Systems Linkages and Access to
Care for Populations at High Risk of
HIV Infection Initiative
Ryan White HIV/AIDS Program Part B
Technical Assistance Webinar
March 18, 2015
HIV/AIDS Bureau
Division of State HIV/AIDS Programs (DSHAP)
DSHAP Mission
• To provide leadership and support to
States/Territories for developing and
ensuring access to quality HIV
prevention, health care, and support
services.
2
Agenda
HAB Announcements
Heather Hauck
Question & Answer
Introduction
Harold Phillips
Systems Linkages Initiative Overview
Adan Cajina
Multi-State Evaluation Overview, UCSF ETAC
Stephen Morin
Demonstration States:
 Virginia
Steve Bailey
Anne Rhodes
 Wisconsin
Casey Schumann
ETAC Lessons Learned
Kim Koester
Edwin Charlebois
Question & Answer
3
Announcements
Heather Hauck, Director
Division of State HIV/AIDS Programs
HIV/AIDS Bureau
4
Question and Answer Session
5
Harold J. Phillips, Director
Division of Training and Capacity
Development
HIV/AIDS Bureau
6
Systems Linkages and Access to
Care for Populations at High Risk of
HIV Infection Initiative
Special Projects of National Significance (SPNS)
Program
Overview
Division of Training and Capacity Development
• Mission: Strengthen and transform health
care systems by supporting the development
of leadership, evaluation, training and
capacity development to assure the
provision of high quality HIV/AIDS
prevention, care and treatment services.
8
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Division of Training and Capacity Development (DTCD)
Administrative
Support
Bukeeia
Goodson
Director
Harold Phillips
Deputy Director
Jose Rafi Morales
Budget
Management
Terri Newman
Chief Medical Officer
Philippe Chiliade/Rupali Doshi
Senior Policy Advisors
Raymond Goldstine (Acting)\
Jewel Bazilio-Bellegarde
Special Projects of National
Significance
Chief – Adan Cajina
Global Health Systems
Chief – George Tidwell
HIV Education Branch
Susan Becker
Acting Chief – Jewel Bazilio-
John Hannay
Bellegarde
Pamela Belton
Richard Poole
Melinda Tinsley
Philippe Chiliade
Jessica Xavier
Janette Yu-Shears
Chau Nguyen
Ellen Caldeira
Natalie Solomon
John Oguntomilade
Renetta Boyd
Christine Lim
Diana Palow
Andrea Knox
Dieunita Gamliel
Mekeshia Bates
9
SPNS Program (Part-F)
• The SPNS Program supports the
development of innovative models of HIV
care to quickly respond to the emerging
needs of clients served by the Ryan White
HIV/ AIDS Program.
•
•
•
•
Evaluation
Dissemination
Replication
Build and Improve IT capacity
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Adan Cajina
Chief, Special Projects of National Significance (SPNS), Division of
Training and Capacity Development
Systems Linkages Initiative
Initiative Overview
4-year initiative (Sept 2011-August 2015)
6 States (LA, MA, NC, NY, VA, WI) $1M/YR
1 Evaluation and Technical Assistance Center
(UCSF) $1.5M/YR
Address critical
gaps along the
Care Continuum
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Systems Linkages Initiative
Goal and Target Population
Goal:
Improve access to and retention in high quality, competent HIV
care and services for hard-to-reach populations of HIV-infected
persons
Objectives:
1. Test linkage interventions in six states
2. Evaluate effectiveness of interventions and disseminate
findings
Target Population:
At high risk for or infected with HIV but unaware
Aware but have never been referred to care
Aware but have refuse referral to care
Aware but have dropped out of care
13
Systems Linkages Initiative
What are Systems Linkages?
Enhancement of existing – or implementation of new
collaborative relationships or partnerships among Ryan White
and other, non-traditional HIV organizations
IT/data systems linkage interventions
• Data system integration (testing, surveillance, care)
Community linkage interventions
• Disease Intervention Specialists
• Navigation
• Corrections
• Enhanced testing
• Social Networks
14
Systems Linkages Initiative
IHI Collaborative Model
Years 1 and 2
Develop and pilot test innovative linkage
interventions using the Collaborative Model
Host collaboration meetings/learning sessions
with assistance from ETAC
• Introduce PDSA techniques and pilot linkage interventions
• Review results of pilot tests
• Identify linkage interventions for wider-scale implementation
Develop state-level evaluation plan
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Systems Linkages Initiative
Linkage Implementation and Evaluation
Years 3 and 4
• Implement successful linkage interventions on
wider scale
• Implement state-level evaluation plan
• Participate in cross-state evaluation with
ETAC
• Disseminate project findings and lessons
learned
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Systems Linkages Initiative
Role of the Evaluation and
Technical Assistance Center (ETAC)
Regents of the University of California,
San Francisco
• Design and implement a cross-state evaluation of
systems linkage interventions
• TA on state local evaluations
• Data collection systems support
• Dissemination
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Systems Linkages Initiative
Key Research Questions
What characteristics of system linkage interventions most
successfully lead to:
• Increases in identifying people living with HIV?
• Increases in the proportion of newly diagnosed individuals
entering care within 3 months of first testing HIV positive?
• Increases in the proportion of people living with HIV who are
continuously in care?
• Increases in successful viral suppression among people
living with HIV?
• What are the structural, policy, provider, and patient
characteristics that facilitate or hinder implementation of
system linkage interventions?
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Systems Linkages Initiative
SPNS Program Staff
Adan Cajina, Branch Chief /acajina@hrsa.gov
Pamela Belton, Project Officer /pbelton@hrsa.gov
(UCSF-ETAC; Wisconsin & New York)
Melinda Tinsley, Project Officer /mtinsley1@hrsa.gov
(Massachusetts & Louisiana)
Jessica Xavier, Project Officer / jxavier@hrsa.gov
(North Carolina & Virginia)
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OVERVIEW OF
INTERVENTIONS
Stephen F. Morin, PhD
Emeritus Professor
Evaluation and Technical Assistance Center
University of California, San Francisco
Patient Navigation
• Provider-mediated interventions
where health departments work with
providers, e.g. “line lists” (MA, NC).
• Contracts with providers for
services, e.g. patient navigation
(VA, NY), peer navigation (NY),
peer-nurse teams (MA) or Linkage
to Care Specialists (WI).
21
Direct Outreach
• Health Department Disease
Investigation Specialists (DIS
officers) are retrained to work
with clients on linkage and reengagement, e.g. State Bridge
Counselors (NC); Active Referral
(VA).
22
Technology Approaches
• Technology-mediated
interventions where surveillance
data meet emergency
department admissions e.g.
public health information
exchanges (LA) or systematic
appointment reminders (NY).
23
Special Populations
• Focused attention on corrections,
e.g. video conferencing prior to
release (LA), Care Coordination
(VA) or mental health screening
and treatment (VA).
24
Increased Case Detection
• Expansion of existing or pilot HIV
testing for increased case
detection (LA, NC, WI).
25
Policy Implications
• Increasingly states are using
surveillance data to facilitate linkage
and retention in care and to monitor
viral suppression.
• Variations on patient navigation
beyond traditional case management
have emerged as key strategy.
26
Policy Implications
• Policy environments matter; in particular states
differ in access to care, e.g. ACA, Medicaid
expansion, ADAP policies, state budgets, hiring
freezes, etc.
• Without increased resources, states and cities
need to redirect funds toward Ryan White early
intervention services.
• Ryan White itself may need to be increasingly
used with a goal to increase the proportion of HIV
patients virally suppressed.
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Virginia Special Projects of
National Significance: Systems
Linkages Interventions
Steve Bailey
Anne Rhodes
VA SYSTEMS LINKAGES STRATEGIES
Unaware of
HIV status
(never tested
or never
received
results
Know HIV
status but
not in care
In some type
of care but
not receiving
regular HIV
medical care
Lost to HIV
medical care
or dropped
out
Infrequent
use of HIV
medical care
Mental Health
Active Referral
Care Coordination (for DOC clients)
Patient Navigation
Fully
engaged in
HIV medical
care
Mental Health:
• Standardized screening and
referral process to provide mental
health (MH) services for clients
with MH barriers for linking and
retaining in care.
•
Sites: Virginia
Commonwealth University (VCU)
Care Coordination:
Coordinated access to medical
care and medications for inmates
released from Virginia
Department of Corrections
(VADOC) and Virginia
Local/Regional Jail (VLRJ)
facilities.
Sites: Statewide coverage
•
•
Populations Targeted: HIVpositive persons with MH needs
Outcomes: LINKAGE,
RETENTION, SUPPRESSION
Populations Targeted:
Released from VDOCs and jails
Outcomes: LINKAGE,
RETENTION, SUPPRESSION
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Active Referral:
Patient Navigation:
A client-centered PN model
• 90 days of services focused on
linking client to care and 12
month retention support
Referral process that requires
Disease Intervention Specialists
(DIS) to actively link patients
directly to care via Patient
Navigators (PNs) or medical
providers.
• Sites: Statewide coverage
• Populations Targeted: Newly
diagnosed
• Outcomes: LINKAGE
• Use Fidelity Monitoring (FM) to
evaluate Motivational
Interviewing (MI) skills
•
•
•
Sites: VCU, Carilion, and Centra
Populations Targeted: Newly
diagnosed and lost to care
Outcomes: LINKAGE, RETENTION,
SUPPRESSION
31
Care and Prevention in the United States
(CAPUS) in Virginia
• CAPUS, awarded by CDC, through HIV Prevention, funds PN,
expanded testing, housing pilot, and social media campaigns
as well as enhanced use of surveillance data
• SPNS and CAPUS collaborated on protocol development for
active referral and selection of PN sites
• SPNS and CAPUS PN sites were located in different
geographical regions of the state to avoid cross contamination
32
SPNS and CAPUS Sites in Virginia
33
Successes: Care Coordination
Successes
• Increased referrals
from DOC to health
department and referrals for support
services for inmates post-release
• Built communications between Care
Coordinator and DOC and local jails
• Increased medication pick up rates postrelease, and set up tracking for retention
• Coordination with other inmate programs
(Comprehensive HIV/AIDS Linkages for
Inmates – CHARLI)
34
Challenges: Care Coordination
• Difficult to get Successes
information from DOC/jails
prior to release, including consistent release
dates
• Relationships with local jails often took a
long time to build, medication provision not
consistent in jails prior to release
• No consistent method for tracking
medication pick up at local health
departments
35
Interim Outcomes
36
Successes: Medication Pick Up
Prior to CC (estimate)
80.0%
CC (n=88)
72.7%
70.0%
62.8%
60.0%
50.0%
50.0%
45.0%
40.0%
30.0%
20.0%
10.0%
0.0%
30 day supply picked up
First ADAP Rx picked up
within 60 days of release
within 90 days of release
37
Successes : Continuum of Care
Overall Care Coordination (N=168)
100.0%
100.0%
Care Coordination Only (N=83)
92.9%
87.1%
85.7%
90.0%
78.3%
80.0%
Care Coordination and CHARLI (N=85)
76.8%
66.3%
70.0%
87.1%
77.4%
67.5%
67.1%
60.7%
54.2%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Clients served
Evidence of a care
Re-engaged in HIV Retained in HIV care Virally suppressed 12
marker 12 months care <= 90 days post-
12 months post-
months post-release
post-release
release
release
*Includes all clients served only by the CC intervention during the timeframe 1/1/2012-12/31/2014.
**Includes all clients served by the CC intervention during the timeframe 1/1/2012-12/31/2014 and who also received
CHARLI services during the timeframe 1/1/2014-12/31/2014
38
Successes:
Client Perspective
• Barriers
• Unable to afford medications or medical visits copayments
• Nearest clinic 2 hours away
• Unemployed with unstable housing
• Limited social support
• Clients had ”given up”
• Intervention: Care Coordinator initiated client contact, noticing medical and
medications had not been accessed
Complex care plan involving 3 different agencies
• Facilitated medical transportation
• Identified copayment assistance resources
• Incorporating telemedicine once medically stable
• Housing and employment assistance
•Successes
• Employed
• Sheltered
• Adherent
• Reduced isolation
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Lessons Learned
•
Target population is difficult to track with many needs and barriers
•
Centralized service is beneficial in areas that do not have many resources
or a referral network; however, face to face involvement through
collaboration with community partners is needed as well
•
Access to medications/medical care not primary perceived need
•
Territoriality can impede collaboration
•
Referral systems from VADOC and VLRJ vary and require time intensive
exploration
•
Prescription authority and procedures are inconsistent across correctional
facilities
40
Sustainability Plan
Care Coordination has been added to the state
ADAP model and will continue to be funded as a
part of ADAP
PN will be funded through Ryan White, HIV
Prevention and other ongoing sources
Mental Health providers are working to utilize
third-party billing
Active Referral is part of standard Disease
Intervention Specialist (DIS) protocol
41
Wisconsin Special Project of
National Significance: Systems
Linkages Interventions
Casey Schumann
March 18, 2015
Wisconsin Department of Health Services
Social Networks Testing
Overview
• Community-based strategy utilizing peers to identify
individuals at high risk for HIV and connect them with
HIV testing services
• Testing agency enlists and coaches recruiters who have
relationships with high-risk networks
• Recruiter identifies associates from their network and
refers them to HIV testing
• Goal to standardize program across agencies (e.g.
limit number of associates, provide minimum number
of coaching sessions, standardize incentives across
agencies)
Linkage to Care Specialist
(LTCS) Overview
• New patient navigation position located in ASOs, HIV
clinics, and community-based organizations
• Employ ten full-time, non-medical professionals
• Work with newly diagnosed, new to care, out of care,
post-incarcerated and at risk clients
• Identify and address client barriers to medical care
over a period of nine months
• Transition clients to case management or selfmanagement
Linkage to Care Specialist
Service Locations
Dane County:
AIDS Network
UW HIV/AIDS Care Program
Milwaukee County:
ARCW
MCW ID Clinic
16th Street CHC
Outreach CHC
Milwaukee Health Services
Reported cases of HIV infection
presumed to be alive by county,
Wisconsin, as of 12/31/13
Number of Cases
1-20
21-40
41-100
101-200
201-3320
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*Excludes 168 cases with the Wisconsin Department of Corrections as the last known address.
Linkage to Care Specialist
Overview (continued)
• Similarities to Case Management:
• Service provision via assessment, individualized service
plan development, and making referrals for needed
services
• Differences from Case Management:
• Specialist approach to barriers preventing linkage or
engagement in medical care
• Smaller case loads (15 clients vs. 60 clients)
• Use of motivational interviewing
• More field work opportunities
• Time limited
Challenges
• Initial role confusion between LTCS and case
managers
• Initial resistance among some providers
• Referrals to LTCS for out of care clients limited to onsite LTCS
• Client resistance to transition out of Linkage to Care
(LTC) Program
• Limits of existing case management system to serve
high need clients
47
Interim Outcomes
48
Successes: Outcomes
HIV Care Outcomes Among Linkage
to Care Specialist Clients and Control Subjects
Controls
100%
80.6%
Percentage of Subjects
90%
80%
70%
Linkage to Care Clients
74.3%
(75/93)
(199/268)
64.4%
66.0%
(177/268)
(199/309)
60%
47%
(126/268)
50%
45.5%
(122/268)
40%
30%
20%
10%
0%
Linkage to Care within
90 Days
Engagement in Care
Viral Suppression
49
Successes: Post LTC
Retention in Care ≥ 6 Months After LTC Intervention:
Linkage to Care Specialist Clients and Control Subjects
100%
83.3%
20/24
Percentage of Subjects
90%
80%
70%
62.5%
15/24
60%
50%
40%
30%
20%
10%
0%
Controls
Linkage to Care Clients
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Successes:
Client Perspective
• Linkage to Care Specialists provided multiple forms
of social support:
•
•
•
•
Mitigated negative feelings associated with HIV stigma
Increased motivation to adhere to medical care
Increased comfort with medical care
Caused reluctance to transition out of LTC
51
Successes:
Client Perspective
“When I had to make appointments she made sure
I got there. She would come and pick me up all of
the time, every time. She never missed a
time...That made me feel more positive to go and
do what I had to do…that is why I’m nondetectable right now...”
52
Successes:
Provider Perspective
“I can’t imagine now trying to function effectively
in clinic without [our LTCS]... I have had
numerous cases where [the LTCS] was
instrumental in getting the patient in to clinic with
me, [and] many more where she was
instrumental in keeping the patient engaged in
care…I can’t imagine how any of these people
would have been successfully engaged in care
without the intensive efforts of [the LTCS]...”
53
Lessons Learned
• The collaborative process led to better integration of
care and prevention services
• Setting client expectations up front was critical to
success and eases transition out of the program
• Both LTCSs with formal social work education and
those without can have success with clients
• Numerous best practices were identified that will be
applied to case management
• All Ryan White funded services will be evaluated
based on their impact on linkage, retention, and
viral suppression
54
Sustainability Plan
• Commit to funding LTCS until final evaluation results
are available (ADAP rebate, Part B case
management dollars, agency revenue)
• Incorporate lessons learned from the LTC Initiative
into newly developed Medical Case Management
Practice Standards
• Motivational interviewing
• Use of text messaging
• More focus on behavior change rather than just referral to
other services
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SYSTEMIC LINKAGES
QUALITATIVE CROSS-SITE
PRELIMINARY DATA
Kimberly Koester, MA
Director of Qualitative Research
Evaluation and Technical Assistance Center
University of California, San Francisco
Developing Interventions
• Over two years, State Health Departments convened
multi-day “learning sessions” with stakeholders (45-80
people) from organizations and institutions serving
people living with HIV.
• Meetings led to communication channels opened where
they had not previously existed.
• Tremendous buy-in on the importance of linkage,
retention and re-engagement efforts emerged as a
priority.
57
Navigation Interventions
• “Navigation” interventions resemble case management,
but have unique elements:
• Intensive services offered to a select group of
patients.
• Services are offered on a short-term basis.
• Caseloads are intentionally small.
• Interventionists are encouraged to leave the office
to meet with patients in non-clinical environments.
58
Implementation Observations
•
•
•
•
•
Overall, patients are responding well to the interventions.
Interventionists are spending more time with patients
than any one else in the clinic.
“Fieldwork” is a common feature and a necessary activity
to reach out of care patients.
Newly diagnosed patients have different (lesser) needs
than those who are out of care.
Goals to support newly diagnosed patients are clear:
support to 1) cope with diagnosis and 2) link and remain
in care.
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SYSTEMIC LINKAGES
QUANTITATIVE CROSS-SITE
PRELIMINARY DATA
Edwin D. Charlebois, III, MPH PhD
Professor of Medicine,
Evaluation and Technical Assistance Center
University of California, San Francisco
Cross-Site Evaluation
The primary goal of the cross-site intervention
outcomes evaluation is:
• To identify significant improvement across
demonstration states in access to and
retention in high quality HIV care for hard-toreach populations of HIV-infected persons that
are associated with innovative mechanisms
which establish effective and sustainable
linkages among Ryan White and other,
community and non-traditional organizations
that provide HIV-related services.
61
SPNS Intervention Study Populations
• Large Population Size to be Touched by
the Collective SPNS Interventions
(N = 68,636)
• Significant Diversity in:
• Geographic Settings
• Race/Ethnicity
• Risk Groups
• Insurance Status
• Client Types (new Dx, Out-of-Care, never linked)
62
Patient Characteristics – New Diagnoses
Based on data reported to the ETAC as of 12/2/2014.
63
Patient Characteristics – New Diagnoses
Newly diagnosed client type was diagnosed with HIV within one year of enrollment in the intervention.
Other race/ethnicity includes Asian, Native Hawaiian/Pacific Islander, American Indian or Alaska Native, and multiracial.
Excludes data from testing intervention clients submitted as a separate dataset.
Based on data reported to the ETAC as of 12/2/2014. Preliminary Data – DO NOT CITE
64
Planned Cross-Site Analyses
• Change analysis for:
Navigation, Corrections, Testing
• Minimum Dose for Success for:
Linkage, Retention, Viral Load Suppression
• Disparities Reduction Analysis:
Race/Ethnicity, Risk Groups
• Client Type Effects Analysis:
Newly diagnosed versus re-engagement clients
65
Cost Analysis
To better understand total resources needed
to implement interventions:
• How do SPNS interventions leverage existing
resource?
• What resources are needed to prepare for
intervention implementation?
• What resources are needed to implement the
intervention?
• What resources are targeted toward which
intervention targets (linkage, re-engagement,
retention)?
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Question and Answer Session
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THANK YOU