ACCESS = HEALTHA Conversation on Funding Access

to & Retention in Care with AIDS United

July 10, 2013

Agenda

Welcome & Logistics Sarah Hamilton, FCAA

Funding HIV Care: AIDS United’s Access to Care Portfolio Vignetta Charles, AIDS United

Strengthening the Health & Resilence of Women, Children & Families Impacted by HIV/AIDS Shannon Hansen, Christie’s Place

Who is Being Served by Access to Care? David Holtgrave & Cathy Maulsby, Johns Hopkins

University

Q&A

Logistics

This is intended to be a safe discussion space for funders! If you wear different hats at your organization, please bring your grantmaking one to the Q&A.

We will open Q&A after all presenters.

In the interim, you can send questions via the question function at your right, via email sarah@fcaaids.org, or via Twitter @FCAA. If you want to ask a question via the phone, please raise your hand to be unmuted.

The call will be recorded and available on www.fcaaids.org after the call.

Funding HIV Care: AIDS United’s Access to Care

Portfolio

Vignetta Charles, PhDSenior Vice President

July 10, 2013

HIV Prevalence and IncidenceUnited States, 1980 - 2010

Number of people living with HIV has grown because incidence is relatively stable and survival has increased

Hall HI et al. JAMA. 2008 Aug 6;300(5):520-9Prejean J et al. PLoS One. 2011;6(8):e17502MMWR Morb Mortal Wkly Rep. 2012 Mar 2;61(8):133-8

Stages of HIV Care(CDC data, July 2012)

Funding streams

• Public-Private Partnership– Social Innovation Fund (Corporation for

National and Community Service)– Matching Private Funders – Local matching requirement

• Private funding– Retention in Care (MAC AIDS Fund)– Positive Charge (Bristol Myers-Squibb)

Grantees

Montgomery, AL

New York, NY

Washington, DC

Boston, MA

Los Angeles, CA

St. Louis, MO

Chicago, IL

San Diego, CA

New Orleans, LA

Durham, NC

Birmingham, AL

Philadelphia, PA

Los Angeles, CA

Indianapolis, IN

San Francisco, CA

Charlottesville, VA

Pittsburgh, PA

• Rigorous evaluation– Local evaluator – Contribute to national evaluation

• Convening• Technical assistance

– Compliance– Organizational development– Programmatic needs

• Social Innovation Fund grantees—local match fundraising

Cohort Requirements

• Evidence-based interventions

• Care coordination thru multi-disciplinary teams that meet regularly to discuss patient/client progress

• Collaborative partnerships that seek to make meaningful, sustainable systems-level change

• Many employ social network recruitment strategies

• Most have formal partnerships with a clinical partner

Common Themes

• Boston—self sufficiency goal achieved through treatment adherence groups, job readiness training, and employment

• New York City—Insurance provider that uses mobile engagement teams to remain connected to enrollees

• Montgomery—telemedicine in rural communities

• Los Angeles and Philadelphia—focus on formerly incarcerated individuals

• Washington, DC—8 month certificate curriculum for Peer Navigators offered through local community college

Unique models

Strengthening the health and resilience of women, children and families

impacted by HIV/AIDS

Christie’s Place is a leading nonprofit communitybased organization in San Diego County that provides culturally competent and comprehensive HIV/AIDS education, support, and advocacy.

Our mission is to empower women, children, and families whose lives have been impacted by HIV/AIDS to take charge of their health and wellness.

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San Diego County Need• In 2010, 69% of women living with HIV who knew their status

were not accessing medical care

• San Diego is the 2nd largest county in CA– 4,200 square miles– Includes City of SD (7th largest city in country)– Borders Mexico (TJ is most active international border)

• No county hospital – rely on community clinics and UCSD

• MSM EMA, as such services tend to focus on men– Overall lack of family and women centered care and competency

• Women generally isolated from local HIV agencies and/or uncomfortable accessing care at traditional service locations

ClientProfile

• Heterosexually infected• Woman of color• Child bearing age• Low-income or poor• Low education level• Single parent or head of

household• Two or more children• Unemployment or lack of

occupation

• Relationship discord or domestic violence

• Trauma or abuse during childhood

• Low self-esteem or mental illness (depression or anxiety)

• Substance abuse or partner with this problem

• Chaotic home life

• Network of Care Model – system wide collaborative care approach to address access and linkage to care– Involves multiple collaborating organizations – Coordinated array of strategies to provide care completion services– Targeted to low income HIV+ women– County-wide

• Collaborative partners:– UCSD Antiviral Research Center– UCSD Mother, Child, and Adolescent Program – UCSD Owen Clinic– Casa Cornelia Law Center– American Friends Services Committee: US Mexico Border Project– Cardea Services (evaluation)

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CHANGE for Women Strategies • Expand capacity of Peer Navigator network at new clinic sites and

through mobile, home-based model

• Medical Home via My Chart

• Increase access to clinical care via enhanced transportation, food and childcare

• “I Am More Than My Status” social marketing campaign

• Center of Excellence in Women’s HIV Care & Research – Expanded hours and bilingual capacity– Integrated medical care and behavioral health services

• Formalized linkages and partnerships with immigration rights and social justice organizations

– Human rights education– Legal advocacy for undocumented women and/or detained women

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Strategic Alliances• Why choose this option? ACA, funding, positioning in community,

diversification of services

• Staying true to our mission and expertise– Understanding and articulating what we bring to the table – the

“value added”/ROI for clinical partners

• Developed/developing strategic alliances with clinical partners– Co-location with primary care

• Peer navigation• Behavioral health• Medical case management

– Part of clinic health teams– Whole person care

• Patient and family support• Social support services

• Strengthening medical home models

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Successes• The “partnership” - tactics are strengthening medical home

model and improving coordinated care– Peer Navigation model has brought 212 out-of-care and

sub-optimally engaged in care HIV+ women back into care– Improved health outcomes of clients

• Expansion of Fem-Owen Clinic, development of Center of Excellence

• Co-location of services and integration with provider teams = enhanced culturally appropriate & person-centered care; comprehensive care management; care coordination

• Since program implementation, local unmet need decreased from 69% in 2010 to 64% in 2011, and then to 57% in 2012.– Increased access to care for HIV+ women by 12%

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Challenges & Discoveries• Obtaining the local funding match • California changes to healthcare (LIHP, Medicare HMO, etc.)

present numerous challenges and care interruption

• Findings that a higher percent of CHANGE for Women clients report sexual assault history than the general population

• CHANGE for Women clients report current and past intimate partner violence, including 18% who are in a relationship currently where they do not feel safe

• Clients reporting substance abuse were:• Less likely to report having ‘basic’ needs like food or money• More likely to report intimate partner violence during the year before

entering C4W• More likely to report needing alcohol/other drug treatment or mental

health services

CHANGE for Women Phase II:

Retention in Care (RiC)

CHANGE for Women Phase II: RiC• Trauma-informed and gender responsive bio/psycho/social model

• Program expands upon established access to care efforts by improving RiC and ART adherence for HIV+ women of color in San Diego County, with an emphasis on African Americans and Latinas, including documented and undocumented immigrants

• Strategies target the well-documented co-occurring barriers that prevent effective engagement in care and RiC and necessitate access to ancillary services to augment HIV care:

mental health conditions substance abuse history of abuse/trauma low health literacy

• 175 women will be assessed and monitored for RiC services over the funding period– 60 women will receive onsite behavioral health services yearly– 30 women will receive onsite strength-based case management yearly– 150 women will engage in monthly educational Treatment Education

Adherence (TEA) sessions yearly

Strategy I. Expand scope and impact of the existing CHANGE for Women program through innovative and replicable interventions that strengthen RiC and ART adherence

• Create system-level change by establishing formalized RiC partnership with UCSD Owen Clinic via Retention in Care Specialist

• Expand capacity of Christie’s Place and partner agencies to deliver trauma-informed RiC services through ongoing training on the principles and practices of trauma-informed service delivery

• Expand Social Marketing Campaign, “I Am More Than My HIV Status” to increase messaging about RiC and the importance of ART adherence

Strategy II. Expand integrated treatment teams to assess, identify and treat specific RiC barriers

• Expanded RiC treatment team allows for thorough assessment of clients who need additional support to meet health outcomes Bilingual RiC Peer Navigators Retention in Care Specialist MSW-level Medical Case Manager Mental Health Clinicians (including Clinical Manager) Primary Care Physician/Provider, Psychiatrist, and other service providers

working with client

• RiC treatment team will develop a tailored service plan for each client

• RiC treatment team will engage in ongoing discipline-specific clinical training on the intersections of trauma, mental health and substance abuse

• Empowerment focused, strength-based, collaborative, gender responsive, culturally competent, and positioned to promote transformative social change

Strategy III. Provide tailored services to address identified barriers that prevent retention & adherence to ART therapies

• Trauma-Informed Client Orientation (fosters hope, informed consent and investment in program participation and ensures client understanding of her role as an active collaborator in the treatment process with the ability to make choices regarding treatment and services)

• RiC Barrier Assessment (strength-based, trauma-informed mental health, substance abuse and support system assessment which ascertains the client’s current level of functioning, barriers to optimal engagement in care and RiC, and the level of social support currently available to the client)

• Behavioral Health individual, family, and group counseling services (clients with significant scores on the aforementioned trauma, substance abuse and/or mental health measures will be referred to the on-site mental health counselor working under the supervision of the Clinical Manager for tailored behavioral health treatment)

• Treatment Adherence Activities (monthly Afternoon TEA [Treatment Adherence and Education] workshops, eight-week Treatment Adherence support group)

Next Steps

• Working with State partners on how to certify

or credential Peer Navigation — can this become a reimbursed service?

• Electronic Health Record technology

• Public and commercial third party insurance reimbursement for behavioral health services• Becoming providers on the Health Exchange/Marketplace plans• Reimbursement through sub-recipient agreements

Acknowledgments/Contact Information

Who is Being Served by Access to Care?

July 2013David Holtgrave & Cathy Maulsby

With abundant thanks to our colleagues and to A2C participants!

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Presentation Objectives• Brief overview of the national evaluation strategy• Discussion of the results:

– Who are the A2C participants?– What are the barriers to care?– What are the trends in participant health outcomes?– How are organizations collaborating at each A2C site?– Are A2C programs ‘cost-saving’ or ‘cost-effective’?

• Dissemination of A2C/national evaluation

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National Evaluation

• Aim to answer, at the national level, cross-cutting questions about identification, linkage, re-engagement and retention in care

• Cross-cutting findings about the successes, challenges, and barriers of linkage to care will inform current and future programs

• Cross-cutting findings will speak to the successes and challenges of the broader health care system, including policy

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National HIV/AIDS Strategy

Blueprint for HIV Treatment -- Linkage and Retention in Care

Contextual Environment•Rural v Urban•Neighborhood•Dependent care

Health Care EnvironmentClinic factors•Clinic distance•Appointment availability•Waiting time

System factors•Mental health services•Substance abuse services•Case management

Provider factors•Trust •Experience•Concordance

Predisposing Factors•Age•Race/ethnicity •Gender•Poverty•Education•Mental illness•Substance abuse

Enabling Factors •Insurance status•Transportation•Housing•Social support•Self-efficacy

Perceived Need•Symptoms•Health beliefs

Linkage to Care

Retention in Care

ARV Receipt & Adherence

Clinical Outcomes•Quality of life•CD4 Count•Plasma HIV RNA•Opportunistic infections•Death

Environmental Patient Characteristics Health behavior Outcomes

(Ulett, 2009)

Three-Pronged Evaluation Strategy

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Strategy: National Evaluation Constructs

Cost Analysis Case Studies

National Research Question Addressed:

• # clients served•Descriptive statistics• Client needs• Barriers to care• Health outcomes

• Type and cost of services provided• Investment in services cost saving or cost effective

• Strengthening of community network of HIV/AIDS providers• Organizational and network changes

National Evaluation Constructs • Developed in collaboration with stakeholders, AU and

grantees• Identified 21 constructs (e.g. linkage to care,

engagement in case management, PCP prophylaxis, adherence, etc.)

• For each construct, identified 2-3 measures based on the literature and best practices

• Feasibility exercise on the 21 constructs (feasibility and relevance)

• 21 12 to be collected across all sites• Data collected at baseline and follow-up

Preliminary Results

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Data Sources• 1st SIF cohort

– July 1, 2011 - August 31, 2012– Baseline & six months (NYC, St. Louis, Boston,

Chicago)– Baseline only (Los Angeles, San Diego,

Montgomery, Washington DC)

• 2nd SIF cohort– Data not yet available

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How many clients were served by SIF and what are the characteristics of those clients?

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SIF1 Total Enrollment (N= 1,197)

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# of

par

ticip

ants

SIF

Demographic CharacteristicsAcross SIF1 Sites

40

% o

f clie

nts

Mean # Years Since First HIV Seropositive Diagnosis

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*Excluding Washington D.C. and Montgomery

What do we know about clients’ service delivery needs?

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Most Frequently Reported Client Needs at Enrollment

(not mutually exclusive)

43*I am going to read you a list of services and resources. Please tell me which ones you currently need (not mutually exclusive)..

% o

f C

lien

ts

San Diego Chicago St. Louis Boston

Most Urgent Need Baseline and T1: Chicago (n=45)

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Participant needs

Per

cent

*Other=job training, transportation, mental health, child care, dental & food

What Barriers are Clients Encountering in Accessing Medical

Care?

45

Most Frequently Reported Client Barriers to HIV Care at Enrollment

(not mutually exclusive)

46Often people with HIV face barriers to getting HIV care. What factors make it hard for you to get care? (don’t read)

% o

f C

lien

ts

San Diego Chicago St. Louis Boston

Most Urgent Barriers to CareBaseline and T1: Chicago (n=45)

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Participant barriers

Per

cent

*Other=drug use, fear, stigma, denial, perceived need, competing priorities, location of care.Of those barriers which is the most urgent for you now?

Stigma at Enrollment

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*Sometimes or often avoided treatment because someone might find out about my HIV** Excluding Washington D.C.

Per

cent

Linkage to Care

49

SIF Linkage to Care and Case Management Service Plans

50

% o

f par

ticip

ants

*Excluding MAO and Washington, DC

What information is available regarding the health status of SIF

clients?

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Baseline Clinical Data

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Site Mean CD4 (SD)

Median CD4 Mean Viral Load (SD)

Median Viral Load

Los Angeles 448 (252) 396 36,053 (69,328) 243San Diego 506 (283) 502 11,145 (62,727) 40Chicago 442 (328) 384 52,331 (17,448) 2008St. Louis 299 (219) 268 434,034 (171,689) 27,230

New York 479 (330) 460 30,496 (131,625) 24Boston 462 (317) 371 14,531 (62,001) 38

Washington DC 429 (260) NA 62,721 (252,181) NAAlabama 668 (NA) 561 541 (NA) 20

Trends in mean CD4 & VL, NYC (n=115)

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Mean C

D4

Time

CD

4

Trends in mean CD4 & VL, Boston (n=11)

54

Mean C

D4

Time

CD

4

Trends in mean CD4 & VL, Chicago (n=6)

55Time

CD

4

Case Studies

• How does the collaborative design of grantee projects strengthen the community networks of HIV/AIDS providers?

• What organizational and network changes take place as a function of this initiative?

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Chicago: Connect2Care Network

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AIDS FOUNDATION OF CHICAGO: Connect2Care Project

Testing

Social Network Recruitment v

Case Yielding through data

OUTREACH & IDENTIFICATION

SUPPORT & LINK TO CARE

HIV PRIMARY CARE PROVIDER

RETENTION IN CARE& SUPPORT SERVICES

Brothers Health Collective

South Side Help Center

4 Regional Hubs

Other Primary Care Providers

Mercy/ CARE Program

Chicago House

The Bridge Project

N.E. IL CM Cooperative

Chicago House

MATEC

MATEC (Comprehensive Plan to Map Pathways)

CARE

Chicago House

South Side Help Center

South Side Health Center

IN CARE

Test Positive Aware Network

HBHC

CORE

EIS Partners

Other Pt A/B EIS Providers

Lawndale

UIC

Open Door Clinic

Mt. Sinai

Lake

HBHC

CORE

Care Programs

Heartland

Retention in Care

N.E. IL CM Cooperative

Hub Group-level Activities/ Access to Care Coordinators at Hubs

CARE

Chicago House

South Side Health Center

Cost Analysis

• Can an argument be made that the investment in services provided has resulted in sufficient health gains that the services could be labeled as "cost-saving" or "cost-effective”?

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Boston: Project LEAP

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Chicago: Connect2Care Project

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Montgomery: MAO

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New York City: AmidaCONNECT

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San Diego: CHANGE 4 Women

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St. Louis: BEACON Project

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Limitations

• Cannot definitively test causal hypotheses• Potential bias emerge from programs

collecting their own data• Data collection methods vary across and

within sites• Programs vary across grantees• Program fidelity may vary within grantee sites• Attrition – Linkage to care vs. retention in care

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Conclusions• SIF1 has enrolled over 1,197 participants• A2C participants meet the national

demographic profile of individuals who are at greatest risk for HIV

• On average date of first diagnosis was 9 years prior to enrollment in A2C

• A2C participants face a variety of structural and psychosocial needs and barriers to care

• A2C participants’ health outcomes are trending in the hypothesized direction from baseline to six months

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Conclusions (II)

• A2C organizations have formed dense complex multi-organization networks that collaborate to link PLWH into care

• Preliminary analyses show that A2C programs appear to have highly achievable cost-saving and cost-effectiveness threshold

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Dissemination

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Access to Care Sites: SIF1

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Access to Care Sites: SIF2

70

Thank you

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Q&A

Thank you!

Visit http://www.fcaaids.org/a2c for resources and a recording of today’s call

A recording of the Part 1 Webinar is available at http://www.fcaaids.org/RyanWhite

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Remaining questions? Share them with us by email sarah@fcaaids.org or via Twitter @FCAA

Save the Date: FCAA 2013 AIDS Philanthropy Summit, 12/9-12/10, Washington, DC