Increasing Access to Care (ATC) for Homeless Individuals

Living with HIV/AIDS: Harlem Model Implementation

Stephen Crowe, ATC Managing DirectorLiza Kasmara, Director of Program Evaluation

Harlem United Community AIDS Center, Inc.HRC Conference 2012, Portland, OR

Learning ObjectivesBy the end of the session, participants will be

able to: Identify barriers to linking and retaining patients in careList essential elements in a patient navigation system to

increase access to and retention in careUnderstand the importance of care coordination

Agency Overview

Founded at height of first phase of AIDS epidemic: 1988.

• Specifically to serve people living with HIV/AIDS (PLWH/As) who were homeless and/or suffering from mental illness and/or substance use.

Agency of last resort for medically-underserved communities of color in Harlem.

• Part of community-based movement to care for PLWH/As• Founded to address lack of response from established providers; • Responding to the unique personal, social, and institutional

barriers to care in Harlem

Organizational StructureCOMMUNITY HEALTH SERVICES

Holistic Provider-Led, Patient-Centered Primary Care and Dental Services

Behavioral Health Services

Patient Navigation/Case

Management Support

INTEGRATED HIV SERVICES

Adult Day Health Centers

Food & Nutrition

Supportive Housing (Women’s Housing, Transitional Housing, Congregate, etc. )

Health Homes (COBRA) Case Management

Family Support

Community-Based HIV/STI/HCV Testing

Access to Care & Support Services

Drug User Health Services (Syringe Access, Harm Reduction, Recovery Support)

Black Men’s Initiative – integrated interventions for YMSM, YTG of color

New Business Development & Outreach Services

Access to Care (ATC) & Support Services

ATC Program DevelopmentNational HIV/AIDS Strategy

Reduce New HIV Infections Increase Access to Care and Improve Health Outcomes for

People Living with HIV Reduce HIV-Related Health Disparities Achieve a More Coordinated National Response to the HIV

Epidemic in the U.S.

Access to Care (ATC) Model Ensure access to and retention in medical care Provide support services needed to achieve optimal health

outcomes Facilitate re-entry into care and support services

ATC Program Development

• Testing team identified needs for Linkage to care (LTC) services for clients who tested positive

• LTC “ninja” was created

2007

Access to Care (ATC) & Support Services

Case Management

Services

Patient Navigation Services

Supportive Services

(Entitlements, Housing

Support, Tx Adherence,

Mental Health)

Outreach & Engagement

Activities

ATC Program Development

ATC Client Characteristics

75% Male, 24% Female, >1% Transgender

95% Black and HispanicPrimarily 35-54 years old65-75% Homeless/Unstably Housed40% HIV+, 15-20% AIDS diagnosis

ATC Program OverviewGOALS:

• To locate and engage out-of-care individuals into care and support services

• To ensure access and retention to medical care and support services

• To provide support services needed to achieve optimal health outcomes

• To navigate through initial medical care and connect to comprehensive case management

SERVICES:

• Supportive Case Management Services

• Patient Navigation & Reengagement Activities

• Support Groups (in English, Spanish & French)

• Connection to Medical Care & Support Services

• Psychosocial Assessments and Counseling (individual and group)

• Health Education/Risk Reduction Counseling

• Treatment Adherence Counseling (individual and group)

• Housing Placement Assistance (individual and group)

• Enrollment into ADAP/ADAP-Plus/APIC/Health Coverage

• Entitlements Assistance

ATC Program Current Model - Structure

Managing Director

LCSW

Program DirectorProgram

Coordinator, Case Management

ServicesCM I CM II

CM III CM IV

CM V CM VI

Program Coordinator,

Patient Navigation Services

PN I PN II

PN III PN IV

PN V PN VI

Program Coordinator, Support Services

Sr. Program Enroller

Housing Specialist I

Treatment Adherence Specialist

Housing Specialist II

Outreach Specialist

ATC Program OverviewProgram Flow

1. PATIENT NAVIGATION SERVICES

2. SUPPORTIVE CASE MANAGEMENT

2A. PSYCHOLOGICAL ASSESSMENT

Target Population(s):• HIV-Positive and High Risk HIV-Negative Homeless Individuals• High utilizers of emergency rooms and detox facilities• Undocumented Immigrants

Target Area(s):• Harlem• South Bronx

CLIENT IDENTIFICATION: Referrals,

Out-of-Care individuals, Community Outreach, Internal Referrals

CLIENT SEARCH:

Conduct record search: ePaces;

correctional databases;

eCW; HASA, AIRS, etc.

REENGAGEMENT:

Conduct home-visit, canvassing; phone calls;

letters; outreach to providers

SERVICE ORIENTATION:

If located, a service

orientation is completed and reconnection

begins

SCREENING:

Service Orientatio

n; Screening

for Insurance & Program Eligibility

INTAKE & ASSESSM

ENT:Service

Plan Developm

ent

SERVICE PLAN

Referrals; Verificatio

n of medical

appointment and

services

SERVICE PLAN

UPDATE:2 Medical

Appts; PCSM;

Reassessment; SP Update

CASE CLOSURE

:Connection to CM;

Case Closure

Summary

ASSESSMENT:Completion of Psychosocial

assessment by LCSW

CASE CONFERENCE:CM staff and LCSW; in service plan; engage client in short-term

counseling

INIDIVIDUAL COUNSELING:

3 - 5 sessions with LCSW with connection to psychiatry services where applicable

ATC Program Overview2B. ENTITLEMENTS

3. SUPPORTIVE SERVICES

SCREENING:If HIV+: Screen for ADAP/ADAP

PlusIf HIV-: Screen for Medicaid

APPLICATION:Verification of

inactive Medicaid;

Collect documentation for ADAP and

Medicaid.

APPLICATION SUBMISSION:

Submit Completed Application;

Verification of Application

CASE CLOSURE:

Ensure entitlement cards: Case

Closure Summary

HOUSING ASSISTANCE

• Housing Assessment• Housing Service Plan

Development• Individual

Engagements• Access to Educational

and Support groups

TREATMENT ADHERENCE EDUCATION

• Tx Adherence Assessment

• Development of Tx Adherence Service Plan

• Case Conference with Medical providers

• Individual Education• Access to Educational

and Support groups

SUPPORTIVE COUNSELING & RISK

REDUCTION PLANNING

• Minimum of 2 Risk Reduction Counseling Sessions

• Interim supportive counseling; minimum of two sessions

• Access to Educational and Support groups

ATC Program: OutcomesRetention in care ART Status

Non-ATC (n=78) ATC (n=78)0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

26%

12%

74%

88%

Retention rate among ATC and non-ATC clients

Not RetainedRetained

Non-ATC (n=58) ATC (n=69)0%

10%

20%

30%

40%

50%

60%

70%

80% 71%

39%

29%

61%

ART status among engaged ATC and non-ATC clients

Not on ARTOn ART

ATC Program: Outcomes

15%

85%

Viral load at baseline - ATC

Undetectable viral load(<400)Detectable viral load (>=400)

58%42%

Viral load at follow up - ATC

Undetectable viral load(<400)Detectable viral load (>=400)

33%67%

Viral load at baseline - Non-ATC

Undetectable viral load(<400)Detectable viral load (>=400)

42%58%

Viral load at follow up - Non-ATC

Undetectable viral load(<400)Detectable viral load (>=400)

ATC and Primary Care

Care CoordinationTeam meetings/daily roundsElectronic ReportsDaily communication between outreach and office

managersPN/Provider ProtocolsE-mails with daily reminders of appointment availabilityPatient Navigation/EscortsCase Management and ProvidersCommunication via electronic health record

Care Coordination

No show list• Extraction of no show list (i.e. list of

clients who consistently do not show up) from eCW

Monthly review

• Submit no-show list to ATC program coordinators monthly

• List is reviewed to determine clients in need of re-engagement activities

Re-engagement

• Patient Navigators conduct re-engagement activities for clients on no show list (e.g. phone calls, home visits, letters, etc)

• Patient Navigators connect clients to care (i.e. escorts, checking provider availability on eCW, tickler system)

Utilizing HU’s Electronic Medical Records, e-ClinicalWorks (eCW), to coordinate care:

Care coordinationTickler system in eCW:• Action items in “Review Actions” feature• Serve as communication tool between PN and clinic• Useful for clients who have chronic no-show issues

ChallengesDifficulty locating clients who are transient or homelessStaff training & development, buy-in, resistance to changePaperwork integration (difficulty in minimizing duplication)Program funded by 6 contracts (city and state) is challenging

to manage since funders have different core requirements, deliverables, expectations, and constraints

Multiple points of entryMultiple databasesEnsuring effective communication happens among all staff

during process of program developmentData entry issues (timeliness, not enough data entry support)

Best practices & Lessons learnedEmploying Harm Reduction modelClient-centered ApproachUsing Motivational Interviewing techniques to engage clientsLow threshold servicesUsing Daily Rounds to case conference clientsCollaborations with internal programs and external agencies

to recruit clientsOngoing staff training and developmentMinimizing duplication of intake and paperwork

throughout entire process

Stephen Crowe, ATC Managing Director scrowe@harlemunited.org

Liza Kasmara, Director of Program Evaluation lkasmara@harlemunited.org

Contact Info

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