Ryan White CARE Act 2002 Grantee Conference Project LINK

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Ryan White CARE Act 2002 Grantee
ConferenceProject LINK

• Shivaun A. Celano, PharmD, MBA
• Research Associate/Adherence Coordinator
• the Johns Hopkins University
• School of Medicine
• August 23, 2002

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Adherence Support for Populations with Multiple
Challenges

• Project LINK - Program Goals
• Enhance adherence to HAART
• Enhance adherence to medical appointments and
  referrals
• Enhance education and support

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• Program Overview
• 1 - CM/NE
• 2 - CM/NE/PA
• 3 - CM/NE/GP
• 4 - CM/NE/PA/GP
• Intervention period 1 year
• Minimum contact monthly (per adherence
  provider)
• CMcase management/ NEnurse education
• PApeer advocate/ GPeducation/support group

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• Target Population
• New or existing clients in clinical practice who
  meet DHHS guidelines for HAART and are starting
  first HAART regimen
• Clients failing their first HAART regimen
• Clients who have missed 4 out of their last 10
  scheduled visits or 30 of visits over the past 6
  months AND are not receiving HAART

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• Program Requirements
• Clients must be willing to enter a drug rehab
  program or get substance abuse counseling if they
  are actively using illicit drugs or abusing
  alcohol
• Clients with mental health issues must be willing
  to get help
• Clients must be willing to participate in the
  LINK program

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• LINK Patient Characteristics
• 7/26/00 - 3/31/02 (N200)
• 56 male
• 95 African American
• median age 46 years old
• High level of active or prior substance abuse
• High level of history of mental health diagnosis
• High level of income lt fed poverty line
• High level of non-permanently housed

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• LINK Client Challenges
• Very selected population, mental health and
  substance abuse are very prevalent in LINK
  clients, and are higher than found in the general
  clinic population
• Labor intensive, with expected relapses in mental
  health and substance abuse issues which compound
  general medication adherence issues
• Many clients have a high level of no show for
  appointments
• Clients are used to service on demand rather than
  keeping scheduled appointments

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• LINK Program Challenges
• Moore Clinic 3000 clients
• in a smaller clinical practice of 200 - 300
  clients, having an adherence program practice
  wide would be more feasible
• Project LINK can only manage a subset of this
  large population due to staffing constraints
• Clinical coordinator of program not funded by
  project
• only clinical staff providing clinical adherence
  support are funded
• Specialized qualifications are necessary for
  staff
• Time limited program

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• Program Client Load
• Nurse Educator 125 clients
• Case Manager 125 clients
• Male Advocate 50 clients
• Female Advocate 50 clients

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• Intensity of Service
• Nurse Educator Ave Encounter35 min
• Case Manager Ave Encounter 31 min
• Male Peer Ave Encounter 28 min
• Female Peer Ave Encounter 25 min

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• Clinical Coordinator
• A clinical coordinator is absolutely necessary in
  a program
• The clinicians are too busy performing clinical
  adherence functions
• The clinical coordinator keeps day to day
  activities on track

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• Complex Personnel Issues
• Staff need special qualifications
• Need professional qualifications (Nurse and
  Social Worker)
• Need specialized HIV training (All)
• Peers need to have HIV 101 and other types of
  training
• Selection, training and supervision of staff is
  very important

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Program Duration

• Project LINK was initially 6 months in duration
• This was found to be insufficient to affect and
  reinforce the behavioral changes targeted in the
  intervention for the following reasons
• client relapse in substance abuse
• client relapse in mental health condition
• client unstable housing
• client unstable lifestyle

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Amount of LINK Participation Correlated with
Patients Receiving AntiretroviralsPreliminary
Outcomes Data (6 months)

• Participation in
• LINK visits
• (over 6 months)
• lt 6 visits
• gt10 visits

• Receiving any Antiretroviral Therapy
• 27
• 86

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Duration of Abstinence from Illicit Drug Use
Correlated with Patients Receiving
Antiretrovirals Preliminary Outcomes Data (6
months)

• Time (months) of Abstinence from Illicit Drug Use
  
• lt 3 months
• gt12 months

• Receiving any Antiretroviral Therapy
• 33
• 93

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12 Month Program

• Sufficient for many clients
• A program time limit tends to foster the goal of
  self sufficiency
• Insufficient for clients who have a relapse in
  substance abuse or untreated mental health issue
• Insufficient for clients who have not fully
  participated in adherence program during the 12
  month period
• We have used a program extension for such clients
• Ideally a program could be of indefinite duration
  for clients with untreated or ongoing substance
  abuse or mental health issues

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Components that Work

• Patient commitment to the concept of adherence is
  the critical factor in our program success
• Working with the client to develop a relationship
  of trust and knowledge helps to achieve this goal
• Adherence providers work to comprehensively know
  the clients needs
• Having a multifaceted approach to adherence has
  helped to achieve our program goals
• Having a flexible program with a set curriculum
  has made it possible to tailor the program to the
  individual clients needs

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Components that work

• Intensity of services is individualized
• Having the goal of an appointment based program
  rather than service on demand
• Scheduled routine team discussion of each client
• A 12 month program with the option to extend
  client program time or have client re-referred to
  program when appropriate
• Post program support which is an option and
  encouraged when necessary with clear limits
  defined
• Having existing clinical resources to transition
  the clients needs to when the adherence program
  is completed

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Components that work

• Adherence staff work well as a team with the same
  client goals
• Adherence staff are well integrated with the
  clinic staff yet have separate, distinct work
• There are ongoing lines of communication between
  adherence staff and medical providers
• The adherence staffs primary duty is to provide
  clinical adherence support
• A clinical coordinator is available to keep the
  program organized and to monitor the quality of
  the program and its services

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• Project LINK
• Shivaun A. Celano
• 410/955-2113
• scelano_at_jhmi.edu

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