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in + care Campaign Meet the Author August 6, 2013

in + care Campaign Meet the Author August 6, 2013. 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)

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in + care Campaign Meet the Author August 6, 2013

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  1. in+care CampaignMeet the Author August 6, 2013

  2. 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

  3. Welcome & Introductions • Welcome & Introductions, 5min • NYC Care Coordination Program, 30min • Q & A Session, 20min • Updates, Reminders & Evaluation, 5min 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 Manager New York, NY

  4. Patient Navigation:A Network Perspective from the NYC HIV Care Coordination Program August 6, 2013 New York City Department of Health and Mental Hygiene Argus Community, Inc. Beth Israel Medical Center

  5. Presenters • Beau J. Mitts, MPH • Director, Ryan White Technical Assistance • NYC Department of Health and Mental Hygiene • Stephanie Chamberlin, MPH, MIA • Evaluation Specialist, Research and Evaluation • NYC Department of Health and Mental Hygiene • Maria Rodriguez, MPA • Program Director, Care Coordination • Argus Community, Inc. • Vanessa Haney, MFA • Program Director, Care Coordination • Beth Israel Medical Center

  6. AGENDA • DOHMH Care Coordination Program (CCP) Model • Background • Development • Implementation • Argus Community Experience • Beth Israel Medical Center Experience • Evaluation • Take-Home Messages

  7. BACKGROUND: The CCP Model Information Sharing Assessment and Planning Outreach

  8. Background: Target Population • Persons at high risk for suboptimal health care outcomes: • newly diagnosed • previously lost to care/never in care • irregularly in care • with recent adherence issues (e.g., viral rebound, resistance)

  9. Background: Patient Navigation • Patient Navigators are key players on the Care team • Most interaction with the clients • Community Health Workers • Bridge the gap between the clinic and the community • Reflect the community they serve • Services provided (often in client’s home) include: • Health promotion • Accompaniment • Treatment adherence • Modified DOT • Caseloads • Patient Navigators: 14 to 20 clients • DOT Specialists: 7 clients • Required clinical supervision

  10. DEVELOPMENT: Research and Timeline • Models reviewed: • Medical Home, Patient Navigation, Chronic Care, Community Health Worker • Prevention and Access to Care and Treatment (PACT) Project • Partnership between Partners in Health (PIH) and Brigham and Women’s Hospital in Boston, MA • Requests for Proposals (RFP) • 2004: Treatment Adherence Program (TAP) • 2006: Maintenance in Care (MIC) • 2009: Care Coordination Program (CCP) • Bradford et al. HIV System Navigation: An Emerging Model to Improve HIV Care Access. AIDS Patient Care and STDs. 2007;21:S49–S58.

  11. DEVELOPMENT: Tools • Program Manual • Version 4.0 released May 29, 2013 • Each version evolved and adapted • Recommended staffing plan • Staff roles and responsibilities • Guidance on program processes • Standardized forms • Excel adherence calculator • eSHARE data reporting system

  12. Development: Training and TA • Trainings • 10-day Care Coordination training • National Development and Research Institutes (NDRI) • HIV 101, case management skills, program forms, etc. • Four-day Health Promotion Training of Trainers (TOT) • PACT trainers along with NYC DOHMH Project Officers • Two trainers at each Care Coordination program • One-day trainings • Care Coordination Refresher • Cultural Sensitivity • Co-occurring Disorders (HIV, MH, and SA) • Technical Assistance • NYC DOHMH Project Officers • Bi-annual Provider Meetings • Site visits and webinars

  13. IMPLEMENTATION: Funded Programs • 28 agencies providing CCP in New York City (NYC) • 16 hospital-based agencies • 12 community-based agencies • Caseloads: • Agency caseloads: 52 to 230 active clients • 9 small programs • 12 medium programs • 7 large programs • ~3,300 PLWH in the active portfolio caseload at any given time • 4,986 unique PLWH served from March 2012 – February 2013

  14. IMPLEMENTATION: Client Demographics

  15. Argus Community, Inc.www.arguscommunity.org 760 East 160th Street Bronx, NY 10456 718-401-5700 Maria Rodriguez, MPA

  16. BACKGROUND: Argus Community, Inc. • Founded in South Bronx in 1968 • Began as substance abuse treatment provider • Expanded to address homelessness, AIDS/HIV, welfare reform • Received national and international recognition • Programs replicated in Washington, DC; San Francisco; Albany; Des Moines; and Belfast, Northern Ireland. • Program created in response to community needs and continues to respond to new emerging needs

  17. PROGRAMS: Argus Community, Inc. • ACCESS I Care Management • ACCESS II Care Coordination • Argus Career Training Institute • Argus Client Money Management • Argus Community Re-Entry Initiative • ARU Outpatient Center • DWI Screening and Assessment • Elizabeth L. Sturz Outpatient Center • Harbor House & Harbor House II • MEDAL Program • Prometheus I and II • RESTART GED Program • Striver House • Youth Intervention and Development

  18. The 3 P’s In Care Coordination Treatment Adherence Maintain a Stable Health Status Become Self-Sufficient Linkage To Care Support and Coach Coordination of Medical Services Home Based Navigation Coordination of Social Services Community

  19. Patients: Argus Community, Inc. • Total Census as of June 2013: 125 Active Patients • Referred by 3 medical facilities, self-referrals, and/or our Health Home program. • Patients By Track Enrollment as of June 2013:

  20. IMPLEMENTATION: Client Demographics

  21. ACCESS IICCPStafF

  22. Program Staff

  23. PROVIDERS • Montefiore Medical Group (MMG) – CICERO Program/Bronx Community Health Network • 11 Clinics from the Montefiore Medical Group CICERO Program • All Med and Rehabilitation of New York • The George and Eva Neil Barbee Family Health Center • The 151st Medical Center

  24. The Model: Referral Process

  25. The ModeL: Building Provider Buy-in • Provider Website • Social Work Luncheon/Program Presentations • Clinical Rounds/Conferences • CCP Patient Report for Providers • Consumer Advisory Board Meetings

  26. The ModeL: Services Provided • Accompaniment • Assistance with Entitlements and Benefits, Health Care, Housing, and Social Services • Care Plan • Case Conference • Directly Observed Therapy (DOT) • Health Promotions • Home Visits • Intake/ Re-Assessment • Outreach for Patient for Reengagement • Treatment Adherence/Pill Box Count

  27. Case Study: Lisa • Lisa was referred by her PCP on 7/15/11 • Initial enrollment track was C2-weekly • CD4 at the time of enrollment was 219 and VL was 29,492 • She began DOT services on 11/16/2011. Her CD4 was 214 and VL 30,494 • CCP staff provided daily DOT services, weekly Health Promotion, and case management until 3/23/2012 when patients lab reported her CD4 was 350 and VL undetectable. • On 9/17/2012 her CD4 was 375 and VL remained undetectable • On 1/18/2013 her CD4 was 465 and VL remained undetectable. • Her last lab report indicates that her CD4 is 397 and VL remains undetectable.

  28. Beth Israel Medical CenterPeter Krueger Center for Immunological Disorderswww.wehealny.org/services/bi_aidsservices 10 Nathan D Perlman Pl, New York, NY 10003 212-420-2620 Vanessa Haney, MFA

  29. BIMC’s AIDS Center timeline

  30. BACKGROUND: Bimc • Inpatient • 1,083certified beds • Emergency Department • Visits (Excluding Admissions) in 2011: 107,178 • Admissions in 2011: 35,376 • Methadone Maintenance Treatment Program • Visits: 1,079,514 • Ambulatory/Outpatient • Visits: 371,083 The Peter Krueger Center • Number of Unique Patients: 1,200 • HIV Primary Healthcare • Specialty Healthcare (Dermatology, Gynecology, Pain Management) • Dental • Mental Health (Psychiatry/Psychology/Counseling) • Transgender Health Care Services • Care Coordination • Social Work and Case Management • Harm Reduction: Project S.H.a.R.E. • Nutrition

  31. Patients: BIMC • Since 2010, 298 people have been enrolled into BI’s CC Program • Total Census as of June 2013: 186 Active Patients • Patients By Track Enrollment as of June 2013:

  32. IMPLEMENTATION: Client Demographics

  33. THE MODEL: Referral Process

  34. Care Coordination: Our Team!

  35. PROGRAM STAFF

  36. EVALUATION: Outcomes

  37. Case study: Brenda • Brenda is a 44 year-old woman test HIV positive in 2004 • History of trauma, depression, and substance use • Enrolled in CCP April 2011 • Viral Load of 100,000 copies and CD4 was 113 • Throughout 2011 and 2012 • Remained difficult to engage but kept on a weekly track • Did not agree to pill boxing and self-reported 100% adherence • March 2013 • Viral Load had risen to 659,892 copies and her CD4 dropped to 11 • April 2013 • Agrees to DOT during her PCP appointment • July 2013 • Viral Load is <75 and her CD4 have risen to 43 • Significant improvement in herpes lesions

  38. Care Coordination Program Evaluation NYC Department of Health and Mental Hygiene Stephanie Chamberlin, MPH, MIA

  39. Evaluation: Process and Outcomes • Cross-agency evaluation utilizing standard metrics, based on the well-defined CCP protocol Process Outcomes Fidelity to Program Model Cross-sectional (2010 – Present) Barriers Facilitators Pre- and Post-CCP Enrollment (2012-Present) Quality Management Short-Term Long-Term

  40. EVALUATION: Time And Effort Study • Background • Method • Sample of six (6) Agencies

  41. EVALUATION: Time And Effort Study

  42. EVALUATION: Engagement In Care n/a

  43. EVALUATION: Viral Load Suppression n/a

  44. NYC DOHMH Care Coordination Evaluation Team

  45. Take Home Messages • Patient Navigators do more than just navigation • Health promotion, treatment adherence, modified DOT, etc. • Diverse Community Health Worker staff • Cultural sensitivity and competency • Field safety training and protocol • Means of communication • Clinical supervision • Technical assistance • Provider meetings • Peer to peer learning • Best practices • Incorporate data collection and evaluation

  46. Questions • Beau J. Mitts, MPH • NYC Department of Health and Mental Hygiene • bmitts@health.nyc.gov • Stephanie Chamberlin, MPH, MIA • NYC Department of Health and Mental Hygiene • schamberlin@health.nyc.gov • Maria Rodriguez, MPA • Argus Community, Inc. • marodriguez@arguscommunity.org • Vanessa Haney, MFA • Beth Israel Medical Center • vhaney@chpnet.org To find Care Coordination tools online visit: www.nyc.gov SEARCH: Care Coordination

  47. Announcements

  48. Upcoming Events and Deadlines • Upcoming Webinars: • Stay Tuned! Campaign staff is hard at work for you • Data Collection Submission Deadline: October 1, 2013 • Improvement Update Submission Deadline: August 15, 2013 Upcoming Monthly Topics • August – Transitory Populations and Retention • September – Women and Retention • October – Sex Work and Retention

  49. Campaign Headquarters:National Quality Center (NQC)90 Church Street, 13th floor New York, NY 10007Phone 212-417-4730 incare@NationalQualityCenter.orgincareCampaign.org youtube.com/incareCampaign

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