SPECTRuM: Nurses and Peers in Partnership October 17, 2013 For Audio: Dial-in#: Participant Code: #

2  Welcome & Overview- 5 mins  SPECTRuM: Nurses and Peers in Partnership – 35 mins  Discussion on Peer Integration, 15 mins  Wrap-up & Evaluation, 5 mins Michael Hager in+care Campaign Manager National Quality Center New York, NY Conversation opportunities throughout webinar Agenda

3 For more information:  This Partners in+care webinar is offered as part of the in+care Campaign.  The in+care Campaign is a national effort to improve retention in HIV care.  Webinars are one of many Partners in+care activities designed to engage people living with HIV/AIDS and their allies in the in+care Campaign. Welcome & Overview

4  This is a “public event.” If you have confidentiality concerns:  Your names appear on-line in the list of webinar registrants -consider just listening to the audio or to viewing the webinar at a later time, after it is posted at  All webinars are recorded - do not use identifying information when asking questions Participation Guidelines For Audio: Dial-in#: Participant Code: #

5  Actively participate and write your questions into the chat area during the presentation; we will also have a “pop up” question exercise, and will pause for conversation during the webinar  Do not put us on hold  Mute your line if you are not speaking (press *6, to unmute your line press #6)  The slides and recording of this and other Partners in+care webinars are available for playback and group presentations at – “Resources” tabwww.incarecampaign.org For Audio: Dial-in#: Participant Code: # Participation Guidelines

6 Visit Pop-up Question Yes No Peer Integration Have you ever used Peers in the delivery of services in your clinic or organization?

7 Visit Pop-up Question Yes – volunteers Yes – part time staff members Yes – full time staff members No I don’t know Peer Integration Are Peers currently providing services in your clinic/organization?

8 SPECTRuM – Nurses and Peers in Partnership Sophie Lewis Director of Service Development, Massachusetts DPH Bureau of Infectious Disease Office of HIV/AIDS Noelle Cocoros Director of Research and Evaluation, Massachusetts DPH Bureau of Infectious Disease

9 99 Strategic Peer-Enhanced Care and Treatment Retention Model Peers and Nurses in Partnership The Massachusetts SPECTRuM Project October 17, 2013

10 Background Massachusetts Department of Public Health (MDPH) is one of six states participating in the SPNS Systems Linkage and Access to Care for Populations at High Risk of HIV Infection Initiative Emphasis is on systems-level changes, use of surveillance data (electronic lab reporting), and innovative organizational and staffing practice.

11 Federal and State Goals National HIV/AIDS Strategy: Reduce HIV incidence Increase access to care and optimize health outcomes Reduce HIV-related health disparities Office of HIV/AIDS State Plan Reduce new HIV and HCV infections Improve health outcomes Reduce disparities in HIV and HCV incidence and in health outcomes 11 National Trends: Test and treat, treatment as prevention, Prevention with Positives The “Care Continuum” Public health obligation to use available data, e.g., lab reports

12 Source: Massachusetts and Southern New Hampshire HIV/AIDS Consumer Study Final Report, December 2011, JSI Research and Training, Inc. MA Consumer Care Experience (Self-Report; N = 1,004)

13 How can we advance linkage and care engagement? Expand Routine HIV testing Strengthen connections between prevention, testing, and care programs Use public health and clinical data to drive and inform program response

14 Integration of Peers The Office of HIV/AIDS (OHA) has a long history of including people living with HIV in the planning and development of services and policies that impact the consumer community In the past few years OHA has expanded peer services and enhanced the role of peers The majority of OHA sites funded for medical case management have interdisciplinary teams that include fully integrated peers

15 SPECTRuM—Three Strategies Peer/Nurse linkage team HIV Surveillance—Program Feedback Loop Systems-level initiatives to increase access to HIV testing and awareness of HIV status

16 Current Sites: Three pilot sites – all offer both strategy 1 and strategy 2:  Boston Medical Center Large urban hospital with approximately 1400 HIV+ patients  Holyoke Health Center Small community based health center in western MA with approximately 225 HIV+ patients  University of Massachusetts Medical School Large teaching hospital with three sites in central MA serving a total of approximately 750 HIV+ patients

17 Expansion Sites Two expansion sites, both offer strategy 2:  Morton Hospital Small community hospital with strong ID expertise. Attracts patients from more rural areas of the state  Brockton Neighborhood Health Center Urban community health center in South Eastern MA. Serves many non-US born, low income patients One expansion site scheduled to start this fall, will offer both strategy 1 and strategy 2  Community health center in South Eastern MA, serves IDU, non-English speaking patients.

18 SPECTRuM Strategy 1: The Peer-Nurse Linkage Team Peer and nurse have distinct and equally important roles Peer brings experience, knowledge and understanding with the credibility of being from the community Nurse provides clinical expertise and support As a team they offer a flexible and responsive service model:  Tailored services to individual needs  Service adjustments based on data

19 SPECTRuM Services Include… Medical Care Coordination  Appointment reminders and/or follow up on missed appointments  Transportation  Preparation for medical appointment  Accompaniment to medical appointment and phlebotomy lab on request  Debrief of medical appointment including discussion of medications and lab results

20 SPECTRuM Services Include… Mental health assessment and referral Substance use assessment and referral Housing assessment and referral Treatment adherence support Health Literacy Sexual health promotion Coordination and/or referral for benefits, food services, legal services, and other support services needed

21 What Makes SPECTRuM Strategy 1 Different from Medical Case Management? SPECTRuM is:  Short term  Time limited  Intensive SPECTRuM staff:  Includes team of nurse and peer  Have small case loads (about 20)  Have frequent (a minimum of bi-weekly) interaction with clients

22 SPECTRuM Strategy 1 Services Eligibility and Referral High acuity patients  Poverty, homelessness, mental illness, substance use, domestic violence, advanced disease, etc. Recently released ex-offenders New arrival immigrants or refugees (past five years) Newly diagnosed individuals History of missed appointment or interruptions in care

23 SPECTRuM Strategy 1 Services Eligibility and Referral Persons recently in recovery or actively using drugs/alcohol Clients recommended for any reason by member of care team Identified through State Surveillance system (strategy 2)  Patients with detectable viral load  Patients with gap of 120 days or more in submission of CD4 and viral load labs Strategy 1 enrollment requires consent

24 SPECTRuM Strategy 1 Services Transition Goal is to transition clients out of SPECTRuM after six months At six month mark acuity tool is administered and service plan is reviewed  Stable clients may transition to case management, peer support, or self management  High acuity client may stay in SPECTRuM

25 Strategy 2 Surveillance-Program Feedback Loop CD4 T-cell counts and HIV viral load results reportable to MDPH as of January 2012 Regular reports from MDPH HIV Surveillance Program to health care providers at pilot sites:  1) Patients without a CD4 or VL submitted to Surveillance within 30 days of initial diagnosis,  2) Patients with a gap of 120 days in receipt of CD4 or VL, and  3) Patients with a detectable VL Sites report client status back to MDPH Strategy 2 does not require consent

26  Increase proportion of newly dx’d linked to medical care within 1 mo to 85% (baseline 60-75%)  Increased proportion virally suppressed to 90% (baseline=72%; 66-85% from sites’ baseline data)  Increase proportion retained in medical care to 95% (≥ 2 HIV medical visits in 12 mo, at least 3 mo apart, no gap >6 mo)  Proportion with mental health issues, substance use, and/or homelessness/housing instability referred for services, and services received within 60 days  Proportion identified by HIV Surveillance as disengaged, who re-engage in clinical care within 1 month SPECTRuM Evaluation: Local Goals and Measures

27 Local Evaluation Plan - Strategy 1  Assessment "dose/response“ relationship of intervention services (type of contact with nurse and peer) and outcomes (retention and adherence measures)  Client outcomes at pilot and expansion sites (all clients) compared to those at matched comparison sites  Client outcomes at pilot/expansion sites (all clients, individual-level changes, within site) pre/post SPECTRuM  Client outcomes at pilot/expansion sites between SPECTRuM and non-SPECTRuM clients to compare client experience within the same site 27

28 Local Evaluation Plan Strategy 2  Individual outcomes among those identified as being out of care, based on Surveillance data  Client outcomes among pilot/expansion sites compared to matched comparison sites; system attributes  Qualitative analyses via interviews with clinic staff regarding the usefulness of system 28

29 Multi-site Evaluation Quantitative: Measures being finalized by UCSF (ETAC)  Seven key indicators for monitoring HHS- funded HIV prevention, treatment, and care services Qualitative:  interviews with select MDPH and pilot site staff,  patient interviews

30 Accomplishments to Date Health Department Increased connection between HIV Surveillance and Office of HIV/AIDS Epidemiologic analysis of Electronic Laboratory Reporting (ELR) data Surveillance-Program feedback loop established, yet to be formally evaluated for impact HIV Prevention and HIV Care contract management staff monitoring implementation of direct service model (across CDC and HRSA frameworks)

31 Accomplishments Program Level BMC: Established nurse/peer model Coordination between CTR and ID clinic Streamlined intake and acuity screen HHC: Established nurse/peer model Routine for running reports and contacting clients UMass: Established nurse/peer model Coordination with ED, primary care, inpatient units Communication with clients before first appointments 31

32 Current Activities and Plans Fine tune acuity-based assessment/reassessment tools Evaluate and improve the Surveillance- Program Feedback Loop Strengthen provider networks across HIV testing and care, in medical and non-medical venues, to support effective linkage Explore 3 rd party reimbursement opportunities for linkage services Disseminate best practices Expand component strategies across prevention and care programs

33 Panel Discussion Sophie Lewis Director of Service Development, Massachusetts DPH Bureau of Infectious Disease Noelle Cocoros Director of Research and Evaluation, Massachusetts DPH Bureau of Infectious Disease Gerald James Peer Navigator, Boston Medical Center SPECTRuM Abbe Muller Nurse, Boston Medical Center SPECTRuM

34 Let us know your experiences in the chat room! What have been some of the barriers to integration and how did you overcome them? Peer Integration

35 Let us know your experiences in the chat room! What is the most important lesson learned in forming these partnerships; designing and implementing the program? Lessons from the Field

36 Campaign Headquarters: National Quality Center (NQC) 90 Church Street, 13 th floor New York, NY Phone Visit Web / Open the Toolkit - “Partners” tab Sign up for Partners in+care Network – “Partners” tab Join Facebook Send to – “Facebook” in subject line Partners in+care Resources