Luncheon Seminar Omni Shoreham Hotel August 27, 2008

1. HIV Medical Case Management: Addressing the Training Needs of Front Line Workers and Ryan White HIV/AIDS Program Grantees Luncheon SeminarOmni Shoreham HotelAugust 27, 2008

2. Today we will … • Provide an overview of • The concepts underlying the medical case management (MCM) service category in the Ryan White HIV/AIDS Treatment Modernization Act of 2006 • HAB’s current requirements regarding medical and non-medical case management (CM) • Approaches used throughout the U.S. to adopt medical CM, with presentations from three metropolitan areas • The Abbott Laboratories and Positive Outcome assessment and curriculum development project

3. Today we will … • Discuss the medical CM training needs of HIV case managers and CM supervisors in your communities, and the extent to which these needs are being addressed • Conduct a written mini-assessment • Get your feedback about meaningful ways our project can help you and your colleagues

4. Defining Medical CM

5. HAB’s Medical CM Definition Medical CM services (including treatment adherence) • A range of client-centered services that link clients with health care, psychosocial, and other services • The coordination and follow-up of medical treatments • Medical CM includes the provision of treatment adherence counseling to ensure readiness for, and adherence to, complex HIV/AIDS treatments • These services ensure timely and coordinated access to medically appropriate levels of health and support services and continuity of care • Through ongoing assessment of the client’s and other key family members’ needs and personal support systems

6. HAB’s Medical CM DefinitionContd • Key activities include • Initial assessment of service needs • Development of a comprehensive, individualized service plan • Coordination of services required to implement the plan • Client monitoring to assess the plan’s efficacy and • Periodic re-evaluation and adaptation of the plan as necessary over the client’s life • Includes client-specific advocacy and/or review of utilization of services • Includes all types of CM including face-to-face, phone contact, and any other forms of communication

7. HAB’s Non-Medical CM Definition • Provision of advice and assistance in obtaining medical, social, community, legal, financial, and other needed services • Does not involve coordination and follow-up of medical treatments, as medical CM does

8. HAB’s CM Treatment Adherence Definition HAB does not explicitly define treatment adherence responsibilities or roles for medical case managers • Treatment adherence strategies used throughout the U.S. include • Assess factors likely to contribute to poor adherence and develop individualized care plans to address those factors • Medication, referral, and appointment adherence interventions • Patient HIV education to expand “health literacy” • HIV medication education, including side effects and their management

9. HAB’s CM Treatment Adherence Definition Contd • Attending medical visits to assist patients to understand the information provided by medical provider • Coordinate appointment scheduling to book multiple visits on the same day and arrange transportation to ensure the patient keeps appointments • Home visiting and other methods of case finding for patients that have broken appointments or dropped out of care • Assess and treat mental illness and/or substance abuse

10. Environmental Challenges in Operationalizing MCM • Good news: HAB’s MCM definition is not proscriptive • Bad news: HAB’s MCM definition does provide a roadmap in designing or improving MCM and non-medical CM systems • The CM workforce in many (not not all) jurisdictions are in crisis • High caseloads, inadequate compensation and training, minimal supervision, high turnover • HAB grantees are re-engineering their CM systems to address these challenges, as well as to “medicalize” CM practice • One missing component to their efforts to medicalize CM practice is the collateral expectation that clinician embrace the role of MSM on the care team

11. Medical Case Management Training Strategies: Approaches Taken by Three Communities

12. Adopting Medical Case Management in the Broward County Eligible Metropolitan Area: Challenges and Opportunities William Green, Broward County Human Services Dept

13. Nationally Focus on newly introduced HIV testing and treatment (AZT) Focus on HIV voluntary testing, primary care, and combination therapy Focus on rapid HIV testing, HAART, and increasingly complex specialty care Ryan White HIV/AIDS Treatment Modernization Act of 2006 identifies two types of CM Focused on hospitalizations & end of life care 2002 2003 2004 1980s Late 1980s-Early 1990s Mid to Late 1990s 2000s 2006 Service Provider Networks (Consortia) Established Broward County Fiscal Impact Study, 2002- “Basic HIV training is needed and might be coordinated with the local AETC performance site.” Broward County developed a Case Management Task Force. Broward County Case Mgmt. Training Needs Survey Report, 2003 -”Using the strengths approach to motivate treatment adherence.” Ft. Lauderdale Broward County EMA

14. HAB/HRSA Project Officer • Technical Assistance • Training Initiatives

16. What components did Broward have to implement medical case management? Broward’s Medical Case Management Infrastructure

17. Converting a non-medical case management system to medical case management Changing Clinician Attitudes About Case Managers Psychosocial Model Used by CBOs and Clinics Low Case Manager Salaries High Caseloads High Turnover

18. Medical Staff • Treatment Plan Medically Focused • Incorporate Multi-disciplinary Staffing • Provide ongoing forums for Continuous Medical Case Management Training Non-Medical Staff

19. Continuous Training Florida Caribbean/AIDS Educational Training Center (AETC) AIDS Community Research Initiative of America (ACRIA) Grantee Sponsored MCM and MCM Supervisor Training

20. Medical Case Management Training Series • Training 1-Treatment Adherence • Training 2-Lab Tracking 101 • Training 3-HIV/AIDS: The Latest Research and Treatments • Training 4-Assessing Client’s Medical/Clinical Needs • Training 5-Cultural Competency

21. HIV Health Literacy Training • Two 8-Hour Days – Offered Twice • Required For All Case Managers • Optional For Outreach Workers • Treatment Adherence Focused

22. Part A Grantee developed training curriculum and contracted with a training subgrantee to train Medical Case Managers and Medical Case Manager Supervisors Pre-requisite Basic Training (16 hours) Advanced Training (36 hours) Trainings are conducted annually

24. Imbedded in the SUPPORT model is the 4-1-1 Supervision Format. The 4-1-1 Format specifies that one hour of supervision should include 40 minutes of case review, 10 minutes discussing professional growth, and 10 minutes discussing administrative functions. This model is premised on the belief that the client’s health is the most important consideration for the MCM and the ability to provide the highest quality of care is directly dependent upon the staff’s performance and skill level.

25. HIV Medical Case Management: Addressing the Training Needs of Frontline Workers and Ryan White Program Grantees Evelyn Torres, MBA Philadelphia Department of Public Health Philadelphia EMA

26. Philadelphia EMA • Nine counties across two states • 70 funded providers • 15,000 consumers • PDPH, AIDS Activities Coordinating Office administers • Part A • Local Part B - Pennsylvania • CDC Prevention & Surveillance • Local HIV funding

27. Philadelphia EMA Service System • Decentralized system • 24 medical agencies • 28 edical case management agencies • 6,600 clients receiving case management services • 1,800 intakes a year completed through the Client Services Unit

28. Profile of Medical Case Management (MCM)Services in Philadelphia • Funding: $7 million (RW A, B, and local) • Services are provided through: • CBOs • ASOs • Hospital outpatient infectious disease clinics • Stand-alone HIV clinics • 2/3 of providers are either ASOs or CBOs

29. MCM Model • Broker model with goals of: • Facilitating access to and retention in medical care • Tracked since 2001 • Providing treatment adherence counseling • Standards of care and outcomes established • Educational requirements for case managers and supervisors • Grantee conducts yearly training and certification of Parts A and B-funded case managers and supervisors

30. MCM Training • Annual training and certification process, coordinated with the local AETC • Core training: nine days on six specific topics for newly hired case managers and supervisors • Ongoing training: 20 hours of mandated training of which 6 hours must be medical • Providers are notified of those employees not completing the annual requirements • 130 case managers and supervisors in the Philadelphia EMA

31. Grantee Response to HAB MCM Model • Fund only MCM • RFP emphasis • Treatment Adherence • Retention in medical care • Supervision • Case closure • Mandates policies and procedures for each of above

32. AACO Medical Case Management Committee Priority Areas Treatment adherence, clinical supervision, and linkage/retention in medical care Tasks • Identify responsibilities and roles of MCM providers • Identify key implementation activities for the CSU, ISU, and PSU • Revise training curriculum to reflect the paradigm shift

33. Training Curriculum Changes • Emphasis on treatment adherence • Assessment of client’s adherence to HIV treatment • Treatment adherence activities • Documentation • Health literacy • Continue focus on medical follow-up by fostering collaboration between community-based case managers and medical providers

34. Pearls of Wisdom • Do not re-invent the wheel • Look at what is out there • Take an integrated approach • Training cannot be done in a vacuum • Highlight best practices • Stress the benefit • Get input from key stakeholders • Surveys • CQI Meetings • Focus Groups

35. Implications for Training and Service Implementation Pat Balducci, LCSW Medical Case Management

36. Presentation Overview • Historical Perspective • The Baltimore Experience • Training Strategies

37. Section I: Historical Perspective Historically, Case Managers focused on helping HIV+ patients and their loved ones grapple with issues such as chronic disease management with few medications, limited entitlements, lifestyle issues, and too often, death and dying

38. HIV – In the Beginning • Few tools • Evolving understanding of disease • Limited medications • Limited entitlements • Limited staff training • Developing Standards of Care

39. Section II: The Baltimore Experience

40. Baltimore EMA Standards of Care • Part A (formerly Title I) Standards of Care were ratified November 1998 and revised October 2003 • Case Management (CM) Standards evolved as a Medical Model • Addressed: • Assessment • Care Plan Development • Plan Implementation • Monitoring and Evaluation • Case Closure • Qualifications (RN or licensed SW with a minimum 3 years experience)

41. Standards of Care Contd • Delineated CM Services • Ensure timely and coordinated access to medical care and support services • Timeline for intake and Care Plan development addressed • Provision of comprehensive forms and related CM tools • Levels of care defined • Emphasis on care coordination, appointment tracking, and access to medication • Technical Assistance/CQI

42. Recruitment of Community-Based Providers • Recognition early on in the Baltimore EMA that consumers and community partners needed to play a greater role in care development and service delivery • Demand for culturally competent HIV CM services grew in conjunction with targeted outreach and care retention strategies • Non-medical, community-based providers were identified through capacity building resulted in additional training needs • HAB requirements further define MCM • Care linkage role broadens to include care coordination and management of medical care plan

43. CaseManagementCycle CM Cycle Assessment Develop Care Plan CM Cycle Case Closure Plan Implementation Monitor Plan

45. Section III: Training Tools & Strategies For Front Line Case Managers

47. CM Training • Diagnostic Assessment • Review local CM Standards and relevant Performance Measures • Conduct individual provider meetings • Perform chart reviews • Offer Corrective Action Plans that emphasize MCM practices and documentation

48. CM Training Contd • Comprehensive TA offered by multi-disciplinary training teams in multiple sessions • Provider engagement/rapport building • Encouragement of provider collaboration and sharing of expertise and experience • Integration of documentation training emphasizing CM indicators • Quality indicators/measurements review • Use of detailed case conferences as mechanism to discuss/learn MCM interventions

49. Comprehensive Training Contd • Practice Care Plan development, emphasizing SMART goals (Specific, Measurable, Attainable, Realistic, Time-Limited) • Facilitated dialogue with other care providers (Medicaid, VA, Social Security, homeless services, etc.) to create linkages and seamless service integration • Provision of CM tools: • Chart and forms templates • EMA specific benefits grid • Web-based tools, online resources, trainings, virtual learning lab, ongoing provider-specific technical support • Training/Updates on available insurance programs and entitlements

50. Ongoing Training/TA Virtual Learning Lab Web-cast Case Conference Case Management Training Direct TA Technical Support 24-7 via e-mail and Virtual Learning Lab Phone support as needed Virtual Learning Lab-Online Resource for providers Monthly Case Conference Web-cast and Web- Tools Multiple Training Sessions For All Case Managers