For Wide-Scale Implementationphase

Summaries of NY Links Interventions

For Wide-Scale ImplementationPhase

November 6, 2013

Introduction

Purpose

Prompt linkage to HIV care and continuous engagement in care improves individual health outcomes. A secondary benefit is that persons with suppressed viral load are less likely to transmit the HIV virus to uninfected partners. In 2011, the Health Resources and Services Administration (HRSA) funded six jurisdictions across the United States to develop interventions to address testing, linkage and retention in HIV/AIDS care, and evaluate their impact at the agency and statewide levels. Since 2011, NY Links, administered by the New York State Department of Health AIDS Institute, has worked with providers of HIV services in New York State (NYS) to develop innovative and systemic models of linkage to care to improve access to and retention in HIV care. The project has brought networks ofservice providers together in local collaborative partnerships that represent defined geographic areas. The goal is to assist HIV providers across NYS to establish and/or improve activities that promote linkage and retention in HIV care thereby reducing disparities in morbidity and mortality, as well as transmission rates, below their current levels. Overtime, NY Links has measured and evaluated the effectiveness of interventions executed in the collaboratives to identify best practices for dissemination and scale-up throughout NYS. The intervention packagesummaries that follow outline five interventions that have been selected for statewide dissemination and scale-up.

Introduction Timeline and Scope

In October and November 2013, four providers who are members of existing regional provider groups, and one provider outside of the regional groups, will be asked to pilot, for four months, one of the NY Links interventions. This pilot period will allow for finalization of each intervention prior to wide-scale dissemination. Concurrently, between November 2013 and January 2014,existing regional provider networks will be asked to consider the interventions from the NY Links menu of evidence-based interventions[1], and will begin the process of assessing implementation of them across their network in a way that will have the greatest impact on their regional HIV cascade. Participating sites may also choose to continue an existing linkage and/or retention activity. Ten individual providers outside of these regional provider networks will also be engaged to implement interventions from the same menu before the end of February 2014.

Collaborating Partners

The interventions will first be selected and rolled out in active NY Links regional provider groups (Upper Manhattan, Queens/Staten Island, and Western New York [Buffalo, and Rochester]). After this roll-out, NY Links will reach out to other providers from other NYS Ryan White regions to engage them in this important activity. These regions include: Albany, Binghamton, LowerHudsonValley, Mid-HudsonValley, Lower Manhattan, Brooklyn, the Bronx, Nassau-Suffolk, and Syracuse.Providers will be targeted to ensure that each NY Links intervention achievesbroad geographic distribution.

In addition to these regional provider groups, NY Links will continue the work with local health departments and representatives from the NYS prison system to further disseminate the chosen interventions to these stakeholders.

Responsibilities

NY Links staff and collaborators are principally responsible for developing these intervention packages;however, feedback from HIV provider organizations is welcomed. NY Links staff will provide technical assistance (TA) to local agencies during implementation of the interventions. Local agencies are responsible for 1) participating in training for the selected intervention; 2) implementing the core elements of the intervention;3) submitting requiredprocess data in a timely manner;and 4) participating in ongoing TA and site visits during 2013-2015.

Impact Evaluation

The CUNY School of Public Health is evaluating the NY Links initiative. They are working closely with the New York State Department of Health and the New York City Department of Health and Mental Hygiene to leverage population-based HIV/AIDS Surveillance data for the impact evaluation of NY Links on agency-level and region-level outcomes (i.e., HIV Care Continuums). They will also use intervention process data collected from sites implementing these five menu interventions. ‘Control’ groups will be chosen from agencies and sites that have not yet implemented any of the interventions from the NY Links menu.

Intended Outcomes

Participation in this initiative will contribute to NYS’s and HRSA’s ability to evaluate the feasibility, uptake, effectiveness, and impact of evidence-based interventions implemented by networks of providers, as well as individual agencies. It is anticipated that implementation of the NY Linksmenu interventions will improve linkage and retention and other downstream outcomesfor the local agency and region.

Timeline

The timeline for the implementation of these five interventions is detailed in the NY Links Work Plan for Year 3 and Year 4 and further described in detail in the NY Links Wide-scale Implementation Plan for Years 3 and 4.

Interventions

What follows are summaries of the five interventions that have been selected for piloting and broader dissemination.

Appointment Procedures

Brief definition/description of intervention: Standardized appointment procedures facilitate scheduling and remind patients of their upcoming appointments to reduce no-show rates, and to ensure that patients are retained in care. If a patient misses an appointment, follow-up occurs to reschedule the appointment ensuring continuity of care. Reminders and follow-ups are systematically and consistently made for all patients via their preferred method of delivery (home phone, cell phone, SMS, email, letter).

1. Intervention impact area: Retention

2. Target population: All clients. However, if resources are limited,clients can be prioritized based on frequency of no-show, disease status, recent labs, and the timing of the most recent visit.

3. How it works (how the intervention is delivered):

Patient Enrollment:Patient is informed of appointment reminders and follow-up procedures. Ensure that the patient has a valid emergency contact available in his/her medical record and confirms that the emergency contact number can be used to help find the patient if the patient has not been scheduling or keeping appointments consistently. Ask the patient for additional contacts and contact options so a full range is available.

Patient Contact Information: Ask every patient at check in to confirm their current contact information. Double check with each patient at check in that the listed preferred method of contact is still accurate.

Appointment Reminders:Provide the patient with reminders of upcoming medical appointments. Confirm that the patient has requisite resources for all relevant appointments and service access (e.g., transportation, accompaniment) and make arrangements to remove barriers if possible.

Missed Appointment Follow-up: Assist the patient in scheduling and rescheduling appointments, when necessary. Staff inform the patient what they should do if the patient cannot make an appointment de-stigmatizing the issue and providing tools in the patient’s hand (i.e., “we understand that things come up and that you might not be able to make a scheduled visit for some reason. The most important thing is that you call this number and reschedule right away. Also, if you miss a visit, you might get a call from us.”)

4. Core components of intervention:

Patient Enrollment

• If possible, revise forms utilized during enrollment as necessary to include information on the appointment reminders procedure
• Expanded contact information for patients is collected at this point. This allows patients to designate alternate methods to be used for contact, i.e. cell phone, texting, face book, family, friends, etc.

Patient Contact Information

• Establish a mechanism by which patients can confirm or update their contact information on a regular basis or at each visit. Include a confirmation of patient’s preferred method of contact. Allow patients the option to include information for a secondary contact, i.e., family member, friend.

Appointment Reminders

• Establish a system to generate regular lists of upcoming appointments (appointments scheduled at least 5 business days in advance, and appointments scheduled for the next business day). These lists will be used in making reminder calls or inputting into an automated call system. At a minimum the list should include: patient name, preferred method of contact, phone number, date of appointment, last appointment.
• Provide the patient with at least two reminders of upcoming appointments; for example, at 5 business days and 1 business day prior to scheduled appointment.
• The frequency and timing of reminders will be determined by the program and consistent for all patients.
• Reminder messages will include a statementabout the importance of keeping up with appointments to patient’s health.
• Assist with rescheduling appointments if needed by the patient. Automated systems might include a message concerning who to call within the organization to reschedule.

Missed Appointment Follow-up

• Establish a system to generate daily lists of missed appointments for use in making follow-up calls or inputting into an automated call system if one exists.
• When a patient misses an appointment:
• Daily contact attempts are made to the patient:
• that include a statement about the importance of keeping up with appointments to patient’s health.
• after the missed appointment for up to 2 weeks or until the patient reschedules an appointment .
• Subsequent contact to the last listed address is not warranted when it becomes apparent that the patient has permanently moved.
• after two weeks of daily contact attempts without reaching the patient, outreach staff, if they exist, are notified to try to locate the patient.
• When patients are contacted, a new appointment can be offered on the spot.
• If 30 days passes and all contact efforts have failed, a certified letter will be sent to the patient expressing concern about the patient's wellbeing and asking them to contact the clinic.
• Conduct internet-based searches for persons whose address may have changed.
• A second, certified letter to the patient is necessary after two sequential months of failed outreach by phone and field/home visit in which no contact with the patient is made. This letter should specify the patient's case may be closed.
• All efforts to contact the patient will be documented in the appropriate vehicle within the organization—case file, EMR, health record, etc.

5. Tools/manuals to be derived or adapted from:

Care Coordination Program Manual for People with HIV

6. Providers who have implemented something similar to this intervention:

Ryan White Part A funded Care Coordination Providers, and in+care Campaign providers including: Mount Sinai Medical Center, Beth Israel Medical Center, The Institute for Family Health, St. Luke’s- Roosevelt Hospital, Harlem Hospital Center, NY Presbyterian Hospital, Lenox Hill, Safe Horizon.

7. Level of evidence and recommendation:

The choosing of this intervention was a consensus-driven process. An intervention panel consisting of experts and staff from the NY Links Evaluation Team, NYC DOHMH and NYS DOH, in addition to consumers and providers participating in existing NY Links collaboratives, were convened in order to prioritize and select interventions for statewide scale-up. A list of interventions used to improve linkage with and retention to HIV care was compiled, assessed and ranked based on the level of evidence, feasibility, specificity, expected impact on linkage or retention, and cost-effectiveness. Given these criteria, the intervention panel deemed this intervention to be one of the most appropriate interventions to be included in the statewide NY Links intervention menu. This intervention has been implemented by 28 NYC agencies with success through the NYC DOHMH Care Coordination Program. Preliminary data from care coordination has shown improvements in engagement in care post enrollment into the program.In Year 2 of NY Links, Erie County Medical Center invested in an automated system that allows patients to choose text or voice appointment reminders and to confirm receipt of call. Reminders are made regardless of staffing (August 2012). HIV+ patients newly enrolled with a medical provider with prescribing privileges who had a medical visit in each of the 4-month periods in the measurement year improved from 57% in August 2012 to 89% in June 2013, entering the top 10% for New York Links at same time national and state averages remained stagnant or decreased. Additionally, other published studies have shown appointment reminders to be effective in increasing rates of kept appointments.

8. Citations:

• NYC Department of Health and Mental Hygiene, Bureau of HIV/AIDS Prevention and Control, Care, Treatment, and Housing Program. Care Coordination Manual. Updated May 2013
• NYC DOHMH Care Coordination Evaluation Team. “Patient Navigation: A network perspective from the NYC HIV Care Coordination Program.” PowerPoint presentation. Presented to In+Care campaign provider, NYC, NY. 6 August 2013
• Perron et al. Reduction of missed appointments at an urban primary care clinic: a randomized controlled study. BMC Fam Pract. 2010 Oct 25, 11:79
• Hahim et al. Effectiveness of telephone reminders in improving rate of appointments kept at an outpatient clinic: A randomized control trial. J A Board Fam Prac. 3, 2001,pp 193-196

9. Intervention documents prepared by:

Jacqueline Rurangirwa, NYC DOHMH

Michael Hager, NYS DOH

Steve Sawicki, New York Links Program

Beau Mitts, NYC DOHMH

John Anthony Eddie

Carol-Ann Watson, NYS DOH

ARTAS (Brief Strengths-based Case Management)

Brief definition/description of intervention: Anti-Retroviral Treatment and Access to Services (ARTAS) is an individual-level, multi-session, time-limited intervention with the goal of linking recently diagnosed persons with HIV to medical care soon after receiving their positive test result, or re-engaging those no longer in medical care/treatment. ARTAS is based on the Strengths-based Case Management (SBCM) model and encourages the client to identify, and to use personal strengths; create goals for himself/herself; and establish an effective, working relationship with client services staff.

1. Intervention impact area: Linkage to medical care/treatment

2. Target population: Newly diagnosed clients (diagnosed within the last 6-12 months) or those returning to care after a more than 6-month lapse

3. How it works (how the intervention is delivered): Newly diagnosed clients who are not engaged in medical care/treatment or who are returning to care after being out of HIV care for more than 9 month are referred to a CM or staff providing client-level supportive services. Five client sessions are conducted over a 90 day period or until the client links to medical care - whichever comes first. The intervention is strength-based case management resource where client sessions are encouraged to take place outside the office or wherever the client feels most comfortable. Following the final client session, the client may be linked to a long-term case management program and/or other service delivery system to address his/her longer term barriers to remaining in care, such as substance use treatment, mental health services, etc.

4. Core components of intervention:

• Conduct between one and five structured sessions with each client
• Focus on the client's strengths by conducting a strengths-based assessment and encouraging client to identify and use his/her strengths, abilities, and skill to link to medical care and accomplish other goals
• Facilitate the client's ability to identify and pursue his/her own goals, and develop a step-by-step plan to accomplish those goals using the ARTAS session plan
• Conduct active, community-based services by meeting each client in his/her environment and outside the office, whenever possible
• Coordinate and link clients to available community resources, both formal (e.g., housing agencies, food banks) and informal (e.g., friends, support groups, spiritual groups) based on each client's needs
• Advocate on the client's behalf, as needed, to link him/her to medical care and/or other needed services

5. Accompanying tools/forms/checklists/appendices:

ARTAS Protocol

ARTAS Client Flow Process

Training and Technical Assistance Program (T-TAP) Training Catalog

6. Providers who have implemented something similar to this intervention:

ACQC, Project Hospitality, Community Healthcare Network

7. Level of evidence and recommendation:

The choosing of this intervention was a consensus driven process. An intervention panel consisting of experts and staff from NY Links, NYC DOHMH and NYS DOH, in addition to consumers and providers from our existing collaboratives, were convened in order to select interventions for statewide scale-up. A list of interventions used to improve linkage and retention to care was compiled, assessed and ranked based on some level of evidence, feasibility, specificity, expected impact on linkage and retention, and cost-effectiveness. Given this criteria, the intervention panel deemed this intervention to be one of the most appropriate interventions to be included in the NY Links intervention menu. This intervention was considered by IAPAC to have a high level of evidence and is recommended for most clients (see Gardner and Thompson citations).

8. Citations:

• Gardner et al. Efficacy of a brief case management intervention to link recently diagnosed HIV infected persons to care. AIDS. 2005 Mar 4;19(4):423-31
• Thompson et al. Guidelines for Improving Entry Into and Retention in Care and Antiretroviral Adherence for Persons With HIV: Evidence-Based Recommendations From an International Association of Physicians in AIDS Care Panel. Ann Intern Med. 2012 Jul, Volume 156, Number 11
• J.A. Craw, L.I. Gardner, G. Marks, R.C. Rapp, J. Bosshart, W.A. Duffus, A. Rossman, S.L. Coughlin, D. Gruber, L.A. Safford, J. Overton, and K. Schmitt, “Brief Strengths-Based Case Management Promotes Entry into HIV Medical Care: Results of the Antiretroviral Treatment Access Study-II,” Journal of Acquired Immunodeficiency Syndromes 47, no. 5 (2008): 597-606
• J. Craw, L. Gardner,a. Rossman, D. Gruber, N. O'Donnell, D. Jordan, R. Rapp, C. Simpson, and K. Phillips, "Structural factors and best practices in implementing a linkage to HIV care program using the ARTAS model," BMC Health Services Research 2010, 10:246
• Danya International Inc. “Effective interventions: HIV prevention that works—ARTAS”. 2012. Web: 26, Sep. 2013.

9. Intervention documents prepared by: