Campaign WebinarLos Angeles County Linkage and Re-engagement Programs

March 5, 2014

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Ground Rules for Webinar Participation

• Actively participate and write your questions into the chat area during the presentation(s)

• Do not put us on hold• Mute your line if you are not speaking (press *6, to

unmute your line press #6)• Slides and other resources are available on our

website at incareCampaign.org• All webinars are being recorded

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Agenda

1. Welcome & Introductions, 5min2. Campaign Update, 10min3. LA DPH, 35min4. Question and Answer, 10min

In the chat room, Enter your:

1. name, 2. agency, 3. city/state, and 4. professional role at agency

Michael Hager, MPH MA NQC Manager,in+care Campaign ManagerNew York, NY

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Campaign Update

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in+care Campaign in 2014• Campaign database running through 2018!• Campaign website running through 2018!• Partners in+care Facebook maintained indefinitely• Campaign Newsletter moves to quarterly• Campaign Webinars move to quarterly• Partners in+care Webinars move to quarterly• Campaign Coaching integrates into NQC

Continuous TA Portfolios• Local Retention Groups that wish to continue

meeting should do so – NQC will support where possible

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Disseminating Improvement Work

Lightning Rounds!• 1 or 2 slides that contain the most salient points of your

retention projects• Include information on patient target, rationale for target selection and

baseline data from your measures (including the date)• Include information on each improvement cycle (what was tried, what

was the result per the data) – for early cycles short measures of change are not necessary, but add value!

• What are your conclusions? How are you sustaining improvement• Simplicity and clarity are the idea!

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in+care Retention Improvement Strategies

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in+care Retention Improvement Strategies

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Data Collection Submission Deadline: April 1, 2014

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Gap Measure Results (12/11 – 2/14)

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Visit Frequency Measure Results (12/11 – 2/14)

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New Patients Measure Results (12/11 – 2/14)

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Viral Load Suppression Measure Results (12/11 – 2/14)

Los Angeles County HIV Linkage-to-Care and Re-Engagement Programs: Preliminary

Results and Lessons Learned

Amy Rock Wohl MPH PhDDivision of HIV and STD Programs

Los Angeles County Department of Public HealthMarch 5, 2014

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Navigation Program

Navigation ProgramBackground:

Goal is to re-engage lost HIV clinic patients in HIV care using enhanced locator techniques and modified strengths-based cm intervention (ARTAS)

Participants to-date are out of care (OOC) patients from 4 LAC publicly-funded HIV clinics

Eligibility includes HIV+ patients who have not had a primary care visit in the past 6 mos and last vl >200 copies/ml; or no HIV primary care visits in 12 mos; or newly-diagnosed and never in care

Current status: Ongoing enrollment

Modified ARTAS Intervention• Based on ARTAS model• Consists of:

• 4-phases administered over a 90-day period instead of ARTAS 5-sessions

• Increase in the number of visits per phase to add flexibility (up to 10)

• Like ARTAS, sessions are 60-90 minutesIntervention Phase Title/Content Number of

SessionsMaximum Timeframe

Phase 1 Building the Relationship 1-2 1 week

Phase 2 Assessment 1-2 1-2 weeks

Phase 3 Linking to Resources/Enhancing Strengths 2-4 1-8 weeks

Phase 4 Disengagement 1-2 1-2 weeks

Preliminary Data• Disposition of 499/6361 Lost Clinic Patients

23%

4%

11%

5%26%

17%

2%

12%In Care Elsewhere

No Longer LAC Resident

Returned to Clinic Independently

Patient is Deceased

Patient is not available/left message

Number is Wrong/Disconnected

Patient Declined Enrollment

Patient Located/Interested in NAV; appt. scheduled

1 137 lost clinic patients were found ineligible due to VL/last appointment date18

Most Effective Data Source1 for Contact Information (n=499)

1 Patient contact data searches were hierarchical starting with clinical medical records, followed by Ryan White Patient database, HIV surveillance, Lexis-Nexis, and Other until patient was successfully contacted2 HIV Surveillance breakdown: iHARS-LAC=24%, eHARS-CA=15%3 Includes LAC Inmate locator, CA Prison Locator, STD surveillance database

HIV Surveillance

Clinic Medical Record

Ryan White Client Database

Lexis-Nexis

Other

36%

39%17%

5%

2%

Series 1

3

2

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Race: 13% African American, 77% Latino, 5% White, 2% Asian, 4% Other

Gender : 26% female, 70% male, 4% transgender Age: 45% <40 yrs, 55% >40 yrs Insurance Status: 61% Uninsured, 36% Public

Insurance, 3% Unsure Substance Use (past 6 months): 5% IDU; 23% any

drugs Current Housing: 90% stable, 8% temporary, 2%

homeless Education: 70% <High School, 30% High School/GED Employment: 38% employed, 13%

disability/SSI/public assistance, 41% unemployed, 8% other

Yearly Income: 52% <$5,000, 22% $5,000-$15,000, 26% >$15,000

Demographics (n=61)

Main Barrier to HIV Care at Time of Enrollment in NAV Intervention (n=61)

Other Life

Prioriti

es (c

hildcare

, work)

Didn't Complete

Applicatio

n Proce

ss

No Transporta

tion

Homeless

ness

Drinkin

g/Using D

rugs

Didn't think N

eeded

HIV C

are0

10

20

30

40 38%

7% 5% 2% 2%7%

Dental Care Food & Other Basic Needs

Benefits Housing/Shelter Mental Health HIV-Related Medical Medications/Pharmacy

0

10

20

30

40

50

60

7067%

44%36%

27%22%

20%

18%

Needed Services1 at Time of Enrollment in NAV Intervention (n=61)

1 Participants listed multiple needs

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HIV Testing, Care and Clinical History at Time of Enrollment (n=551)

Variable Min Max Median Mean

Time Since Positive Result 9 months 17 yrs 6.4 yrs 7 yrs

Time Since Last Medical Appt. 21 days 3 yrs 308 days 358 days

Last Viral Load Prior To Enrollment (copies/ml)

20 1,011,623 2,221 58,046

1 Data pending for 6 patients

Intervention, Linkage and Engagement in Care (n=551)

•Avg # of NAV visits = 7 (range 3-10)•Avg # of hours spent with NAV = 15 (range 2-44)

•98% (n=54/55) linked to care (attended 1 HIV medical visit) following intervention enrollment

•20 of 34(48%) patients who were enrolled in NAV for at least 6 months engaged in care; (i.e. attended 2 or more medical visits and were referred for long-term case management and retention)

•NAV patient referrals: housing, substance abuse treatment, mental health, nutrition, transportation, assistance w health insurance and ADAP enrollment

1 Data pending for 6 patients

Lessons Learned and Next Steps• Preliminary Lessons Learned

– More efficient to start with surveillance rather than clinic data to identify OOC patients

– HIV surveillance and clinic data provided most useful contact information for finding OOC patients

– OOC patients vary in the intensity of intervention needed; NAV needs to work with OOC patients longer to promote long-term engagement in care

– Structural roadblocks • LACDPH legal concerns with sharing surveillance

information• Clinic administrative requirements

• Next Steps– Incorporate lessons learned into county-based LTC program

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Navigation Program Version 2.0

Navigation Program Flow Chart

Contacted! Patient Agreed

NAV contacts patient to

schedule initial appointment and

enroll in Navigation Program

Moderate (MI)

IN CONSISTENT CARE (Intervention Ends)

Yes

In care elsewhere, case closed Linked to care

(medical, case management)

Unable to find, case

closed

Yes

No

Case closed

Low (Resources)

Initial appointment with NAV:

-consent

-survey

-intervention intensity assignment (Low, Mod, ARTAS)

ARTAS

Intervention

Transitional Retention

- NAV follow-up for 6 months after linkage

- additional NAV visits as needed

Not Linked

Not Linked

Clinic staff updated info in Casewatch

Referral to navigator

(NAV)

Initial attempt to contact using

clinic contact info

Clinic/Surveillance list of out of care

individuals Located

?

1) Utilize HARS/ Casewatch to gather contact info/status

2) Coordinate with MCC & prioritize

3) Utilize MMP/PHI investigative methods to locate

No Confirm eligibility with

clinic staff

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Project Engage

Project EngageBackground:

Goal is to identify OOC HIV+ persons and link them to HIV care

OOC HIV+ persons (alters) are identified through social network referrals from seeds or direct recruitment by staff; alters may recruit OOC persons

Incentives: $40 for baseline survey for seed/alter; additional $40 for seed/alter when alter links to care

Seeds identified from:1. HE/RR programs at CBOs for at-risk MSM (eg crystal

meth support group)2. HIV clinic patient populations3. Flyer/pocket card recruitment

Current status: Ongoing Enrollment

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Flyer

Pocket Card

Preliminary Results

Study Screening and Recruitment Screened

Seeds: 99 HIV+ Alters: 1041

Enrolled Seeds: 56 HIV+ Out of Care Alters: 29

8 (28%) have enrolled as recruiters 21 (72%) have linked to care

Site Specific Enrollment: APLA: 8 seeds and 20 alters (12 linked) OASIS Clinic: 12 seeds and 3 alters (all linked) GLC Clinic: 30 seeds and 3 alters (all linked) Direct Recruitment: 6 seeds 3 alters (all linked)

321 62% were ineligible/not HIV infected per HIV surveillance

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Out-of-Care Alters (n=29) Race: 41% African American, 10% Latino, 28% White, 21% Other HIV Status: 100% HIV-positive 76% MSM; 24% heterosexual Insurance Status: 38% Insured, 62% Uninsured Reported Sex Work: 24% Incarceration History: 86% lifetime, 55% past 12 months Recent/Current Homelessness: 79% Illicit Substance Use:

IDU: 48% lifetime, 21% past 3 months Non-IDU: 62% lifetime, 41% past 3 months

Seeds (n=56) Race: 42% African American, 22% Latino, 25% White, 11% Other HIV Status: 75% HIV-positive 96% MSM; 4% heterosexual Insurance Status: 89% Insured, 11% Uninsured Incarceration History: 51% lifetime, 4% past 12 months Reported Sex Work: 7% Recent/Current Homelessness:16%

Demographics

Out-of-Care Alters (n=29) Testing and Care History

Time since 1st HIV+ test: Avg=10.8 years (range: 3 mos-29 yrs)

Time between 1st HIV+ test and 1st HIV doctor visit: Avg=12.8 months (range: 1d-6yrs)

Number of clinics attended: Avg=2.6 (range: 1-20) ART use: Ever taken= 72%, Currently taking=17%

Readiness to Engage in Care Scale1 11 “contemplative” about starting care 18 “ready for action” about starting care

Sexual Behaviors (last 6 mos) # of sexual partners (n=20): Avg=6.5 (range: 1-40) 31% report UAI 34

1 Scoring based on Transtheoretical model of behavior change

Characteristics of Out-of-Care Alters Linkage, Care, VL

Linkage and Care • Avg time out of care (n=21): 9.7 mos (range: 0-26)• Avg time to link to care (n=21): 12.4 days (range: 0-97)• Avg staff time dedicated to link to care (n=28): 373.9 min/6.2

hours (range: 140-840 min) Viral Load

Last reported vl before enrollment (n=27): Avg=50,184 copies/ml (range: 48-370,660)

Acceptability Survey Out-of-care alters who linked to care (n=16) stated:

• Project Engage helped get them into care: 16 • Were satisfied with the help they received: 16• Would recommend PE to friends who were out of care: 15

11/16 (79%) stated that without PE, they would not have entered care themselves 35

Unmet Needs and Barriers to Care for Out-of-Care Alters

Unmet needs (social & medical services) Number of unmet needs: Avg=7.7 (range: 1-14) Most reported not being able to obtain:

Regular HIV care (n=25) Dental care (n=22) Medical Case Management/Mental Health

Counseling (n=21)

Barriers to Care Did not know where to obtain services Experienced disrespect from HIV clinic staff Challenges completing needed paperwork

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Case Study #1Case 1 is an older homeless minority MSM who tested HIV positive in 2006. He has been out of care for 26 months. He is a crystal meth user and prostitutes for survival and sleeps in parks and alleys. He reported 5 sex partners in the last 6 mos and was the insertive partner for UAI with all 5 partners. He has been incarcerated several times due to his drug use and prostitution. His physical appearance suggested he was feeling the effects of both his medical and social situation (several lesions on his face and arms, frail body and missing teeth).

After enrolling him into Project Engage, he was linked into care in one day (4 hrs PE staff time). He was very excited and happy that someone took such an interest in his situation. After his first treatment appointment, he went back to the park where he hangs out and told his friends about his positive experience. One week later his physical appearance had improved dramatically and he stated that he is on the medication and feeling much better.

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Case Study #2Case 2 is a 29 year old homeless minority MSM who tested positive anonymously in June 2013 but had never linked to care. His mother gave him and his two sisters up for adoption when he was a child. He became homeless at the age of 18 after his adopted parents passed away and he moved from the midwest to California. He is currently homeless and lives on the streets in Los Angeles.

He is a crystal meth user but does not currently engage in prostitution. He has spent time in jail for stealing, drug possession and prostitution. He reported 5 sex partners in the last 6 months and was the insertive partner for UAI for all 5 and also receptive partner with 1 of the 5 partners. He was very well-spoken and was appreciative that a program was in place like Project Engage to help people with HIV link into care. After enrolling into Project Engage, he was linked into care within two days by Project Engage staff (6 hours PE staff time). He is currently working with the HIV clinic staff to secure housing and other needed social services.

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Preliminary Lessons Learned: Agency-based recruitment more effective than

clinic-based recruitment A few productive seeds is critical to success Labor intensive to identify OOC persons Labor intensive to link OOC persons to HIV care Capacity needed to help OOC alters obtain photo ID

to enroll in medical care/ADAP LTC intervention needed for some

Next Steps: Scale up staff (currently 1 FTE); increase incentives? Expand direct field recruitment at parks/street

corners; enhanced recruitment at more CBOs, at-risk youth agency, mobile testing vans, skid row clinic

Add 3-tiered intervention option in next phase Incorporate into county-based LTC program 39

Acknowledgments

Saloniki JamesRhodri Dierst-Davies

Alla VictoroffSonali Kulkarni

Heather NorthoverJeff Bailey

Brian Risley

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Question & Answer

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Campaign Headquarters:National Quality Center (NQC)90 Church Street, 13th floorNew York, NY 10007Phone 212-417-4730incare@NationalQualityCenter.org

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