ask, screen, intervene 4 cities project training exchange june 20, 2013 for audio dial:...

Ask, Screen, Intervene 4 Cities ProjectTraining ExchangeJune 20, 2013

For Audio dial: 1-800-591-2259 Passcode: 959325Please remember to mute your speakers

Training Exchange Objectives• Discuss updates to the Ask, Screen,

Intervene (ASI) curriculum• Review the ASI Four Cities Project• Identify lessons learned from the

implementation of the ASI framework in community health clinics

• Describe preliminary results from the evaluation of the project

Agenda

▫Welcome and Call Purpose --- Joanne Phillips

▫Ask, Screen, Intervene (ASI) Curriculum Updates 2013 --- Helen Burnside

▫Ask, Screen, Intervene Four Cities Project --- Joanne Phillips Introduction of the project Collaborators Timeline

Agenda

• Four Cities Updates▫ Needs Assessment:

process and findings▫ Training Design▫ Training Evaluation Data:

barriers and anticipated practice changes

▫ Lessons Learned▫ Clinic Experience▫ Plans for Sustainability

•Baltimore•Chicago•Miami•Los Angeles

Agenda▫Evaluations of the curriculum

implementation --- AETC NEC Evaluation Design Data Collection Data Analysis Results

▫Summary of the Project --- Helen Burnside▫Question and Answer --- Joanne Phillips

ASI Curriculum Updates•2012 4 modules→ 3 modules

▫Risk assessment & screening for STDs▫Prevention Interventions▫Partner Services

•2012-2013 Revisions completed from DHAP and DSTDP Clearance

•Contact National Resource Centers for access to DRAFT curriculum

http://www.cdc.gov/hiv/prevention/programs/pwp/index.html

Project Overview•MAI-funded project through HRSA HAB

▫Supports National HIV/AIDS Strategy goals•Began Fall 2011

▫2 year project•Project activities

▫Planning and implementation▫Training and on-going technical assistance▫Program assessment and evaluation

Project Objectives•Enhance clinician ability to conduct effective

risk screening, conduct prevention counseling, and refer for services

•Increase the number of HIV-positive persons who receive information about transmission risks and regularly receive risk reduction counseling

•Increase the number of HIV-positive persons who are screened for STDs

•Assist in strengthening linkages to referral services

Collaborators

•HRSA HAB•CDC•4 regional AETCs and 4 PTCs•National Resource Center for NNPTCs•AETC National Resource Center•AETC National Evaluation Center•8 Ryan White Part C clinics/FQHCs in 4

cities

4 Cities and Clinics

•Baltimore▫Chase Brexton Health Services (3 sites)▫Total Health Care, Inc. (10 sites)

•Chicago▫Access Community Health Network▫Erie Family Health Center, Inc.▫Heartland Health Outreach, Inc.

Selected based on ECHPP

designation and

application review

4 Cities and Clinics

•Los Angeles▫Alta Med Health Services Corporation

•Miami▫Jessie Trice Community Health Center, Inc.▫Miami Beach Community Health Center

Project Activities•Planning & Implementation (Fall 2011 -

Winter 2012)

Project Activities•Training (Spring 2012- Summer 2012)

▫Tailor to clinic needs▫Clinic project coordinator help facilitate

and monitor •Assessment & Evaluation (Spring 2012 –

Summer 2012)▫Training Data

FTCC PIF▫Training Evaluation Summaries

NRC for the NNPTCs

Project Activities•Ongoing Training and Technical

Assistance (Fall 2012-June 2013)

•Program level (feasibility, fidelity, impact)▫AETC National Evaluation Center

AETCs and PTC updates on: needs assessment process, training design, training evaluation data, lessons learned, clinic experience, and plans for sustainability

ChicagoRicardo Rivero: Midwest AETCDeyanira Flores: ACCESS Clinic

Chicago: Needs Assessment•Meeting with clinic leadership and key staff

•Specific needs related to 3 ASI modules:What’s in place alreadyWho would be involvedEMRWhat needs to be covered from ASI curriculum

•Plans for sustainability

Chicago: Training Design•All 3 training modules were tailored …

AudienceLocal informationTime

•Training / TA beyond ASI:STI: Overview & What’s NewMotivational Interviewing BootcampFilling Your Prevention Tool BoxRisk screeners

Chicago: Practice Changes

•Risk screening (e.g., paper and iPad tools, etc.)

•Screening of STDs

•Delivering prevention messages

•Use of behavioral counseling

•Referral to more intense prevention interventions

Chicago: Barriers

•Time (per encounter and for training)

•Lack of confidence in skills

•Competing priorities

•Changes in leadership

•Staff turnover

Chicago: Lessons Learned

•Clinic leadership and providers buy-in•Needs assessment •Single contact at the clinic •Clinic-centered trainings and TA•Periodic site visits•Partner services … the weakest link?

Chicago: Clinic Experience

Deyanira Flores, Project CoordinatorACCESS Community Health:•Overall experience•Major accomplishments•Barriers worth mentioning

Chicago: Plans for Sustainability All 3 sites will continue implementation at different levels:

ACCESS Community Health will expand to another site as of July 1, 2013

Erie Family Health Center and ACCESS will continue working with the PTC to conduct risk assessments with iPads

Heartland Health Outreach … new leadership and programmatic staff

Los Angeles

Tom Donohoe, UCLA Pacific AETCLinda Creegan, CA HIV/STD Prevention Training CenterArdis Moe, UCLA Pacific AETCAlberto Perez, CA HIV/STD Prevention Training Center

HIV Clinic in Los Angeles, California

Main HIV Clinic, Commerce, California

Los Angeles: Needs Assessments/ Training Design

• Initial Assessments: Winter-Spring 2012

•Scheduling: Spring 2012• ‘Overview’ session•Modules I, II, III delivered May-

June 2012• ‘Implementation’ session June 2012•“Wrap up” in-person session May

2013

Los Angeles: ASI Training Design

All ASI modules delivered at clinic and utilized Turning Technologies ARS

Overview session was important to review what ASI implementation project was/wasn’t (i.e., exit interviews)

Draft clinic signage was used to facilitate training experience and discussion of clinic specific implementation of ASI

Bilingual signs for HIV waiting room

Bilingual HIV WaitingRoom Signage

Pin: “Ask me aboutSexual Health”

Los Angeles: Training Evaluation•Barriers

▫Existing Secondary Prevention Programs▫Existing ideas of ideal clinic flow for prevention▫EMR implementation/trainings during project

•Practice changes▫Increased STD testing/partner services referral▫Increased sharing of patient risk information▫Enhanced discussion of hard-to-reach patients

Los Angeles: Lessons Learned• Important not to make patients feel like they are

public health hazards---that assessing sexual health and prevention needs is part of high-quality HIV care

• Combine ASI questions and protocols with existing prevention and STI screening procedures to enhance patient experience (without repeating sensitive questions)

• Clinicians and support staff need to share prevention information and screening information, ideally through the EMR

• Changing clinician/staff ‘routines’/beliefs may be harder than changing the EMR

Los Angeles: Sustainability of ASI•PAETC/PTC will work with clinic to assist with

future ASI-related training needs, including options for dealing with ‘condom refusers.’

•The clinic now doing six month RA screening, with some staff more frequently

•Partner Services always offered as standard of care (not always accepted, but increased)

• Increased rectal and pharyngeal testing

Los Angeles: Sustainability of ASI• Increase interactions within HIV staff

groups (front office/back office, clinicians, mental health, case managers)

•EMR key for future sustainability (billing)•More specific questions about prevention

needs helped change exam room interaction but this is long term process

•Might be helpful to have level III observational experience for each discipline

Los Angeles: ASI-related trainings needs

PAETC, PTC or other (PS ATTC) will offer:• PrEP• Brief Mental Health Screenings for non-

mental health clinicians• Billing for Prevention in the ACA Era• SBIRTS• Medical Marijuana and HIV• Crack Cocaine and HIV• Meth and HIV• Alcohol and HIV

BaltimoreTerry Hogan: Johns Hopkins PTCAbby Plusen: Pennsylvania/Mid-Atlantic AETCJennifer Kunkel: Total Health Care

Baltimore: ASI Collaboration▫ Introductory Meetings

Training Centers’ Staffers Clinics’ Staffers

▫ Training Centers’ Responsibilities Technical Assistance Training

▫ Clinics Operations Total Health Care, Inc. Chase Brexton Health Services

▫ Needs Assessments

Baltimore: Needs Assessment▫ Conducted face-to-face meetings with key

stakeholders at each clinical setting▫ Collected needs assessment data with

stakeholders Used format developed in partnership with full

ASI, 4-Cities Project Group Prepared full report Shared with clinic partners

▫ Sent reports to ASI, 4-Cities Project

Baltimore: ASI Trainings▫ Scheduled trainings based on clinic schedules

Chase Brexton – held trainings on several different dates to accommodate all staff

Total Health Care – held one training to coincide with full clinic meeting

▫ Collaborated with BCHD faculty for Module 4▫ Assured sustainability through TOT for selected

staff Recognized that traditional TOT not best for staff

resource

Baltimore: Clinic Perspective

Implementation▫ Key components What clients need to know

Am I at risk What puts me at risk What can I do to prevent risk

What providers and support staff need to know How can I implement ASI in a high volume primary care

setting What does it take to document ASI activities How to evaluate the impact of ASI on affected population

Baltimore: Barriers & Lessons Learned▫ Primary Care Settings

Not offering exclusive HIV services Diverse clinic census Electronic medical records

Already established ASI risk questions

▫ HIV Care Patients Total Health Care – separate clinic visits

Many HIV-specific visits Some chose to stay with primary care providers

Chase Brexton – incorporated into clinic

Baltimore: Clinic Perspective/Outcomes▫ Primary Care Side and Meaningful Use Questions

Brief ASI intervention Imperative in high volume setting

Incorporate ASI intervention into Electronic Medical Record is ideal

Coordinate HIV Medical Services with Primary Care▫ Clinic Accomplishments

Total Health Care, Inc. 398 HIV-positive clients screened/documented – 2012

Chase Brexton Health Services 933 Clients screened/documented – 09.2012-05.2013

Ongoing collaboration between clinics

Baltimore: Sustainability▫ TOT model▫ TA

Linkage Reverse Preceptor? AETC + PTC as a resource

▫ Collaboration between two large service providers

MiamiYvette Rivero: Florida/Caribbean AETCRichard Meriwether: AL/NC PTCRuth Duval: Jesse Trice Clinic Coordinator

Clinics in Miami, Florida• Jessie Trice Community Health Center (JTCHC)

5361 NW 22nd Avenue, Miami, FL 33142

•Miami Beach Community Health Center (MBCHC)710 Alton Road, Miami Beach, FL 33139

Miami: Needs Assessments• Initial Assessment

▫March 2012•2nd Assessment

▫October 2012 (sites requested training on HPV, Mental Health in HIV, STD, Substance Abuse, and Cultural Sensitivity)

•3rd Assessment▫April 2013 (Sexual Health survey has been implemented as

part of Primary Care and updates on STD will be provided yearly)

•Last assessment pending June 2013

Miami: ASI Training Design

Modules delivered monthly in a previously scheduled training slotTraining slot was 3-5:00pm to avoid overtime pay and cutting into clinic hoursTraining conducted in conference rooms at clinicsAll clinic staff attended trainings

Miami: Training Evaluation Practices

•Barriers▫Time constraints of clinic visit▫Client refusal to take Sexual Health survey

•Practice changes▫Allocating more time to provider▫Allowing a Medical Assistant (MA) to assist

provider▫Providing education to clients that refuse

to take Sexual Health survey

Miami: Supplemental Trainings•Cultural Sensitivity –

▫MBCHC, May 22, 2013▫JTCHC, tentative for June

•HPV and HPV Vaccines – ▫JTCHC, May 3, 2013

•STD updates – ▫MBCHC, Feb. 21, 2013▫JTCHC, May 17, 2013▫Mental Health and HIV – (pending) June

2013

Miami: Additional trainings

•Module I training provided on March 29, 2013, to:▫Community Health Centers of South

Florida, Inc. ▫Borinquen Medical Centers of Miami

Clinic posters for waiting area, provider’s office

Miami: Lessons Learned• Provider administered Sexual Health survey is

more likely to be more comprehensive and/or complete than self-administered survey

• Patients were more willing to discuss sexual history because they knew that the sexual survey would be administered

• Implementation of the Sexual Health survey has helped staff to facilitate sexual health discussions

• Local involvement is crucial to program implementation

• Prior to training, clinic involvement is crucial to program implementation

Miami: Sustainability of ASI•F/C AETC Coordinator has committed to

provide STD training updates to staff at both clinics yearly.

•The clinics have established the Sexual Health survey as part of their Primary Care visit, which can be accessed in the EMR.

•The clinics have already made changes to have every patient screened at every visit for sexual history in order to reduce HIV transmission.

Tim Buisker, Julia James, Andres Maiorana, and Janet Myers: AETC National Evaluation Center

OverviewOverview

•Evaluation Design Overview▫Risk Screener Data▫Patient Exit Survey Data▫Ryan White Services Report/Client Level

Data▫Qualitative Interviews

•Preliminary Results

Evaluation Design Overview Evaluation Design Overview

Feasibility

Integration

Impact

Evaluation Design Overview Evaluation Design Overview

Risk Screener DataRisk Screener DataN=5673N=5673

RSR Data RSR Data

Triangulate

Qualitative InterviewsQualitative InterviewsASI Trainers (8)Providers (27)

Patient Exit Patient Exit SurveysSurveysN=589N=589

• Patient Exit SurveysPatient Exit Surveys▫Min 30 patients every other month in 400+

patient clinics▫Min 12 patients every other month in <400

patients▫Procedures tailored to clinic

• Clinical Record Risk DataClinical Record Risk Data▫½ from EMR, ½ extracted using paper form

• RSR DataRSR Data▫Was HIV risk reduction screening/counseling

conducted?▫Syphilis, Hep C, Hep B screening over time.

Quantitative Methods Quantitative Methods

• Study Participants:Study Participants:▫At least one ASI trainer per clinic▫Planned for at least 4 providers per clinic

• Methods: Methods: ▫Semi-structured Interviews ▫30-60 minutes conducted over the phone▫Interviews were audio-recorded and

transcribed using a transcription service▫Transcripts were coded iteratively by two

independent researchers using an open-coding process (Strauss and Corbin 1998)

Qualitative Interview Qualitative Interview Methods Methods

Preliminary ResultsPatient Exit Survey

Demographics

Age: 18-24 7.1%25-34 20.5%35-44 26.8%45+ 45.0%(missing) 0.5%

Racial/ethnic background: African-American or black 53.5%White 9.7%Hispanic/Latino 33.3%Asian or Pacific Islander 0.5%Native American 0.2%Mixed Race 2.0%Other 0.2%(missing) 0.7%

Demographics

Gender: Male 66.7%Female 32.4%MtF 0.3%FtM 0.0%Other 0.2%

Sexual orientation: Heterosexual 53.8%Homosexual 37.7%Bisexual 5.9%Other 1.2%

Demographics

Age: 18-24 7.1%25-34 20.5%35-44 26.8%45+ 45.0%(missing) 0.5%

Education: Less than 8th grade 10.7%8th-11th grade 30.4%12th grade or high school graduate or GED 27.5%Some college or AA degree 17.3%College graduate 9.7%Graduate education or graduate degree 1.5%

Risk discussion topics

In this visit, did your provider discuss… HIV/sexual behavior:

How to choose sex partners? 62.7%Choosing HIV+ sex partners (serosorting)? 57.7%Telling partners HIV status? 67.8%Asking partners about HIV status? 60.9%Talking to partners about safe sex? 68.8%Having less unprotected anal sex? 63.1%Having less unprotected vaginal sex? 51.6%Getting help to disclose HIV status? 52.1%

Condom use: How often you carry condoms? 64.8%Using condoms more often? 72.1%

Risk discussion topicsIn this visit, did your provider discuss…Injection drug use:

Sharing needles, works, cotton or water? 38.4%Using needle exchanges? 34.8%Using clean needles, works, cotton, H2O? 31.9%Using drugs while having sex 39.0%

STI screening: Getting screened for any STI? 73.8%Gonorrhea? 64.2%Syphilis? 68.4%Hepatitis C? 66.8%HPV? 51.6%Chlamydia? 62.0%Disclosing STIs to partners? 46.8%

Overall…

On a scale of 1 to 10, how important is it to you that your provider discuss HIV risks this visit?

Mean: 8.48

Preliminary ResultsProvider Interviews

Interview Guide – Selected Interview Guide – Selected QuestionsQuestions•How has the way you talk to patients

about prevention changed after using ASI compared to before using ASI?

•How did the ASI training prepare you to talk to your patients about STD screening and HIV prevention with their partners?

•How integrated do you think ASI has become to clinic procedures or protocols?

•ASI provided a formal structure for discussing PwP with patients

•Clinic procedure: EMR adapted to include questions from ASI

•ASI led to discussions about capacity for screening at the clinic

•Medical providers and other staff were involved in implementing ASI

Feasibility

“I guess that what I would say about it is that it is a good reminder of something that, for the most part, we’re doing.”

-- Medical Provider

FeasibilityFeasibility

•ASI served as a reminder for providers on the importance of PwP

•ASI raised awareness of oral and anal swab testing in STI screening for gonorrhea

•The Risk Screener facilitated conversations between patients and providers

• Improved communication among team members helped medical providers learn more about their patients

Integration

“I would say doing [ASI] has been pretty seamless because I couldn’t even differentiate. It’s not like we fill out a form that says, ‘Fill out this form that you’ve completed ASI.’ We have to do more. It’s just part of what you do with every patient.”

-- Medical Provider

IntegrationIntegration

•Time •Knowledge transfer to new hires •Need for ongoing training•Need for special services for high risk

patients and for those with comorbidities

Barriers

“What this project did was make us talk about [STD screening] and just figure out how to make it available. Because our last lab wasn’t able to process everything correctly, we changed labs. It made us really figure out the process. From that, we’ve been able to do more. It just got everyone on the same page in the clinic about doing routine screening.”

-- Medical Provider

ImpactImpact

“Now, as part of the HIV care team, we're not going to pull back on discussing people's risks and how to intervene for a particular patient. We have those conversations weekly and we're going to continue that. We will also develop new tools and approaches for helping people.”

-- Medical Provider

Evaluation Team

•Faye Malitz, HRSA•Janet Myers, AETC NEC at UCSF•Andre Maiorana, AETC NEC at UCSF•Tim Buisker, AETC NEC at UCSF•Julia James, Fellow, UCSF

Helen Burnside: NNPTC NRC

ASI Training Considerations

•Patients want to discuss sexual health/Patient reluctance as a provider barrier

•Needs assessment with clinic prior to training▫Lab needs▫Clinic flow/process and responsibilities of staff▫Documentation: use of EMR, risk screener

integration, partner service protocol, & data sharing

▫Clinic and provider buy-in

Project Summary: Keys to Success•Multidisciplinary approach/medical home

model•Sustainability: increase implementation

success▫Booster trainings ▫Clinic champion ▫Referral process▫Incorporate ASI framework into clinic routine“Changing clinician behavior is harder then

changing an EMR”

ASI Resources and Materials

•Contact your AETC or NNPTC NRC for the ASI curriculum

•Clinic posters are under development by NRCs

•ASI provider guide

Joanne Philips: AETC NRC