Transcript Sporadic - hivguidelines.org

PROVIDING ADHERENCE
SUPPORT TO SPECIAL
POPULATIONS
Reaching, Engaging, and Retaining Elusive
Individuals in Consistent Care
Debbie Indyk, Ph.D., M.S.
Mount Sinai School Of Medicine
Sporadic
• Occurring at irregular intervals; having no
pattern or order.
• Appearing singly or at a widely scattered
localities..
Statement of the Problem
• Large numbers of individuals lack access to consistent
care;
• New approaches must be developed to locate and
engage HIV-positive individuals who don’t come for
ongoing care and services;
• HIV is one of a multitude of complex problems facing
these individuals;
• Reducing barriers to care requires:
– patient-centered, multidisciplinary care;
– addressing seemingly non-medical patient priorities
– holistic care
– caring for the whole person, not just the disease
Questions and Challenges
that Shape the Formation of the Model
• Where can infected and high-risk individuals not
engaged in care be reached and served?
• Who are they? What is their profile of need?
• What harm reduction services can be offered to
those not ready to engage in care?
• How can home-based services be linked to more
intensive services?
• How can we measure effectiveness and
replicability?
CHALLENGES
• Find critical masses of “high-risk” individuals,
• Engage them through an aggressive harm
reduction model and
• Link them to and support their retention in
appropriate levels of primary, specialty,
complementary and preventive care, mental health
services and clinical trials.
Reasons given for not being in care...
• “I did [go to the doctor] before I was incarcerated, but
I never made it back.”
• “I just don’t care anymore.”
• “There’s a two month wait for an appointment. If
they don’t want to see me...”
• “I have other things bothering me. My 9 year-old
daughter was murdered last year.”
• “I was going when I lived in Brooklyn, but I’m not in
Brooklyn anymore.”
• “I don’t need any medicine. I’m not sick yet.”
A Harm Reduction Approach to
Adherence
• To insure that clients have access to
adherence support services at every point
along the continuum of treatment adherence
• To involve clients in the creation of clientspecific treatment adherence support plans,
based on current knowledge and
understanding about adherence
The Adherence Continuum
Prevention-Care-Prevention
• Managing Illness
• Managing Wellness
• Managing Risk
Goals of Low Threshold Model
• Bringing individuals into care
• Keeping clients in care
• Reducing additional risk
• Linking Prevention and Care
Grassroots organizations and the public health
system do reach individuals “below the surface,”
but these services are sporadic, narrowly-focused,
and lack continuity.
As a result, the majority of SRO residents are not
reached by any of the three systems and do not
receive the resources, prevention and care they
need to reduce the negative consequences of HIV
infection.
Where And How To Reach Individuals In Sporadic Care
ENTRY POINTS IN EXISTING CARE AND PUBLIC HEALTH SYSTEMS
M
E
D
I
C
A
L
S
Y
S
T
E
M
AIDS
AND IN
CARE
EPISODICALLY
AT-RISK AND IN
CRISIS
AWARE OF DIAGNOSIS, NOT
CURRENTLY IN CARE
INTERVENTIONS
TO
REDUCE
HIV RISK
TERTIARY,
SECONDARY,
PRIMARY RISK
REDUCTION
EDUCATION
CHRONICALLY AT-RISK
GRASSROOTS
ORGANIZATIONS
P
U
B
L
I
C
H
E
A
L
T
H
SYSTEM
INDIVIDUALS:
RECEIVING EPISODIC CARE
IN NEED OF PROPHYLAXIS
IN NEED OF RISK-REDUCTION
AND ADHERENCE SUPPORT
COUNSELING
AND
TESTING
PREVENTIVE
CASE
MANAGEMENT
SUPPORT GROUPS
AT-RISK INDIVIDUALS AND THEIR SOCIAL NETWORKS
WORKSHOPS
AWARE AND UNAWARE OF HIV STATUS
STD TREATMENT
SOME RECEIVING HARM REDUCTION SERVICES FOR SUBSTANCE USE
PARTNER
NOTIFICATION
INDIVIDUALS EPISODICALLY AT RISK
INDIVIDUALS AGING INTO RISK
INDIVIDUALS CHRONICALLY AT-RISK BECAUSE OF ENVIRONMENTAL,
PYSCHOSOCIAL OR MEDICAL RISK FACTORS
VACCINATIONS
Distribution of
Medicaid Sequence Numbers of
Active Clients
5<x<10
10<X<15
15<X<20
20<x<25
25<X<30
30<X35
Transience of SRO Residency
60 rooms
•
•
•
•
42 Rooms housed 84 clients
13 Rooms housed 39 clients
2 Rooms housed 8 clients
3 Rooms housed 10 clients
Health Bridge Clients Enrolled
• 370 Individuals
– 114 Currently Active
– 256 Closed
“Length of Stay”
in Months of Closed Clients
180
160
140
120
100
#
80
60
40
20
0
<6
6<x<12
12<x<18
18<x<24
>24
REASONS FOR CLOSURE
•
•
•
•
•
•
•
•
Care elsewhere
Deceased
Incarcerated
Left SRO
Inactivated by staff
Lost to f/u
Entered SNF
Rehoused
12
18
8
39
22
15
7
22
Number of Actions/Services
Average: 73 actions/client
n=114
35
30
25
20
15
Clients
x>300
200<x<299
150<x<199
100<x<149
50<x<99
0
<50
10
5
Months in Care
(Active Clients)
>24
18<x<24
12<x<18
6<x<12
1<x<6
# Clients
<1
40
35
30
25
20
15
10
5
0
The SRO Health Bridge Project:
What it means...
On-Site Low Threshold Care
– No travel time or cost for patient;
– Familiar, non-threatening environment;
– Provides continuum from urgent care to
comprehensive primary care and follow-up.
– Allows provider to meet patients at different stages
of readiness to receive care;
– Escort/transportation voucher to off-site care;
– Social network nearby;
Holistic Model
•Treats the whole person, not just their disease;
•Prevention/health education measures are made
relevant to and provided within the context of
patients’ lives;
•Harm reduction approach which opens the door to
further education, treatment, and behavior change.
Participant Centered
•Staff learn from PLWAs in the context of their
lives;
•Designed to meet patients’ self-perceived needs
and priorities first;
•De-emphasizes unequal power relationship and
increases opportunities to develop trust.
Services Offered to Engage
•Home-based Assessment/Triage Visits
•Public Health Outreach, STD Screening
•Routine Medical Care On-Site
•Flu Vaccine
•Dental Care
•Urgent Care On-Site
•Low Threshold Mental Health Services
•Follow-Up Home Visits for Missed
Appointments
•Directly Observed Therapy
HIV ADHERENCE NETWORK
DEVELOPMENT
H.A.N.D. MENU ITEMS
•
•
•
•
•
•
•
•
•
•
Logistical Supports
One-on-one Treatment Education
Strategy group
Group Education Sessions
One-on-one Counseling Sessions
Buddy Program
Support groups
Enhanced Pharmacy Services
Intra-network referral
Directly Observed Therapy
Stages of Readiness
Awareness of Need and Willingness to
Deal with Need
• Medications to reduce viral load and disease
progression
• Antibiotics to reduce the risks of opportunistic
infection
• Behavioral Risk Reduction
Stages of Engagement
of 114 Active Clients
•
•
•
•
•
•
9 New
47 Not on HIV meds or prophylaxis
28 On Prophylaxis
6 On HAART
17 On HAART and Prophylaxis
41 in HAND
Engagement Requires Multiple Visits,
Reminders, Incentives and Reaching Out to
Clients
• Through sustained “outreach” to the SROs by
various members of the staff, a safety net is built
which can quickly identify crisis and change in
status as well as engagement, for those who are
ready to receive medical care, drug treatment and
other intensive treatment and ready to manage
living with HIV.
Reducing Degrees of Separation
Between Clients, Providers and Systems
of Care
•
•
•
•
Front Line Workers
Medical and Mental Health Practitioners
Linkages between Prevention and Care
Case Conferencing/Continuous Quality
Improvement
• Linkages to Community Based
Organizations
• Linkages to Primary and Specialty Care
• Linkages to Social Services
A Harm Reduction Approach to
Adherence
• Clients may be ready
– to open the door but not let anyone in
– for nutritional support but not ready for a flu shot
– to have their bloods drawn in their room, but not ready to go for a
comprehensive medical exam
– to go to the dentist, but not ready to go the ID clinic
– for detox but not ready for prophylaxis
– to take AZT to reduce the risk of perinatal transmission of HIV to
their child, but not ready to be put on a regimen to treat their own
disease
PROGRAM APPROACH
 The program incorporates behavioral change and
harm reduction theory and practice to reach
individuals “where they’re at”:
• geographically, emotionally, spiritually,
psychologically, financially and physically
• while assessing each person’s readiness for risk
reduction, engagement in care and engagement in
wellness and disease management
• while considering the individual’s stage of HIV
disease progression, mental health status and other
co-morbidities
For more HIV-related resources,
please visit www.hivguidelines.org