Linkage to Care StrategiesCBO ORIENTATION 1/28

Importance of Linkage NHAS Goal #2: Increase access to care and optimize health outcomes for people living with HIV◦ Step 1: Establish a seamless system to immediately link people to continuous

and coordinated quality care when they learn they are infected with HIV. ◦ Linkage: 65% 85%

“Some studies show that persons who stay in care during their first year of outpatient HIV medical care are more likely to start ART than persons with early lapses in care, have high adherence to ART, achieve virologic suppression, and practice safer sexual behaviors.”

◦ CDC HIV Prevention Guidelines, 2014

HPTN 065: TLC-PLUS: FEASIBILITY OF AN ENHANCED TEST, LINK-TO-CARE PLUS TREAT APPROACH FOR HIV PREVENTION IN THE US.: BERNARD M. BRANSON, MD; AUGUST 2010

HPTN 065: TLC-PlusTest

Adoption of safer behaviors

Enroll in Care

Maintain viral suppression

Decrease in HIV Transmission

Treat

HIV PositiveLINKAGE TO CARE

Initiation of ART

Adherence to ART

Testing

Positive Prevention

96%Varies

Making Changes

Stage One: Plan Identify an area for improvement

Recruit your team

Study your current processes and results

Determine your aims

Establish your measures

Select a change

Brainstorm alternatives

Develop an action plan and M&E process

Types of Change Improve Work Flow Change the Work Environment Client Interface Focus on Variation

Error Proofing Time Management Eliminate Waste Optimize Inventory

Stage Two: Do Implement the action plan on a small scale and/or timeline

Collect data

Document successes and challenges - qualitative

Assess system impact

Stage Three: Study

Institute for HealthCare Improvement

Stage Four: Act Refine the change, based on data & reflection

Standardize the change

Monitor to ensure ongoing success

Share your results

Return to Step One: Plan

Throwing out the bucket…IMPROVEMENT

Process

Acceptance of baseline

Reversible

Superficial

TRANSFORMATION

System

Baseline is problematic

Irreversible

Profound

Reviewing the Literature…

Testing Site

ClientCare Home

Testing & Counseling Experience (post-poz)

Missed Connections: HIV-infected People Never in Care

Top five reported reasons for not entering care◦ 57% - Lack of money or health insurance

◦ 97% had income <300% of FPL◦ 55% - Not wanting to think about being HIV-positive◦ 55% - Feeling good and healthy◦ 45% - Feeling depressed◦ 43% - Not wanting to disclose HIV-positive status

Bertolli J, Garland PM, Valverde EE, Beer L, Fagan JL, Hart C. Missed Connections: HIV-Infected Persons Never in Care. Public Health Reports. 2013;128(2):117–26.

Missed Connections: HIV-infected People Never in Care

Top two factors reported as making care entry more likely ◦33% - Sufficient money or health insurance◦31% - Feeling sick

Bertolli J, Garland PM, Valverde EE, Beer L, Fagan JL, Hart C. Missed Connections: HIV-Infected Persons Never in Care. Public Health Reports. 2013;128(2):117–26.

CTR Experience of HIV+ persons who never entered medical care…

Satisfied◦ Prenatal clinic, drug treatment facility, or CTR site◦ Provided with sufficient education or information after receiving

results◦ Level of comfort and support provided by the person conducting

the HIV test

Garland PM, Valverde EE, Fagan F, Beer L, Sanders C, Hillman D, et al. HIV counseling, testing, and referral experiences of persons diagnosed with HIV who have never entered HIV medical care. AIDS Educ Prev. 2011;23(Suppl 3):117–127.

CTR Experience of HIV+ persons who never entered medical care…

Dissatisfied◦ STD clinic, inpatient facility, private doctor’s office or infectious disease clinic◦ Perceived lack of counseling, insufficient counseling, poor quality of counseling◦ Inadequate information or missing information

What could have been done differently?◦ More counseling at diagnosis: “They could’ve sat down and really talked to me

about it.”

Garland PM, Valverde EE, Fagan F, Beer L, Sanders C, Hillman D, et al. HIV counseling, testing, and referral experiences of persons diagnosed with HIV who have never entered HIV medical care. AIDS Educ Prev. 2011;23(Suppl 3):117–127.

Sources of information Qualitative feedback

Linked clients

Returning-to-care clients (out-of-care)

Consumer advisory board/Peers

Testers

Mystery shopper

Examples of ImprovementINFORMATION: MESSAGING

Purpose of and importance of entering HIV care as soon as possible

Existence of insurance, care & medication support programs

Existence of support services for transportation, food, benefits management, etcetera

Messaging◦ Determine

◦ Who (delivers/receives)◦ Just testers? Follow-up call? Receiving agency?◦ All positives? Different for new versus repeat? High-risk negatives?

◦ What & how?◦ Brief, positive, easy-to-understand (but not patronizing), and consistent◦ Run it by consumers

◦ Training & Monitoring◦ Tracking & Evaluation

Example Benefits of entering care

◦ Studies show that people who enter care soon after testing positive are far more likely to live long, healthy lives than those who delay.

◦ There is treatment available to keep you well and also reduce your risk of passing HIV to one of your partners.

◦ Some people put off visiting a medical provider until they feel sick, which hurts their chances of full treatment success because HIV is doing harm to your body even if you can’t feel it.

◦ We recommend that everyone who tests positive complete at least one visit with a medical specialist within 90 days of testing to confirm your diagnosis, evaluate where you’re at, and discuss your options for moving forward.

Example Services available to help enter care

◦ There are programs and funds available to help those who test positive to access treatment, including support with insurance, medication, housing, and other benefits.

◦ Even if you decide to delay medical treatment, we recommend you meet with a case manager to determine what sort of benefits are available to you and how to take advantage of them.

Examples of ImprovementCOUNSELING: APPROACH

Trauma-informed◦ Understanding stigma – racism,

homophobia, transphobia, mental illness, drug use, poverty, etcetera

Motivational Interviewing◦ ARTAS◦ Stages of Change

Testing Site

ClientCare Home

Referrals

Examples of ImprovementACTIVE VERSUS PASSIVE

Preparation◦ Relationships

◦ Coordination vs. collaboration◦ Resource Guide

Facilitating the connection◦ Menu of options◦ Hierarchy of needs◦ Making the call

Follow-through◦ It’s not over ‘til it’s over

Testing Site

ClientCare Home

Engagement

Examples of ImprovementFIRST IMPRESSION

New patient friendly Red carpet treatment Orientation Online information

Examples of ImprovementCARE TEAM COORDINATION

Huddles to discuss new patients

Linkage/navigation specialist

Link and Retain: The Official Blog of NY Links (linkandretain.wordpress.com)

WHAT HAS WORKED FOR YOUR AGENCIES?