11 Campaign Webinar Migrants and Retention September 25, 2013

22 Ground Rules for Webinar Participation Actively participate and write your questions into the chat area during the presentation(s) Do not put us on hold Mute your line if you are not speaking (press *6, to unmute your line press #6) Slides and other resources are available on our website at incareCampaign.org All webinars are being recorded

33 Agenda 1. Welcome & Introductions, 5min 2. Campaign Update, 5min 3. Migrant Clinicians’ Network, 35min 4. NO AIDS Task Force, 10min 5. Announcements, 5min In the chat room, Enter your: 1. name, 2. agency, 3. city/state, and 4. professional role at agency

44 Campaign Update

55 in+care Campaign in 2014 Campaign database running through 2018! Campaign website running through 2018! Partners in+care Facebook maintained indefinitely Campaign Newsletter moves to quarterly Campaign Webinars move to quarterly Partners in+care Webinars move to quarterly Campaign Coaching integrates into NQC Continuous TA Portfolios Local Retention Groups that wish to continue meeting should do so – NQC will support where possible

in+care Campaign Activities ActivitiesJULAUGSEPOCTNOVDECJANFEBMARAPRMAYJUNJULAUGSEPOCTNOVDEC 1-Campaign Webinar 2-Journal Club Webinar 3-Campaign Data Reporting Cycle by Participants 4-Availability of Database Benchmark Function 5-Improvement Strategy Cycle 6-in+care Website and Posting of Updates 7-Campaign Newsletter 8-Partners Webinar 9-Partners in+care Facebook 10-Campaign Coaching Availability 11-Local Retention Group Availability 12-Case Study Drafting 13-Final Report Drafting 14-Communications with participants around transition

77 Reported Retention Interventions Nationwide

88 Submit Improvement Updates!

99 IAPAC Guidelines – Retention Improvement Ideas!

10 Disseminating Improvement Work Lightning Rounds! 1 or 2 slides that contain the most salient points of your retention projects Include information on patient target, rationale for target selection and baseline data from your measures (including the date) Include information on each improvement cycle (what was tried, what was the result per the data) – for early cycles short measures of change are not necessary, but add value! What are your conclusions? How are you sustaining improvement Simplicity and clarity are the idea!

11 Disseminating Improvement Work Case Studies Help us tell your story! Campaign coaches are seeking longer, written stories about various groups’ journey through the in+care Campaign Contact your Campaign quality coach if you are interested in sharing your story! We are collecting 12 stories in total for publication

in+care Campaign webinar September 25, 2013 Health Network Ensuring continuity of care through bridge case management A force for health justice for the mobile poor

“Fernando” is a 56 year old migrant farmworker diagnosed with diabetes at age 49. He traveled each year from South Texas to Minnesota or “wherever I can find work” Enrolled in Health Network 8/02 10/02 1/03 10/03 11/05 12/06 6/07 10/07 4/09 Fernando was closed out of Health Network in 2013 because he said that he was no longer migrating. Over the ten years he was enrolled, Health Network made 46 clinic contacts, 124 patient contacts, transferred medical records 9 times to 6 different clinics.

10,000 constituents Founded in 1984 Oldest clinical network serving the mobile poor MCN’s primary constituents Federally funded Migrant & Community Health Centers State and local health departments Photo © Alan Pogue

OUR MISSION To be a force for justice in healthcare for the mobile poor

In million people lived outside their country of birth United Nations, Department of Economic and Social Affairs, Population Division (2009). Trends in International Migrant Stock: The 2008 Revision (United Nations database, POP/DB/MIG/Stock/Rev.2008). and U.S. Census Bureau, International Database.

In 2005 there were 195 million international migrants 3.1% United Nations, Department of Economic and Social Affairs, Population Division (2009). Trends in International Migrant Stock: The 2008 Revision (United Nations database, POP/DB/MIG/Stock/Rev.2008). and 2005 World Population Data Sheet

In 2012…

United Nations' World Population Prospects: The 2008 Revision, Highlights

“Whether I migrated from the Limpopo to Gauteng to look for work, or from another country to South Africa fleeing conflict or in search of a better life, or I fled into exile during Apartheid to fight for freedom, or sent my children overseas to study, you are, we are and I Am a Migrant Too.”

Mobility Status - Movers Living in a different house at the end of the period. Living in a different county, state, region, or moving from abroad. Moving within or between central cities, suburbs, and non-metropolitan areas of the United States. Photo © earldotter.com

Working definition A Migrant is a person who: Crosses a prescribed geographic boundary by chance, instinct, or plan Stays away from their normal residences Engages in remunerated activity Photo © Ed Zuroweste

24 Changes in Migration New migration patterns New populations migrating to new places Diversification of work in the U.S. Photo © earldotter.com

Agriculture has traditionally been one of the sectors that has most relied on migratory labor

Migrant Health Underserved population whose health is challenged by… –Migratory lifestyle –Cultural and language barriers –Immigration status –Inherent dangers and health risks of occupation –Lack of access to insurance or financial resources –Lack of regulatory protection Photo © earldotter.com

Health Network TBNetDiabetesPrenatalCancerHIV General Health

Health Network has established and maintained relationships with various National Health Programs around the world

Health Network IMPACT Bridge between patients and their providers Fewer patients lost to follow up Higher % of patients completing treatment for Active and/or Latent TB Higher % of patients with continuity of care for chronic illnesses (DM, HTN, HIV)Treatment completion reports

Barriers to Health Care Language / cultural differences Understanding test results Lack of health insurance Cost of care Legal status / fear Incomplete numbers / addresses Frustration over detention / journey back home Understanding treatment regimens © Earl Dotter

Confidentiality is critical to all MCN staff and all Health Network procedures conform to HIPAA standards All patients are asked to sign (or have a witness sign) a consent form before enrollment in Health Network

Challenges to Success  Staff turnover at clinics  Patient Cooperation  Identifying migrant patients  Incorrect patient information  Delay in enrollment

Ask Yourself… Who will follow these patients if the results come back positive? How can these patients remain adherent while moving to a different state / country? How can I get completion results for patients that have started treatment?

Let HN work for you! Our years of experience, a culturally- competent team, and streamlined protocols will provide you with solutions

To be successful, consider these questions: Who will enroll / set-up interviews? How are faxes / other communications going to be handled? Which patients should be enrolled? What will be the timeline for enrollment? What type of information is HN going to need from the patient? How can I incorporate HN enrollment into the routine workflow? © Earl Dotter

1 Health Network Enrollment Criteria Patient is: Already mobile OR Likely to move 2 Patient has: HIV/AIDS Active or latent tuberculosis Diabetes/Hypertension Been tested for or is at risk for breast, cervical or colon cancer Is pregnant and needing prenatal care In need of a clinic for follow-up of Chronic condition

Educating patients How HN works and how they will benefit from participating (clinical support) How to use HN How HN keeps all patient information confidential The benefits, responsibilities and expectations © Ryan K White

Maintaining a Patient in Care The Patient’s Role… © Earl Dotter

1.Provide HN with as many phone numbers as possible 2.Contact HN after arriving to new area 3.Stay on treatment until indicated 4.Inform HN of address / Phone changes 5.Notify clinics of enrollment in HN

MCN’s Health Network does not discriminate on the basis of immigration status and will not share personal patient information without patient permission

Participant Benefits: A clinic / doctor / nurse is waiting Updated records are forwarded to clinic / patient Toll free number in the U.S. and Mexico Better understanding and diagnosis of condition Completion results stored in patient file Patient confidentiality © Earl Dotter

Forms Required for Enrollment

Consent Form Gives MCN staff legal permission to transfer participants’ medical records and contact participants This form must have the participant’s signature Valid if sent to HN staff within 5 business days of being signed by patient, and remains valid for 24 months from the date signed Participants may renew their consent after it expires if they still need assistance

Patient Information Form It is critical to get as much contact information as possible, such as: –Home, Cell, work numbers (area codes) – address –Friends and family in hometown –family member who does not move in US / other countries that often/always knows where they are, etc. –person who will take a message for you if we cannot get in touch with you

Option 1 We Interview: 1.Simply have us interview the patient, we explain the program, fill out the forms. 2.We will then fax the forms to you to have the patient sign them.* 3.Then fax us the signed forms along with the patient’s medical records. *Please be ready to have the patient sign the faxed consent form immediately after an interview.

Option 2 You Interview: 1.Fill out the information about the patient. 2.Have the patient sign the consent form and provide all the contact information (must include phone numbers). 3.Fax the signed forms and medical records to Health Network staff

After Enrollment… Once consent form received, address will be verified HN staff orients the patient Obtain more contact information HN staff discusses next steps with patient Photo © Alan Pogue

Health Network confidential fax number

Tools for Maintaining a Patient in Care Make sure patients have the HN toll free number: or if calling from Mexico

Continuous Quality Improvement Timed follow up with patient / clinic Completion rates Number of clinic referrals Review of cases Periodic calls / s with facilities – How can we help – How can adapt our protocols Photo © Candace Kugel

Health Network Stories © Earl Dotter

HIV Case Study 47 year old Hispanic male

Diagnosed HIV + at an ICE facility in Texas Enrolled in HN Moved to California Diagnosed with Kaposi’s Sarcoma lesions and with with Cirrhosis (NASH-Non- alcoholic Steatohepatitis)

DateCD4 countViral Load 3/14/ ,005 4/12/2011* /7/ <40 3/15/ <40 6/8/ <40 2/26/ <40 *ART started 3/23/2011

200 pages of Medical Records sent to HN on 5 separate occasions from two health centers 20 clinic contacts 41 patient contacts

Class 3 Active TB Treatment Results ,145 Class 3 Active TB Cases Referred 34 treatment not recommended by destination country 1,111 Treatment Recommended 13 deceased 1,098 Followed by TBNet for Active TB 112 lost to follow up 64 refused treatment 922 Complete Treatment = 84.0%

Continuity of Care Worldwide

February, 2010 Screened in an ICE facility Negative smear RUL consolidation TST 20 mm Asymptomatic Medication was not started February, 2010 Screened in an ICE facility Negative smear RUL consolidation TST 20 mm Asymptomatic Medication was not started Enrolled in TBNet prior to being deported to Central America March, 2010 TBNet notified of positive culture results Medical records sent to his home country and family notified May 2010, wife calls TBNet to say that her husband is being held by “coyotes” on the west coast of the United States. TBNet case manager calls and is able to speak to the patient to explain the need for treatment TBNet staff then initiates a human trafficking investigation via ICE June 2010 patient contacts TBNet from the east coast having been released by coyotes” Medical records sent to clinic by TBNet and patient started on 4 drug regimen using DOT September 2010 patient calls TBNet to say he had moved to another east coast state Clinic found Appointment made Medical records transferred from both previous clinics Patient resumed DOT Wife in Central America updated on his progress

Bridge Case Management for you

Contact Us Health Network telephone: (U.S.) (from Mexico) Health Network fax: MCN website: If you have additional questions about the program, you may also contact Ricardo Garay: or

Contact Ed Zuroweste, MD © Candace Kugel

Assisting HIV+ Undocumented, Monolingual Spanish Speakers in their Healthcare Transition from the United States to Central America: A Case Study NO/AIDS Task Force in New Orleans: An Overview Services for Spanish speakers Services for undocumented individuals What happens when an HIV+ person is deported? HIV/AIDS is not a reason to be granted asylum (In)accessibility of HIV medicine and treatment in Central America The importance of a coordinated transition from the US to Central America Language barriers Uncertainty upon arrival Accessibility of HIV treatment and medicine

Transitioning from New Orleans to Honduras: The Case Study 1.1/8/13-Client switched from Truvada & Isentress to Atripla. 2.1/17/13-MCN referral completed and faxed, medical records requested at NATF, ADAP approves client for a 3 month vacation supply of Atripla. 3.1/25/13-NATF speaks with MCN on the phone, they arrange to call husband and to perform records request from NATF. 4.MCN speaks to the patient's husband, they are unaware of health services in Honduras. 5.MCN contacts Health Ministry where a clinic and clinician is assigned (based on the patient's address and health condition). 6.A clinic referral is done and the patient and her husband are notified of the clinic and clinician that will follow this case. 7.The patient has a scheduled appointment on 4/8/2013. Blood work is done and patient continues under treatment. 8.Patient continues to receive treatment and is still awaiting appointment/call back from embassy. 9.Health Network continues to follow-up with patient and clinic. Successes? Failures? Lessons Learned?

65 Announcements

66 Upcoming Webinars  Women and Retention | Christie’s Place | September 26 at 3pm ET  Partners in+care |’ Positive Women’s Network USA | October 8 at 1pm ET Campaign Monthly Topics: ―October Topic – New Patients and Retention ―November Topic – Retaining Trans Patients in HIV Care  Journal Club | Baligh Yehia | November 12 at 2pm ET Data Collection Submission Deadline: October 1, 2013 Improvement Update Submission Deadline: October 15, 2013 Upcoming Deadlines and Topics

67 Campaign Headquarters: National Quality Center (NQC) 90 Church Street, 13 th floor New York, NY Phone incareCampaign.org youtube.com/incareCampaign