency
Structure Options:
1. Centralized: hiring, training, supervision,
monitoring and evaluation, with peers
assignment to providers
2. Partially centralized: training, supervision,
involvement in recruitment, assistance and
evaluation; providers hire & supervise
3. Decentralized: multiple providers hire,
train, supervise
37
Value of Centralized or Partially
Centralized Structure
• Training quality – larger group for training, likely to
be more structured, with consistent quality
• Consistent implementation of model – staff
understand program model
• Cost effectiveness – only one agency develops and
delivers training
• Flexibility – peers supervised day to day (and often
hired) by multiple providers, allowing for variations
based on population needs and organizational culture
• Evaluation – single evaluator
38
11. Full or Part Time Peers?
• Full time: Regular employee, easier to provide
benefits, full caseload, good return on training
investment
• Part time: May be needed to protect the health of the
peer; allows smaller communities to hire several peers
that match different populations or communities
• Limited Hours due to SSDI/SSI: Allows PLWH on
disability to work 30-50% time and keep benefits; allows
for a diverse peer team; but smaller individual
caseloads
• Stipends: Peers tend to be hired away by other
providers; level of work usually too great for stipends
39
Typical Challenges
•
•
•
•
•
•
•
Training
Boundaries
Personal health issues
Compensation
Provider and partner attitudes
Understanding of EIS
Setting limits on work with a single client
40
Example: Positive Pathways
Pilot Program (DC)
• Assists HIV-positive African Americans to participate
in HIV medical care; focus on women
• Funded through Social Innovations Fund
• Central agency (CommonHealth Action) manages
program for Washington AIDS Partnership
• Training includes formal community health worker
certificate program at community college plus HIVspecific training and practical experience
• CHWs placed community and medical organizations
• Peer support group
• Training and support for supervisors
41
Example: Design for New
Washington, DC Part A Program
• Central agency to provide training, oversight,
assistance, & evaluation
• Individual providers to hire and supervise peer
community health workers
• 160 hours of classroom training plus 800 hours
of practicum over 6 months
• Peer and supervisor support networks
• Both full- and part-time employment
• Focus on unmet need and PLWH loosely
connected to care
42
Other EIS & Related Programs
• People to People (P2P) – started by African
American AIDS Task Force, Minneapolis/Saint Paul
Part B Program
• Michigan Programs:
– Youth Link Program of AIDS Partnership MI – Detroit
– MI Patient Navigator Program of Sacred Heart
Rehabilitation Center – Saginaw
– Wayne State Physician Group Peer Navigator Program
– Detroit
• Hand in Hand – New Orleans
• Christie’s Place – San Diego
• Linking to Care, Positive Connections – Charlotte
(no longer operating)
43
Resources from Consumer
LINC Project
• "Designing a Peer-Based Early Intervention
Program: Components, Strategies, and Key
Decisions"
• Other Consumer LINC project materials
• Links to other materials
• See http://www.mosaica.org/Resources/
HIVAIDS/ProjectConsumerLINC.aspx
44
Other Resources
• Community Health Workers National Workforce Study
- http://bhpr.hrsa.gov/healthworkforce/chw/
• Building Blocks to Peer Success - 2 toolkits - PEER
Center, Boston University http://www.hdwg.org/peer_center/training_toolkit
• Integrating Peers into Multidisciplinary Teams: 2
toolkits - Cicatelli Associates - http://careacttarget.org/
library/peers/ToolkitForPeerAdvocateSupervisors.pdf
• “The Utilization and Role of Peers in HIV
Interdisciplinary Teams” - HRSA/HAB Consultation http://hab.hrsa.gov/newspublications/peersmeeting
summary.pdf
45
Questions and Comments