Integrating Prevention, Care and ADAP - nastad

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Jul 31, 2015 - to us social media to spread the word to their social networks ... have elevated interest in CHWs (CDC, C
Integrating Prevention, Care and ADAP Outreach, Retention and Adherence Strategies for Black and Latino Gay Men Strategies

Friday, July 31, 2015

Chad Hendry, Manager of Disease Intervention Services, Howard Brown Health Centers

Abby Charles, iPHI, Senior Manager, Community Connectors Program Courtney Coffey, iPHI, Program Manager, We Connect

Community Based Partner Services Chad Hendry Manager of HIV/STI Partner Services Howard Brown Health Center

Our Mission Howard Brown exists to eliminate the disparities in health care experienced by lesbian, gay, bisexual and transgender people through research, education and the provision of services that promote health and wellness.

All programs are designed to promote services in a confidential, supportive, and nurturing environment.

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Brown Elephant Resale Shops

Older Adult Services

Medical Services Behavioral Health Services

Today, Howard Brown is one of the nation’s largest LGBT organizations, serving more than 27,000 adults and youth each year through its eight main programs

Youth Services (BYC)

HIV/STD Prevention

Research Women’s Services

Funding HBHC has diversified sources of funding and support, that include billable services (primary care and mental health), donations, resale retail (Brown Elephant), 340B pharmacy, and a variety of grants incl. gov’t grants, such as: • Ryan White Parts A, B, C,D • HRSA – SPNS (TWOC) • Chicago Department of Public Health • Illinois Department of Public Health • Centers for Disease Control and Prevention

HIV Prevalence in Chicago, Courtesy of AIDSVu • HBHC 3 clinical care sites in 60613 and 60657

Four zip codes with highest HIV prevalence in Chicago • • • •

60660: 60640: 60613: 60657:

2.6% prevalence 2.9% prevalence 2.8% prevalence 2.1% prevalence

Increased Access to Walk-In Services Based upon self reported income, we operate our walk-in clinic on a sliding scale which ranges from $0-$150. The following services are included regardless of your ability to pay.

• • • • • • • • • •

HIV Testing and Counseling Couples Based HIV testing and Counseling Syphilis Testing and Treatment Urogenital Chlamydia and Gonorrhea Testing and treatment Pharyngeal and Rectal Chlamydia and Gonorrhea Testing and treatment Hepatitis A, B, and C Testing Vaccinations for Hepatitis A & B, Meningitis TB Testing Pregnancy Testing PEP

What is Partner Services(DIS)? Partner Services interview persons infected with STD/HIV to elicit information about their partners and social contacts. These partners and contacts can then be confidentially notified of their possible exposure or potential risk. Partner Services also fulfill other functions: • Prevention counseling

• Testing for HIV and other types of STDs, hepatitis screening, and vaccination • Treatment or linkage to medical care • Linkage or referral to other prevention services • Linkage or referral to other services (e.g., reproductive health services, prenatal care, substance abuse treatment, social support, housing assistance, legal services, and mental health services).

History of Partner Services Program at Howard Brown • 2002 - funded by CDPH to hire 1 full-time DIS to provide Syphilis Case Management - Improve Cultural Competency - Increase % of new cases interviewed - Build an Innovative Partnership - Case Review Done by CDPH

• April of 2006 – Case Review and Supervision transferred to HBHC Staff – Manger of Disease Intervention • Currently we are funded to do HIV, Syphilis and Gonorrhea Partner Services

Why Howard Brown? • Existing good relationship with Chicago Department of Public Health doing HIV testing and providing HIV care

• In 2001 Chicago saw a significant rise of Syphilis cases. A large number of those cases were being diagnosed at Howard Brown. • CDPH had a lot of challenges working with MSM. A high number of MSM cases were UTL. For those that were interviewed the number of partners elicited was very low.

What makes us different from the local health department? • DIS model is fully integrated in the medical clinic – Partner Services Interview is seen as part of the standard of care • Interview technique • Cultural Competency – Our team at Howard Brown reflects the communities that we serve. We believe members of the community can best help the community. • Flexibility in how we conduct our disease intervention notifications

• Clinic based DIS/Partner Services program vs. Surveillance based

HIV/STI Prevention Team

Integrated Partner Services and Linkage to Care • Partner Services meets with all patients diagnosed with HIV at the time of their diagnosis. • We conduct linkage to care activities including scheduling and ensuring the patient makes their first medical appointment. Typically with in 72 hours. • We meet with the patient at the time of their first medical appointment and introduce them to their case manager. • We conduct partner services interviews with the patient at the time of diagnosis or at the first medical appointment.

What are the benefits of integrated PS and LTC? • Limited number of interactions with staff during what could be a very difficult time. • The patient is linked to care within 72 hours of the time of diagnosis. • Expedient partner services with no follow up required by the health department. • For patients co-infected with Syphilis or Rectal Gonorrhea, we concurrently conduct the partner services interview during the HIV partner services interviews. This allows the patient to have less interactions. • We link the patient and their partners to any additional services or treatment that may be needed.

Syphilis Cases in 2014

2014: 422 cases • 389 cisMSM • 2 HETcismen • 1 cisMSTF • 25 transwomen • 5 HETciswomen

Total Syphilis Cases, HBHC, 2007—2014 450 400 350 300

Primary: 72 Secondary: 100 Early Latent: 173 Latent: 77

250 200 150

=82% confirmed incident infections

100 50 0 2007

2008

2009

2010

2011

2012

2013

2014

Syphilis Testing and Positivity, 2014 Howard Brown Health Center, Syphilis Testing, 1/1—12/31/2014 All syphilis tests

Cisgender MSM

Transgender women

All others

13,057 tests (100%)

9677 tests (74.1% of all tests)

701 tests (5.4% of all tests)

2,679 tests (20.5% of all tests)

23.3% reactive (3,042 tests)

28.2% reactive (2,730 tests)

22.1% reactive (155 tests)

4.7% reactive (126 tests)

3.2% NEW reactivity (422 syphilis cases)

4.0% NEW reactivity (393 syphilis cases)

2.9% NEW reactivity (21 syphilis cases)

0.2% NEW reactivity (8 syphilis cases)

Syphilis Cases at Howard Brown

Syphilis New Case Positivity 1st & 2nd Quarter, 2015

Syphilis Cases by Race 1st & 2nd Quarter, 2015 80

Total Tests

70 60 50

White

74 72

40

65

30 20 10

8

0 White

African American

Hispanic

Asian Pacific Islander

New Syphilis Positivity Cases Rate

5955

74

1.2%

African American

963

72

7.5%

Hispanic

1235

65

5.3%

294

8

2.7%

Asian/Pacific Islander

HIV Cases at Howard Brown

HIV Cases by Race

HIV New Diagnoses

1st & 2nd Quarter, 2015

1st

&

2nd

Quarter, 2015 (Identified by HBHC)

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Total Tests

30 25

White

29

Reactive Tests

Positivity Rate

2983

29

1.0%

990

19

1.9%

1306

19

1.5%

371

3

0.8%

20 19

15

African American

19

Latino

10

5 3

0 White

African American

Hispanic

Asian/Pacific Islander

Asian/Pacific Islander

African Americans and Hispanics are disproportionately affected by HIV across the board, but even higher if you break it out by MSM.

Partner Services and Outreach Engagement Strategies • Work with club promotors • Hosted a Ball “Back2Basics” which offered raffles prices, testing, linkage to and reengagement in care. • Offering vaccinations and testing in traditionally underserved areas • Meeting the clients where they are at (hang out, spend time, live) • Outbreak Response of Meningitis - Patients who received the Meningitis vaccination were asked to us social media to spread the word to their social networks (examples #Vaccinatenow, #HowardBrownHealthCenter etc.) • Social Networking Strategy

Acknowledgements • HBHC Partner Services Department • Daniel Pohl, Rolando Renteria, Phillip Prado, Kristen Bunting, Erick Nava • HBHC Clinical Department • HBHC Outreach Team

• Chicago Department of Public Health • Illinois Department of Public Health

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Thank you for having me! Chad T. Hendry Manager of HIV/STI Partner Services Howard Brown Health Center 4025 N Sheridan Road. Chicago, IL 60613 PH 773-388-8931 Email: [email protected]

Community Agents for Linkage and Retention in Care

Abby Charles and Courtney Coffey Institute for Public Health Innovation

July 31, 2015

Presentation Objectives • Describe a public health intervention incorporating CHWs with various health systems. • Identify current opportunities to build the communitybased public health workforce for prevention, care, and ADAP. • Share lessons learned.

Twitter: @InstitutePHI 28

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NASTAD Presentation

Our Mission We build partnerships across sectors and cultivate innovative solutions to improve health and wellbeing for all people and communities throughout DC, MD and VA, particularly those most affected by health inequities.

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The Opportunity to Strengthen and Scale CHW-Based Preventive Health Services • There’s a strong evidence base for CHW-based interventions as a means for improving population health and strengthening cost-effective health care. • National policy changes and demonstration projects have elevated interest in CHWs (CDC, CMS, HRSA, Dept. of Labor, etc.).

• In the DC, MD, and VA region, there is a strong foundation of CHW training and CHW-based service delivery, but the services are currently not well financed or sustainable.

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Community-Based HIV/AIDS Prevention & Care Services by NonLicensed Professionals            31

Prevention outreach HIV testing Supportive counseling Social support Treatment adherence support Disease self-management support Home visits and home-based support Service system navigation Care coordination Linkage to services to address basic needs Cultural liaison (may incl. language services) 7/31/2015

NASTAD Presentation

What is Distinctive About Community Health Workers (CHWs)? • Expertise is based on shared life experience (often culture, community, and health) with people served. • Relate to community members as peers rather than purely as clients or patients. • Rely on relationships and trust more than on clinical expertise. • Do not provide clinical care. • Generally do not hold a professional license. • Can achieve certain results that other professionals cannot.

Acknowledgement: Carl Rush, Community Resources LLC

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IPHI’s Role Creating Sustainable CHW Models • CHW workforce and integrated care

team training

Developing Adapting Implementing Evaluating

CHW program models across the region to create best practices for the region.

 300+ CHWs trained  32 CHW jobs created  24 CHWs directly employed by IPHI  > 1500 people enrolled in CHWbased HIV services since 2011  Launched CHW professional associations in DC, MD and VA

• Creating partnerships with CBOs,

medical providers, and Medicaid MCOs to test CHWs as a business strategy • Facilitating state-level CHW policy development in DC, MD and VA

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The Approach to our CHW initiatives • FT Community Health Workers placed across clinical and community settings: – Identifying and (re)engaging PLWH – Building peer-based trust and knowledge – Providing personalized assistance to navigate systems, supporting PLWH throughout early part of care – Assisting access to other resources to address barriers to accessing care  Consistent training across sites  CHWs integrated in multidisciplinary teams at hospitals, clinics, CBOs,

MCOs & health departments  Systematized use of peers across DC, MD and VA  Multi-cultural team of CHWs working across populations

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Targeted Individual and Structural Outcomes Engagement and retention in HIV care Reduced viral load Improved health and QOL

Individual health outcomes

Community health outcomes

Health systems change

Reduced community viral load 35

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New HIV care models Strengthened/ expanded community health workforce

NASTAD Presentation

Case Example: The Need for a Scaled HIV/AIDS Intervention in the District of Columbia ● DC’s HIV/AIDS epidemic is highly generalized  3-5% of total population are estimated to be HIV-positive  Higher % of people with HIV/AIDS in high poverty areas: • Approx. 5.2% heterosexuals (non-IDU) • Approx. 6.3% of women (non-IDU) ● In 2010 when the intervention was designed, nearly half (46%) of all PLWH/A had not received HIV care in last 12 months ● High viral load affects both individual health/QOL and likelihood of further transmission

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The Positive Pathways Intervention Model Individual focus: ● Linkage and retention in HIV care services using CHW-based model for African-Americans, particularly females and their partners, in particular neighborhoods ● 12 CHWs placed across 8 community-based support service organizations and HIV medical care providers Structural focus: ● Change in service system at community and org levels ● Focus on building the CHW workforce  Community-level CHW training  Collaborative work to formalize the CHW workforce  Creation of CHW Professional Association of DC

● Finance reform as a sustainability strategy

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Case Example: The Need for a Regional CHW Intervention in Northern Virginia  Linkage and retention in HIV care services using CHW-based model for PLWH In Northern Virginia (specifically Fredericksburg, Winchester & Arlington Counties)  4 CHWs placed across 4 community-based support service organizations and HIV medical care providers  Ryan White EIS funding and CDC HIV Prevention funding through VDH  CHWs work closely with case managers to identify clients for recruitment, and throughout the development of the care plan for the client in the intervention  Through P4P, CHWs are strongly connected to the VDH CAPUS project and are trained to work closely with DIS workers

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Case: Regional Ryan White Funded CHW based EIS project  Linkage and retention in HIV care services using CHW-based model across the DC HIV EMA (Montgomery County and Prince George’s County Maryland, Northern Virginia & Washington, DC)  6 CHWs placed across 7 community-based support service organizations and HIV medical care providers  Ryan White EIS funding  CHWs work closely with case managers to identify clients for recruitment, and throughout the development and implementation of the care plan for the client in the intervention.  Support groups integrated into the intervention

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Shared Measurement  Mutually agreed upon individual and community measures  Medical care (re)engagement and timing  Individual viral load and CD4 changes  Community viral load

 Shared responsibility and systems for data collection, with backbone support  Shared focus on structural change outcomes 40

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CHW Professionalization • Community Health Worker (CHW) Scope of Practice • CHW Core Competencies • CHW Training Requirements • Recommendations on Credentialing System 41

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Opportunities for Financing of Community-Based Preventive Health Services • The CMS Rule change: Allows states the option to finance non-licensed professionals to provide preventive health services as recommended by a licensed practitioner • Medicaid Managed Care Organizations (MCOs): • Taking advantage of existing flexibility that MCOs may have • Changes through MCO contracts • Internal investments based on ROI

• HIV service providers could negotiate contracts with other health care providers or MCOs to provide these services (FFS, fixed-price, or value-based arrangement) • New value-based payment structures

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Preliminary Outcomes • Changes in HIV service delivery models • Changes in public HIV funding policy to incorporate the CHW model • Over 1,500 People living with HIV/AIDS enrolled in CHW-based linkage/retention services in 4 years • Preliminary findings suggest significant individual health outcomes (reduced viral load) • Hundreds of CHWs trained • Progress toward developing the CHW profession

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Reflections and Lessons Learned • Peer CHWs are strong at reaching some of the hardest to reach clients to get them back into care. • We have observed that sites where the CHWs are more strategically integrated into the system (working with MDs, CMs, nurses, DIS) have greater success with patient linkage and retention. • Funding for CHW management and supervision must be included in any project. • Formative research/planning can assist with the partner engagement that is essential for CHW approaches. • CHW projects must be strategic, recruitment and enrollment may be low when there are other ‘competing” projects. • For grant-funded work, it’s critical to consider sustainability strategies beyond simply seeking more grant funding. These may be the structural change goals. 44

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• • • • • • • • •

Community Health Workers – The Time is Now Increased recognition of the strong evidence base related to improved health outcomes Growing evidence base demonstrating significant Return on Investment (ROI) 3:1 – 15:1 Recognition of CHWs as an official job classification by the Department of Labor in 2010 Policy and resource shifts at federal agencies, including CDC, HRSA, and CMS Many states involved in CHW workforce development Emergency room readmission penalties Trends toward Patient-Centered Medical Homes Trends toward value-based financing in Medicaid and Medicare Overall trend toward population health, chronic disease prevention, and reforming our “sick care” system

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Q&A

Section Title

Thank you!!! •

Chad Hendry, [email protected]



Courtney Coffey, [email protected]



Abby Charles, [email protected]

• it