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in+care CampaignWebinar

February 12, 2013

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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

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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 MANQC Manager

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Improvement Strategies Discussion

Participant Submissions• 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

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Submit Improvement Updates!

A Project of the Alamo Area Resource Center

THRIVE

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.

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:

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: 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

Active Street Outreach Street corners Convenient stores Local Bars

Fixed Site Outreach Homeless Shelters Correctional Facilities

Residential Outreach Notice of Visit

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

Other Activities: 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

therapyPsychological symptoms and severityHousehold dynamicsSubstance 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 ClinicsClient 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

Upon completion of the Milestones, clients mustdemonstrate a decrease in needs, maintainmedical adherence, and an increase towards selfsufficiency to transition out of the Thrive Programby: 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.

Early Intervention Services of South Texas (EIS)

65.29

20.72

11.980.67

0.89

1.56

2012 Ethnicity Statistics

Hispanic (65%)

African American (20.72%)

Caucasian (11.98%)

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 16Total 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

VIA Bus Shelters Junior Poster Billboards Posters Advertising in local

Publications Commercials HIV/AIDS National

Awareness Days Community Events and

Health Fairs

Marketing Determined by:

Zip 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 ComponentThe cooperation of the medical providers The program designPeer Treatment Advocate ProgramDedicated StaffMarketing CampaignClient’s dedication and success

For Programmatic or Marketing InformationContact:

Randy Hinkle, Programs Manager– 210-358-9893- randyh@aarcsa.com

For Client ServicesContact:

Jesús Ortega, Director of EIS– 210-358-9639- jesuso@aarcsa.com Kristin Thompson, EIS Case Manager- 210-358-9502-

kristint@aarcsa.com Loraine Diaz, EIS Specialist– 210-358-9505- lorained@aarcsa.com Jacob Wasonga, EIS & Re-Entry Specialist– 210-358-3758-

jacobw@aarcsa.com

www.aarcsa.com/thrive thrive@aarcsa.com

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Time for Questions and Answers

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Let us know your experiences in the chat room!

How do consumers in San Antonio view Project THRIVE?

Speaking from Experience:Retention on a Patient-by-Patient Basis

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Let us know your experiences in the chat room!

What things do staff members for a program like Project

THRIVE need to know about local people with HIV to do

their job?

Speaking from Experience:Retention on a Patient-by-Patient Basis

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Let us know your experiences in the chat room!

What is the relative strength of a Milestones-based approach

rather than a fully individualized service plan?

Speaking from Experience:Retention on a Patient-by-Patient Basis

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Announcements

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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!

• Campaign Webinar: Patient Experience Evaluation and RetentionTo 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

Upcoming Events

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• Campaign Office Hours: Mondays & Wednesdays 4-5pm ET

• 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

• Data Collection Submission Deadline: April 1, 2013

• Improvement Update Submission Deadline:February 14, 2013

Upcoming Deadlines and Office Hours

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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:• 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 michael@nationalqualitycenter.org 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 floorNew York, NY 10007Phone 212-417-4730incare@NationalQualityCenter.org

incareCampaign.orgyoutube.com/incareCampaign