Transcript Early Intervention Services of South Texas

in+care Campaign
Webinar
February 12, 2013
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Agenda
• Welcome & Introductions, 5min
• Data Review and Discussion of Retention Strategies
Collected Through the Campaign, 10min
• Project THRIVE, 25min
• Panel Dialogue and Q&A Session, 15min
• Updates & Reminders, 5min
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Improvement
Strategies Exercise
Michael Hager, MPH MA
NQC Manager
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Improvement Strategies Discussion
Participant Submissions
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Network-wide linkage agreements / MOUs
Use data to identify targets for special interventions to retain patients
Hire a linkage coordinator to manage patient referral progress
Rely on community planning processes to identify weak points for linkage
within service delivery system / continuum of care
Initiate special projects for linkage, when funding is available (SPNS Linkage
to Care and CDC CAPUS)
Network leads can build up Bridge Counseling services
Health Literacy Education that focuses on Life Skills as part of linkage to care
Patient handed info on next appointment and activities/goals/objectives to
meet before leaving current appointment
Case conferencing around individual patients and their needs
Submit Improvement Updates!
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THRIVE
A Project of the Alamo Area Resource Center
Jacob Wasonga, EIS and Re-entry Outreach Specialist
Loraine Diaz, EIS Specialist
Kristin Thompson, EIS Case Manager
Jesús Ortega, Director of EIS and Care Retention
AARC provides the broadest spectrum of supportive services
to mostly unduplicated clients (Persons Living With
HIV/AIDS) in San Antonio.
AARC’s services are provided to PLWHA’s who know their
status and who are recently diagnosed of who are not in
primary medical care. Services are provided in coordination
with HIV testing and counseling sites, as well as primary
medical care providers.
In March 2012, AARC expanded the Early Intervention
Services (EIS) program to include testing in non-traditional
locations such as: parks, libraries, churches, parole boards,
colleges, and universities.
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December 2008 - EISST was funded by Ryan White Part A and
Ryan White Part B – SD.
December 2008 – One EIS Case Manager and One EIS
Specialist were hired.
January 2009 - First clients were enrolled.
August 2009 – Added additional EIS Specialist.
November 2009 – Funded by Baptist Healthcare Foundation.
May 2010 – EISST was funded by Ryan White Part A MAI
(Minorities) and Ryan White Part B – State Services.
June 2010 – Added EIS Outreach.
March 2012 – Added HIV Testing and Counseling.
The primary goal of EIS is to facilitate early access to medical
care and remove barriers to ensure medical adherence. EIS
activities provided by AARC include assistance and support
with:
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Initial Intake and Assessment.
Case Management (short term, intensive, and client-centered).
Referrals to access HIV medical management services.
Applying for entitlement program benefits.
Targeted outreach on clients who are out of medical compliance for six
months or longer.
Targets unconventional sites for HIV testing & counseling.
 Initial
Intake
 Gather general socio demographic information
 Program General Overview
 Address immediate barriers to care
 Case
Management /Assessment (short term, intensive, and
client-centered)
 Identifying and screening clients for eligibility and determining the need for
services
 Assessing each client’s medical and psycho-social history in order to link
their needs with available resources
 Completing Acuity Scale created by Administrative Agency’s Quality
Management/Quality Improvement Plan in order to evaluate client’s level
of need
 Developing a service plan that is updated regularly which is based on the
client’s needs and goals with strategies for completion
 Implementing the plan in a timely manner
Referrals to access HIV medical management services:
 AIDS Drug Assistance Program (ADAP)
 Health Insurance Continuation Program (HICP)
 Local drug reimbursement program
 Nutritional assessment & counseling
 Dental care
 Mental health and Substance abuse treatment services
 Home health services
 Medical Transportation
 Food
 Housing
Applying for entitlement program benefits such as:
 Medicare or Medicaid
 Veteran's Administration
 Targeted outreach on clients who are out of medical compliance for
six months or longer which is conducted via:
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Telephone and Internet Outreach
 Social Media sites such as Facebook.com and Myspace.com
 Incarceration status on VineLink.com
 Verifying living/death status on Legacy.com
 Utilize various person locator websites
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Active Street Outreach
 Street corners
 Convenient stores
 Local Bars
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Fixed Site Outreach
 Homeless Shelters
 Correctional Facilities
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Residential Outreach
 Notice of Visit
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HIV Testing and Counseling targets unconventional sites and
high risk populations with the purpose of :
Promoting risk reduction
 Distributing male and female condoms
 Identifying new HIV positive cases
 Linking new cases to EIS and medical care
 Reducing HIV stigma with education
 Providing referrals to community resources as needed
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Other Activities:
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Monitoring the efficacy and quality of services through
periodic re-evaluation.
Advocating on behalf of clients to decrease service
gaps and remove barriers to services.
Help and empower clients to develop and utilize
independent living skills and strategies.
Discharge or transfer clients who no longer require
Early Intervention Services.
1st Medical Appointment
Mental health and substance abuse
assessment and services
Health Education and Risk Reduction
Class
Nutrition Assessment
Tracked with Primary Medical or Infectious Disease
Provider:
 FFACTS
Clinic
 Centro Med
Comprised of two separate appointments to meet the
completion of the Milestone:
 First
medical appointment includes lab work and meeting
with a medical social worker
 Second medical appointment (scheduled within two weeks
of first appointment) includes obtaining lab results and
medication therapy if needed
Referred for initial Mental Health and Substance
Abuse Screening to AARC’s counseling services or
other mental health provider of clients’ preference
Conducts Bio-psycho-social assessment addressing:
 Medical history and current/former medication
therapy
 Psychological symptoms and severity
 Household dynamics
 Substance use
Client is referred to Peer Treatment Advocacy (PTA)
education program.
 PTAs
are medically compliant HIV+ volunteers who
receive HIV/AIDS training in order to teach their peers and
act as a role model
Client receives initial comprehensive education on:
 HIV
101
 Medical Adherence
 Medication Adherence
 Risk Reduction
Client completes pre and post test for completion of
milestone.
Client may continue to access PTA program for more
intensive education on individual needs
Client is referred to a registered dietician (RD)
at the FFACTS or Centro Med Clinics
Client must complete initial assessment to
meet milestone which includes:
 Comprehensive
nutrition education based on client’s needs
 Subjective and objective assessment of client’s current
nutritional habits
 Client creates goals with RD to improve deficits in nutrition
and exercise
Additional education is provided for clients with
severe nutritional deficits or clients requesting
further evaluation
Early Intervention Services of South
Texas (EIS)
Upon completion of the Milestones, clients must
demonstrate a decrease in needs, maintain
medical adherence, and an increase towards self
sufficiency to transition out of the Thrive Program
by:
 Continuing
on to Primary Case Management
 Being discharged from EIS but maintaining an ACTIVE
status with AARC where client self – refers for needed
services
Clients are tracked up to six months post
transition for medical adherence.
2012 Ethnicity Statistics
Hispanic (65%)
20.72
0.67
11.98
African American
(20.72%)
Caucasian (11.98%)
1.56
0.89
65.29
Asian/Pacific Islander
(0.67%)
American Indian/Other
Pacific Islander/Native
Hawaiian (0.89%)
Age Groups RDR
UDC
<2
3
2-12
67
13-24
132
25-44
**429**
45-64
246
65 and over
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Total
893
Status
%
Newly Diagnosed
59.97%
Returning to Care
40.03%
Total
100.00%
742 Positive Individuals
Medically Re-Activated or
Transitioned Status
UDC
%
Compliant with Medical Care
619
83.42%
Non-Compliant with Medical Care
123
16.58%
Total
742
100.00%
Type of Marketing
Marketing Determined by:
 VIA
 Zip
Bus Shelters
 Junior Poster Billboards
 Posters
 Advertising in local
Publications
 Commercials
 HIV/AIDS National
Awareness Days
 Community Events and
Health Fairs
Codes of Newly
Diagnosed in Past 3 years
 Zip Codes of Lost to Care
Population
 Demographics of Target
Population
July and August 2009 expanded Marketing Plan to
include Spanish Billboards and Bus Shelters
2010, updated and extended existing Billboards and
Bus Shelters
2011, Expanded Bus Shelters
2012, updated and extended existing Billboards and
Bus Shelters
VIA BUS SHELTERS
JUNIOR POSTER
BILLBOARDS
Marketing Plan
Success of the THRIVE Program can be attributed to:
 The intensive case management component
 Targeted Outreach Component
 The cooperation of the medical providers
 The program design
 Peer Treatment Advocate Program
 Dedicated Staff
 Marketing Campaign
 Client’s dedication and success
For Programmatic or Marketing Information
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Contact:
Randy Hinkle, Programs Manager– 210-358-9893- [email protected]
For Client Services
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Contact:
Jesús Ortega, Director of EIS– 210-358-9639- [email protected]
Kristin Thompson, EIS Case Manager- 210-358-9502- [email protected]
Loraine Diaz, EIS Specialist– 210-358-9505- [email protected]
Jacob Wasonga, EIS & Re-Entry Specialist– 210-358-3758- [email protected]
www.aarcsa.com/thrive
[email protected]
Time for Questions
and Answers
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Speaking from Experience:
Retention on a Patient-by-Patient Basis
How do consumers in San
Antonio view Project THRIVE?
Let us know your experiences in the chat room!
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Speaking from Experience:
Retention on a Patient-by-Patient Basis
What things do staff members
for a program like Project
THRIVE need to know about
local people with HIV to do
their job?
Let us know your experiences in the chat room!
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Speaking from Experience:
Retention on a Patient-by-Patient Basis
What is the relative strength of
a Milestones-based approach
rather than a fully
individualized service plan?
Let us know your experiences in the chat room!
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Announcements
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Upcoming Events
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Campaign Webinar: Social Service Providers Have a Role in
Retention! Date Pending – to be announced!
•
Combined Journal Club and Partners in+care Webinar:
Our Experiences and Retention in+care – to be announced!
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Campaign Webinar: Patient Experience Evaluation and Retention
To be announced!
March Topic – Patient Experience Evaluation
April Topic – Viral Suppression as the Ultimate Goal
May Topic – Youth, Transition, and Retention in+care
June Topic – Latinos and Retention
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Upcoming Deadlines and Office Hours
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Campaign Office Hours:
Mondays & Wednesdays 4-5pm ET
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Wednesday, February 13 – Care in Context: identifying the social needs of PLWH
Monday, February 18 – Campaign Offices Closed, No Office Hours
Wednesday, February 20 – Collaboration to Maximize Retention Efforts
Monday, February 25 – Open Space, no set topic
Wednesday, February 27 – Successful Partnerships with Social Services Providers
Monday, March 4 – Open Space, no set topic
Wednesday, March 6 – Integration of Retention Dialogues into Community
Processes and Conversations
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Data Collection Submission Deadline:
April 1, 2013
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Improvement Update Submission Deadline:
February 14, 2013
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MedScape Retention in HIV Care Series
• Technical Working Group working on articles for a new
Medscape Today News Series.
• We recommend that you subscribe to HIV/AIDS MedPlus to
be informed of new and exciting articles in this series!
• Published Pieces:
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HIV Care Retention and the Goal of an AIDS-Free Generation
Improving Retention in HIV Care in Resource-Limited Settings
Implementing QI in HIV Clinics to Improve Retention in Care
Monitoring Rates of Retention in HIV Care Across the State
How Health Departments Promote Retention in HIV Care
Improving Retention in HIV Care: Which Interventions Work?
Engaging in HIV Care: What We Learned from AIDS 2012
How Should We Measure Retention in HIV Care?
Retention In HIV Care: The Scope of the Problem
http://www.medscape.com/index/section_10285_0
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Partners in+care
• Partners in+care Private Facebook Group is live!
• Share tips, stories and strategies
• Join a community of PLWH and those who love them
• Email [email protected] for more details
• Partners in+care website is live!
• http://www.incarecampaign.net/index.cfm/77453
• Join our mailing list (a list-serv version of the FB Group)
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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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