National Association of Community Health Centers ( NACHC)

2. National Association of Community Health Centers (NACHC) Who We Are NACHC is the national trade association serving and representing the interests of America’s community health centers Our Mission To promote the provision of high quality, comprehensive health care that is accessible, coordinated, culturally and linguistically competent, and community directed for all underserved populations

3. AGENDA • Background • Model • Results

4. Health Centerscont.HIV 33% RWCA Title III grantees are Health Centers 10% of health centers receive RWCA Title III funding HIV services are available at both RWCA-funded and non-funded sites

5. Health Centerscont.HIV • 3,854 health center users with symptomatic HIV • 21,096 users with asymptomatic HIV • 692pregnant users known to be HIV-positive • 413,986 users received an HIV test 2005 Uniform Data System (UDS)

6. Health Centers cont. HIV NACHC HIV Survey Results 96% of RWCA Title III funded health centers vs 63% of non-RWCA funded health centers provided HIV testing (P <.0001) 71% of health centers receiving CDC funding vs 40% of health centers without CDC funding provide outreach or off-site HIV testing (P <.03) 82% of urban health centers provide on-site HIV testing compared to 64% of rural centers(P <.0001)

7. Guiding Principles • Unit of analysis is the Patient • It is a chronic disease • Routine testing across organization same day • Routine testing across the life cycle • Apply redesign and Collaborative learning models, change theories, and lessons learned (+ work with leadership) • Build on existing infrastructure • Leverage Community and State Partnerships • Timing: Commitment, Site Visit, Staff Orientation and Launch within 1-2 months • Intense coaching and communication via phone, emails, onsite visits to create momentum, trust, support, and quality outcomes.

9. Redesign Principles • Don't Move the Patient.  This principle focuses on the importance of organizing the work of a patient visit around the patient rather than organizing the patient around the work.  For instance, this means that a center should avoid moving patients from place to place to place during a single visit (e.g., check in area to a vitals room then on to the exam room).  Rather, the goal is to deliver routine services to patients in the exam room. • Increase Clinician Support.  This principle assumes clinicians can be optimally productive only with optimum support.  This requires that practices ensure the proper ratio of nursing or other support staff to clinicians as well as being sure clinicians are focused on clinical work, not other supportive services that can be delivered by other members of the care team. • Create Broad Work Roles.  This principle emphasizes the importance of cross-training staff to perform multiple roles.  For example, nursing support can open the patient visit in the exam room rather than relying solely on front desk staff.  Another example, relevant to our current effort, is having nursing staff perform the oral swab rapid HIV tests in the exam room.  Similarly, we want to remove or reduce narrow specialization, such as an "HIV Counselor", when integrating HIV testing into routine primary care (with those patient testing positive or preliminary positive still requiring counseling by someone knowledgeable and experienced in this process).

10. Redesign Principles • Organize Care Teams.  This principle speaks to the high quality, integrated care that comes when a patient care team works together day in and day out to meet the needs of a defined patient population.  This team learns to work well together, anticipate each others needs, and become more intimately familiar with their patient panel. • Communicate Directly.  Direct communication in real-time helps insure that patients need are met, and met in a timely manner.  Direct communication also helps eliminate errors and misunderstandings that can occur when notes, voice messages or other indirect methods of communication are used. • Start All Visits On Time.  This principle speaks to the importance of a health center, and each care team, being prepared for the day that lies ahead and beginning the first patient visit of the day on time.  Delays at the start of the day have an impact on all visits that follow.

11. Patient Flow Model Front Desk Front desk greets patient and determines whether they are an appt or walk-in. Walk-ins are offered a same day appt if available (then proceed as an appointed patient). Front desk registers the patient, verifying insurance and demographics. Encounter form is printed and handed to patient who places it in a bin in the hallway for pick-up by nursing staff. HIV Rapid Test Waiting Room Patient reviews HIV testing information available in waiting room. Mini Lab Vitals Area Nurse escorts patient to vitals area for height (pediatrics), weight, temperature, and blood pressure. Nurse/MA carries timer to alert them test is complete. Nurse escorts pt to mini lab for fingerstick/HIV Rapid test. Exam Room Patient escorted into exam room by nursing staff. Provider performs clinical exam; orders necessary follow-up visits and/or referrals. All results, negative or reactive, are given by provider. Laboratory If blood work necessary, provider writes an order. Patient carries lab request to the lab for blood draw. Check Out Patient takes encounter form and proceeds to check out area for co-payment and scheduling of next visit..

12. HIV Screening Algorithm Patient accepts test NEGATIVE No action REACTIVE Draw Western Blot CPT#86689 Lab Corp test #005462 (Do NOT draw Screening “HIV” test) Counsel Patient Give “Reactive” handout Confidentially notify Lab Director Western Blot NEGATIVE Repeat in 3 months Western Blot POSITIVE SEE REFERRAL GUIDELINE Counsel patient Given “Day 1” handout Schedule ID appt Forward Medical Records Western Blot NEGATIVE No Action Western Blot POSITIVE

13. Implementation Model(2006-07) • Pre- Work • On-site needs assessment and Leadership buy-in • External partnership building • Assessment of current model; Design of Routine HIV screening model • Create data collection system and tool • Build/enhance referral arrangements • Kick-off • Host an all staff workshop and educational forum • Train staff in HIV Rapid Test • Institute process for data collection

14. Implementation Model(2006-07) • Launch • Implement Routine HIV screening and data collection organization wide • Maintenance • Periodic site visits • Intensive coaching • Linkage to local/state training and support • Review, feedback and correction of data

15. Routine HIV Screening in Primary Care Settings:Evaluation Results fromSix Non-Ryan White Community Health Centers (21 sites) Janet Myers, PhD, MPH University of California, San Francisco Supported by Gilead

16. EvaluationProject Goals • To describe best practices and program models associated with successful implementation. • To evaluate the effectiveness of implementation for making screening routine in these settings. • To assess clinic, provider and patient factors associated with feasibility and acceptability of recommended routine HIV screening. • To determine the effectiveness of the pilot program in terms: • HIV screening tests offered and accepted; • Number of successful referrals for HIV-infected patients.

17. EvaluationOverview • Quantitative documentation of tests offered (n=6863), tests accepted and results. (3 mo.) • Qualitative interviews (face to face and telephone) with patients (n=3), clinic staff (n=12), primary care providers (n=3), medical directors (n=4) and executive directors (n=2). • Harvest Meeting with health center leadership and medical directors with review of supporting documents (protocols, procedures, flow diagrams, etc.).

18. HIV TESTING DATADental

19. HIV TESTING DATASCHOOL-BASED

20. EvaluationPatients Offered Screening

21. EvaluationPatients Offered Screening • Compared to general clinic population, African Americans and Whites were more often offered the test; Latinos were less often offered the test. • Women were also offered the test more often.

22. EvaluationWho Refuses? • The primary reason for refusal was that patient did not perceive they are at risk (61%). • Other top reasons for refusal: • Recently tested for HIV (19%) • Doesn’t want to today (17%)

23. EvaluationOverview of HIV Tests Performed

24. Patient Comments: • “I thought the HIV test was a good experience and relieving. Everyone should get tested. I got the results back in 10 minutes.” • “Not necessary because I’m not having sex” • “I had the HIV test and it was free. It didn’t take long for them to tell me that I did not have it. I was glad they asked me to take the test.”

25. Staff Comments • “Good step for the community, because County A has an increase of HIV in the community.” • “Health centers are in the best position to reach out in ways that other clinicians cannot.” • “I think it’s important to do everything we can in the interest of the patient’s overall good health.”

26. Evaluation…Challenges Challenges • Business Plan • Test kits • Western Blot • Reimbursement • Lack of Infrastructure • Documentation • Linking to Care • Traditional HIV sites with primary care sites • Sustainability

27. Next Steps • Continue with data collection for one year • Increase acceptance rate • Explore refusals • Analyze and publish results • Spread the models • Web-based page to access tools, resources,and ask the experts

28. “We live in this community, and know that this disease is not about someone else – it’s about our families and our neighbors. It’s about us.” Ms. Aurelia Jones-Taylor