1. Patient Navigation Program
Monthly Meeting
November 18, 2016

2. Agenda Check-in and Site Updates Monthly Data Report & Data Review
Current: Active patients and care cascade
Future: Assessment and referrals summary
Program Progress and Discussion: Patient Support Needs
Case Presentation: Ellie MacGregor
1min

3. Active in HERO PN Program*
Program Progress: Patient Navigation Enrollment (October 1, 2016– October 31, 2016)
Newly Enrolled in PN
Active in HERO PN Program*
Albuquerque
Baltimore
Boston
Bronx* 3
Morgantown
Providence* 4
San Francisco
Seattle*
Total 7
(5min)
Data was reported from 3 sites, which are actively enrolling. Seattle reported 0 participants, as participants were yet to be enrolled into PN there.
Required trainings are printed in agenda, pull these up before meeting:
Check Hep C online training (for all). All modules can be completed in 2 hours at once or throughout the week. (Best viewed in Google Chrome. Go to: hepfree.nyc/check-hep-c-online-training and enter password: projecthero)
Viral Hepatitis 101 offered at the NYC Health Department, OR confirm completion of equivalent Hepatitis C basics training at the NYC Health Department, NYS AIDS Institute or your organization. (Go to: bit.ly/ttapnyc)
“Online Learning: Overview of Motivational Interviewing” offered online at NYS AIDS Institute (Go to: bit.ly/aidsinstitute)
Measures are used as a guide to ensure patients complete these defined steps to complete medical evaluation and start treatment.

4. October 1-31, 2016: PCORI Check Hep C Program Care Cascade
*enrolling sites: NY, RI, and WA*
(5min)
The cascade of care normally looks like the figure shown here. For the sake of giving you a bit of an overview, I included some of the cumulative data from the first month of the program. The measures are used as a guide to ensure patients complete these defined steps to complete medical evaluation, start treatment, complete treatment and achieve HCV cure.

5. Patient Support Needs (Assessment, Referrals, Care Plan)
Open Forum Discussion
Patient Support Needs (Assessment, Referrals, Care Plan)
(5min)
Now that sites are actively enrolling participants and participants are being randomized to patient navigation, I wanted to open up some space for discussion of patient support needs. Once we have a few months of data, we might be able to detect trends in patient engagement and provide feedback and guidance to help patients progress through the steps in the cascade of care. Does anyone currently have any questions, comments or suggestions about assessment, referrals and care planning at this time?

6. Assessment & Referral: Mental Health

7. Assessment & Referral: Alcohol Use

8. Assessment & Referral: Drug Use
For the purpose of this study, all of the participants should be initially marked as having used within the last year or having used ever in the Database. Drug use included injection and intranasal in the past year. Injection ever and/or in a substance use treatment program also included.

9. Assessment & Referral: Housing, Transportation & Referrals

10. Program Expectations Complete required trainings
REVIEW
Program Expectations
Complete required trainings
Attend monthly technical assistance meetings
Submit database monthly
Recommendation: Attend HepCure Webinars
Next week: Testing & Linkage to Care by Stacey Trooskin, MD, PhD Director of Viral Hepatitis, Philadelphia FIGHT Health Centers
Measures:
By the project’s end, ~63 patients at each site will be assigned to PN
Check Hep C Program Goals:
~100% of participants should be treatment candidates
50% of patients eligible for treatment will start treatment
(5min)
Required trainings are printed in agenda, pull these up before meeting:
Check Hep C online training (for all), Hep ABCs Basics Training, Motivational Interviewing Training and Review. All modules can be completed in approximately 2 hours or less. (Best viewed in Google Chrome. Go to: hepfree.nyc/check-hep-c-online-training and enter password: projecthero)
“Online Learning: Overview of Motivational Interviewing” offered online at NYS AIDS Institute (Go to: bit.ly/aidsinstitute)
Measures are used as a guide to ensure patients complete these defined steps to complete medical evaluation and start treatment.

11. Patient Navigator Encounters
REVIEW
Patient Navigator Encounters
Encounter: An interaction with patient in-person, by phone, or
3 In-Person
1 Remote or In-Person
(10min)
We have defined patient navigation activities to be delivered as encounters. As outlined in the patient workflow, most patient navigation services can be delivered in a minimum of 4 encounters, with 3 of those encounters being in-person and the fourth in-person or remotely, by phone or .
Initial (recommended in-person): outreach, enrollment, assessment, referrals and care plan development
Treatment readiness (recommended in-person): care coordination, linkage to care and completion of medical evaluation,
Treatment adherence (any encounter type)
After treatment (recommended in-person)

12. Patient Navigation Service Level
REVIEW
Patient Navigation Service Level
After completing the Assessment, indicate a service level to the patient based on support needed:
Low intensity:
Need four minimum Patient Navigation encounters
Need few reminders, can attend visits independently, and minimal support in accessing referrals, or getting through HCV medical evaluation and treatment
Have a history of adherence to medications
May be at low risk for HCV reinfection after treatment
High intensity:
Need more than four Patient Navigation encounters
Need multiple reminders, and regular accompaniment, or support in accessing supportive referrals, or getting through medical evaluation or treatment
Struggles adhering to medications as prescribed
May be at high risk for HCV reinfection after treatment.
(3 min)

13. Case Presentation Ellie MacGregor, The Miriam Hospital
Internally referred participant from MMTP with a history of anxiety and severe depression
Met 3 days after enrollment
Patient Navigation Form Completed
Health Promotion Guide – addressed current use
Helpful phrase: “These next few questions are slightly more personal. I want to let you know you only have to answer what you are comfortable answering.”
Referred to On-site Mental Health Services
Agreed to linkage to care
Referred to care
Case conferenced to assess Care Plan
Followed up with patient
10:40AM

14. Contact Us
Let us know if you have questions or concerns, or need help with any aspect of the program. Early identification is the key to prevention!  Angie Woody Program Assistant Nirah Johnson, LMSW, Director of Capacity Building and Program Implementation
(1min)
Add Jessie?