Transcript NYC Care Coordination Webinar Slides 8.6.13

in+care Campaign
Meet the Author
August 6, 2013
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Welcome & Introductions
 Welcome & Introductions, 5min
 NYC Care Coordination Program, 30min
 Q & A Session, 20min
 Updates, Reminders & Evaluation, 5min
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
August 6,
2013
PATIENT NAVIGATION:
A Network Perspective
from the NYC HIV Care
Coordination Program
New York City
Depar tment of
Health and
Mental Hygiene
Argus
Community, Inc.
Beth Israel
Medical Center
PRESENTERS
 Beau J. Mitts, MPH
 Director, Ryan White Technical Assistance
 NYC Department of Health and Mental Hygiene
 Stephanie Chamberlin, MPH, MIA
 Evaluation Specialist, Research and Evaluation
 NYC Department of Health and Mental Hygiene
 Maria Rodriguez, MPA
 Program Director, Care Coordination
 Argus Community, Inc.
 Vanessa Haney, MFA
 Program Director, Care Coordination
 Beth Israel Medical Center
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AGENDA
 DOHMH Care Coordination Program (CCP) Model
 Background
 Development
 Implementation
 Argus Community Experience
 Beth Israel Medical Center Experience
 Evaluation
 Take-Home Messages
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BACKGROUND: The CCP Model
Benefits and
Services
Coordination
Navigation
Treatment
Adherence
Health
Promotion
Outreach
BACKGROUND: Target Population
 Persons at high risk for suboptimal health care
outcomes:
 newly diagnosed
 previously lost to care/never in care
 irregularly in care
 with recent adherence issues (e.g., viral rebound, resistance)
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BACKGROUND: Patient Navigation
 Patient Navigators are key players on the Care team




Most interaction with the clients
Community Health Workers
Bridge the gap between the clinic and the community
Reflect the community they serve
 Services provided (often in client’s home) include:




Health promotion
Accompaniment
Treatment adherence
Modified DOT
 Caseloads
 Patient Navigators: 14 to 20 clients
 DOT Specialists: 7 clients
 Required clinical supervision
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DEVELOPMENT: Research and Timeline
 Models reviewed:
 Medical Home, Patient Navigation, Chronic Care, Community
Health Worker
 Prevention and Access to Care and Treatment (PACT) Project
 Partnership between Partners in Health (PIH) and Brigham and
Women’s Hospital in Boston, MA
 Requests for Proposals (RFP)
 2004: Treatment Adherence Program (TAP)
 2006: Maintenance in Care (MIC)
 2009: Care Coordination Program (CCP)
 Bradford et al. HIV System Navigation: An Emerging Model to Improve
HIV Care Access. AIDS Patient Care and STDs. 2007;21:S49–S58.
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DEVELOPMENT: Tools
 Program Manual
 Version 4.0 released May 29, 2013
 Each version evolved and adapted
 Recommended staffing plan
 Staff roles and responsibilities
 Guidance on program processes
 Standardized forms
 Excel adherence calculator
 eSHARE data reporting system
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DEVELOPMENT: Training and TA
 Trainings
 10-day Care Coordination training
 National Development and Research
Institutes (NDRI)
 HIV 101, case management skills,
program forms, etc.
 Four-day Health Promotion Training of
Trainers (TOT)
 PACT trainers along with NYC DOHMH
Project Officers
 Two trainers at each Care Coordination
program
 One-day trainings
 Care Coordination Refresher
 Cultural Sensitivity
 Co-occurring Disorders (HIV, MH, and SA)
 Technical Assistance
 NYC DOHMH Project Officers
 Bi-annual Provider Meetings
 Site visits and webinars
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IMPLEMENTATION: Funded Programs
 28 agencies providing CCP in New York City (NYC)
 16 hospital-based agencies
 12 community-based agencies
 Caseloads:
 Agency caseloads: 52 to 230 active clients
 9 small programs
 12 medium programs
 7 large programs
 ~3,300 PLWH in the active portfolio caseload at any given time
 4,986 unique PLWH served from March 2012 – February 2013
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IMPLEMENTATION: Client Demographics
Grant Year (GY) 2012, Care Coordination Program (All Agencies),
N = 4,986
AGE GROUP
<25
%
GENDER
6.9%
25-44
38.4%
45-64
50%
65+
4.7%
RACE/ETHNICITY
%
Female
37.3%
Male
60.9%
Transgender
%
BOROUGH
1.8%
%
Hispanic
37.1%
Manhattan
21.0%
Black
52.6%
Brooklyn
32.8%
Bronx
31.1%
RISK
MSM
IDU
Heterosexual
%
28.3%
7.8%
58.6%
INSURANCE
Public Insurance
Uninsured
%
80.2%
9.7%
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ARGUS COMMUNITY, INC.
760 East 160 th
Street
Bronx, NY
10456
718-401-5700
www.arguscommunity.org
Maria
Rodriguez,
MPA
BACKGROUND: Argus Community, Inc.
 Founded in South Bronx in 1968
 Began as substance abuse treatment provider
 Expanded to address homelessness, AIDS/HIV, welfare reform
 Received national and international recognition
 Programs replicated in Washington, DC; San Francisco; Albany;
Des Moines; and Belfast, Northern Ireland.
 Program created in response to community needs and
continues to respond to new emerging needs
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PROGRAMS: Argus Community, Inc.
ACCESS I Care Management
ACCESS II Care Coordination
Argus Career Training Institute
Argus Client Money
Management
 Argus Community Re-Entry
Initiative
 ARU Outpatient Center
 DWI Screening and Assessment




 Elizabeth L. Sturz Outpatient
Center
 Harbor House & Harbor House II
 MEDAL Program
 Prometheus I and II
 RESTART GED Program
 Striver House
 Youth Intervention and
Development
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The 3 P’s In Care Coordination
Treatment
Adherence
Patients
Linkage
To
Care
Coordination
of
Medical
Services
Providers
Community
Maintain a
Stable
Health
Status
Become
SelfSufficient
Program
Staff
Coordination
of
Social Services
Support
and
Coach
Home
Based
Navigation
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PATIENTS: Argus Community, Inc.
 Total Census as of June 2013: 125 Active Patients
 Referred by 3 medical facilities, self -referrals,
and/or our Health Home program.
 Patients By Track Enrollment as of June 2013:
Track
Enrollment
A (Quarterly, no ART)
5
B (Quarterly, with ART)
18
C1 (Monthly)
47
C2 (Weekly)
36
D (Daily Directly Observed Therapy)
19
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IMPLEMENTATION: Client Demographics
GY 2012, Argus Community, N = 208
AGE GROUP
<25
All CCP
6.9%
Argus
25-44
38.4%
2.6%
26.3%
45-64
50%
66.5%
65+
4.7%
4.6%
RACE/ETHNICITY
All CCP
Argus
GENDER
All CCP
Argus
Female
37.3%
44.3%
Male
60.9%
55.6%
Transgender
1.8%
1.0%
BOROUGH
All CCP
Argus
Hispanic
37.1%
49.5%
Manhattan
21.0%
9.3%
Black
52.6%
45.4%
Brooklyn
32.8%
2.1%
Bronx
31.1%
86.6%
RISK
MSM
IDU
Heterosexual
All CCP
Argus
28.3%
16.1%
INSURANCE
7.8%
10.7%
Public Insurance
58.6%
62.4%
Uninsured
All CCP
Argus
80.2%
88.7%
9.7%
7.2%
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ACCESS II
CCP
STAFF
PROGRAM STAFF
Data Manager
Medical Center
Liaison
Patient Navigator
Patient Navigator
Care Coordinator
Patient Navigator
Program Director
DOT Field Specialist
Patient Navigator
Patient Navigator
Care Coordinator
Patient Navigator
DOT Field Specialist
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PROVIDERS
1. Montefiore Medical Group (MMG) – CICERO
Program/Bronx Community Health Network
 11 Clinics from the Montefiore Medical Group CICERO
Program
2. All Med and Rehabilitation of New York
3. The George and Eva Neil Barbee Family Health Center
4. The 151 st Medical Center
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THE MODEL: Referral Process
Walkin/Word
of Mouth
Provider
Referral
Linkage
to Care
Referrals
Argus
ACCESS
II CCP
Health
Home
Referrals
New York
City 311
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THE MODEL: Building Provider Buy -in
1. Provider Website
2. Social Work Luncheon/Program Presentations
3. Clinical Rounds/Conferences
4. CCP Patient Report for Providers
5. Consumer Advisory Board Meetings
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THE MODEL: Services Provided
 Accompaniment
 Assistance with Entitlements and Benefits, Health Care, Housing, and
Social Services
 Care Plan
 Case Conference
 Directly Observed Therapy (DOT)
 Health Promotions
 Home Visits
 Intake/ Re-Assessment
 Outreach for Patient for Reengagement
 Treatment Adherence/Pill Box Count
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CASE STUDY: Lisa
 Lisa was referred by her PCP on 7/15/11
 Initial enrollment track was C2-weekly
 CD4 at the time of enrollment was 219 and VL was 29,492
 She began DOT services on 11/16/2011. Her CD4 was 214 and VL
30,494
 CCP staff provided daily DOT services, weekly Health Promotion, and
case management until 3/23/2012 when patients lab reported her
CD4 was 350 and VL undetectable.
 On 9/17/2012 her CD4 was 375 and VL remained undetectable
 On 1/18/2013 her CD4 was 465 and VL remained undetectable.
 Her last lab report indicates that her CD4 is 397 and VL remains
undetectable.
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BETH ISRAEL MEDICAL
CENTER
PETER KRUEGER
CENTER FOR
IMMUNOLOGICAL
DISORDERS
www.wehealny.org/services/bi_aidsservices
10 Nathan D
Perlman Pl,
New York, NY
10003
212-420-2620
Vanessa
Haney, MFA
BIMC’S AIDS CENTER TIMELINE
Donna Mildvan, MD (Chief of Infectious Disease) notices enlarged
1978-1979 lymph nodes in gay men studied for sexually transmitted intestinal
infections
1980
Beth Israel sees its first AIDS patient, a 33-year old West German man
1981
Beth Israel’s Infectious Disease Clinic opens
1988
BIMC is given Designated AIDS Center status
1989
Beth Israel’s Infectious Disease Clinic is renamed The Peter Krueger
Center for Immunological Disorders
1993
The Robert Mapplethorpe Residential Treatment Facility is founded by
the Robert Mapplethorpe Foundation
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BACKGROUND: BIMC
 Inpatient
 1,083 certified beds
 Emergency Department
 Visits (Excluding Admissions)
in 2011: 107,178
 Admissions in 2011: 35,376
 Methadone Maintenance
Treatment Program
 Visits: 1,079,514
 Ambulatory/Outpatient
The Peter Krueger Center
 Number of Unique Patients: 1,200
 HIV Primary Healthcare
 Specialty Healthcare (Dermatology,
Gynecology, Pain Management)
 Dental
 Mental Health
(Psychiatry/Psychology/Counseling)
 Transgender Health Care Services
 Care Coordination
 Social Work and Case Management
 Harm Reduction: Project S.H.a.R.E.
 Nutrition
 Visits: 371,083
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PATIENTS: BIMC
 Since 2010, 298 people have been enrolled into BI’s CC
Program
 Total Census as of June 2013: 186 Active Patients
 Patients By Track Enrollment as of June 2013:
Track
Enrollment
A (Quarterly, no ART)
0
B (Quarterly, with ART)
15
C1 (Monthly)
102
C2 (Weekly)
64
D (Daily Directly Observed Therapy)
5
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IMPLEMENTATION: Client Demographics
GY 2012, Beth Israel, N = 223
AGE GROUP
<25
All CCP
Beth Israel
GENDER
All CCP
6.9%
Female
37.3%
41.3%
Male
60.9%
56.1%
Transgender
1.8%
2.7%
Beth Israel
25-44
38.4%
3.1%
21.1%
45-64
50%
70.0%
65+
4.7%
5.8%
All CCP
Beth Israel
Hispanic
37.1%
43.5%
Manhattan
21.0%
39.0%
Black
52.6%
44.8%
Brooklyn
32.8%
30.9%
Bronx
31.1%
18.8%
RACE/ETHNICITY
RISK
MSM
IDU
Heterosexual
BOROUGH
All CCP
Beth Israel
28.3%
21.5%
INSURANCE
7.8%
29.1%
Public Insurance
58.6%
65.0%
Uninsured
All CCP
All CCP
Beth Israel
Beth Israel
80.2%
89.2%
9.7%
1.8%
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THE MODEL: Referral Process
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CARE COORDINATION: Our Team!
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PROGRAM STAFF
Data Entry
Care
Coordinator
Patient
Navigator
Patient
Navigator
Patient
Navigator
Patient
Navigator
Program
Manager
Patient
Navigator
Patient
Navigator
Care
Coordinator
Patient
Navigator
Patient
Navigator
Patient
Navigator
EVALUATION: Outcomes
CCP Quarterly Viral Loads: N=50
Percent Undetectable
90
82.05
80
72.93
70
60
50
Percent Detectable
69.23
65.85
52.08
47.92
40
34.15
30.77
27.07
30
17.95
20
10
0
Prior to Enrollment
QTR 1 (Jan-Mar
2011)
QTR 2 (Apr-Jun
2011)
QTR 3 (Jul-Sep
2011)
QTR 4 (Oct-Dec
2011) 36
CASE STUDY: Brenda
 Brenda is a 44 year -old woman test HIV positive in 2004
 History of trauma, depression, and substance use
 Enrolled in CCP April 2011
 Viral Load of 100,000 copies and CD4 was 113
 Throughout 2011 and 2012
 Remained difficult to engage but kept on a weekly track
 Did not agree to pill boxing and self-reported 100% adherence
 March 2013
 Viral Load had risen to 659,892 copies and her CD4 dropped to 11
 April 2013
 Agrees to DOT during her PCP appointment
 July 201 3
 Viral Load is <75 and her CD4 have risen to 43
 Significant improvement in herpes lesions
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CARE COORDINATION
PROGRAM EVALUATION
NYC
Depar tment of
Health and
Mental Hygiene
Stephanie
Chamberlin,
MPH, MIA
EVALUATION: Process and Outcomes
 Cross-agency evaluation utilizing standard metrics, based on
the well-defined CCP protocol
Fidelity to Program Model
Process
Barriers
Facilitators
Quality
Management
Outcomes
Cross-sectional
(2010 – Present)
Pre- and Post-CCP Enrollment
(2012-Present)
Short-Term
Long-Term
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EVALUATION: Time And Effort Study
Hours Worked per Day (7.37 Average )
100%
80%
2.67
Direct Client
Services
60%
1.99
1.22
0%
Program Activities
N/A
40%
20%
Indirect Client
Services
Background
Method
Sample of six
(6) Agencies
Administrative
Blank, Illegible,
0.78
Missing
0.49
0.22
Patient Navigators n = 35
40
EVALUATION: Time And Effort Study
All Client Services (Direct and Indirect): Average Hours per Day
Travel Time to/from Client Encounters
1.18
Health Promotion
0.59
All Assistance w/ Activities
0.47
Outreach for Reengagement
0.25
All Adherence Logs
0.16
DOT Field
0.16
All Accompaniment
0.11
All Case Conferences
0.10
Intake and Reassessment
0.04
Care Plan
0.01
0
0.2
0.4
0.6
0.8
1
Patient Navigators n = 35
1.2
1.4
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EVALUATION: Engagement In Care
n/a
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EVALUATION: Viral Load Suppression
n/a
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NYC DOHMH
Care
Coordination
Evaluation
Team
TAKE HOME MESSAGES
 Patient Navigators do more than just navigation
 Health promotion, treatment adherence, modified DOT, etc.
 Diverse Community Health Worker staff
 Cultural sensitivity and competency
 Field safety training and protocol
 Means of communication
 Clinical supervision
 Technical assistance
 Provider meetings
 Peer to peer learning
 Best practices
 Incorporate data collection and evaluation
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QUESTIONS
 Beau J. Mitts, MPH
 NYC Department of Health and Mental Hygiene
 [email protected]
 Stephanie Chamberlin, MPH, MIA
 NYC Department of Health and Mental Hygiene
 [email protected]
 Maria Rodriguez, MPA
 Argus Community, Inc.
 [email protected]
 Vanessa Haney, MFA
 Beth Israel Medical Center
 [email protected]
To find Care Coordination
tools online visit:
www.nyc.gov
SEARCH: Care Coordination
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Announcements
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Upcoming Events and Deadlines
 Upcoming Webinars:
―
Stay Tuned! Campaign staff is hard at work for you
 Data Collection Submission Deadline:
October 1, 2013
 Improvement Update Submission Deadline:
August 15, 2013
Upcoming Monthly Topics
―
August – Transitory Populations and Retention
―
September – Women and Retention
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―
October – Sex Work and Retention
Campaign Headquarters:
National Quality Center (NQC)
90 Church Street, 13th floor
New York, NY 10007
Phone 212-417-4730
[email protected]
incareCampaign.org
youtube.com/incareCampaign
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