engaging hard-to-reach populations in hiv care: empowering the patient
DESCRIPTION
This Webinar was the last of a three-part series synthesizing some of the successful practices in engaging hard-to-reach populations from SPNS population-specific initiatives. Speakers included: Dr. Angulique Outlaw from Wayne State University and the SPNS Young Men who have Sex with Men Initiative, discussing motivational interviewing Dr. Nikki Cockern from Wayne State University and the SPNS Young Men who have Sex with Men Initiative, discussing enhanced case management Dr. Margaret Hargreaves from Mathematica and Principal Investigator for the Latino HIV Care Best Practices Study, discussing engagement and retention of Latinos in HIV careTRANSCRIPT
Engaging Hard-to-Reach Populations: Empowering the Patient May 15, 2013
Agenda
Introduction to SPNS Integrating HIV Innovative Practices (IHIP) project Sarah Cook-Raymond, Impact Marketing +
Communications
Presentations from SPNS grantees Angulique Outlaw, Horizons Project Nikki Cockern, Horizons Project Margaret Hargreaves, Mathematica
Brief post-Webinar questionnaire
Q & A
IHIP Resources:Innovative Approaches to Engaging Hard-to-Reach Populations Living with HIV/AIDS into Care
IHIP Tools on Engaging Hard-to-Reach Populations Training Manual Curriculum Webinar Series
Outreach – April 18; see archive recording Inreach – May 1; archive recording to be up soon! Empowering the Patient - May 15
An Introduction to Motivational Interviewing (MI)
An Introduction to Motivational Interviewing (MI)
Angulique Y. Outlaw, Ph.D.Assistant Professor
Director of Prevention ServicesWayne State University School of Medicine
Horizons Project
Outline
• What Is MI?
• How Does MI Work?
• How Are We Using MI?
Why Is Change So Hard?• Lack of motivation from within a person
– People are not motivated by nagging or fear– Most people don’t change for another person– When pushed, people push back– Ambivalence (pros and cons)
• Lack of confidence (self-efficacy)• Lack of social support, role models• Life gets in the way!
What Do We Do To Try To Make Other Change?
• Given them Insight – if you can just make people see, then they will change
• Give them Knowledge – if people just know enough, then they will change
• Give them Skills – if you can just teach people how to change, then they will do it
• Give them Hell – if you can just make people feel bad or afraid enough, they will change
What Is Motivational Interviewing (MI)?
• Evidenced based intervention to promote health behavior change
• *MI is – Client-centered, – Goal-oriented approach – Focused on increasing intrinsic motivation
for change by:•Resolving ambivalence about different
potential courses of action •Increasing self-efficacy about change
*Miller & Rollnick (2002, 2007)
What Is MI?• A method of communication
– Not a specific session by session intervention
– Not a bag of tricks • Good communication at a micro-level• Making every word count• Develop rapport, understand the
client’s view• Elicit and reinforce any and every
communication about behavior change
Advantages Of MI
• Client-centered intervention• Can be performed by a variety
of staff members • Occurs in a natural setting• Ambivalence is addressed
What Does The Conversation Look Like?
•Empathic and warm•Listening and understanding•Expressing optimism and hope•Reinforcing specific strengths•Emphasizing personal choice and
responsibility•Offering menu of options•Discussing value-behavior incongruence
MI Elements
MI
MI Spirit
Change Talk
MI Principles
MI Methods (OARS)
MI Principles
• Express Empathy• Develop Discrepancy • Roll with Resistance• Support Self-Efficacy
The “RULE”s Of MI
•Resist the righting reflex
•Understand your client’s motivation
•Listen to your client
•Empower your client
Spirit of MI
• Collaborative (vs. Coercive)– Working jointly together
• Evocative (vs. Educational)– Elicit motivation, perceptions, goals, and
values
• Autonomy supportive (vs. Authoritative)– Self-directing freedom (Choice)
MI Methods
• Open-Ended Questions• Affirmations• Reflective Listening• Summaries
Change Talk
• Disadvantages of doing what you are doing
• Advantages of change• Optimism about change• Intention to change
Horizons Project
• Dedicated to providing HIV prevention services to at-risk youth and direct care services to youth living with HIV ages 13-24
• Is the only comprehensive HIV/AIDS program in Michigan focusing on youth
Continuum Of Care
Other Medical SitesServing HIV+
Youth
C&T Sites
Horizons C&T
Horizons CommunityOutreach
Horizons Field &Internet Outreach
Horizons Peer Advocacy
Horizons Case Finding:Agency/Field Outreach
Community Agenciesand Resources
Primary Medical CareMedical Specialty Care
Nursing ServicesHealth Education
Adherence SupportSocial Work ServicesCase ManagementOngoing Advocacy
MentoringConsumer InvolvementTherapeutic Activities
TransportationPsychological Services Psychiatric ConsultationEducation and Training
MI for RetentionPrevention Services
(MI and Group)
HorizonsClinical
Care Team
HIV+
HIV+
How We Use MI
• Single session (30 minutes) – As part of field outreach to encourage HIV
C&T
• Single session (30 minutes)– At initial appointment or first return to
care appointment focused on engagement and retention in care
– Focused on adherence to antiretroviral therapy (initiation and maintenance)
– Focused on risk reduction
MI Computer Applications
• *Motivational Enhancement System for Sexual Risk & Adherence– MISTI (Sexual Risk)(Feasibility study)
• Single session face-to-face or computer delivered intervention
– MISTI-II (Sexual Risk) • Two session computer delivered intervention (Baseline
and 3 months)
– MESA (Adherence)• Two session computer-delivered intervention (Baseline and 1 month)
*adapted by Ondersma et. al
To Sum Up• Remember MI Elements
– Spirit• Collaboration, Evocation, & Autonomy
– Principles• Express Empathy, Develop Discrepancy, Roll
with Resistance, & Support Self-Efficacy
– OARS• Open-Ended Questions, Affirmations,
Reflective Listening, & Summaries
To Sum Up• Remember MI Elements
– Change Talk•Disadvantages of Staying the Same,
Advantages of Change, Positive Things About Change, & Intention to Change
MI Resources
• Motivational Interviewing (2012, 2007, 2002) Miller and Rollnick
• Motivational Interviewing with Adolescents and Young Adults (2010) Naar-King & Suarez
• www.motivationalinterviewing.org
Thank You!!
Engaging & Retaining Youth in Care
Engaging Hard To Reach Populations – HRSA
Webinar
Nikki Cockern, PhDAssistant Professor
Clinical Care ManagerWayne State University School of Medicine
Horizons ProjectMay 2013
Issues of Adolescence
• Trust
• Often not ready to change, not motivated
• Lack of impulse control
• Rebel against prescriptive approaches – educational, skills building, traditional counseling
• Physical Changes (thanks to puberty)
• Peak of peer involvement and peer norms
• Heightened experimentation
What’s Unique about Adolescents?
Environment-vitally important
Separation/individuation • Identity formation as separate from authority
figures • Translating personal goals into behavior within a
constrained environment• Mood fluctuates• Trying to figure out who they are and try
different roles
Communication skills are still developing
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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Engagement Strategies
“One-stop shopping” & multidisciplinary approach to HIV care, that is youth sensitive & culturally competent. Meeting youth “where they are” and focusing on building relationship
Intensive Case Management Services Identification of needs (initial & ongoing) Development of comprehensive service plan, including strategies for implementation Coordination of care & services
Mental Health/Psychosocial Services
Client Advocacy
Transportation
Treatment Adherence Program
Lost to Follow-Up (L2FU) Program
Use of Multi-media tools
Horizons Project Enhancements
• Advocates assist youth in enrolling and remaining in care• Rapid linkage into care
• Intake and medical appointments are provided within the first week of contact
• Youth often receive resources prior to their med visit• Direct linkage & support to ancillary care services and
resources• Motivational Interviewing is offered• Multi-modal contact to youth in preferred medium (i.e.
phone, text, email, Facebook inboxes)• Jam Sessions (support groups) • Transportation to ‘life critical’ services (DHS)
• Provide a link to advocacy services if youth do not want to enroll in medical care
• Actively Promote Consumer Involvement
Horizons Project Modifications
• Quickly establish and maintain rapport• Highlight and vitally protect confidentiality, while treating each with dignity and
respect• Contact with youth is consistent, yet at varied times and amongst several staff• Staff is available outside of typical “working hours/days” and can be reached via cell
and email daily
• Patient advocacy is vital to keeping youth connected and meeting their needs• Staff often accompany youth to other necessary medical and ancillary care
appointments (i.e. DHS, colposcopy, Dental, GYN, etc.)• Phone contacts for transportation to clinical and ancillary appointments, JAM sessions,
other care related activities
• Decrease barriers to access services• Increase frequency of medical clinics held, so more appointment slots are available (including
separate day youth can come in for treatment)• Reserved new patient and sick patient slots during each clinic session• Combined mom/baby or family clinic sessions to decrease the frequency of visits parents
have to keep• Use of laptops in medical clinic in order to complete on-line applications for insurance and/or
supplemental coverage programs
• Provide incentives for improved adherence• i.e. keeping appointments, reducing drug use ,decreasing incidence of STIs, etc. (works with
mental health team)
• Provide lost to follow-up outreach • i.e. phone calls, letters, and home visits (MI)
L2FU Program Protocol
1. Maintain ListIdentify youth who
missed clinic appt. & not
able to reschedule
4.3rd month
Home Visit
5.Contact made w/
Client & clinicvisit scheduled
OrRepeat
2.1st month aftermissed clinic
visit. Advocate attempts
Contact via phone/text
3.2nd month Mail postCard sent
MI via phoneMI @ HV if
contact made
MI @ point of contact & @ clinic appt.
Social Media ToolsGeneral Information and linkage to Horizons Project
and Community Services• Horizons Project Website:
http://peds.med.wayne.edu/horizons
Horizons specific information and events/activities• FaceBook • Twitter
Adherence to Appointments & ARV regimenText Messages (regular, timed texts for youth starting meds &
those w/sig adherence problems) (appointment reminders & check ins)
Email invites on the spot for upcoming med visits w/alarm
Private inbox message through Facebook
Suggestions for Programs Working with Adolescents
Summary One stop shopping, multi-disciplinary team approach to
care• Clinical Services, including intensive case management• Psychosocial Services
Engagement & Retention Strategies include:• Rapid Linkage to Care• Multiple clinic sessions options• Practical and Concrete Support for accessing resources• Peer Advocacy, access to support outside conventional
time • Transportation• Treatment Adherence Program• L2FU Program• Use of social media tools
Staff Acknowledgement
Director of Medical Service and Research: Elizabeth Secord, MDDirector of Prevention Services: Angulique Outlaw, PhDConsultant for Psychological Services and Research: Sylvie Naar-King,
PhDATN Behavioral Research Coordinator: Monique Green Jones, MPHATN Clinical Research Coordinator: Charnell Cromer, MSNClinical Care Manager: Nikki Cockern, PhDClinical Nurse Practitioner: Debbie Richmond, NPClinical Social Worker: Tiffani Hollowell, CMSWCare Coordinator/Case Manager: Keshaum Houston, BSAdolescent Consultant: Jessica Daniel, MPHMSM Prevention Coordinator: Jeremy ToneyMSM Outreach Workers: Bre’ Campbell, David PerrettATN C2P Coordinator: Emily Halden Brown, MPP ATN Research Assistant: Cindy Chidi, BSATN Linkage to Care Specialist: Valentina Djelaj, LLMSWATN 110/117 Outreach Coordinator: Bryan Victor, MSWFisher HRH Prevention Coordinator: Te’Neice Dobbins, BS
Thank you!—Questions/Comments
?
Nikki Cockern, PhD; 313.745.4892; [email protected]
http://www.peds.med.wayne.edu/horizons
Latino HIV Best Practices: Improving Access, Engagement and
Retention in Care May 15, 2013
Engaging Hard-to-Reach Populations – HRSA Webinar Margaret Hargreaves, Ph.D., M.P.P.
Review of the literature– Impact of HIV/AIDS epidemic on Latinos– Evidence of effective practices for engaging and
retaining HIV-positive Latinos in HIV care
Site visits to 10 exemplary sites– 6 States selected for study– 10 sites selected across 6 states– 1 to 1.5 day site visits by bilingual teams
Analysis of sites’ 2009 RDR and 2010 RSR data– Racial/ethnic analysis of client characteristics, service
use, and clinical outcomes
Study Methods
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– CARE Resource, Miami, FL– CommWell Health, Dunn, NC– Elmhurst Hospital Center – ID Clinic, Brooklyn, NY– Centro de Salud Familiar La Fe, El Paso, TX– Miami Beach Community Health Center – Immune
Support Program, Miami, FL– Mission Neighborhood Health Center – Clinica
Esperanza, San Francisco, CA– Montefiore AIDS Center, Bronx, NY– San Ysidro Health Center – CASA, San Ysidro, CA– Valley AIDS Council, Harlingen, TX– West Side Community Health Center – Clinic 7, St.
Paul, MN
Selected Sites
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Site Locations
7 Federally Qualified Health Centers (FQHCs), 2 hospital outpatient departments, 1 AIDS service organization
RWHAP Funding: Parts A, B, C, D, F, MAI, SPNS
Populations served: Mexico, Caribbean, Central America, South America, Migrant farm workers
HIV clients served: 160 clients - 2665 clients
Percentage Latino clients: 20 – 80 percent
Site Characteristics
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9 providers prescribed HAART to Latino clients at same or higher rate than non-Latinos
4 providers conducted CD4 counts for over 90% of Latino clients in the last year; another 3 providers conducted CD4 counts for over 80% of Latinos in the last year
3 providers conducted viral load tests for over 90% of Latino clients in the last year; another 4 providers conducted viral load tests for over 80% of Latinos in the last year
Sites’ Quality of Latino HIV Care
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Barriers to Latino access, engagement, and retention in HIV care identified at five levels– Individual – Clinician– Organization– System– Community
Total of 43 strategies were used by HIV providers to address identified barriers to Latino access, engagement, and retention in HIV care
Barriers and Strategies
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– Help completing applications and obtaining eligibility documentation for Medicaid, Medicare, ADAP, SSA, Ryan White, SNAP (n=10)
– Referrals for social services, including food and housing assistance, domestic violence services, legal aid, immigration services (n=10)
– Transportation assistance, including vans and metro/bus cards (n=9)
– Targeted Latino support groups for MSM, women, transgender, Spanish speakers, hepatitis C, treatment adherence, substance abuse, domestic violence, HIV education (n=8)
Strategies to Address Individual-level Barriers
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– Peer health educators, peer counselors, buddies, who provide health education, system navigation, social support, and client advocacy (n=7)
– Reinforcement of treatment adherence messages geared to client literacy levels, using reminder calendars, pictures, symbols, color codes, pill boxes, key chains, directly observed therapy, literacy lessons (n=7)
– Home or clinic delivery of HIV medications by pharmacy or clinic staff (n=3)
– Client social groups, knitting, arts, crafts (n=3)
Individual-level Strategies, Cont.
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– Knowledge of traditional home remedies, foods, cultural values, religious beliefs, differences among Latino subpopulations (n=10)
– Showing warmth, respect, friendship to clients and their families; having a passion for the work (n=10)
– Fluent Spanish speakers, interpreter lines, translation support from bilingual staff, certified interpreters (n=10)
– Staff “willing to go the extra mile” for clients (n=7)
– Home visits, hospital visits, long-term follow-up (n=7)
– Mostly Latino/Hispanic staff (n=5)
– Avoidance of culturally loaded terms such as gay, mental health, and psychiatry (n=5)
– Training in cultural competency (n=3)
Strategies to Address Clinician-level Barriers
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– Comprehensive one-stop shop of HIV ambulatory outpatient care and supportive services (n=10)
– Flexible scheduling, double-booking, walk-ins, open slots for emergencies (n=10)
– Clinic materials in Spanish (signs, notices, videos, website, brochures, medication labels, posters) (n=10)
– Frequent appointment reminder calls, missed appointment follow-up calls, free cell phones to receive reminders (n=9)
– Close tracking of visits, labs, medications, and contact information for treatment adherence and retention purposes (n=9)
– Client confidentiality policies and practices (n=8)
Strategies to Address Organization-level Barriers
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– Universal screenings for mental health and/or substance abuse to reduce treatment stigma (n=7)
– Discreet name and location of clinic (n=6)– Long appointment times for visits with clinicians, case
managers, and counselors (n=6)– Multidisciplinary teams, team meetings, patient
briefings, case conferences (n=6)– Expanded clinic hours, evening hours (n=5)– Comfortable, home-like environment (n=3)– Offices arranged to facilitate staff/client interaction
and communication (n=3)– HIV clinician team includes specialists (i.e.,
dermatology, OB-GYN) (n=3)
Organization-level Strategies, Cont.
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– Network of client referrals from Latino-serving organizations; no wrong door entry into system (n=10)
– Partnerships, consortia, and collaborations of Latino-serving organizations (n=8)
– HIV care tracking and coordination across inpatient/outpatient settings, agencies, states, U.S./Mexican border (n=7)
– Latino representation on HIV prevention and treatment planning councils (n=6)
– Health policy or funding advocacy for Latino HIV services (n=5)
– Expedited, client hand-offs among testing, linkage, bridge, and retention services staff (n=4)
Strategies to Address System-level Barriers
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– Targeted outreach to Latino subpopulations—MSM, women, incarcerated, transgender, migrants, undisclosed MSM (n=9)
– Discrete identity of outreach and linkage staff to protect client privacy (n=7)
– Pride events and Latino celebrations to reduce stigma (n=6)
– Regional HIV conferences and retreats to improve HIV care (n=4)
– HIV talks to community groups, in churches, on radio, TV (n=3)
– Latino theatre troops to increase awareness of HIV (n=2)
Strategies to Address Community-level Barriers
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Some strategies are linguistically or culturally specific to Latino populations
Some strategies address barriers common to underserved populations
Some strategies cost little or nothing to start
By addressing barriers, providers can reduce or eliminate disparities in Latino access, use, and retention in HIV care
Preliminary Conclusions
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Q&A
Twitter: @impactmc1| Facebook: ImpactMarCom |www.impactmc.net | 202-588-0300
Connect with UsSarah Cook-Raymond, Managing Director |Impact Marketing +
Communications |
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