engaging hard-to-reach populations in hiv care: empowering the patient

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Engaging Hard-to-Reach Populations: Empowering the Patient May 15, 2013

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This Webinar was the last of a three-part series synthesizing some of the successful practices in engaging hard-to-reach populations from SPNS population-specific initiatives. Speakers included: Dr. Angulique Outlaw from Wayne State University and the SPNS Young Men who have Sex with Men Initiative, discussing motivational interviewing Dr. Nikki Cockern from Wayne State University and the SPNS Young Men who have Sex with Men Initiative, discussing enhanced case management Dr. Margaret Hargreaves from Mathematica and Principal Investigator for the Latino HIV Care Best Practices Study, discussing engagement and retention of Latinos in HIV care

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Page 1: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

Engaging Hard-to-Reach Populations: Empowering the Patient May 15, 2013

Page 2: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

Agenda

Introduction to SPNS Integrating HIV Innovative Practices (IHIP) project Sarah Cook-Raymond, Impact Marketing +

Communications

Presentations from SPNS grantees Angulique Outlaw, Horizons Project Nikki Cockern, Horizons Project Margaret Hargreaves, Mathematica

Brief post-Webinar questionnaire

Q & A

Page 3: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient
Page 4: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

IHIP Resources:Innovative Approaches to Engaging Hard-to-Reach Populations Living with HIV/AIDS into Care

IHIP Tools on Engaging Hard-to-Reach Populations Training Manual Curriculum Webinar Series

Outreach – April 18; see archive recording Inreach – May 1; archive recording to be up soon! Empowering the Patient - May 15

Page 5: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

An Introduction to Motivational Interviewing (MI)

An Introduction to Motivational Interviewing (MI)

Angulique Y. Outlaw, Ph.D.Assistant Professor

Director of Prevention ServicesWayne State University School of Medicine

Horizons Project

Page 6: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

Outline

• What Is MI?

• How Does MI Work?

• How Are We Using MI?

Page 7: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

Why Is Change So Hard?• Lack of motivation from within a person

– People are not motivated by nagging or fear– Most people don’t change for another person– When pushed, people push back– Ambivalence (pros and cons)

• Lack of confidence (self-efficacy)• Lack of social support, role models• Life gets in the way!

Page 8: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

What Do We Do To Try To Make Other Change?

• Given them Insight – if you can just make people see, then they will change

• Give them Knowledge – if people just know enough, then they will change

• Give them Skills – if you can just teach people how to change, then they will do it

• Give them Hell – if you can just make people feel bad or afraid enough, they will change

Page 9: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

What Is Motivational Interviewing (MI)?

• Evidenced based intervention to promote health behavior change

• *MI is – Client-centered, – Goal-oriented approach – Focused on increasing intrinsic motivation

for change by:•Resolving ambivalence about different

potential courses of action •Increasing self-efficacy about change

*Miller & Rollnick (2002, 2007)

Page 10: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

What Is MI?• A method of communication

– Not a specific session by session intervention

– Not a bag of tricks • Good communication at a micro-level• Making every word count• Develop rapport, understand the

client’s view• Elicit and reinforce any and every

communication about behavior change

Page 11: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

Advantages Of MI

• Client-centered intervention• Can be performed by a variety

of staff members • Occurs in a natural setting• Ambivalence is addressed

Page 12: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

What Does The Conversation Look Like?

•Empathic and warm•Listening and understanding•Expressing optimism and hope•Reinforcing specific strengths•Emphasizing personal choice and

responsibility•Offering menu of options•Discussing value-behavior incongruence

Page 13: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

MI Elements

MI

MI Spirit

Change Talk

MI Principles

MI Methods (OARS)

Page 14: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

MI Principles

• Express Empathy• Develop Discrepancy • Roll with Resistance• Support Self-Efficacy

Page 15: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

The “RULE”s Of MI

•Resist the righting reflex

•Understand your client’s motivation

•Listen to your client

•Empower your client

Page 16: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

Spirit of MI

• Collaborative (vs. Coercive)– Working jointly together

• Evocative (vs. Educational)– Elicit motivation, perceptions, goals, and

values

• Autonomy supportive (vs. Authoritative)– Self-directing freedom (Choice)

Page 17: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

MI Methods

• Open-Ended Questions• Affirmations• Reflective Listening• Summaries

Page 18: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

Change Talk

• Disadvantages of doing what you are doing

• Advantages of change• Optimism about change• Intention to change

Page 19: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

Horizons Project

• Dedicated to providing HIV prevention services to at-risk youth and direct care services to youth living with HIV ages 13-24

• Is the only comprehensive HIV/AIDS program in Michigan focusing on youth

Page 20: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

Continuum Of Care

Other Medical SitesServing HIV+

Youth

C&T Sites

Horizons C&T

Horizons CommunityOutreach

Horizons Field &Internet Outreach

Horizons Peer Advocacy

Horizons Case Finding:Agency/Field Outreach

Community Agenciesand Resources

Primary Medical CareMedical Specialty Care

Nursing ServicesHealth Education

Adherence SupportSocial Work ServicesCase ManagementOngoing Advocacy

MentoringConsumer InvolvementTherapeutic Activities

TransportationPsychological Services Psychiatric ConsultationEducation and Training

MI for RetentionPrevention Services

(MI and Group)

HorizonsClinical

Care Team

HIV+

HIV+

Page 21: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

How We Use MI

• Single session (30 minutes) – As part of field outreach to encourage HIV

C&T

• Single session (30 minutes)– At initial appointment or first return to

care appointment focused on engagement and retention in care

– Focused on adherence to antiretroviral therapy (initiation and maintenance)

– Focused on risk reduction

Page 22: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

MI Computer Applications

• *Motivational Enhancement System for Sexual Risk & Adherence– MISTI (Sexual Risk)(Feasibility study)

• Single session face-to-face or computer delivered intervention

– MISTI-II (Sexual Risk) • Two session computer delivered intervention (Baseline

and 3 months)

– MESA (Adherence)• Two session computer-delivered intervention (Baseline and 1 month)

*adapted by Ondersma et. al

Page 23: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

To Sum Up• Remember MI Elements

– Spirit• Collaboration, Evocation, & Autonomy

– Principles• Express Empathy, Develop Discrepancy, Roll

with Resistance, & Support Self-Efficacy

– OARS• Open-Ended Questions, Affirmations,

Reflective Listening, & Summaries

Page 24: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

To Sum Up• Remember MI Elements

– Change Talk•Disadvantages of Staying the Same,

Advantages of Change, Positive Things About Change, & Intention to Change

Page 25: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

MI Resources

• Motivational Interviewing (2012, 2007, 2002) Miller and Rollnick

• Motivational Interviewing with Adolescents and Young Adults (2010) Naar-King & Suarez

• www.motivationalinterviewing.org

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Thank You!!

Page 27: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

Engaging & Retaining Youth in Care

Engaging Hard To Reach Populations – HRSA

Webinar

Nikki Cockern, PhDAssistant Professor

Clinical Care ManagerWayne State University School of Medicine

Horizons ProjectMay 2013

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Issues of Adolescence

• Trust

• Often not ready to change, not motivated

• Lack of impulse control

• Rebel against prescriptive approaches – educational, skills building, traditional counseling

• Physical Changes (thanks to puberty)

• Peak of peer involvement and peer norms

• Heightened experimentation

Page 29: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

What’s Unique about Adolescents?

Environment-vitally important

Separation/individuation • Identity formation as separate from authority

figures • Translating personal goals into behavior within a

constrained environment• Mood fluctuates• Trying to figure out who they are and try

different roles

Communication skills are still developing

Page 30: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

Horizons Project

• Dedicated to providing HIV prevention services to at-risk youth and direct care services to adolescents and young adults living with HIV (ages 13-24)

• Has continued to grow as the only comprehensive HIV/AIDS program in Michigan focusing on youth

• Wayne State University School of Medicine (WSU) and the Detroit Medical Center (DMC) serve as fiduciaries.

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Page 31: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

Engagement Strategies

“One-stop shopping” & multidisciplinary approach to HIV care, that is youth sensitive & culturally competent. Meeting youth “where they are” and focusing on building relationship

Intensive Case Management Services Identification of needs (initial & ongoing) Development of comprehensive service plan, including strategies for implementation Coordination of care & services

Mental Health/Psychosocial Services

Client Advocacy

Transportation

Treatment Adherence Program

Lost to Follow-Up (L2FU) Program

Use of Multi-media tools

Page 32: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

Horizons Project Enhancements

• Advocates assist youth in enrolling and remaining in care• Rapid linkage into care

• Intake and medical appointments are provided within the first week of contact

• Youth often receive resources prior to their med visit• Direct linkage & support to ancillary care services and

resources• Motivational Interviewing is offered• Multi-modal contact to youth in preferred medium (i.e.

phone, text, email, Facebook inboxes)• Jam Sessions (support groups) • Transportation to ‘life critical’ services (DHS)

• Provide a link to advocacy services if youth do not want to enroll in medical care

• Actively Promote Consumer Involvement

Page 33: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

Horizons Project Modifications

• Quickly establish and maintain rapport• Highlight and vitally protect confidentiality, while treating each with dignity and

respect• Contact with youth is consistent, yet at varied times and amongst several staff• Staff is available outside of typical “working hours/days” and can be reached via cell

and email daily

• Patient advocacy is vital to keeping youth connected and meeting their needs• Staff often accompany youth to other necessary medical and ancillary care

appointments (i.e. DHS, colposcopy, Dental, GYN, etc.)• Phone contacts for transportation to clinical and ancillary appointments, JAM sessions,

other care related activities

• Decrease barriers to access services• Increase frequency of medical clinics held, so more appointment slots are available (including

separate day youth can come in for treatment)• Reserved new patient and sick patient slots during each clinic session• Combined mom/baby or family clinic sessions to decrease the frequency of visits parents

have to keep• Use of laptops in medical clinic in order to complete on-line applications for insurance and/or

supplemental coverage programs

• Provide incentives for improved adherence• i.e. keeping appointments, reducing drug use ,decreasing incidence of STIs, etc. (works with

mental health team)

• Provide lost to follow-up outreach • i.e. phone calls, letters, and home visits (MI)

Page 34: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

L2FU Program Protocol

1. Maintain ListIdentify youth who

missed clinic appt. & not

able to reschedule

4.3rd month

Home Visit

5.Contact made w/

Client & clinicvisit scheduled

OrRepeat

2.1st month aftermissed clinic

visit. Advocate attempts

Contact via phone/text

3.2nd month Mail postCard sent

MI via phoneMI @ HV if

contact made

MI @ point of contact & @ clinic appt.

Page 35: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

Social Media ToolsGeneral Information and linkage to Horizons Project

and Community Services• Horizons Project Website:

http://peds.med.wayne.edu/horizons

Horizons specific information and events/activities• FaceBook • Twitter

Adherence to Appointments & ARV regimenText Messages (regular, timed texts for youth starting meds &

those w/sig adherence problems) (appointment reminders & check ins)

Email invites on the spot for upcoming med visits w/alarm

Private inbox message through Facebook

Page 36: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

Suggestions for Programs Working with Adolescents

Page 37: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

Summary One stop shopping, multi-disciplinary team approach to

care• Clinical Services, including intensive case management• Psychosocial Services

Engagement & Retention Strategies include:• Rapid Linkage to Care• Multiple clinic sessions options• Practical and Concrete Support for accessing resources• Peer Advocacy, access to support outside conventional

time • Transportation• Treatment Adherence Program• L2FU Program• Use of social media tools

Page 38: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

Staff Acknowledgement

Director of Medical Service and Research: Elizabeth Secord, MDDirector of Prevention Services: Angulique Outlaw, PhDConsultant for Psychological Services and Research: Sylvie Naar-King,

PhDATN Behavioral Research Coordinator: Monique Green Jones, MPHATN Clinical Research Coordinator: Charnell Cromer, MSNClinical Care Manager: Nikki Cockern, PhDClinical Nurse Practitioner: Debbie Richmond, NPClinical Social Worker: Tiffani Hollowell, CMSWCare Coordinator/Case Manager: Keshaum Houston, BSAdolescent Consultant: Jessica Daniel, MPHMSM Prevention Coordinator: Jeremy ToneyMSM Outreach Workers: Bre’ Campbell, David PerrettATN C2P Coordinator: Emily Halden Brown, MPP ATN Research Assistant: Cindy Chidi, BSATN Linkage to Care Specialist: Valentina Djelaj, LLMSWATN 110/117 Outreach Coordinator: Bryan Victor, MSWFisher HRH Prevention Coordinator: Te’Neice Dobbins, BS

Page 39: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

Thank you!—Questions/Comments

?

Nikki Cockern, PhD; 313.745.4892; [email protected]

http://www.peds.med.wayne.edu/horizons

Page 40: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

Latino HIV Best Practices: Improving Access, Engagement and

Retention in Care May 15, 2013

Engaging Hard-to-Reach Populations – HRSA Webinar Margaret Hargreaves, Ph.D., M.P.P.

Page 41: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

Review of the literature– Impact of HIV/AIDS epidemic on Latinos– Evidence of effective practices for engaging and

retaining HIV-positive Latinos in HIV care

Site visits to 10 exemplary sites– 6 States selected for study– 10 sites selected across 6 states– 1 to 1.5 day site visits by bilingual teams

Analysis of sites’ 2009 RDR and 2010 RSR data– Racial/ethnic analysis of client characteristics, service

use, and clinical outcomes

Study Methods

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Page 42: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

– CARE Resource, Miami, FL– CommWell Health, Dunn, NC– Elmhurst Hospital Center – ID Clinic, Brooklyn, NY– Centro de Salud Familiar La Fe, El Paso, TX– Miami Beach Community Health Center – Immune

Support Program, Miami, FL– Mission Neighborhood Health Center – Clinica

Esperanza, San Francisco, CA– Montefiore AIDS Center, Bronx, NY– San Ysidro Health Center – CASA, San Ysidro, CA– Valley AIDS Council, Harlingen, TX– West Side Community Health Center – Clinic 7, St.

Paul, MN

Selected Sites

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Page 43: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

Site Locations

Page 44: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

7 Federally Qualified Health Centers (FQHCs), 2 hospital outpatient departments, 1 AIDS service organization

RWHAP Funding: Parts A, B, C, D, F, MAI, SPNS

Populations served: Mexico, Caribbean, Central America, South America, Migrant farm workers

HIV clients served: 160 clients - 2665 clients

Percentage Latino clients: 20 – 80 percent

Site Characteristics

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Page 45: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

9 providers prescribed HAART to Latino clients at same or higher rate than non-Latinos

4 providers conducted CD4 counts for over 90% of Latino clients in the last year; another 3 providers conducted CD4 counts for over 80% of Latinos in the last year

3 providers conducted viral load tests for over 90% of Latino clients in the last year; another 4 providers conducted viral load tests for over 80% of Latinos in the last year

Sites’ Quality of Latino HIV Care

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Page 46: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

Barriers to Latino access, engagement, and retention in HIV care identified at five levels– Individual – Clinician– Organization– System– Community

Total of 43 strategies were used by HIV providers to address identified barriers to Latino access, engagement, and retention in HIV care

Barriers and Strategies

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Page 47: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

– Help completing applications and obtaining eligibility documentation for Medicaid, Medicare, ADAP, SSA, Ryan White, SNAP (n=10)

– Referrals for social services, including food and housing assistance, domestic violence services, legal aid, immigration services (n=10)

– Transportation assistance, including vans and metro/bus cards (n=9)

– Targeted Latino support groups for MSM, women, transgender, Spanish speakers, hepatitis C, treatment adherence, substance abuse, domestic violence, HIV education (n=8)

Strategies to Address Individual-level Barriers

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Page 48: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

– Peer health educators, peer counselors, buddies, who provide health education, system navigation, social support, and client advocacy (n=7)

– Reinforcement of treatment adherence messages geared to client literacy levels, using reminder calendars, pictures, symbols, color codes, pill boxes, key chains, directly observed therapy, literacy lessons (n=7)

– Home or clinic delivery of HIV medications by pharmacy or clinic staff (n=3)

– Client social groups, knitting, arts, crafts (n=3)

Individual-level Strategies, Cont.

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Page 49: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

– Knowledge of traditional home remedies, foods, cultural values, religious beliefs, differences among Latino subpopulations (n=10)

– Showing warmth, respect, friendship to clients and their families; having a passion for the work (n=10)

– Fluent Spanish speakers, interpreter lines, translation support from bilingual staff, certified interpreters (n=10)

– Staff “willing to go the extra mile” for clients (n=7)

– Home visits, hospital visits, long-term follow-up (n=7)

– Mostly Latino/Hispanic staff (n=5)

– Avoidance of culturally loaded terms such as gay, mental health, and psychiatry (n=5)

– Training in cultural competency (n=3)

Strategies to Address Clinician-level Barriers

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Page 50: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

– Comprehensive one-stop shop of HIV ambulatory outpatient care and supportive services (n=10)

– Flexible scheduling, double-booking, walk-ins, open slots for emergencies (n=10)

– Clinic materials in Spanish (signs, notices, videos, website, brochures, medication labels, posters) (n=10)

– Frequent appointment reminder calls, missed appointment follow-up calls, free cell phones to receive reminders (n=9)

– Close tracking of visits, labs, medications, and contact information for treatment adherence and retention purposes (n=9)

– Client confidentiality policies and practices (n=8)

Strategies to Address Organization-level Barriers

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Page 51: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

– Universal screenings for mental health and/or substance abuse to reduce treatment stigma (n=7)

– Discreet name and location of clinic (n=6)– Long appointment times for visits with clinicians, case

managers, and counselors (n=6)– Multidisciplinary teams, team meetings, patient

briefings, case conferences (n=6)– Expanded clinic hours, evening hours (n=5)– Comfortable, home-like environment (n=3)– Offices arranged to facilitate staff/client interaction

and communication (n=3)– HIV clinician team includes specialists (i.e.,

dermatology, OB-GYN) (n=3)

Organization-level Strategies, Cont.

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Page 52: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

– Network of client referrals from Latino-serving organizations; no wrong door entry into system (n=10)

– Partnerships, consortia, and collaborations of Latino-serving organizations (n=8)

– HIV care tracking and coordination across inpatient/outpatient settings, agencies, states, U.S./Mexican border (n=7)

– Latino representation on HIV prevention and treatment planning councils (n=6)

– Health policy or funding advocacy for Latino HIV services (n=5)

– Expedited, client hand-offs among testing, linkage, bridge, and retention services staff (n=4)

Strategies to Address System-level Barriers

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Page 53: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

– Targeted outreach to Latino subpopulations—MSM, women, incarcerated, transgender, migrants, undisclosed MSM (n=9)

– Discrete identity of outreach and linkage staff to protect client privacy (n=7)

– Pride events and Latino celebrations to reduce stigma (n=6)

– Regional HIV conferences and retreats to improve HIV care (n=4)

– HIV talks to community groups, in churches, on radio, TV (n=3)

– Latino theatre troops to increase awareness of HIV (n=2)

Strategies to Address Community-level Barriers

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Page 54: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

Some strategies are linguistically or culturally specific to Latino populations

Some strategies address barriers common to underserved populations

Some strategies cost little or nothing to start

By addressing barriers, providers can reduce or eliminate disparities in Latino access, use, and retention in HIV care

Preliminary Conclusions

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Page 55: Engaging Hard-to-Reach Populations in HIV Care: Empowering the Patient

Please contact:– Meg Hargreaves

[email protected]

For More Information

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Q&A

Twitter: @impactmc1| Facebook: ImpactMarCom |www.impactmc.net | 202-588-0300

Connect with UsSarah Cook-Raymond, Managing Director |Impact Marketing +

Communications |

To be informed when these upcoming IHIP resources are ready, keep an eye out for HRSA announcements or sign up for the IMC

newsletter email [email protected].