in + care campaign meet the author august 6, 2013
DESCRIPTION
in + care Campaign Meet the Author August 6, 2013. 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) - PowerPoint PPT PresentationTRANSCRIPT
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in+care CampaignMeet the Author
August 6, 2013
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Ground Rules for Webinar Participation
Actively participate and write your questions into the chat area during the presentation(s)
Do not put us on holdMute 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.orgAll webinars are being recorded
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Welcome & Introductions Welcome & Introductions, 5min NYC Care Coordination Program, 30min Q & A Session, 20min Updates, Reminders & Evaluation, 5minIn the chat
room, Enter your: 1. name, 2. agency, 3. city/state, and 4. professional role at agency
Michael Hager, MPH MA NQC Manager,in+care Campaign ManagerNew York, NY
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August 6, 2013
New York City Department of
Health and Mental Hygiene
Argus Community,
Inc.
Beth Israel Medical Center
PATIENT NAVIGATION:
A Network Perspective from the NYC HIV Care Coordination Program
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PRESENTERSBeau J. Mitts, MPH
Director, Ryan White Technical Assistance NYC Department of Health and Mental Hygiene
Stephanie Chamberlin, MPH, MIA Evaluation Specialist, Research and Evaluation NYC Department of Health and Mental Hygiene
Maria Rodriguez, MPA Program Director, Care Coordination Argus Community, Inc.
Vanessa Haney, MFA Program Director, Care Coordination Beth Israel Medical Center
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DOHMH Care Coordination Program (CCP) Model Background Development Implementation
Argus Community ExperienceBeth Israel Medical Center ExperienceEvaluationTake-Home Messages
AGENDA
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BACKGROUND: The CCP ModelInf
ormati
on S
harin
g
Outreach
Assessment and Planning
Benefits and Services
Coordination
Navigation
Health Promotion
Treatment Adherence
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Persons at high risk for suboptimal health care outcomes: newly diagnosed previously lost to care/never in care irregularly in care with recent adherence issues (e.g., viral rebound,
resistance)
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BACKGROUND: Target Population
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Patient Navigators are key players on the Care team Most interaction with the clients Community Health Workers Bridge the gap between the clinic and the community Reflect the community they serve
Services provided (often in client’s home) include: Health promotion Accompaniment Treatment adherence Modified DOT
Caseloads Patient Navigators: 14 to 20 clients DOT Specialists: 7 clients
Required clinical supervision9
BACKGROUND: Patient Navigation
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Models reviewed: Medical Home, Patient Navigation, Chronic Care, Community
Health WorkerPrevention and Access to Care and Treatment (PACT)
Project Partnership between Partners in Health (PIH) and Brigham
and Women’s Hospital in Boston, MARequests for Proposals (RFP)
2004: Treatment Adherence Program (TAP) 2006: Maintenance in Care (MIC) 2009: Care Coordination Program (CCP)
Bradford et al. HIV System Navigation: An Emerging Model to Improve HIV Care Access. AIDS Patient Care and STDs. 2007;21:S49–S58.
DEVELOPMENT: Research and Timeline
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Program Manual Version 4.0 released May 29, 2013
Each version evolved and adapted Recommended staffing plan Staff roles and responsibilities Guidance on program processes
Standardized forms Excel adherence calculator
eSHARE data reporting system
DEVELOPMENT: Tools
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Trainings 10-day Care Coordination training
National Development and Research Institutes (NDRI)
HIV 101, case management skills, program forms, etc.
Four-day Health Promotion Training of Trainers (TOT) PACT trainers along with NYC DOHMH
Project Officers Two trainers at each Care Coordination
program One-day trainings
Care Coordination Refresher Cultural Sensitivity Co-occurring Disorders (HIV, MH, and SA)
Technical Assistance NYC DOHMH Project Officers Bi-annual Provider Meetings Site visits and webinars
DEVELOPMENT: Training and TA
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28 agencies providing CCP in New York City (NYC) 16 hospital-based agencies 12 community-based agencies
Caseloads: Agency caseloads: 52 to 230 active clients
9 small programs 12 medium programs 7 large programs
~3,300 PLWH in the active portfolio caseload at any given time
4,986 unique PLWH served from March 2012 – February 2013
IMPLEMENTATION: Funded Programs
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IMPLEMENTATION: Client Demographics
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Grant Year (GY) 2012, Care Coordination Program (All Agencies),N = 4,986
AGE GROUP % GENDER %<25 6.9% Female 37.3%25-44 38.4% Male 60.9%45-64 50% Transgender 1.8%65+ 4.7%
RACE/ETHNICITY % BOROUGH %Hispanic 37.1% Manhattan 21.0%Black 52.6% Brooklyn 32.8%
Bronx 31.1%RISK %
MSM 28.3% INSURANCE %IDU 7.8% Public Insurance 80.2%Heterosexual 58.6% Uninsured 9.7%
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760 East 160 th StreetBronx, NY 10456
718-401-5700
Maria Rodriguez, MPA
ARGUS COMMUNITY, INC.
www.arguscommunity.org
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Founded in South Bronx in 1968 Began as substance abuse treatment provider
Expanded to address homelessness, AIDS/HIV, welfare reform
Received national and international recognition Programs replicated in Washington, DC; San
Francisco; Albany; Des Moines; and Belfast, Northern Ireland.
Program created in response to community needs and continues to respond to new emerging needs
BACKGROUND: Argus Community, Inc.
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ACCESS I Care ManagementACCESS II Care CoordinationArgus Career Training
InstituteArgus Client Money
ManagementArgus Community Re-Entry
InitiativeARU Outpatient CenterDWI Screening and
Assessment
Elizabeth L. Sturz Outpatient Center
Harbor House & Harbor House II
MEDAL ProgramPrometheus I and IIRESTART GED ProgramStriver HouseYouth Intervention and
Development
PROGRAMS: Argus Community, Inc.
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The 3 P’s In Care Coordination
Patients
Program StaffProviders
Support
andCoach
BecomeSelf-
SufficientLinkag
e To
Care
Maintain aStable Health Status
Home Based
NavigationCommunit
yCoordination
of Social
Services
TreatmentAdherence
Coordinationof
Medical Services
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Total Census as of June 2013: 125 Active Patients
Referred by 3 medical facilities, self-referrals, and/or our Health Home program.
Patients By Track Enrollment as of June 2013:
PATIENTS: Argus Community, Inc.
Track EnrollmentA (Quarterly, no ART) 5B (Quarterly, with ART) 18C1 (Monthly) 47C2 (Weekly) 36D (Daily Directly Observed Therapy) 19
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IMPLEMENTATION: Client Demographics
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GY 2012, Argus Community, N = 208
AGE GROUP All CCP Argus GENDER All CCP Argus
<25 6.9% 2.6% Female 37.3% 44.3%25-44 38.4% 26.3% Male 60.9% 55.6%45-64 50% 66.5% Transgender 1.8% 1.0%65+ 4.7% 4.6%
RACE/ETHNICITY
All CCP Argus BOROUGH All CCP Argus
Hispanic 37.1% 49.5% Manhattan 21.0% 9.3%Black 52.6% 45.4% Brooklyn 32.8% 2.1%
Bronx 31.1% 86.6%RISK All
CCP Argus
MSM 28.3% 16.1% INSURANCE All CCP Argus
IDU 7.8% 10.7%Public Insurance 80.2% 88.7%
Heterosexual 58.6% 62.4% Uninsured 9.7% 7.2%
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ACCESS IICCP
STAFF
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PROGRAM STAFF
Program Director
Data ManagerMedical Center Liaison
Care Coordinator
Patient Navigator
Patient Navigator
Patient Navigator
DOT Field Specialist
Care Coordinator
Patient Navigator
Patient Navigator
Patient Navigator
DOT Field Specialist 22
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1. Montefiore Medical Group (MMG) – CICERO Program/Bronx Community Health Network 11 Clinics from the Montefiore Medical Group
CICERO Program
2. All Med and Rehabilitation of New York
3. The George and Eva Neil Barbee Family Health Center
4. The 151st Medical Center
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PROVIDERS
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Argus ACCESS II CCP
Provider
Referral
Walk-in/
Word of
Mouth
Linkage to Care
Referrals
Health Home Referr
alsNew York City 311
THE MODEL: Referral Process
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1.Provider Website 2.Social Work Luncheon/Program
Presentations3.Clinical Rounds/Conferences4.CCP Patient Report for Providers5.Consumer Advisory Board Meetings
THE MODEL: Building Provider Buy-in
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THE MODEL: Services Provided
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Accompaniment Assistance with Entitlements and Benefits, Health Care,
Housing, and Social Services Care Plan Case Conference Directly Observed Therapy (DOT) Health Promotions Home Visits Intake/ Re-Assessment Outreach for Patient for Reengagement Treatment Adherence/Pill Box Count
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Lisa was referred by her PCP on 7/15/11 Initial enrollment track was C2-weekly CD4 at the time of enrollment was 219 and VL was 29,492 She began DOT services on 11/16/2011. Her CD4 was 214 and
VL 30,494 CCP staff provided daily DOT services, weekly Health Promotion,
and case management until 3/23/2012 when patients lab reported her CD4 was 350 and VL undetectable.
On 9/17/2012 her CD4 was 375 and VL remained undetectable On 1/18/2013 her CD4 was 465 and VL remained undetectable. Her last lab report indicates that her CD4 is 397 and VL remains
undetectable.
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CASE STUDY: Lisa
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10 Nathan D Perlman Pl, New York, NY 10003
212-420-2620
Vanessa Haney, MFA
BETH ISRAEL MEDICAL CENTER
PETER KRUEGER CENTER FOR
IMMUNOLOGICAL DISORDERS
www.wehealny.org/services/bi_aidsservices
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1978-1979
Donna Mildvan, MD (Chief of Infectious Disease) notices enlarged lymph nodes in gay men studied for sexually transmitted intestinal infections
1980 Beth Israel sees its first AIDS patient, a 33-year old West German man
1981 Beth Israel’s Infectious Disease Clinic opens1988 BIMC is given Designated AIDS Center status
1989 Beth Israel’s Infectious Disease Clinic is renamed The Peter Krueger Center for Immunological Disorders
1993 The Robert Mapplethorpe Residential Treatment Facility is founded by the Robert Mapplethorpe Foundation
BIMC’S AIDS CENTER TIMELINE
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BACKGROUND: BIMC Inpatient
1,083 certified beds Emergency Department
Visits (Excluding Admissions) in 2011: 107,178
Admissions in 2011: 35,376
Methadone Maintenance Treatment Program Visits: 1,079,514
Ambulatory/Outpatient Visits: 371,083
The Peter Krueger Center Number of Unique Patients: 1,200 HIV Primary Healthcare Specialty Healthcare (Dermatology,
Gynecology, Pain Management) Dental Mental Health
(Psychiatry/Psychology/Counseling) Transgender Health Care Services Care Coordination Social Work and Case Management Harm Reduction: Project S.H.a.R.E. Nutrition
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Since 2010, 298 people have been enrolled into BI’s CC Program
Total Census as of June 2013: 186 Active PatientsPatients By Track Enrollment as of June 2013:
PATIENTS: BIMC
Track EnrollmentA (Quarterly, no ART) 0B (Quarterly, with ART) 15C1 (Monthly) 102C2 (Weekly) 64D (Daily Directly Observed Therapy) 5
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IMPLEMENTATION: Client Demographics
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GY 2012, Beth Israel, N = 223
AGE GROUP All CCP
Beth Israel GENDER All CCP Beth
Israel<25 6.9% 3.1% Female 37.3% 41.3%
25-44 38.4% 21.1% Male 60.9% 56.1%
45-64 50% 70.0% Transgender 1.8% 2.7%
65+ 4.7% 5.8%
RACE/ETHNICITY
All CCP
Beth Israel BOROUGH All CCP Beth
IsraelHispanic 37.1% 43.5% Manhattan 21.0% 39.0%
Black 52.6% 44.8% Brooklyn 32.8% 30.9%
Bronx 31.1% 18.8%
RISK All CCP
Beth Israel
MSM 28.3% 21.5% INSURANCE All CCP Beth Israel
IDU 7.8% 29.1%Public Insurance 80.2% 89.2%
Heterosexual 58.6% 65.0% Uninsured 9.7% 1.8%
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Peter Kruege
r Center: CCP
Providers
Inpatient Social Work
Project S.H.a.R.E
. Clinical Trials
Case Finding in EMR
THE MODEL: Referral Process
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CARE COORDINATION: Our Team!
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PROGRAM STAFF
Program Manager
Data Entry
Care Coordinator
Patient Navigator
Patient Navigator
Patient Navigator
Patient Navigator
Care Coordinator
Patient Navigator
Patient Navigator
Patient Navigator
Patient Navigator
Patient Navigator
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Prior to En-rollment
QTR 1 (Jan-Mar 2011)
QTR 2 (Apr-Jun 2011)
QTR 3 (Jul-Sep 2011)
QTR 4 (Oct-Dec 2011)
0102030405060708090
47.92
72.9365.85
82.05
69.23
52.08
27.0734.15
17.95
30.77
CCP Quarterly Viral Loads: N=50Percent Undetectable Percent Detectable
EVALUATION: Outcomes
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Brenda is a 44 year-old woman test HIV positive in 2004 History of trauma, depression, and substance use
Enrolled in CCP April 2011 Viral Load of 100,000 copies and CD4 was 113
Throughout 2011 and 2012 Remained difficult to engage but kept on a weekly track Did not agree to pill boxing and self-reported 100% adherence
March 2013 Viral Load had risen to 659,892 copies and her CD4 dropped to 11
April 2013 Agrees to DOT during her PCP appointment
July 2013 Viral Load is <75 and her CD4 have risen to 43 Significant improvement in herpes lesions
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CASE STUDY: Brenda
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NYC Department of Health and Mental Hygiene
Stephanie Chamberlin, MPH, MIA
CARE COORDINATION PROGRAM
EVALUATION
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Cross-agency evaluation utilizing standard metrics, based on the well-defined CCP protocol
EVALUATION: Process and Outcomes
Process Outcomes
Barriers
Facilitators
Fidel
ity to
Pro
gram
M
odel
Quality Management
Cross-sectional (2010 – Present)
Pre- and Post-CCP Enrollment (2012-
Present)Short-Term
Long-Term39
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Patient Navigators n = 350%
20%
40%
60%
80%
100%
0.220.490.781.22
1.99
2.67
Hours Worked per Day (7.37 Average )
Indirect Client ServicesDirect Client ServicesProgram Activi-tiesN/AAdministrativeBlank, Illegible, Missing
Background
MethodSample of six (6) Agencies
EVALUATION: Time And Effort Study
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Care PlanIntake and Reassessment
All Case ConferencesAll Accompaniment
DOT FieldAll Adherence Logs
Outreach for ReengagementAll Assistance w/ Activities
Health Promotion
Travel Time to/from Client Encounters
0 0.2 0.4 0.6 0.8 1 1.2 1.40.010.04
0.100.11
0.160.16
0.250.47
0.591.18
All Client Services (Direct and Indirect): Average Hours per Day
Patient Navigators n = 35
EVALUATION: Time And Effort Study
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EVALUATION: Engagement In Care
n/a
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EVALUATION: Viral Load Suppression
n/a
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NYC DOHMHCare CoordinationEvaluation Team
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Patient Navigators do more than just navigation Health promotion, treatment adherence, modified DOT, etc.
Diverse Community Health Worker staff Cultural sensitivity and competency
Field safety training and protocol Means of communication
Clinical supervisionTechnical assistance
Provider meetings Peer to peer learning Best practices
Incorporate data collection and evaluation
TAKE HOME MESSAGES
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Beau J. Mitts, MPH NYC Department of Health and Mental Hygiene [email protected]
Stephanie Chamberlin, MPH, MIA NYC Department of Health and Mental Hygiene [email protected]
Maria Rodriguez, MPA Argus Community, Inc. [email protected]
Vanessa Haney, MFA Beth Israel Medical Center [email protected]
QUESTIONS
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To find Care Coordination tools online
visit:www.nyc.govSEARCH: Care Coordination
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Announcements
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Upcoming Webinars: ― Stay Tuned! Campaign staff is hard at work for you
Data Collection Submission Deadline: October 1, 2013
Improvement Update Submission Deadline: August 15, 2013
Upcoming Events and Deadlines
― October – Sex Work and Retention
― August – Transitory Populations and Retention
― September – Women and Retention
Upcoming Monthly Topics
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Campaign Headquarters:National Quality Center (NQC)90 Church Street, 13th floorNew York, NY 10007Phone [email protected]
incareCampaign.orgyoutube.com/incareCampaign