Linkage to Care Linking newly diagnosed HIV-infected Persons

Linkage to Care: Linking newly diagnosed HIV-infected Persons to Medical Providers through Linkage-to-Care Case Management (LTC) Amber Rossman, LMSW Kansas City Free Health Clinic

Linkage to Care: CDC ARTAS: l ARTAS = Antiretroviral Treatment Access Study l Objective: link persons living with HIV to medical care l Features: Strengths-based case management: – – Empowerment & self efficacy Clients identify internal strengths & assets Sources: Samet et al. AIDS 2001; 15: 77 -85, del Rio et al. 8 th CROI 2001; Abstract. S 21, Gardner et al. AIDS 2005; 19: 423 -431

Linkage to Care: CDC ARTAS Findings: l Compared to the standard of care group, people in the ARTAS case management were more likely to have visited their HIV provider: – – l At least once in 6 months (78% v. 60%) At least twice in 12 months (64% v. 49%) Additional steps needed to improve linkage to HIV care Source: Gardner et al. AIDS 2005; 19: 423 -431

(during ARTAS II study) Kansas City EMA Historical HIV Positivity Rates Year Number dx HIV+ % Engaged in Medical Care 2001 230 33 2002 161 32 2003 168 43 2004 167 60 2005 193 68 Source: Kansas City Health Department. Percentages rounded to the nearest whole. 4 Objective is to increase the engagement in care among newly diagnosed HIV+ individuals from 43% to 60 -80% per year.

… w No LTC: Eligibility Guidelines (adapted) l l l HIV+ newly diagnosed Not more than 2 HIV medical appointments and never been on treatment (i. e. ARVs) Other HIV+ considered: – – – 5 “Lost to Care” patients welcome (piloting) Repeat clients (if lost) assessed for appropriateness New to area clients (in HIV care in other city and risk being lost to care)

… w No 6 Today LTC: From Referrals to Active Handoff

Results: Kansas City ARTAS II Project 199 referred, 91 participated 94% linked to care* within 90 days 89% retained in care* at 6 months 84% engaged in care* at 12 months 7 *“care” = attended appointment with a prescribing provider MD, DO, NP et al

Referring Sites • Hospitals • Health Depts (KC, Jx, Jo, Wy, MO) HIV Diagnosis • Publicly Funded Testing Sites • Free Clinic (KCFHC) Page Linkage to Care – 20 m response • Med Offices/Other Initial Response – meet with patient and diagnosing provider • Self Referral Intervention - Enrollment or Referrals Linkage to Care - 90 Day, intensive intervention of LTC Case Management (continuation w/ referral to CM services) 87% COMPLETE: 5% NOT COMPLETE: Graduate to long term HIV Case Management Services, continue engagement in care 8 8% COMPLETE: Graduate to self-sufficiency, continued HIV care with own resources Lost to Care, Unable to Contact, Disengaged from Program; cont’d attempts re-engagement 84% of graduates still in care after 12 months.

Terms Important to Our LTC Program l l l l 9 l “passive referrals” vs. “active referrals” “linked to care” vs. “engaged in care” On call (incoming referrals) Graduated disengagement Strengths Perspective (SBCM) LTC Coordinator vs. Case Manager (ALCM) First & second medical appointment Active handoff (strict standard)

In the beginning (first 2 years) KC ARTAS Referral Sources Referrals include ALL referrals screened by ALCMs regardless of eligibility form completed or enrollment status. 10

Recruiting, Retaining, Sustainability Administrative Set up for LTC e Car C n __ are about ntial a ___ e n to C on ge o lear confid __ a ___ Link and t am is ___ t r act ___ ont ntmen prog C oi ___ his is _ app re. T ent a m to c oint app our Y 11 _ w. 16 on kc -9 __ fre 92 __ e. 0 -2 or 4 __ g, 11 __ 81 s __ ch 6__ 75 ed _ 3 - ule 51 y 44 ou r Yo ur Ap ap po in po tm Ca en ti ll S in s __ ap ara tm __ po h G __ in o __ tm od en __ en w __ t. in t __ ww at 8 to ge a ink L 11 -24 nfidentiagl et linked 0 -99 tor for atcooptionsf c–harge __ 816 oordinareatmend free o ______ t • Setting the Stage • Preparing your System • Accountability to LTC Standards

Incoming (referrals in to LTC) Pre-intervention recruitment Setting the stage • Commitment of System Supervisors 1 241 Yo ur Ap ap po in po tm Ca en ti ll S in s __ ap ara tm __ po h G __ in o __ tm od en __ en w __ t. in t __ ww at 8 e kag Lin e Car to 990 - 816 12 _ w. 16 on kc -9 __ fre 92 __ e. 0 -2 or 4 __ g, 11 __ 81 s __ ch 6__ 75 ed _ 3 - ule 51 y 44 ou r ial linked ent nfid – get co r a ptions arge h r fo __ ato ent o e of c ___ din m oor t treat and fre ___ C __ are abou ntial ___ e n to C on ge o lear confid __ a ___ Link and t am is ___ t r act ___ ont ntmen prog C oi ___ his is _ app re. T ent a m to c oint app our Y • Buy-in from Testing sites Preparing the system • Training D. I. S. /Public Health of multiple Integrating into procedures systems • Communication: Reminders of • Developing tools for easy referral Program / LTC staff presence at meetings Strong standards & results! • Commitment to opt-out referrals • 20 minute pager response • Reinforce “active referrals” • ALCM gives available at delivery of positive results

Outgoing (referrals out of LTC) Post-intervention graduation Setting the stage • Commitment of Supervisors 1 241 Yo ur Ap ap po in po tm Ca en ti ll S in s __ ap ara tm __ po h G __ in o __ tm od en __ en w __ t. in t __ ww at 8 e kag Lin e Car to 990 - 816 13 _ w. 16 on kc -9 __ fre 92 __ e. 0 -2 or 4 __ g, 11 __ 81 s __ ch 6__ 75 ed _ 3 - ule 51 y 44 ou r ial linked ent nfid – get co r a ptions arge h r fo __ ato ent o e of c ___ din m oor t treat and fre ___ C __ are abou ntial ___ e n to C on ge o lear confid __ a ___ Link and t am is ___ t r act ___ ont ntmen prog C oi ___ his is _ app re. T ent a m to c oint app our Y • Buy-in from Case Preparing the system Management sites • Coaching Case Managers • Integrating into CM system • Clear, deliberate documentation standards • LTC presence at system meetings Strong standards & results! • Perform “intake” tasks/documentation • Reinforce “active referrals” to long term CM system • Continuum of care goals

Success Checklist: Implementing a Linkage to Care Program ü Existing, strong working relationships with q q ü ü 14 ü City/State Health Departments Disease Intervention and C & T Services HIV Case Management Systems Medical Care facilities Continuum of Programs - as much onsite as possible Experienced staff, strong in Case Management Demonstrated leadership in HIV services Major networking skills! Customer Service (view professionals as secondary client)

Checklist: Defining Your Program’s Linkage to Care 15 Branding the service for entire system Outreach to C & T referral sources Outreach to medical referral destinations Know points of entry of HIV+ individuals Broad outreach to potential clients Targeted outreach to potential clients Market using client and system outcomes publically

Checklist: Active Referrals Activity Client readiness to accept or act on a referral Highlight motivator – attuned to what client wants (motivational interviewing) 16 Preparing, using both didactic and experiential education Visualizing goals and outcomes Attending appointment with client Active “hand off” and follow up

Checklist: Active Referrals Tools ü ü ü ü 17 Hotline or pager number for referrals “Where can I find you” form/tool Material without the word “HIV” or “AIDS” Maps, pictures, forms of care sites/services Offer to train HIV testing staff throughout service area Report back on outcomes of referral Act as “sales representative” touching base w/ referral sites monthly

LTC Staff: An Advanced Skill Set l l 18 Previous experience in RW or hospital case management Previous experience with homeless, SA, youth populations STRONG expertise in HIV/AIDS BSW or MSW (strengths model experience or understanding) (continued)

LTC Staff: An Advanced Skill-Set l l 19 Harm Reduction understanding and practice application Flexible hours to meet client needs (whatever it takes spirit) Outcome focused (involved in all areas of project) Customer service attitude with both clients and referring professionals

Commitment to the LTC Process Using LTC short-term Case Management model (ARTAS adapted) l l l 20 graduated disengagement (90 day) active referrals (into program & in service coordination) cross training staff LTC staff as trainers (outreach to professionals) active hand-off (graduating program) case conference (weekly)

Further Reading: Craw, J. , Gardner, L (2010), Rossman, A. , et al. Structural factors and Best Practices in Implementing a Linkage to HIV Care Program Using the ARTAS Model. BMC Health Services Research 2010, 10: 246 (20 August 2010) Craw, J. , Gardner, L. , et al. Brief Strengths Based Case Management Promotes Entry Into HIV Medical Care: Results of the Antiretroviral Treatment Access Study II (ARTAS II). JAIDS / J Acquir. Immune Defic Syndr 2008; 47: 597 -606. 21 Recommendations for Case Management Collaboration and Coordination in Federally Funded HIV/AIDS Programs. Federal Interagency HIV/AIDS Case Management Work Group: US Department

Amber Rossman, LMSW Questions: 22 www. kcfree. org