Identifying effective linkage and retention strategies in NY Links for manualization and...

Identifying effective linkage and retention strategies in NY Links for manualization

and dissemination

Denis Nash, PhD, MPHProfessor, Epidemiology and Biostatistics Program

CUNY School of Public Health

1

NY Links Evaluation

Objectives• Evaluate the effectiveness of strategies piloted in collaboratives to

improve linkage, engagement and retention in HIV care.– Identify ‘best-practice’ strategies for improving linkage and retention

• Evaluate the statewide impact of dissemination and scale-up of strategies felt to be most effective at improving outcomes.

• Participate in and contribute to the multi-state evaluation process.

TimelineYears 1 & 2– Evaluate collaborative activities

Collect/analyze new and existing data on program outcomes, identify best practices for improving linkage and retention for statewide scale-up.

Years 3 & 4– Evaluate impact of statewide dissemination and scale-up Collect/analyze new and existing data to monitor scale-up of effective linkage and

retention strategies across New York State

2

Evaluation of collaborative activities:Data sources and methods

• Outcomes (linkage, engagement, retention, VL suppression)– NY Links Site-based Measures – NY Links Surveillance-based measures

• Linkage/retention strategies (type, timing)– Evaluation site surveys

• Analysis methods– Assess influence of linkage and retention strategies on key

outcomes• Linkage, engagement, retention, and viral suppression

• Develop a menu of linkage and retention strategies to manualize and disseminate in Years 3 and 4 based on:– Evidence from NY Links evaluation– Evidence outside of NY Links (e.g., literature)

* See Lamb et al. PLoS One 2012; Nash et al. AIDS 2011; Nash et al. JAIDS 20093

Linkage and retention strategies being implemented/evaluated by NY Links providers

Existing strategies• In place prior to start of NY Links

Strategies being tested or newly implemented• Tested/evaluated as part of NY Links• Fully implemented during NY Links

What have we learned thus far regarding linkage and retention improvement strategies being utilized by NY Links providers?

4

Baseline Evaluation Survey to assess strategies in place prior to start of SPNS

• Survey distributed to sites during site visits• Completed through online survey tool• Areas of focus included:

– Types of services provided (HIV testing, supportive services, HIV care)– # of newly diagnosed clients– # of patient/clients accessing clinical care and supportive services– Existing strategies aimed at improving linkage and retention

• Additionally, new strategies or planned enhancements to existing strategies

– Formal and informal partnerships used to increase linkage and retention

5

Categories of most common EXISTING* strategies that impact linkage and retention at UMRG sites

6

Category Most Common Strategy N (%)Case Management Medical case management 18 (13%)

Appt Reminders/Follow up Reminder/follow-up phone calls 2) Missed appointment letters 32 (23%)

Outreach & Linkage with other organizations Use of Field Services Unit 4 (3%)

Use of incentives/patient engagement Patient education 2) Provision of supportive services 7 (5%)

Patient Navigator/Care Coordinator Use of care coordination and/or patient navigation team generally 17 (12%)

Combined same day services Same day care 15 (11%)

Streamline/Standardize referrals Patient escort to medical services 16 (11%)

Tracking those lost to follow-up Outreach (letters and phone calls) to those who have been out of care for >1 month 3 (2%)

Other Home visits; Providing transportation 29 (20%)Total number of strategies 141 (100%)

Data Source: Baseline Evaluation Survey, updated: May 11, 2012

Existing strategies are those that were in place prior to Nov 1st, 2011 and start of UMRG collaborative

Category Most Common existing strategies N

Case Management Case management generally; Social worker calls patient

13

Appt. reminders/Follow up

Phone call and letter reminders 10

Supportive services Supportive services generally; Medication management

7

Same day services Walk-in appointments 3

On-site services Comprehensive services all in one location generally; On-site supportive services

4

Other 1) Peer education/outreach; 2) linkages w/other organizations; 3) tracking those out of care; 4) care coordination; 5) consumer committees

18

Data Source: Evaluation baseline site survey, updated: August 31, 2012 7

Overall categories of most common EXISTING linkage and retention strategies for WNY sites

Intervention Strategy Tracking Tool(to track linkage and retention strategies newly tested or

implemented during NY Links/SPNS)

• Purpose of Intervention Strategy Tracking Tool:– Capture information on new strategies being tested and implemented

to increase linkage to and retention in care– Connect the testing and implementation of new strategies to the PM

data results– Develop of a compendium of successful linkage and retention

strategies

•Frequency: every two months

•Domains:-Types of strategies tested-Intended impact of strategies-Populations targeted- Strategy coverage/fidelity -Use of Plan-Do-Study-Act (PDSA) cycles-Challenges/barriers to success-Outcomes

8

UMRG preliminary results: types of strategies being tested or implemented

Strategy category # of strategies # of sites reporting

Developing tracking systems to measure linkage/retention

3 2

Tracking/engagement of those out of care 3 3

Outreach and linkage w/ other organizations 1 1

Case management/Patient navigation 2 2

Streamlining/standardizing referrals 4 3

Other (includes staff engagement, self management and same day services strategies)

3 2

No strategies tested or implemented N/A 5

Number of sites not yet know what strategies are being tested/implemented

N/A 5

Data Source: Intervention Strategy Tracking Tool, UMRG— August 28, 2012 9

Total number of sites known to be testing or implementing strategies: 9Data excludes 5 sites whose participation status in NY Links is undetermined.NY Links coaches have detailed description of strategies.

Existing and new SPNS interventions/strategies and the evidence base: What’s next?

• Mapping interventions/strategies to improve linkage and retention in SPNS to the evidence base– Will review as a group at future learning sessions in the

hopes of assisting sites in deciding which interventions/strategies to try

• Today’s webinar is intended to initiate and inform a longer discussion on SPNS linkage and retention strategies– Tested and evaluated in Y1 and Y2– Manualized and disseminated in Y3 and Y4

10

Michael J. Mugavero, MD, MHScUniversity of Alabama at Birmingham

January 8, 2013

HPTN 052 Press release, May 12, 2011

96% reduction in new HIV infections

Moore RD & Bartlett JG. Clin Infect Dis 2011;53:600

Johns Hopkins HIV Clinical Cohort

Adapted from: Gardner et al. Clin Infect Dis 2011;52:793, Cohen et al. MMWR 2011;60:1618

HIV Treatment Cascade

49%

Ulett et al. AIDS Pt Care STDS 2009;23:41-49, Mugavero et al. Clin Infect Dis 2011;52(S2).

12

3

Adapted from: Mugavero et al. Clin Infect Dis 2011;52(S2)

National HIV/AIDS Strategy

Increase linkage to care w/in 3 months of Dx from 65% to

85%

Increase HIV serostatus

awareness from 79% to 90%

Increase RW clients

in continuous care from

73% to 80%

Increase proportion of HIV Dx’d persons

with undetectable VL by 20%Ulett et al. AIDS Pt Care STDS 2009;23:41-49, Mugavero et al. Clin Infect Dis 2011;52(S2).

Factors Linked to Poor EngagementYounger age

Female sexRacial / ethnic minorityLack of health insuranceMental illnessSubstance abuseUnstable housingUnmet needs for supportive servicesPassive referral to careHIV testing in community setting

Keruly et al. AJPH 2002;92, Robbins et. al. JAIDS 2007;44Giordano et al. Clin Infect Dis 2007;44, Mugavero et al. JAIDS 2009;50, Metsch et al. Clin Infect Dis 2008;47, Hall et al. JAIDS 2012;60

Implications of Poor Engagement

Individual Level– Delayed ART receipt & ART non-

adherence– Inferior CD4 count & viral load outcomes– Emergence of HIV resistance mutations– Increased risk for clinical events &

mortality

Population Level – Mediator of health care disparities– Role in transmission PwP• Change in risk transmission behaviors• Impact of ART in reducing transmission

Keruly et al. AJPH 2002;92, Robbins et. al. JAIDS 2007;44, Park et al. J Intern Med 2007;261, Giordano et al. Clin Infect Dis 2007;44, Mugavero et al. JAIDS 2009;50, Marks et al. AIDS 2006;20, Metsch et al. Clin Infect Dis 2008;47, Cohen et al. N Engl J Med 2011;365

Adapted from: Gardner et al. Clin Infect Dis 2011;52:793, Cohen et al. MMWR 2011;60:1618

COMMUNITY CLINIC

Thompson MA et al. Ann Intern Med 2012;156:817-33

37 Evidence-based recommendations 5 Recommendations for linkage and retention Emphasis on special populations Recommendations for future research

Quality of Body of Evidence Interpretation

Excellent (I) RCT evidence without important limitationsOverwhelming evidence from observational studies

High (II) RCT evidence with important limitationsStrong evidence from observational studies

Medium (III) RCT evidence with critical limitationsObservational study evidence without important limitations

Low (IV) Observational study evidence with important or critical limitations

Strength of Recommendation

Strong (A) Almost all patients should receive the recommended course of action.

Moderate (B) Most patients should receive the recommended course of action. However, other choices may be appropriate for some patients.

Optional (C) There may be consideration for this recommendation on the basis of individual patient circumstances. Not recommended routinely.

Evidence-Based Recommendations:Entry into and Retention in Care

Systematic monitoring of successful entry into HIV care recommended for all individuals diagnosed w/ HIV (IIA)

Systematic monitoring of retention in HIV care is recommended for all patients (IIA)

Brief, strengths-based case management for individuals with a new HIV diagnosis is recommended (IIB)

Intensive outreach for individuals not engaged in medical care within 6 months of a new HIV diagnosis may be considered (IIIC)

Use of peer or paraprofessional patient navigators may be considered (IIIC)


Brief, strengths-based case management for individuals with a new HIV diagnosis

(IIB)

1Gardner LI et al. AIDS 2005;19

CDC ARTAS1: Multi-site RCT to test linkage case management (CM) vs. SOC to improve linkage to careEmpowerment & self efficacy Asks clients to identify internal strengths &

assetsUp to 5 CM contacts allowed in 90 days

78% linkage to care w/in 6 months in CM group vs. 60% in SOC group (P<0.01)High (II):

RCT evidence w/ limitations Strong evidence from observational studies

Moderate (B):Most patients should receive Other choices may be appropriate for some

Gilman. AIDS Pt Care STDS 2012;26

Case study of 7 LTC programs in 5 jurisdictions

Barriers: System/Community, Organizational, Clinician/Staff, Individual/Client

“One of the key findings of this study is that LTC programs vary widely based on

the needs, resources, partnerships, organizational structures, leadership,

target populations, and policies of each setting”

Key characteristics:

Low cost Paraprofessional staff

Intensive Significant time investment

Time-limited

LTC services of short duration

Unique Distinct from medical case management

Flexible Tailored to community needs/resources

LTC: testing in non-primary care settings


Core components:Dedicated linkage staff

Training in MI counseling, HIV, & local healthcare and HIV

resourcesActive referral

Client education and skill building, assistance scheduling /

attending visitsPerson-centered

Focus on client “assets”

Cultural concordance

Cultural and linguistic concordance of linkage workers

with population served



Operational factors:Protocol adherence

Developing and adhering to LTC protocol

Selection of LTC staff

Personality, cultural background, experience and

interpersonal skillsExecution of LTC program

Coordination & integration of services across and w/in

organizationsProgram sustainability

Coordination of federal, state, local resources from multiple

funders



Case Managem

ent

Standard of Care

P-value

6 months 78% 60% <0.01

Gardner et al. AIDS 2005;19

Linkage case management efficacious, but early retention in care a formidable challenge…

12 months 64% 49% <0.01

ARTAS: Early retention in care

Intensive outreach for individuals not engaged in medical care w/in 6 mos of a

new diagnosis (IIIC) Recommendation based upon HRSA SPNS

initiative1

A series of observational studies with comparators that measured behavioral and biological outcomes

Outreach recommendation based on 1 study (n=104)

Intensive outreach improved retention in care and HIV-1 RNA suppression in pts underserved by health system Youth, women, mental health, substance abuse

Medium (III): RCT evidence w/ critical limitationsObservational evidence w/o limitations

Optional (C):Consideration based on individual circumstances Not recommended routinely

1Naar-King S et al. AIDS Patient Care STD. 2007;21 Suppl 1

10 Demonstration projects– Non-randomized design without

comparison or control groups in most studies

– Focus on linkage to care, retention of sporadic users & re-engagement of pts LTFU

Conceptual framework: IOM barriers to care:– Structural barriers– Financial barriers– Personal / Cultural barriers

Individual site & multi-site mixed methods evaluation

Tobias et al. AIDS Pt Care STDS 2007;21:S3, Rajabuin et al. AIDS Pt Care STDS 2007;21:S9

HRSA SPNS Outreach Initiative

Study sites:– Community based organizations = 7– Community based health centers = 2– Hospital based clinic = 1

Heterogeneous approaches & samples:– Behavioral interventions– Intensive case management– Health literacy and life skills– Outreach in provision of medical services– Supportive services included in 8 of 10

programsTobias et al. AIDS Pt Care STDS 2007;21:S3, Rajabuin et al. AIDS Pt Care STDS 2007;21:S9


On balance, interventions were effective

Structural, financial & personal barriers common, and highly correlated with retention– Reduction in barriers improved retention

Factors associated with loss to follow-up (29%)– Illicit drug use– Unstable housing– Unmet supportive service needs


Bradford. AIDS Pt Care STDS 2007;21:S85

Barriers to HIV care can be reduced or removed with sufficient resources

Coaching, skill-building, knowledge gains, respectful trusting relationships b/t client and outreach worker facilitate HIV care utilization

Additional resources and system changes needed for most disadvantaged persons

Outreach interventions can be implemented to comply with research standards



1Bradford JB et al. AIDS Patient Care STDS. 2007;21 Suppl 1

Recommendation based upon HRSA SPNS initiative1

A series of observational studies with comparators that measured behavioral and biological outcomes

PN rec based upon 4 studies (n>1100 pts)

PN associated w/ increased retention in care from 64% to 79% and 50% increase in HIV-1 RNA suppression @ 12 months

Use of peer or paraprofessional patient navigators may be considered (IIIC)

Medium (III): RCT evidence w/ critical limitationsObservational evidence w/o limitations

Optional (C):Consideration based on individual circumstances Not recommended routinely

Patient navigation shares features w/ advocacy, health education, case management

Distinctive features:– Concerned with individuals vs. system– Less proactive in addressing knowledge

gaps– Principles of CM, but no “home agency”– Apply strengths-based principles w/o BSN

or SW– Peers or near-peers with shared cultural

background


HIV system navigation

Comparative evaluation of monitoring strategies in conjunction with intervention studies

Comparison of retention measures with one another

Operational research to optimize and standardize measurement

Comparative evaluation of CM in community settings

Comparative evaluation and cost effectiveness for best practices for implementation of CM interventions

Comparative evaluation of other intervention approaches: peer support, patient navigation, health literacy, life skills

Prospective evaluation of pay for performance

Future Research Recommendations


Mugavero et al. Clin Infect Dis 2011;52(S2).

Feedback loop: An approach to monitor & implement engagement interventions

Systematic monitoring

Thank you!

What’s next in SPNS/NY Links?• Mapping SPNS linkage/retention interventions/strategies

to the evidence base– To be jointly reviewed at next learning session

• Develop a menu of linkage and retention strategies to manualize and disseminate in Years 3 and 4 based on:– Evidence from NY Links evaluation– Evidence outside of NY Links (e.g., literature)

• Discussion questions:– Of the IAPAC evidence-based linkage and retention

strategies/interventions:• Which ones are you already implementing? Do you use a manual/protocol?• Which ones are you considering implementing?

– Which other linkage and retention interventions are you implementing?

• Do you use a manual/protocol? 41

Upper Manhattan Regional Group Important Next Steps

Next Learning SessionJanuary 23, 2013 at 8:30amCUNY School of Public Health at Hunter College

Tracey E. Wilson, PhD, Professor, Department of Community Health Sciences, SUNY Downstate Medical Center, School of Public Health will present on "A Low-Effort, Clinic-Wide Intervention Improves Attendance for HIV Primary Care," published in Clinical Infectious Diseases in October, 2012.

Lightning Rounds Power Point Templates (Past Due)Agencies will be have 3-minutes at the upcoming meeting to share these

slides describing a strategy that they have implemented in the past year and how it has positively impacted linkage and retention in primary care for clients/patients

Next Data SubmissionFebruary 1, 2013

Western New York StateImportant Next Steps

Wednesday, January 9th

Buffalo Collaborative Meeting at Evergreen Health Services

Thursday, January 10th

Rochester Collaborative Meeting at AIDS Care

Next Data SubmissionFebruary 1, 2013

Queens and Staten Island Important Next Steps

Please contact one of the following NY Links staff to schedule your introductory visit if you have not yet done so:

Steve Sawicki, [email protected] Buck, [email protected] Simon, [email protected]

Please attend one of the following timeslots for the introductory webinar if you have not yet attended one:

Friday, January 11 at 1:00pmTuesday, January 15 at 10:00amThursday, January 17 at 3:00pm

mailto:[email protected]



Identifying effective linkage and retention strategies in NY Links for manualization and...

Documents

Transcript of Identifying effective linkage and retention strategies in NY Links for manualization and...