Transcript Document
Engaging and Retaining
Youth in Care
-Horizons ProjectPresenter
Nikki Cockern, PhD, Psychologist
Horizons Project
Children’s Hospital of Michigan/Wayne State University
Detroit, MI
[email protected]
http://www.peds.med.wayne.edu/horizons
**Funded by HRSA, MDCH, City of Detroit and United Way**
Horizons Project
Horizons Project
Dedicated to providing HIV prevention services to
at-risk youth and direct care services to adolescents
and young adults living with HIV (ages 13-24)
Has continued to grow as the only comprehensive
HIV/AIDS program in Michigan focusing on youth
Wayne State University School of Medicine (WSU)
and the Detroit Medical Center (DMC) serve as
fiduciaries.
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Adolescent Development
Adolescence is the developmental period in
animals (not just humans) during which the
body and brain emerge from an immature
state to adulthood (spear, 2000; Steinberg &
Morris, 2001).
This period is gradual and we don’t know the exact moment
this happens
Puberty=sexual maturation occurs during this time
This period of transition is marked by
pronounced changes in cognition, behavior,
and temperament (Kelley, Schochet, &
Landry, 2004).
Risk taking increases here & is associated with brain
changes rather than puberty
Overall Adolescent Issues
Trust
Often not ready to change, not
motivated (intrinsically)
Lack of impulse control
Rebel against prescriptive approaches –
educational, skills building, traditional
counseling
Developmental tasks & milestones for
Adolescents
Cognitive ability
Formal operations
Complexity – consider many elements
Imagine abstract possibilities
More emphasis on social and emotional
consequences
Less emphasis on physical, goal oriented or risk
amplifying
Problem solving – limited ability to generate practical
options
Challenges with perspective taking
Identity Formation
What’s Unique About Adolescents?
Environment is vital
Separation/individuation
Identity formation as separate from authority figures
Translating personal goals into behavior within a
constrained environment
Communication skills are still developing
Our Experience With Adolescents
Both Care and Prevention
High frequency of literacy issues
Prolonged academic difficulties
Frequent acquisition of STI’s
Use of marijuana and alcohol
Huge trust issues
Low priority of knowing HIV status despite high
risk (prevention)
Hard to prioritize care (HIV+)
Limited support systems
Minimal supervision
Mental health issues (i.e. depression, anxiety,
conduct disorder)
Do You Know What These Mean?
Acronym
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ASL (R P)
BF / GF
BRB
CD9 Code 9
GNOC
GTG
IDK
(L)MIRL
LOL
MorF
MOS
NIFOC
Noob
NMU
P911
PAW
PIR
POS
PRON
PRW
S2R
TDTM
Warez
W/E
WTF
LMAO
Definition
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Horizons Project’s
Comprehensive Continuum of Care
Other Medical Sites
Serving HIV+
Youth
Horizons Group
Prevention
HIV+
Horizons Community
Outreach
Horizons Peer
Advocacy
C&T Sites
HIV+
Horizons Field &
Internet Outreach
Horizons C&T and MI
Horizons Case Finding:
Agency/Field Outreach
Horizons Group
Prevention
Horizons
Clinical Care
Team
Primary Medical Care
Medical Specialty Care
Nursing Services
Health Education
Adherence Support
Social Work Services
Case Management
Ongoing Advocacy
Mentoring
Consumer Involvement
Therapeutic Activities
Transportation
Psychological Services
Psychiatric Consultation
Education and Training
MI for Retention
Prevention Services
(MI and Group)
Community Agencies
and Resources
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Horizons Project Demographics
Clinical Care
2009
194 youth medically (143 males, 51 females);48 new and 93%
African-American
101 youth identified as MSM (71%)
2010
147 youth medically (100 males, 43 females, 4 transgender); 22
newly diagnosed
91%YMSM
Prevention & Outreach
2009
365 youth received HIV C&T (90% MSM; 96% AA)
2010
94 youth received HIV C&T (93% MSM; 98% AA)
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Approach to Clinical Care
“One stop shopping” approach
Primary Medical Care (access to Clinical Trials)
Treatment Adherence
Advocacy and Risk Reduction
Health Education Services
Nursing Services
Case Management
Social Work Services
Mental Health Services including psychiatric
consult
Support Groups
Transportation
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Approach to Clinical Care
Multi-disciplinary Team
Physician
Nurse Practitioner
Clinical Psychologist
Psychiatric Nurse Practitioner
Social Worker
Case Manager/Care Coordinator
Peer Advocate
Health Systems Navigator
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Ancillary Services
Community site for delivery of psychosocial services
Individual Counseling/Therapy
Case Management
Social Work
Treatment Adherence Program
Transportation
Transportation, health education, treatment adherence, mentoring,
support groups (Jam sessions) and therapeutic activities
Advocacy
Advocates assist youth in enrolling and remaining in care
Consumer Involvement
Motivational Interviewing is offered program-wide
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Transportation
Transportation:
Bus tickets
Vans
Cabs
Available for clinical and ancillary appointments
Some changes have been made due to rising fuel costs
and funding cuts
Accessed through some insurance plans
Also available for Jam Sessions and support
groups
Treatment Adherence Program
The program focuses on:
Adherence to medical appointments
Adherence to medication regimens
Risk behaviors
HIV knowledge and education
Youth with adherence concerns:
Are discussed at MDT
Treatment plans are modified as necessary
Treatment Adherence Program
Incentives are provided for:
Attending appointments
Improvement in lab values
Reducing risk behaviors
Increased scores on HIV knowledge tests
Incentives include:
Gift cards, access to special events, prizes,
conference opportunities, etc.
Lost to Follow-Up (L2FU) Program
L2FU Definition:
Youth who have not attended a clinic appointment within 90
days
Process:
Phone Calls
Post Cards
Home Visits
Social media: texting and Facebook
Motivational Interviewing integrated into calls, home visits,
and clinical appointments
Youth not retained in care are discussed at L2FU MDT
L2FU Program Protocol
5.
Contact made,
clinic visit
scheduled OR
Repeat
1.
“No show”
to visit, call (p/c)
to reschedule
2.
Month after
missed visit,
advocate
continues p/c
4.
rd
3 month
Home Visit
3.
month
Mail post
card
2nd
Program Summary
One stop shopping, multi-disciplinary team
approach to care
Clinical Services
Psychosocial Services
Retention Strategies include:
Peer Advocacy
Transportation
Treatment Adherence Program
L2FU Program
Characteristics of youth who are
Inconsistently Engaged in Care
Often newly diagnosed
Young (chronologically and/or emotionally)
Higher VL, lower CD4s
Often not feeling badly (non symptomatic)
Additional adherence issues
Not on meds, but may need to be soon
Avoidance and issue with status
This includes issues related to disclosure, shame,
etc.
Factors Affecting Attendance and
Engagement
Key reasons:
Low or inadequate social support
Competing priorities
Often in “survival mode”
Limited problem solving and/or
communication skills
Chaotic environment
Retention Measure
HIVQUAL retention measure
2008 = 95%
7/1/08-6/30/09 = 98% or 2-3 patients
7/1/09-6/30/10 = 94% or 10 patients
7/1/10-11/30/10 = 95% or 7 patients
Difficulty quantifying no show rate due to
multiple appointments
Issues in Retaining Youth
Multiple interventions to maintain contact
Circumstances can change daily
Health is not a priority
Developmental concerns
Enormously challenging to get them to
show 2/year
L2FU Program Protocol
5.
Contact made,
clinic visit
scheduled OR
Repeat
1.
“No show”
to visit, call text,
Facebook email to
reschedule
4.
month
Home Visit
3rd
3.
2nd month
Mail post
card
2.
Month after
missed visit,
advocate
Continues
phone, text,
Facebook,
email
What We’ve Learned
Youth contacted
prior to appointment and confirmed,
during missed appointments and
as soon as possible after missing appointments
are more likely to reschedule and attend
next appointment.
Youth Tracking Log
List of youth who miss at least one
appointment.
Taken off list if next appointment kept.
Updated and reviewed at
Weekly clinical team meeting and
Monthly for in depth discussion during clinical
team meeting
Learning from Past QI Project
Of 68 youth (Jan-Aug 09) listed as missed
appointments, 38 or 56% returned to care,
Home visits did not yield significant return to
care (4 out of 11 or 36% returned)
36 returned (89% of the 38)
Phone calls (if timely and frequently)
Added texting, email, and Facebook
21 still being pursed
Effectiveness of Social Media
Texting (approx 30-40%)
Facebook (approx 30%)
Email (approx 2%)
Shifting Responsibility to Youth
Use of motivational interviewing to
decrease number of youth who miss
appointments
Discuss barriers
Problem solve ways to address barriers
Increase motivation to take care of their health
and to keep appointments
PDSA 2: October 09 – October 2010
Total number of youth: 160
80 Youth on Tracking List since Oct 1st (or
52% of youth miss at least one
appointment during 10 month period)
Motivational Interviewing (MI)
Improvement Process-Missed Appointment Process
Youth who have missed a scheduled medical clinic appointment, without contacting team and scheduling another within 30 days.
List Prioritization
1. Clients who missed their clinic appointment within the first month (21-30) days and have not rescheduled
2. Clients who have not attended a clinic appointment in 2-6 months
3. Clients who have not attended a clinic appointment in 6-12 months
MI @ point of
contact & @
clinic appt.
1. Maintain List
Identify youth who
missed clinic
appt. & not
able
to reschedule
5.
Contact made w/
Client & clinic
visit scheduled
Or
Repeat
MI via
phone
MI @ HV if
contact
made
2.
month after
missed clinic
visit. Advocate
attempts
Contact via phone/text
1st
4.
month
Home Visit
3rd
3.
2nd month
Mail post
Card sent
Reduce Number on List and Repeaters
on List
80 = Total number of youth on tracking list since
October
51 Motivational Interviewing
92% or 47 kept appointments and are not on current list
Of 29 who didn’t get MI
ER (3), moved/removed from list (2), care elsewhere (7),
incarcerated (2), not ready to come in (1), located and
pending appointments (8) in 1-2 weeks, can’t find (7 - no
information (MIA))
Current L2FU List
Total number: 20
4 on current list had MI (2 seen at recreational
activity and have appointments, 2 by phone and
have appointments)
8 pending appointments
7 can’t find
1 not ready to come in
Summation: To retain Youth
Maintain Youth Tracking Log
Contact youth to
confirm before appointments,
if missed then during appointments or as soon as
possible after missed appointment
Continue use of
Social media: texting and facebook
Motivational Interviewing integrated into calls, home
visits, and clinical appointments
Challenges when working with youth
Engagement
Adherence
Drug and alcohol use
Media
Peers
Confidentiality
Shift How We Do Business
Starts with a paradigm shift
Examine how we (providers) think about the teens we serve
What type of language do we use (assets vs. risk)
Move from (implied) superiority
Develop cultural competence
Empowerment: Give youth an opportunity to be
the “expert”; demonstrate mutual respect &
partnership
Address stigma, assumptions, judgmental
behavior within the care delivery system
Provide integrated peer driven medical and
psychological support models
Address the ‘real affects’ of denial and
depression while increasing hopefulness and
opportunities for success
Staff Acknowledgement
Director of Medical Service and Research: Elizabeth Secord, MD
Consultant for Psychological Services and Research: Sylvie NaarKing, PhD
Director of Prevention Services: Angulique Outlaw, PhD
Manager of Clinical & Prevention Services: Monique Green Jones,
MPH
Clinical Manager: Nikki Cockern, PhD
Clinical Nurse Practitioner: Debbie Richmond, NP
Clinical Social Worker: Joyce Alexander, LMSW
Care Coordinator: Linda Hyter
Peer Advocates: Terry Pross, Amanda Waterman
Adolescent Consultant: Jessica Daniel, MPH
Outreach and Prevention Coordinator: Dwain Bridges
Outreach workers: Raynard Campbell/Terrance Terry
Adolescent HIV Resources
www.peds.med.wayne.edu/horizons
http://www.mihivnews.com/stats.htm
http://www.chagdetroit.org/UFM.html
www.cdc.gov/hiv
www.kff.org
Thank you!—Questions/Comments?
Nikki Cockern, PhD; 313.745.4892; [email protected]
Monique Green-Jones, MPH; 313.966.9763 [email protected]
http://www.peds.med.wayne.edu/horizons