Lessons Learned from the SPNS Outreach Demonstration Project

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Lessons Learned from the SPNS Outreach
Demonstration Project
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Overview of the Initiative

• 5 year HRSA SPNS demonstration project to engage
  and retain underserved populations in HIV care
• 10 programs funded to enhance interventions and
  evaluate for 3 years
• 3 Years is up today - and the results are in

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Major findings

• 1133 people enrolled in longitudinal study
• 3 at risk populations
• Not in care at all (small group)
• Tenuously connected
• At high risk of dropping out of care

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Profile of clients

• 85 people of color
• 11 primary language is Spanish
• 38 female
• ¼ had history of hospitalization for mental
  illness ½ in MH treatment
• 2/3 unstably housed
• 2/3 with history of cocaine use

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Lessons Learned from the SPNS Outreach
Demonstration Project

• Horizons Project Detroit, MI
• Cascade AIDS Project Portland, Oregon
• Whitman-Walker Clinic Washington DC

This presentation is supported by grants from the
Health Resources and Services Administration
(HRSA), Special Projects of National Significant
(SPNS) program.  The presentation's contents are
solely the responsibility of the authors and do
not necessarily reflect the official view of HRSA
or the SPNS program.
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Horizons ProjectGet Here, Get Down(GHGD)

• Wayne State University/
• Childrens Hospital of Michigan
• Principal Investigator Sylvie Naar-King, PhD
• Co- Principal Investigator Kathryn Wright, DO
• Project Manager Monique Green-Jones, MPH
• Data Manager Angulique Outlaw, PhD

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Horizons Project

• A community-based program affiliated with Wayne
  State University and the Detroit Medical Center
  offering a comprehensive continuum of medical,
  ancillary, prevention and outreach services to
  at-risk and HIV youth ages 13-24
• So what does a comprehensive continuum look like?

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Horizons Projects Comprehensive Continuum of
Care
Horizons Group Prevention
HIV-
MI HIV
MI
MI HIV
MI
MI
HIV-
Horizons Group Prevention
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GHGD Key Questions

• Are motivational interventions effective in
  enrolling and retaining youth in HIV-oriented
  primary medical care?
• Can we train existing staff (including peers) to
  provide evidence based interventions with good
  fidelity
• Are different formats of MI differentially
  effective?

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Get Here Get Down Design

• Single MI session every 6 months
• Focus on changing behavior or maintenance
• Focus on attending quarterly primary care
  appointments
• 0 gaps one appointment each quarter in 6 months
• 1 gap only one appointment in 6 months
• 2 gaps no appointments in 6 months
• Randomized to one of four cells
• MIF by Masters
• MIF by Peer
• MIVC by Masters
• MIVC by Peer

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CareLink,Cascade AIDS Project

• Project Investigator Maureen Rumptz, PhD
• Project Manager Alison Frye, MPH
• Data Manager Tim Holbert, BA

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CareLink, Cascade AIDS Project

• Founded in 1983, Cascade AIDS Project (CAP) is
  the oldest and largest community-based provider
  of HIV services, housing, prevention/education
  and advocacy in Oregon and SW Washington
• CareLink is an outreach and advocacy program of
  CAP that helps men and women with HIV access
  needed medical care

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CareLink Goals

• To seek out and identify people living with HIV
  who are not utilizing medical care and/or case
  management services or who are at risk of falling
  out of care
• To link out of care/at-risk PLWH to medical
  and/or case management services and provide them
  support to remain and be successful in care
•  
•        

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Eligible Target Populations

• Adults with HIV/AIDS who are not engaged in
  medical care who are
• Hard to reach (i.e., having one or more (usually
  multiple) access barriers including substance
  abuse, mental health problems, incarceration,
  homelessness, lack of health insurance, or a past
  history of disconnecting from care)
• Latino

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Core Intervention Components

• Initial and on-going assessment
• Relationship building
• Motivational work
• Education individual and group

• Outreach
• Peer advocacy
• Service coordination
• On-going assessment
• Health literacy class

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Healthy Connections for Positive Living

• Whitman-Walker Clinic and Georgetown University
• Washington, DC

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Collaborative Team

• Whitman-Walker Clinic
• Co-Investigator/Outcomes Coordinator Debra
  Dekker, PhD
• Retention Care Coordinators Kathy Dolan, BS
  Paul Doherty, BS, Mark Dean, BA
• Georgetown University School of Nursing and
  Health Studies
• Principal Investigator Michael Relf, PhD, AACRN
• Co-Investigator/Qualitative Methods Kevin
  Mallinson, PhD, AACRN

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Whitman-Walker Clinic

• Established in 1973 to provide health care
  services to the GLBT community
• Serve persons living with or affected by HIV/AIDS
  
• WWC served more than 6,500 individual clients in
  2005
• Staff of 250
• 1,000 volunteers

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Our Sites
Administration Northwest DC
Max Robinson Center Southeast DC
Elizabeth Taylor Health Center Northwest DC
WWC of Northern Virginia
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WWC Client Services

• HIV-oriented Primary Medical Care
• Behavioral Health
• Health Promotion and Disease Prevention
• Legal

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Purpose of the Study
To examine the factors associated with retention
in HIV-oriented primary medical care while
determining the social and structural
determinants of staying in care.
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WWC--Intervention Methodology

• 6 or 12 months of Intensive Outreach
• Courtesy call reminders before appointments
• Follow-up for all no-shows
• Barrier elimination to reduce no-shows
• Babysitting assistance
• Transportation assistance
• Chaperone clients to appointments
• Facilitate system navigation
• Appointment scheduling/rescheduling
• Prescription refills
• Knowledge development

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Program How Tos

• Horizons Project Detroit, MI
• Cascade AIDS Portland, Oregon
• Whitman-Walker Clinic Washington, DC

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WWC Screening Algorithm
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Motivational Interviewing (MI)

• Miller Rollnick (2002) evidenced-based
  intervention to promote health behavior change
• Client-centered, directive method concentrating
  on the issues of motivation at various points
  along a continuum of behavior change.
• MI strategies attempt to deal with the resistance
  and ambivalence that are common among those in
  the earlier stages of behavior change.

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Get Here Get Down

• Single motivational intervention session every 6
  months
• Focus on attending quarterly primary care
  appointments
• Focus on changing behavior or maintenance
• Compare Two Formats
• MI plus Cognitive Strategies (MICS)
• MI plus Values Clarification (MIVC)
• Compare Masters prepared versus Peer

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Quality Assurance

• Formal training conducted by a certified
  Motivational Interviewing Network Trainer (MINT)
• Ongoing weekly supervision by MINT supervisor
• Audiotape sessions
• Supervisor review
• Coding System

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Who Did We Help?
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CareLink--Building a Niche

• New Ryan White category not familiar to community
  not case management, not prevention
• Designed to work with PLWH who did not have a
  relationship with case management or who could
  not stay connected to traditional system
• Involved working alongside Case Managers and
  avoiding duplication

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CareLink--Building a Niche (cont.)

• Key to program success was integration into the
  service continuum assess the local environment
• Challenges associated with a CBO (not affiliated
  with a medical site) identifying out-of-care PLWH
• Relationships with providers was key on their
  terms MOUs increased accountability

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CareLink--What Makes Us Unique?

• Mobility Services provided where target
  population is or where clients request service
  provision
• Client-centered Individualized goal plans and
  Meeting People Where they Are
• Going into Corrections Less fragmented
• re-entry
• Emphasis on Relationship Time-intensive service
• On-going Assessment Adapting to changing needs,
  not losing track of progress

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Program Evaluation Findings

• Horizons Project
• Cascade AIDS Project/CareLink
• Whitman-Walker Clinic

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GHGD Outcomes Retention

• Retention rates does not include transfers
• 90 of youth (N82) attended at least one
  appointment between baseline and 6 month
  follow-up based on chart review
• 77 attended at least one appointment between 6
  and 12 month follow-ups
• 93 retention over 12 months of GHGD

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GHGD Results MI Formats

• MIF vs. MIVC
• No differences in retention
• Fidelity MIVC higher scores on some dimensions
• Satisfaction MIVC higher on some dimensions
• Masters vs. Peer
• No difference in retention
• Fidelity Equivalent fidelity scores
• Satisfaction Peers higher on some dimensions
• Dose Response
• Youth who received 2 sessions had significantly
  better retention than those who received 0 or 1
  sessions, even when controlling for
  pre-enrollment retention in care

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GHGD Outcomes Feasibility

• Counselors showed good fidelity to the protocol
  as evidenced by high coding scores
• In the first 6 months, 90 of youth received at
  least one of the two offered intervention
  sessions

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GHGD Results Lessons Learned

• What did we find out?
• Treatment fidelity quality assurance procedures
  are critical for obtaining outcomes and to ensure
  that treatment is delivered as intended
• Training, supervision and CQI are time-consuming
• Funding for these procedures is essential to
  obtaining outcomes

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CareLink Preliminary Evaluation Findings

• 105 clients interviewed at baseline, 86 study
  retention at 12 months follow up.
• 50 White non-Hispanic 30 Latino (19
  considered Spanish their primary language)
• Co-occurring problems included incarceration
  history (71), unstable housing (53), injection
  drug history (56), and taking mental health
  medication (37)
• 11 had never seen a provider
• 53 of those who had seen a provider reported
  periods of 6 months or more without care
• 42 have had AIDS diagnosis

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CareLink Preliminary Evaluation Findings

• At the 12-month follow-up
• Improvement in the following Quality of Life
  dimensions health worries (p.01), financial
  worries (plt.01), disclosure worries (plt.02), and
  provider trust (p.03)
• Percent of clients with a case manager increased
  from 52 to 85
• Percent with insurance increased from 57 to 81
• 91 had a regular provider
• Percent needing to take meds but not decreased
  from 24 to 13.

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CareLink Preliminary Evaluation Findings

• At the 12-month follow-up
• Emergency room visits decreased from 1.46 to .68
  ( p0.0)
• Primary care visits (from medical records)
  increased from 2.5 to 3.4 visits (p 0.01)
• Number of missed appointments decreased from 1.13
  to 0.84
• Mean CD4 increased and mean viral load decreased
• Percent with an undetectable viral load increased
  from 22 to 43 (p .01)

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WWC Utilization PatternsNo-Show Rate
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WWC--What helps to keep appointments?
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WWC--Why do you miss appointments?