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?
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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
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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