Promoting Quality Prevention Counseling Project What have we

Promoting Quality Prevention Counseling Project: What have we learned? Spring 2005 Texas Tour Dallas, Fort Worth, Houston, Midland, Austin

Agenda n Welcome and Introduction n Background n Overview of project n Implementation experiences by sites n General evaluation findings n Next Steps n. Q & A

Background n Revised HIV Counseling, Testing and Referral (CTR) Guidelines, November 2001

Background Cont’d n CDC’s Project RESPECT: Evidence-based intervention showing significant reduction of STDs with protocol-based HIV prevention counseling n RESPECT-2: Refined HIV prevention counseling protocol & further developed “counseling quality assurance” methods

RESPECT Methodology n 5758 heterosexual, HIV-negative patients older than 14 years who came in for STD examination n Five public STD clinics (Baltimore, Denver, Long Beach, Newark and San Francisco)

Project RESPECT Results*: HIV Prevention Counseling Effective (*p<0. 05) Kamb, M. L. , et al (1998) Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases, JAMA, 280 (13): 1161 -1167

How could we translate this intervention into a real-world setting? n Risk Reduction Specialist support n Supervisor support n Practical tools

Goals of the Project n Develop and evaluate tools to support protocol-driven prevention counseling based on the RESPECT model n Develop and evaluate QA procedures n Better understand the barriers and facilitators of good prevention counseling

Definitions n Evidence-based interventions n Interventions that have demonstrated desired outcomes through rigorous research n Core elements n Components of the intervention that are believed to be essential to achieve the desired behavior change n Protocol n A structured approach to achieve core elements

Definitions n Client-centered prevention counseling n One-on-one interactions with risk-reduction as its primary goal n Risk Reduction Specialist n A trained specialist responsible for maintaining the focus on a client’s specific risk reduction needs n Tools n Job aides to ensure fidelity to core elements of protocol

Site Locations Tarrant County Health Dept. Ft. Worth, TX Resource Center Of Dallas, TX City of Laredo Health Dept. cc Laredo, TX Valley AIDS Council, Mc. Allen, TX cc Brownsville, TX

What was introduced during the project? n Counseling protocol n Training on the protocol n Counseling tools n Spiral book with goals and sample questions n Laminate “wheel” n Documentation form with space for RR plan and referrals n Personal review form

Session Documentation Form

What QA activities were part of the project? n QA protocol n Emphasizing standardized preceptorship, observation, routine meetings, documentation review, and feedback on observations and documentation n QA tools n Supervisor observation tool n RRS self assessment n Chart abstraction and summary tools

Quality Assurance Tools

Comparison of Core Elements GOAL PCPE RESPECT Protocol 1: 1 Counseling Yes Yes 2 -Session Model Yes Yes Follow Protocol No Yes Focus: Client Risk Behavior Yes Yes Increase self-perception Risk Yes Yes Negotiate Realistic RR Step Yes Yes Provide Referrals Yes Yes Support Test Decision Yes Yes Interpret test results Yes Yes Partner Elicitation/ Referral Yes No Yes Standardized QA Procedure No Yes QA Tools Specified No No Yes Session Tools No Yes

Implementation n Training developed for protocol, tools and QA n Supervisors and Risk Reduction Specialists trained in October 2003 n On-site and off-site TA provided for startup n Staggered and tailored implementation of protocol, tools, and QA n Additional ongoing TA after start-up

What Do We Want to Learn? n n n Can you implement protocol-based prevention counseling with existing resources? Did the protocols and tools help them implement the intervention with fidelity? What were some of the facilitators and barriers of the implementation of the protocols?

Evaluation Design n Two data collection phases: Pre- and Post- intervention n Evaluation data triangulation: 9 complementary quantitative and qualitative instruments

Quantitative Instruments n Supervisor time logs (pre and post) n Client Questionnaires (pre and post) n Counseling chart reviews (pre and post) n Observations of counseling by evaluators (pre and post)

Qualitative Instruments n n n Risk Reduction Specialist (pre and post) Supervisors (pre and post) Site Program Managers (post only) WAP (post only) TDH (post only)

Results Lessons Learned

Did the protocols and tools help implement the intervention with fidelity?

Observations: Initial Session Goals *P<. 05

Observations: Follow-up Session Goals *P<. 05

Client survey: Initial session Goals *P<. 05

Client survey: Initial session Goals (cont’d) *P<. 05

Client survey: Follow-up session Goals *P<. 05

Client Surveys: Client Participation *P<. 05

Chart reviews Goals *P<. 05

Significant changes seen in initial sessions Goals Observation Client Report Documentation Introduction/Orientati on Enhanced risk percept. X Recent risk discussed X Reviewed past RR X X Sum up pattern of risk X X X Risk reduction plan X X Support and referral X Test decision counseling Appt and reminder X X X (2) X X 33

Significant changes seen in follow up sessions Goals Observation Orient and give results X Review RR efforts X Risk reduction plan Support and referral X X Summarize and close Client Report Documentation X X X 34

“That you had to follow every single task even though they didn't all apply to everybody [is a problem]. Protocol doesn't allow for individual counseling styles or use of skills RRS's have received at prior trainings…it seems cumbersome and redundant to use this protocol with clients with very few risks - although it's easy enough to move through the protocol by saying this doesn't really apply to you [for certain tasks]. ” -Risk Reduction Counselor

“[The protocol improved the quality of my counseling] because I had a structure to make sure I wasn’t leaving anything out. ” -Risk Reduction Counselor

Observations: Initial Visit Use of Counseling Skills *P<. 05

Observations: Follow-up Session Use of Counseling Skills *P<. 05

Client Surveys: Client experience *P<. 05

What were some of the facilitators and barriers of the implementation of the protocols?

Overall themes and feedback n Delivery of protocol-driven prevention n Provided structure n Improves with practice n Aided in identifying risk behaviors and patterns n Protocol questions felt rigid n More training and TA is essential

Overall themes and feedback (cont’d) n Spanish version tools are needed n Supervisor buy-in is essential n Supervisor’s other responsibilities need to be considered due to time constraints of quality assurance n Difficult with certain clients (such as low risk, outreach, drug treatment and jail)

Using the Counseling Tools n Most of the RRS found the cards to be the most helpful of the tools (72%) n Cards help ensure you cover everything in order (44%) n Wheel was not as helpful (83%) n Spanish version of the tools is needed

Counseling QA by RRS n Most helpful n Observation by supervisor n General feedback n Role play n Observation by peer/peer observation/document review n Case conference

Counseling QA by RRS (cont’d) n Least helpful n Documentation review n Observation by peer n Case conference/self assessment

Counseling QA by Supervisor n Most helpful n Observation by supervisor n General feedback n Document review n Case conferences n Least helpful n Observation by peer n Self-assessment

QA Activities by RRS

“[The supervisor observation form] is better because it is less subjective and more structured. …the priorities of the tasks are made clear by the forms and that feedback using these forms makes the whole process self-reinforcing [the process of understanding the expectations of the protocol, using the protocol, and getting feedback—all have the same language, structure, and expectations]…the new feedback is less stressful for everybody, including the observer for the stated reasons. ” ---Risk Reduction Specialist

I think this new protocol is great—fabulous! Before when they first told us about the program and we went to training, we were all ‘iffy’ and said ‘it’s not gonna work’ ‘no way in heck’ it would be accepted by the people. Now that we are implementing it, we are doing a great job. When you have to write steps, the clients leave with RR plan in hand, a referral, an appointment card with the date on it in hand. As for review forms used by the supervisor on documentation, etc. You have the form yourself to be able to discuss ‘met’ or ‘not met. ’ ---Risk Reduction Specialist

What has been done? n Changes to training Trainers have bought in n Preceptorship is done first, then attend training n More time for role play n Develop their own questions for each step n Not a gripe session n n Sites learning from each other Role plays/Peer observations for practice n Sign in waiting room for length of sessions n Regularly scheduled QA sessions n

What Now? n State-wide roll-out begins May 2, 2005 n All DSHS HIV/STD contractors n Roll-out completed by July 2006 n Protocol Based Counseling Training (PBCT) replaces PCPE by August 2006 as the state mandated prevention counseling course for risk reduction specialists

HOW? ? n 11 -week training and technical assistance cycles One month of supervisory training and development n Two week employee preceptorship n Three weeks of employee training and TA n Two weeks of independent implementation and TA n n Ongoing technical assistance and support 7 training staff dedicated to rollout initially n Field operations and regional staff support n

When? n Cycle 1 – May 2 n SE Texas area agencies n Cycle 2 – July 18 Cycle 3 – September 19 Cycles 4 -6 in 2006 n Agency selection for cycle based on: n n n Epi data Field Ops Agency Readiness

Programmatic PBC is the prevention counseling model that must be used if contracted to perform PCPE or an ILI as a component of your GLI. n Once committed - no going back to old PCPE. n Changes in the RFP and contract language. o State 2005/6 o Federal 2006 n Big competitive RFP released Spring 2006 to start funding state 9/1/06 and federal 1/1/07 n

Points to Ponder… Structural - your program overall? Buy-in from your administration, capacity? n Staffing – Supervision requirements, hiring, vacancies, current staff n Time for supervision, time for staffing, time for QA activities, time to perform the sessions. n Who needs to be trained? PCM, EBI, TCADA, Case Managers? n

Budgets – how to pay for upcoming trainings, how to compensate your staff? n Outreach workers’ conference, Ora. Sure, salary savings n One week of Austin training for supervisor and any team leaders. n All PCPE staff one week in possibly local area. n Possible budget amendments n Start thinking about new budgets for 2006 n

Workplans n n n Where are you doing your PC? What populations are you serving? What does your PC look like now? How does this change the structure of the work that you do? What type of changes will you need to make in your workplan? Look at settings and time and how this will work? Partner with your fellow providers to perform activities in various settings.

THINGS YOU CAN DO NOW! Look at the quality assurance guidelines and your contract. Are you doing as required now? n Review the PBC tools QA. Please do not use them until you are trained n What does your orientation plan look like? Some do a type of preceptorship already. n Are you using the TDH documentation guide and sample? Are you using a PCPE review tool? Get them off our web. n

Things to do now. . Review your objectives, what do you need to meet your return rates, link to EI, and PE? n What does your counseling look like now? n Clean RECN data n

TA and Monitoring FO staff will go through Mega-training with their program n TA provided with Training staff n Monitoring schedule will start six months after all trained date n

Q&A