Transcript Linkage and Reengagement Programs 03052014
Campaign Webinar
Los Angeles County Linkage and Re-engagement Programs March 5, 2014
2
Ground Rules for Webinar Participation
• Actively participate and write your questions into the chat area during the presentation(s) • Do not put us on hold • Mute your line if you are not speaking (press *6, to unmute your line press #6) • Slides and other resources are available on our website at incareCampaign.org
• All webinars are being recorded
Agenda
1.
2.
3.
4.
Welcome & Introductions, 5min Campaign Update, 10min LA DPH, 35min Question and Answer, 10min In the chat room, Enter your: 1. name, 2. agency, 3. city/state, and 4. professional role at agency
3
Michael Hager, MPH MA NQC Manager, in + care Campaign Manager New York, NY
4
Campaign Update
5
in+care Campaign in 2014
• Campaign database running through 2018!
• Campaign website running through 2018!
• Partners in+care Facebook maintained indefinitely • Campaign Newsletter moves to quarterly • Campaign Webinars move to quarterly • Partners in+care Webinars move to quarterly • Campaign Coaching integrates into NQC Continuous TA Portfolios • Local Retention Groups that wish to continue meeting should do so – NQC will support where possible
6
Disseminating Improvement Work
Lightning Rounds!
• 1 or 2 slides that contain the most salient points of your retention projects • Include information on patient target, rationale for target selection and baseline data from your measures (including the date) • Include information on each improvement cycle (what was tried, what was the result per the data) – for early cycles short measures of change are not necessary, but add value!
• What are your conclusions? How are you sustaining improvement • Simplicity and clarity are the idea!
7
in+care Retention Improvement Strategies
8
in+care Retention Improvement Strategies
9
Data Collection Submission Deadline:
April 1, 2014
10
Gap Measure Results
(12/11 – 2/14)
11
Visit Frequency Measure Results
(12/11 – 2/14)
12
New Patients Measure Results
(12/11 – 2/14)
13
Viral Load Suppression Measure Results
(12/11 – 2/14)
Los Angeles County HIV Linkage-to-Care and Re-Engagement Programs: Preliminary Results and Lessons Learned
Amy Rock Wohl MPH PhD Division of HIV and STD Programs Los Angeles County Department of Public Health March 5, 2014
Navigation Program
15
Navigation Program
Background:
Goal is to re-engage lost HIV clinic patients in HIV care using enhanced locator techniques and modified strengths-based cm intervention (ARTAS)
Participants to-date are out of care (OOC) patients from 4 LAC publicly-funded HIV clinics
Eligibility includes HIV+ patients who have not had a primary care visit in the past 6 mos and last vl >200 copies/ml; or no HIV primary care visits in 12 mos; or newly-diagnosed and never in care
Current status:
Ongoing enrollment
Modified ARTAS Intervention
• •
Based on ARTAS model Consists of:
•
4-phases administered over a 90-day period instead of ARTAS 5-sessions
•
Increase in the number of visits per phase to add flexibility (up to 10)
•
Like ARTAS, sessions are 60-90 minutes Intervention Phase Phase 1 Phase 2 Phase 3 Phase 4 Title/Content
Building the Relationship Assessment Linking to Resources/Enhancing Strengths Disengagement
Number of Sessions
1-2 1-2 2-4 1-2
Maximum Timeframe
1 week 1-2 weeks 1-8 weeks 1-2 weeks
Preliminary Data
•
Disposition of 499/636 1 Lost Clinic Patients 12% 23% In Care Elsewhere No Longer LAC Resident 2% Returned to Clinic Independently 17% 26% 5% 4% 11% Patient is Deceased Patient is not available/left message Number is Wrong/Disconnected Patient Declined Enrollment Patient Located/Interested in NAV; appt. scheduled
18
1 137 lost clinic patients were found ineligible due to VL/last appointment date
Most Effective Data Source
1
for Contact Information (n=499)
Series 1 HIV Surveillance 2 39% Clinic Medical Record Ryan White Client Database Lexis-Nexis Other 3 2% 5% 17% 36% 1 Patient contact data searches were hierarchical starting with clinical medical records, followed by Ryan White Patient database, HIV surveillance, Lexis-Nexis, and Other until patient was successfully contacted 2 HIV Surveillance breakdown: iHARS-LAC=24%, eHARS-CA=15% 3 Includes LAC Inmate locator, CA Prison Locator, STD surveillance database
19
Demographics (n=61)
Race: 13% African American, 77% Latino, 5% White, 2% Asian, 4% Other Gender : 26% female, 70% male, 4% transgender Age: 45% <40 yrs, 55% >40 yrs Insurance Status: 61% Uninsured, 36% Public Insurance, 3% Unsure Substance Use (past 6 months): 5% IDU; 23% any drugs Current Housing: 90% stable, 8% temporary, 2% homeless Education: 70%
20
40 35 30 25 20 15 10 5 0
Main Barrier to HIV Care at Time of Enrollment in NAV Intervention (n=61)
38% 7% 7% 5% 2% 2% Other Life Priorities (childcare, work) Didn't Complete Application Process No Transportation Homelessness Drinking/Using Drugs Didn't think Needed HIV Care
Needed Services
1
at Time of Enrollment in NAV Intervention (n=61)
70 60 50 67% 40 30 20 10 44% 0 Dental Care Food & Other Basic Needs 1 Participants listed multiple needs 36% Benefits 27% Housing/Shelter 22% 20% 18% Mental Health HIV-Related Medical Medications/Pharmacy
22
HIV Testing, Care and Clinical History at Time of Enrollment (n=55
1
)
Variable Time Since Positive Result Time Since Last Medical Appt. Last Viral Load Prior To Enrollment (copies/ml) Min 9 months 21 days 20 Max 17 yrs 3 yrs 1,011,623 Median 6.4 yrs 308 days 2,221 Mean 7 yrs 358 days 58,046 1 Data pending for 6 patients
• •
Intervention, Linkage and Engagement in Care (n=55
1
)
Avg # of NAV visits = 7 (range 3-10) Avg # of hours spent with NAV = 15 (range 2-44)
•
98% (n=54/55) linked to care (attended 1 HIV medical visit) following intervention enrollment
•
20 of 34(48%) patients who were enrolled in NAV for at least 6 months engaged in care; (i.e. attended 2 or more medical visits and were referred for long-term case management and retention )
•
NAV patient referrals: housing, substance abuse treatment, mental health, nutrition, transportation, assistance w health insurance and ADAP enrollment 1 Data pending for 6 patients
• •
Lessons Learned and Next Steps
Preliminary Lessons Learned
–
More efficient to start with surveillance rather than clinic data to identify OOC patients
–
HIV surveillance and clinic data provided most useful contact information for finding OOC patients
–
OOC patients vary in the intensity of intervention needed; NAV needs to work with OOC patients longer to promote long-term engagement in care
–
Structural roadblocks
•
LACDPH legal concerns with sharing surveillance information
•
Clinic administrative requirements Next Steps
–
Incorporate lessons learned into county-based LTC program
Navigation Program Version 2.0
26
Clinic/Surveillance list of out of care individuals Confirm eligibility with clinic staff Intervention Low (Resources) Not Linked Moderate (MI) Not Linked ARTAS Navigation Program Flow Chart Referral to navigator (NAV) Initial attempt to contact using clinic contact info Located ? Yes No 1) Utilize HARS/ Casewatch to gather contact info/status 2) Coordinate with MCC & prioritize 3) Utilize MMP/PHI investigative methods to locate Initial appointment with NAV: -consent -survey -intervention intensity assignment (Low, Mod, ARTAS) Linked to care (medical, case management) Transitional Retention
-
NAV follow-up for 6 months after linkage additional NAV visits as needed NAV contacts patient to schedule initial appointment and enroll in Navigation Program Yes Contacted! Patient Agreed No Case closed Unable to find, case closed In care elsewhere, case closed Clinic staff updated info in Casewatch IN CONSISTENT CARE (Intervention Ends)
Project Engage
28
Project Engage
Background:
Goal is to identify OOC HIV+ persons and link them to HIV care
OOC HIV+ persons (alters) are identified through social network referrals from seeds or direct recruitment by staff; alters may recruit OOC persons
Incentives: $40 for baseline survey for seed/alter; additional $40 for seed/alter when alter links to care
Seeds identified from: 1.
2.
3.
HE/RR programs at CBOs for at-risk MSM (eg crystal meth support group) HIV clinic patient populations Flyer/pocket card recruitment Current status:
Ongoing Enrollment
29
Flyer Pocket Card
30
Preliminary Results
Study Screening and Recruitment
Screened
Seeds: 99
HIV+ Alters: 104 1
Enrolled
Seeds: 56
HIV+ Out of Care Alters: 29
8 (28%) have enrolled as recruiters
21 (72%) have linked to care
Site Specific Enrollment:
APLA: 8 seeds and 20 alters (12 linked)
OASIS Clinic: 12 seeds and 3 alters (all linked) GLC Clinic: 30 seeds and 3 alters (all linked) Direct Recruitment: 6 seeds 3 alters (all linked) 1 62% were ineligible/not HIV infected per HIV surveillance
32
Demographics
Out-of-Care Alters (n=29)
Race: 41% African American, 10% Latino, 28% White, 21% Other
HIV Status: 100% HIV-positive 76% MSM; 24% heterosexual Insurance Status: 38% Insured, 62% Uninsured Reported Sex Work: 24% Incarceration History: 86% lifetime, 55% past 12 months Recent/Current Homelessness: 79% Illicit Substance Use:
IDU: 48% lifetime, 21% past 3 months
Non-IDU: 62% lifetime, 41% past 3 months
Seeds (n=56)
Race: 42% African American, 22% Latino, 25% White, 11% Other
HIV Status: 75% HIV-positive
96% MSM; 4% heterosexual
Insurance Status: 89% Insured, 11% Uninsured
Incarceration History: 51% lifetime, 4% past 12 months
Reported Sex Work: 7%
Recent/Current Homelessness:16%
33
Out-of-Care Alters (n=29)
Testing and Care History
Time since 1 st HIV+ test: Avg=10.8 years (range: 3 mos-29 yrs)
Time between 1 st HIV+ test and 1 st Avg=12.8 months (range: 1d-6yrs) HIV doctor visit:
Number of clinics attended: Avg=2.6 (range: 1-20) ART use: Ever taken= 72%, Currently taking=17%
Readiness to Engage in Care Scale 1
11 “contemplative” about starting care 18 “ready for action” about starting care
Sexual Behaviors (last 6 mos)
# of sexual partners (n=20): Avg=6.5 (range: 1-40)
31% report UAI 1 Scoring based on Transtheoretical model of behavior change
34
Characteristics of Out-of-Care Alters
Linkage, Care, VL
Linkage and Care
• • •
Avg time out of care (n=21): 9.7 mos (range: 0-26) Avg time to link to care (n=21): 12.4 days (range: 0-97) Avg staff time dedicated to link to care (n=28): 373.9 min/6.2 hours (range: 140-840 min) Viral Load
Last reported vl before enrollment (n=27): Avg=50,184 copies/ml (range: 48-370,660)
Acceptability Survey
Out-of-care alters who linked to care (n=16) stated:
• • •
Project Engage helped get them into care: 16 Were satisfied with the help they received: 16 Would recommend PE to friends who were out of care: 15
11/16 (79%) stated that without PE, they would not have entered care themselves
35
Unmet Needs and Barriers to Care for Out-of-Care Alters
Unmet needs (social & medical services)
Number of unmet needs: Avg=7.7 (range: 1-14)
Most reported not being able to obtain:
Regular HIV care (n=25)
Dental care (n=22)
Medical Case Management/Mental Health Counseling (n=21)
Barriers to Care
Did not know where to obtain services
Experienced disrespect from HIV clinic staff Challenges completing needed paperwork
36
Case Study #1
Case 1 is an older homeless minority MSM who tested HIV positive in 2006. He has been out of care for 26 months. He is a crystal meth user and prostitutes for survival and sleeps in parks and alleys. He reported 5 sex partners in the last 6 mos and was the insertive partner for UAI with all 5 partners. He has been incarcerated several times due to his drug use and prostitution. His physical appearance suggested he was feeling the effects of both his medical and social situation (several lesions on his face and arms, frail body and missing teeth).
After enrolling him into Project Engage, he was linked into care in one day (4 hrs PE staff time). He was very excited and happy that someone took such an interest in his situation. After his first treatment appointment, he went back to the park where he hangs out and told his friends about his positive experience. One week later his physical appearance had improved dramatically and he stated that he is on the medication and feeling much better.
37
Case Study #2
Case 2 is a 29 year old homeless minority MSM who tested positive anonymously in June 2013 but had never linked to care. His mother gave him and his two sisters up for adoption when he was a child. He became homeless at the age of 18 after his adopted parents passed away and he moved from the midwest to California. He is currently homeless and lives on the streets in Los Angeles.
He is a crystal meth user but does not currently engage in prostitution. He has spent time in jail for stealing, drug possession and prostitution. He reported 5 sex partners in the last 6 months and was the insertive partner for UAI for all 5 and also receptive partner with 1 of the 5 partners. He was very well-spoken and was appreciative that a program was in place like Project Engage to help people with HIV link into care. After enrolling into Project Engage, he was linked into care within two days by Project Engage staff (6 hours PE staff time). He is currently working with the HIV clinic staff to secure housing and other needed social services.
38
Preliminary Lessons Learned:
Agency-based recruitment more effective than clinic-based recruitment
A few productive seeds is critical to success Labor intensive to identify OOC persons Labor intensive to link OOC persons to HIV care Capacity needed to help OOC alters obtain photo ID
to enroll in medical care/ADAP LTC intervention needed for some
Next Steps:
Scale up staff (currently 1 FTE); increase incentives?
Expand direct field recruitment at parks/street corners; enhanced recruitment at more CBOs, at risk youth agency, mobile testing vans, skid row clinic
Add 3-tiered intervention option in next phase Incorporate into county-based
39
LTC program
Acknowledgments
Saloniki James Rhodri Dierst-Davies Alla Victoroff Sonali Kulkarni Heather Northover Jeff Bailey Brian Risley
40
41
Question & Answer
42 Campaign Headquarters: National Quality Center (NQC) 90 Church Street, 13 th floor New York, NY 10007 Phone 212-417-4730 [email protected]
incareCampaign.org
youtube.com/incareCampaign