stephen crowe, atc managing director liza kasmara, director of program evaluation
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Increasing Access to Care (ATC) for Homeless Individuals
Living with HIV/AIDS: Harlem Model Implementation
Stephen Crowe, ATC Managing DirectorLiza Kasmara, Director of Program Evaluation
Harlem United Community AIDS Center, Inc.HRC Conference 2012, Portland, OR
Learning ObjectivesBy the end of the session, participants will be
able to: Identify barriers to linking and retaining patients in careList essential elements in a patient navigation system to
increase access to and retention in careUnderstand the importance of care coordination
Agency Overview
Founded at height of first phase of AIDS epidemic: 1988.
• Specifically to serve people living with HIV/AIDS (PLWH/As) who were homeless and/or suffering from mental illness and/or substance use.
Agency of last resort for medically-underserved communities of color in Harlem.
• Part of community-based movement to care for PLWH/As• Founded to address lack of response from established providers; • Responding to the unique personal, social, and institutional
barriers to care in Harlem
Organizational StructureCOMMUNITY HEALTH SERVICES
Holistic Provider-Led, Patient-Centered Primary Care and Dental Services
Behavioral Health Services
Patient Navigation/Case
Management Support
INTEGRATED HIV SERVICES
Adult Day Health Centers
Food & Nutrition
Supportive Housing (Women’s Housing, Transitional Housing, Congregate, etc. )
Health Homes (COBRA) Case Management
Family Support
Community-Based HIV/STI/HCV Testing
Access to Care & Support Services
Drug User Health Services (Syringe Access, Harm Reduction, Recovery Support)
Black Men’s Initiative – integrated interventions for YMSM, YTG of color
New Business Development & Outreach Services
Access to Care (ATC) & Support Services
ATC Program DevelopmentNational HIV/AIDS Strategy
Reduce New HIV Infections Increase Access to Care and Improve Health Outcomes for
People Living with HIV Reduce HIV-Related Health Disparities Achieve a More Coordinated National Response to the HIV
Epidemic in the U.S.
Access to Care (ATC) Model Ensure access to and retention in medical care Provide support services needed to achieve optimal health
outcomes Facilitate re-entry into care and support services
ATC Program Development
• Testing team identified needs for Linkage to care (LTC) services for clients who tested positive
• LTC “ninja” was created
2007
Access to Care (ATC) & Support Services
Case Management
Services
Patient Navigation Services
Supportive Services
(Entitlements, Housing
Support, Tx Adherence,
Mental Health)
Outreach & Engagement
Activities
ATC Program Development
ATC Client Characteristics
75% Male, 24% Female, >1% Transgender
95% Black and HispanicPrimarily 35-54 years old65-75% Homeless/Unstably Housed40% HIV+, 15-20% AIDS diagnosis
ATC Program OverviewGOALS:
• To locate and engage out-of-care individuals into care and support services
• To ensure access and retention to medical care and support services
• To provide support services needed to achieve optimal health outcomes
• To navigate through initial medical care and connect to comprehensive case management
SERVICES:
• Supportive Case Management Services
• Patient Navigation & Reengagement Activities
• Support Groups (in English, Spanish & French)
• Connection to Medical Care & Support Services
• Psychosocial Assessments and Counseling (individual and group)
• Health Education/Risk Reduction Counseling
• Treatment Adherence Counseling (individual and group)
• Housing Placement Assistance (individual and group)
• Enrollment into ADAP/ADAP-Plus/APIC/Health Coverage
• Entitlements Assistance
ATC Program Current Model - Structure
Managing Director
LCSW
Program DirectorProgram
Coordinator, Case Management
ServicesCM I CM II
CM III CM IV
CM V CM VI
Program Coordinator,
Patient Navigation Services
PN I PN II
PN III PN IV
PN V PN VI
Program Coordinator, Support Services
Sr. Program Enroller
Housing Specialist I
Treatment Adherence Specialist
Housing Specialist II
Outreach Specialist
ATC Program OverviewProgram Flow
1. PATIENT NAVIGATION SERVICES
2. SUPPORTIVE CASE MANAGEMENT
2A. PSYCHOLOGICAL ASSESSMENT
Target Population(s):• HIV-Positive and High Risk HIV-Negative Homeless Individuals• High utilizers of emergency rooms and detox facilities• Undocumented Immigrants
Target Area(s):• Harlem• South Bronx
CLIENT IDENTIFICATION: Referrals,
Out-of-Care individuals, Community Outreach, Internal Referrals
CLIENT SEARCH:
Conduct record search: ePaces;
correctional databases;
eCW; HASA, AIRS, etc.
REENGAGEMENT:
Conduct home-visit, canvassing; phone calls;
letters; outreach to providers
SERVICE ORIENTATION:
If located, a service
orientation is completed and reconnection
begins
SCREENING:
Service Orientatio
n; Screening
for Insurance & Program Eligibility
INTAKE & ASSESSM
ENT:Service
Plan Developm
ent
SERVICE PLAN
Referrals; Verificatio
n of medical
appointment and
services
SERVICE PLAN
UPDATE:2 Medical
Appts; PCSM;
Reassessment; SP Update
CASE CLOSURE
:Connection to CM;
Case Closure
Summary
ASSESSMENT:Completion of Psychosocial
assessment by LCSW
CASE CONFERENCE:CM staff and LCSW; in service plan; engage client in short-term
counseling
INIDIVIDUAL COUNSELING:
3 - 5 sessions with LCSW with connection to psychiatry services where applicable
ATC Program Overview2B. ENTITLEMENTS
3. SUPPORTIVE SERVICES
SCREENING:If HIV+: Screen for ADAP/ADAP
PlusIf HIV-: Screen for Medicaid
APPLICATION:Verification of
inactive Medicaid;
Collect documentation for ADAP and
Medicaid.
APPLICATION SUBMISSION:
Submit Completed Application;
Verification of Application
CASE CLOSURE:
Ensure entitlement cards: Case
Closure Summary
HOUSING ASSISTANCE
• Housing Assessment• Housing Service Plan
Development• Individual
Engagements• Access to Educational
and Support groups
TREATMENT ADHERENCE EDUCATION
• Tx Adherence Assessment
• Development of Tx Adherence Service Plan
• Case Conference with Medical providers
• Individual Education• Access to Educational
and Support groups
SUPPORTIVE COUNSELING & RISK
REDUCTION PLANNING
• Minimum of 2 Risk Reduction Counseling Sessions
• Interim supportive counseling; minimum of two sessions
• Access to Educational and Support groups
ATC Program: OutcomesRetention in care ART Status
Non-ATC (n=78) ATC (n=78)0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
26%
12%
74%
88%
Retention rate among ATC and non-ATC clients
Not RetainedRetained
Non-ATC (n=58) ATC (n=69)0%
10%
20%
30%
40%
50%
60%
70%
80% 71%
39%
29%
61%
ART status among engaged ATC and non-ATC clients
Not on ARTOn ART
ATC Program: Outcomes
15%
85%
Viral load at baseline - ATC
Undetectable viral load(<400)Detectable viral load (>=400)
58%42%
Viral load at follow up - ATC
Undetectable viral load(<400)Detectable viral load (>=400)
33%67%
Viral load at baseline - Non-ATC
Undetectable viral load(<400)Detectable viral load (>=400)
42%58%
Viral load at follow up - Non-ATC
Undetectable viral load(<400)Detectable viral load (>=400)
ATC and Primary Care
Care CoordinationTeam meetings/daily roundsElectronic ReportsDaily communication between outreach and office
managersPN/Provider ProtocolsE-mails with daily reminders of appointment availabilityPatient Navigation/EscortsCase Management and ProvidersCommunication via electronic health record
Care Coordination
No show list• Extraction of no show list (i.e. list of
clients who consistently do not show up) from eCW
Monthly review
• Submit no-show list to ATC program coordinators monthly
• List is reviewed to determine clients in need of re-engagement activities
Re-engagement
• Patient Navigators conduct re-engagement activities for clients on no show list (e.g. phone calls, home visits, letters, etc)
• Patient Navigators connect clients to care (i.e. escorts, checking provider availability on eCW, tickler system)
Utilizing HU’s Electronic Medical Records, e-ClinicalWorks (eCW), to coordinate care:
Care coordinationTickler system in eCW:• Action items in “Review Actions” feature• Serve as communication tool between PN and clinic• Useful for clients who have chronic no-show issues
ChallengesDifficulty locating clients who are transient or homelessStaff training & development, buy-in, resistance to changePaperwork integration (difficulty in minimizing duplication)Program funded by 6 contracts (city and state) is challenging
to manage since funders have different core requirements, deliverables, expectations, and constraints
Multiple points of entryMultiple databasesEnsuring effective communication happens among all staff
during process of program developmentData entry issues (timeliness, not enough data entry support)
Best practices & Lessons learnedEmploying Harm Reduction modelClient-centered ApproachUsing Motivational Interviewing techniques to engage clientsLow threshold servicesUsing Daily Rounds to case conference clientsCollaborations with internal programs and external agencies
to recruit clientsOngoing staff training and developmentMinimizing duplication of intake and paperwork
throughout entire process
Stephen Crowe, ATC Managing Director scrowe@harlemunited.org
Liza Kasmara, Director of Program Evaluation lkasmara@harlemunited.org
Contact Info
References Baggett, T. P. et al. (2010). The unmet health care needs of homeless adults: A national study. American
Journal of Public Health, 100(7), 1326-1333. Barrett, B. et al. (2011). Assessing health care needs among street homeless and transitionally housed
adults. Journal of Social Service Research, 37, 338-350. Bunger, A. C. et al. (2010). Defining service coordination: A social work perspective. Journal of Social
Service Research, 36, 385-401. Carter, M. (2012). Majority of HIV-positive patients in US not receiving regular medical care. AIDS Map.
Retrieved from www.aidsmap.com/Majority-of-HIV-positive-patients-in-US-not-receiving-regular-medical-care/page/2228542/
Craw, J. et al. (2008). Brief strengths-based case management promotes entry into HIV medical care. Acquir Immune Defic Syndr, 47(5), 597-606.
Craw, J. et al. (2010). Structural factors and best practices in implementing a linkage to HIV case program using the ARTAS model. BMC Health Services Research, 10(246), 1-10.
Dudley, J.R. (2009). Social work evaluation: Enhancing what we do. Charlotte, NC: Lyceum Books, Inc. Findley, S. E. et al. (2012). Building a consensus on community health workers’ scope of practice: Lessons
from New York. American Journal of Public Health, 102(10), 1981-1987. Frerich, E. A. et al. (2012). Health care reform and young adults’ access to sexual health care: An
exploration of potential confidentiality implications of the Affordable Care Act. American Journal of Public Health, 102(10), 1818-1821.
Hwang, S. W. et al. (2010). Universal health insurance and health care access for homeless persons. American Journal of Public Health, 100(8), 1454-1461.
Torian, L. V. et al. (2011). Continuity of HIV-related medical care, New York City, 2005-2009: Do patients who initiate care stay in care? AIDS Patient Care and STDs, 25(2), 79-88.
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