Outreach in SRO hotels Chinazo Cunningham MD Division

Outreach in SRO hotels Chinazo Cunningham, MD Division of General Internal Medicine Dept of Family and Social Medicine MMC/AECOM

SRO hotels

HIV+ SRO Hotel Residents Characteristic Age (mean) Male Race: % 45 yrs 72 Black 59 Hispanic 30 White/other 11 Heterosexual 79 < High school education 49 Income < $8000/yr 90 Medicaid 83 Drugs: Cocaine/crack 49 Heroin/opioids 21 Have regular HIV provider Cunningham, AIDS Pt Care STDs 2005 85

Do HIV+ SRO hotel residents need outreach?

How accurate are self-reported HIV primary care visits? • Cross-sectional study of 522 HIV+ SRO hotel residents (14 hotels) • Data – Self report (ACASI) vs. medical record extraction – HIV-related ambulatory care visits (0, 1, >2 visits) • Analysis – percent agreement & Kappa statistic

Visits by medical records <2 Total <2 36 (8. 9) 14 (3. 5) 50 (12. 4) >2 151 (37. 6) 201 (50. 0) 352 (87. 6) Total Visits by self-report >2 187 (46. 5) 215 (53. 5) 237 (58. 9) Kappa = 0. 12 (0. 06 -0. 19) Cunningham. Med Care 2007

Does outreach work to bring/keep HIV+ people in care?

Few good studies of outreach • Definition of outreach is problematic – Outreach = letters, calls, face-to-face street contacts – Outreach workers = peers, RNs, MDs • Only 1 RCT of outreach • Most studies are observational – biases • Despite this, $24 million allocated to outreach via Ryan White CARE Act

Outreach studies • RCT of RN outreach to women • Multi-site outreach study – marginalized HIV+ people in 10 sites • Medical Outreach to NYC SRO hotels • Outreach to youth • Outreach to IDUs with SEP • Outreach characteristics and kept appts

RCT of RN outreach to women • RCT of RN outreach intervention vs. usual care • 75 women with HIV, mental illness, substance abuse with recent missed appt • Outreach intervention – Weekly visits with RN at pts’ home or outreach clinic – Activities • • Made medical appts for pts Linked pts to CM Addressed insurance and transportation needs Accompanied pts to appts • 1 year f/u, health care utilization = outcome Andersen. AIDS Patient Care STDS 2005

Andersen. AIDS Patient Care STDS 2005

Multi-site outreach study • Observational study that examined how outreach is assoc with retention in care • 773 HIV+ people from 7 sites in U. S. • Data = interviews, program logs, medical records (12 -mo f/u) • Outreach – – Appt reminder or reschedule Service coordination Relationship building / counseling Provide concrete services (e. g. food, transportation) • Analysis – Outcome = time to 4 -mo gap in care – Independent variable = # outreach contacts first 3 mos Cabral. AIDS Pt Care STDS 2007

Cabral. AIDS Pt Care STDS 2007

Medical outreach to SRO hotels • Observational pre-post study examining medical outcomes assoc with medical outreach • Targeted HIV+ residents of 8 NYC SRO hotels • Intervention - door-to-door in SRO hotels – Pre-intervention = Citi. Wide outreach team • Information about Citi. Wide services, supplies, syringe exchange, transportation – Intervention = Citi. Wide outreach team + MD • All the activities above • Med consultation, triage & evaluation, prescriptions, wound care, next-day appts • Data = interviews (pre/post, 8 -18 mo lag) • Outcome = having a primary care provider

Cunningham. J Health Care Poor Underserved 2005

Outreach characteristics & kept appts • Observational study examining patient and program characteristics assoc with kept appts • 2781 medical appt records (2003 -2005) • Patient and program characteristics – – sociodemographic info Appt type: same day/walk-in vs. future appt Appt location: Citi. Wide vs. SRO hotel vs. CHCC Person making appt: MD/NP vs. peer • Data = program logs, medical records • Analysis – Chi-square, regression analysis Cunningham. Am J Public Health 2007

Future appts kept Same day appts kept 357 (23. 3)* 309 (41. 9) 245 (28. 1)* 309 (41. 9) SRO hotel 32 (10. 6) -- CHCC 80 (22. 1) -- MD/NP 143 (18. 1)* 21 (30. 4)* Peer 214 (28. 7) 288 (43. 1) Total Location of appt Citi. Wide Person making appt *p<0. 05 Cunningham. Am J Public Health 2007

Summary • SRO hotel residents – Self-report in care, but validity? ? ? • Outreach studies – 1 RCT of RN outreach intervention • No difference in visits – Observational studies of outreach • >9 outreach contacts/3 mos - gap in care • After medical outreach - report primary care provider – Characteristics of outreach • Consider outreach by peer