ltc strategies for cbo's - lara jackson
TRANSCRIPT
Importance of Linkage NHAS Goal #2: Increase access to care and optimize health outcomes for people living with HIV◦ Step 1: Establish a seamless system to immediately link people to continuous
and coordinated quality care when they learn they are infected with HIV. ◦ Linkage: 65% 85%
“Some studies show that persons who stay in care during their first year of outpatient HIV medical care are more likely to start ART than persons with early lapses in care, have high adherence to ART, achieve virologic suppression, and practice safer sexual behaviors.”
◦ CDC HIV Prevention Guidelines, 2014
HPTN 065: TLC-PLUS: FEASIBILITY OF AN ENHANCED TEST, LINK-TO-CARE PLUS TREAT APPROACH FOR HIV PREVENTION IN THE US.: BERNARD M. BRANSON, MD; AUGUST 2010
HPTN 065: TLC-PlusTest
Adoption of safer behaviors
Enroll in Care
Maintain viral suppression
Decrease in HIV Transmission
Treat
HIV PositiveLINKAGE TO CARE
Initiation of ART
Adherence to ART
Testing
Positive Prevention
96%Varies
Stage One: Plan Identify an area for improvement
Recruit your team
Study your current processes and results
Determine your aims
Establish your measures
Select a change
Brainstorm alternatives
Develop an action plan and M&E process
Types of Change Improve Work Flow Change the Work Environment Client Interface Focus on Variation
Error Proofing Time Management Eliminate Waste Optimize Inventory
Stage Two: Do Implement the action plan on a small scale and/or timeline
Collect data
Document successes and challenges - qualitative
Assess system impact
Stage Four: Act Refine the change, based on data & reflection
Standardize the change
Monitor to ensure ongoing success
Share your results
Return to Step One: Plan
Throwing out the bucket…IMPROVEMENT
Process
Acceptance of baseline
Reversible
Superficial
TRANSFORMATION
System
Baseline is problematic
Irreversible
Profound
Missed Connections: HIV-infected People Never in Care
Top five reported reasons for not entering care◦ 57% - Lack of money or health insurance
◦ 97% had income <300% of FPL◦ 55% - Not wanting to think about being HIV-positive◦ 55% - Feeling good and healthy◦ 45% - Feeling depressed◦ 43% - Not wanting to disclose HIV-positive status
Bertolli J, Garland PM, Valverde EE, Beer L, Fagan JL, Hart C. Missed Connections: HIV-Infected Persons Never in Care. Public Health Reports. 2013;128(2):117–26.
Missed Connections: HIV-infected People Never in Care
Top two factors reported as making care entry more likely ◦33% - Sufficient money or health insurance◦31% - Feeling sick
Bertolli J, Garland PM, Valverde EE, Beer L, Fagan JL, Hart C. Missed Connections: HIV-Infected Persons Never in Care. Public Health Reports. 2013;128(2):117–26.
CTR Experience of HIV+ persons who never entered medical care…
Satisfied◦ Prenatal clinic, drug treatment facility, or CTR site◦ Provided with sufficient education or information after receiving
results◦ Level of comfort and support provided by the person conducting
the HIV test
Garland PM, Valverde EE, Fagan F, Beer L, Sanders C, Hillman D, et al. HIV counseling, testing, and referral experiences of persons diagnosed with HIV who have never entered HIV medical care. AIDS Educ Prev. 2011;23(Suppl 3):117–127.
CTR Experience of HIV+ persons who never entered medical care…
Dissatisfied◦ STD clinic, inpatient facility, private doctor’s office or infectious disease clinic◦ Perceived lack of counseling, insufficient counseling, poor quality of counseling◦ Inadequate information or missing information
What could have been done differently?◦ More counseling at diagnosis: “They could’ve sat down and really talked to me
about it.”
Garland PM, Valverde EE, Fagan F, Beer L, Sanders C, Hillman D, et al. HIV counseling, testing, and referral experiences of persons diagnosed with HIV who have never entered HIV medical care. AIDS Educ Prev. 2011;23(Suppl 3):117–127.
Sources of information Qualitative feedback
Linked clients
Returning-to-care clients (out-of-care)
Consumer advisory board/Peers
Testers
Mystery shopper
Examples of ImprovementINFORMATION: MESSAGING
Purpose of and importance of entering HIV care as soon as possible
Existence of insurance, care & medication support programs
Existence of support services for transportation, food, benefits management, etcetera
Messaging◦ Determine
◦ Who (delivers/receives)◦ Just testers? Follow-up call? Receiving agency?◦ All positives? Different for new versus repeat? High-risk negatives?
◦ What & how?◦ Brief, positive, easy-to-understand (but not patronizing), and consistent◦ Run it by consumers
◦ Training & Monitoring◦ Tracking & Evaluation
Example Benefits of entering care
◦ Studies show that people who enter care soon after testing positive are far more likely to live long, healthy lives than those who delay.
◦ There is treatment available to keep you well and also reduce your risk of passing HIV to one of your partners.
◦ Some people put off visiting a medical provider until they feel sick, which hurts their chances of full treatment success because HIV is doing harm to your body even if you can’t feel it.
◦ We recommend that everyone who tests positive complete at least one visit with a medical specialist within 90 days of testing to confirm your diagnosis, evaluate where you’re at, and discuss your options for moving forward.
Example Services available to help enter care
◦ There are programs and funds available to help those who test positive to access treatment, including support with insurance, medication, housing, and other benefits.
◦ Even if you decide to delay medical treatment, we recommend you meet with a case manager to determine what sort of benefits are available to you and how to take advantage of them.
Examples of ImprovementCOUNSELING: APPROACH
Trauma-informed◦ Understanding stigma – racism,
homophobia, transphobia, mental illness, drug use, poverty, etcetera
Motivational Interviewing◦ ARTAS◦ Stages of Change
Examples of ImprovementACTIVE VERSUS PASSIVE
Preparation◦ Relationships
◦ Coordination vs. collaboration◦ Resource Guide
Facilitating the connection◦ Menu of options◦ Hierarchy of needs◦ Making the call
Follow-through◦ It’s not over ‘til it’s over
Examples of ImprovementFIRST IMPRESSION
New patient friendly Red carpet treatment Orientation Online information
Examples of ImprovementCARE TEAM COORDINATION
Huddles to discuss new patients
Linkage/navigation specialist