Behavioral Health Workshop: A Closer Look at What Works for Ryan White Programs - News You Can Use.
F-16, August 25, 2010

Standing room only was the tone of this session as many were turned away.  Andrew Moore from the University of Oklahoma in Oklahoma City discussed their Part C funded behavioral health program.  They have been providing mental health services as part of their continuum of care.  With the use of the motivational  interviewing model, they have provided 799 counseling session and 380 psychiatric appointments in 2009 alone. 

So what is motivational interviewing? 

• It is a client centered directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence;

• It creates a non judgmental affirming relationship between client and therapist;

• It allows clients to exercise freedom of choice and self direction

• It utilizes “OARS” techniques: Open ended questions, Affirmations, Reflective listening, and Summarize.

• It works because it utilizes positive reinforcement and empathy; it gives priority to resolving ambivalence; and makes clients responsible for their progress.

Andrew shared barriers to treatment and lessons learned while providing mental health services.  For more information and/or questions regarding University of Oklahoma’s behavioral health program, please contact Andrew Moore at andrew-moore@ouhsc.edu

 

Testing, Referral, and Linkage to Care: Models and Resources for Grantees
F-11, August 25, 2010

An estimated 21% of PLWHA are unaware of their seropositive status, according to national estimates. Additionally, a significant number enter care late: 38% receive an AIDS diagnosis within  12 months. These troubling data have not gone unnoticed by CDC and HRSA, which have been working for a number of years to get more infected persons into care.  The need to do so has been reinforced by new legislative requirements in the 2009 Ryan White reauthorization, which put emphasis on identifying and linking infected persons into care. The point is further reinforced by the recently-released National HIV/AIDS Strategy, particularly in the form of a goal to increase the percentage of persons who enter care within 3 months of diagnosis—from current estimates of 65% to 85% (see the National HIV/AIDS Strategy at AIDS.GOV).

This workshop highlighted approaches to better link people into HIV/AIDS care, ranging from specialized case management to expanded HIV testing, along with technical resources available from HRSA and CDC to undertake such work.

ARTAS is an ongoing CDC initiative to explore the efficacy of “linkage case management” in connecting HIV-infected persons to care.  Two randomized controlled studies have been conducted—ARTAS I and II—with results indicating that case management linkage support is a highly effective way to get infected persons in case.

CDC speaker Lytt Gardner outlined the following “best practices” agencies should consider if they undertake implementation of a case management linkage to care project:

• Selecting an implementing agency.  Most ARTAS sites were community based agencies.

• Establish and strengthen partnerships—with health departments, HIV clinics, etc. This is perhaps the standout best practice because many of the other best practices are unlikely to work if relationships with other agencies are not in place.  For example, you will have difficulty maintaining and documenting referrals and transitioning clients to care without cooperation.

• Distinguish ARTAS linkage case management (ALCM) from long term case management, meaning: the role of an ARTAS case manager is to link people to care, not take on the traditional role of case managers. Failing to do so can cause huge problems with case managers and their roles in providing support to clients.

• Communicating the benefits of an ALCM program.

• Maintain referrals; document and track outcomes.  Providers need to know whether people were linked to care.

• Transportation.  Staff need to be able to meet with clients out of their own offices.

• Transition clients from ALCM to long term case management.

• Provide consistent support and supervision to the linkage case manager.  If not given, and given well,

HRSA Activities on Engaging People in Care.  Steven Young from HRSA/HAB’s Division of Training and Technical Assistance outlined what has been learned about linking people into care under HRSA-sponsored work, including under SPNS demonstration work.  Young also outlined resources and technical assistance available to help agencies as they work to link more people into care.

• Training of clinicians in order to expand HIV testing in clinical settings.  These activities were carried out under the auspices of the AETC training network under a CDC/HRSA partnership.  A wealth of training curricula and other resources are available from the AETC National Resource Center and are also online at the TARGET Center.

• A CDC/HRSA pilot project with Health Centers to expand HIV testing is underway. 

• Multiple past and currently ongoing SPNS research and demonstration projects focus on outreach and retention in care.  Among these is a SPNS outreach project, Targeted Outreach Initiative: Engaging and Retention in HIV Medical Care, documented factors that influence entry to care (e.g., ease, access, and availability of care) and techniques that facilitate entry and retention, like frequent contact and activities such as appointment reminders and counseling.   The SPNS project also identified key, and well-known, barriers to care entry—competing needs, mental health and substance abuse challenges, and others.

• A series of HRSA/HAB consultations examining aspects of engaging people in care, including one session that looked at the “unmet need” requirement in the Ryan White legislation and the new requirements around testing, referral and linkage to care, as well as another meeting to look at ways to bridge prevention and care through community collaborations.  The outcome of this latter consultation is an expected new SPNS Initiative to focus on this topic.

Resources on engaging people in care are available from HRSA at the TARGET Center (search terms such as Outreach, Retention, and Linkages).  Examples include a document on connecting people to care, a recruitment and retention curriculum, and use of peers/consumers in engaging people in care.

 

Creative Consumer Involvement in System-Level Quality Improvement
D-14, August 24, 2010

The Seattle Part A TGA explored with participants the benefits of consumer involvement and how to develop creative approaches for partnering with consumers to improve quality. 

• The session explored four “Consumer Awareness Campaigns” used to improve on consumer knowledge of lab values, adherence, on-time renewals of insurance, and cervical cancer screening.  Participants brainstormed messages and images for use in future campaigns. 

• The later part of the workshop focused on the “Consumer Quality Leadership Program” designed to increase the number of consumers who feel prepared and confident in participating in a program and system level groups that affect the quality of HIV care.

Keep an eye out for future TARGET Center posting of this workshop’s resources and tools, which can be modified and replicated in multiple settings.

 

Using Multi-Media to Recruit and Educate Funders, Providers, and Patients
F-28, August 25, 2010

Show, Don’t Tell.  Several Ryan White-funded providers shared their experiences using digital stories—made up of photos, voiceovers, and music—as an effective and relatively inexpensive way to communicate with a range of audiences including consumers, staff, other organizations, and the community at large.  Stories were developed to demonstrate the value of peers in clinical programs (targeting clinicians) and the importance of dental services for people living with HIV.

Here are some of their How-to Tips:

• Inexpensive software, such as Vegas and Audacity, are available.  It is likely that some of the more “tech savvy” people on your staff are already familiar with this software.  If not, it is relatively easy to develop the necessary skill (for ongoing in-house capacity).
• Take time to prepare the script.  The intent is to tell a compelling, personal story.  Your subjects should spend some time thinking about what they want to say.  The script should be in place before you consider the visuals.
• Recycle your photos.  Photos of your organizations and events can be reused in other digital stories, cutting down on the time required for your “photo shoots.”
• Care should be taken in working with consumers and they should understand that the stories will be shown in public, and even posted online.  Producers should spend some time explaining the implications of participation in the project and consent waivers obtained.  In recruiting consumers, producers suggested reaching out to more than you need since some may change their minds about participation along the way.

And the benefits of using multimedia videos and peers are extensive:

• Videos are an ongoing way to educate staff and other providers about consumers and their needs.
• Videos are an effective way to conduct outreach to other organizations, planning bodies, and the community at large.
• Videos can leverage the use of consumers in community outreach and education.  When you can’t coordinate to have someone in-person at a presentation, you still have a powerful way to personalize the epidemic by using the video.
• Consumers that have participated have found the experience to be empowering and have become even more involved in their organizations.

Check out some of their stories online.

• Changing Lives through Good HIV Oral Health
• HIV Alliance: Dental Program
• AIDS Care Group: HIV/Dental Program
• Peer Education and Evaluation Resource Center videos

 

Bridging the Gap Between Prevention and Treatment
C-6, August 24, 2010

Do your clients have difficulty disclosing their HIV status to family, friends and their partners?  Siouxland Community Health Center presented two interventions that have changed behaviors and improved the communication skills of their clients.  They include:

• CLEAR: Choosing Life, Empowerment, Action, Result, and
• Healthy Relationships.

These CDC-supported interventions can be accessed at www.effectiveinterventions.org.

 

Emerging Concerns in the Treatment of Adolescents:  Transitioning Youth from Pediatrics into Adult Care
F-5, August 25, 2010

Transitioning of HIV+ adolescents into adult care is a difficult process for both the adolescent and the pediatric/adolescent provider.  This process can be filled with obstacles and barriers and if not handled delicately may negatively impact the adolescent’s healthcare.

The following are the “key points of transitioning” as shared in the session: transitioning includes both the process of changing and the actual transition event of moving out of adolescent-focused care; transitioning begins at the day of diagnosis; providers need reminders to let go; adolescents must be involved in decision-making; and coordination across systems is essential.

The important take home tips are that there needs to be a structured plan in place, early discussions about transitioning, options, a selection of appropriate adult providers, and, most importantly, flexibility.

Contact Dr. Ana Garcia at agarcia2@med.miami.edu for a reference list of transition articles.

 

Institute: Linking Supportive Services with Vocational and Employment Services for People Living with HIV/AIDS

F-9, G-7, H-7

This workshop Institute (3 sessions) covered multiple topics related to employment and PLWHA, including a presentation on data from the National Survey of People with HIV on Employment and Vocational Rehabilitation.  The survey examined demographics, knowledge of vocational/employment services; the impact of HIV/AIDS on employment on health and ability to work; and work considerations for PLWHA ages 18 and older living in Arkansas and New York (n=2,538).  According to the survey:

• Many unemployed consumers were not aware of laws which protect and/or facilitate employment rights (e.g., Americans with Disabilities Act, Reasonable Accommodations Act, Family, Medical Leave Act and Workforce Investment Act, and State-Federal Vocational Rehabilitation System).

• Employment positively influenced health outcomes of PLWHA. Consumers often said that employment improved self care, medication adherence, CD4 counts, and decreased behavioral risk factors.

• Unemployed consumers perceived loss of benefits, discrimination, and loss of health insurance, disclosure, lack of education and lack of employment services as reasons for unemployment.

Presenters noted employment might not be a healthy option for all PLWHA. More research and analysis to better understand survey findings are forthcoming. 

 

Health Care Reform: What Ryan White Providers Need to Know
Special Session, August 25, 2010

Room capacity—144 people and completely full at this 8:30 AM session about health care reform.  Panelists from national HIV/AIDS associations outlined opportunities, uncertainties, and expansions of coverage in the HIV care system that are likely as a result of the Affordable Care Act. 

Directors Andrea Weddle of the HIV Medicine Association, Laura Hanen of the National Alliance of State and Territorial AID Directors, and Carl Schmid of The AIDS Institute addressed issues regarding Affordable Care Act provisions and insurance coverage expansion, highlighting how the bulk of our Ryan White population will benefit from the changes. Said speaker Carl Schmid: “You no longer have to be full blown AIDS, just poor.” According to recent ADAP data, about half of Ryan White clients are below the Federal Poverty Level.  Health reform improvements include expansion of Medicaid to all persons under 133% of the poverty level and under age 65. Lauren Hanen from NASTAD pointed out how the range of the Federal Premium and Cost-Sharing subsidies under the Affordable Care Act will range from 133% to 400%.