Care Continuum Interventions

CARE CONTINUUM STAGE

RETENTION

SAMHSA YMSM Training

Details

Stigma reduction, making services fun/engaging for kids, strategies for behavioral change leading to patient engagement

Population:

Youth, MSM of Color

Care Continuum Stage:

Retention, Viral Load Suppression

Intervention Type:

Case Mgmt, Experience Evals

Duration:

1 day, FU based on links back to resources for further education

Cost:

$

Type:

Other Lit

Inputs:

F2F training including support (online version coming eventually), website resources too

Outputs:

trained professionals

Practice-based Evidence Seminars

Details

Call for applications across the US based on innovative YMSM activities. Focus groups were formed to discuss and describe what work is occuring in the field. By service, how are patients brought in and retained? How are the service needs of a population different from the needs of other populations.

Population:

Youth

Care Continuum Stage:

Retention, Viral Load Suppression

Intervention Type:

Capacity Building, Experience Evals, Patient Focused

Duration:

2 day summit and lots of followup

 

Cost:

$$

 

Type:

Other Lit

Inputs:

SMEs and indivduals interested in making a difference. Need to have strong recording

Outputs:

white paper to categorize and rate the various methods to engage YMSM LGBT pops in BH services

Brothers Saving Brothers (based on CDC EBI Many Men Many Voices)

Resource Links

https://careacttarget.org/sites/default/files/rw2010/papers/A-23A.pdf

Details

Didactic series – 6 subcomponents to each section/group (ie. Comfort with my sexuality). Highly interactive. Video (10min) to seed more discussion. Standardized curriculum, but advise more listening than talking for the person delivering. Outreach via facebook, palm cards, condom drops at bars, peer-led (recruit from friend/network bases). Try to keep to 10 clients

 

Population:

MSM Of Color

Care Continuum Stage:

Retention, Viral Load Suppression

Intervention Type:

Capacity Building

Duration:

5 session intervention over 2 days (was been dropped to 3 sessions over 2 days. Now its one 5 hour intervention on 1 day). A Booster session is available for folks who have done the original more than 6 months back.

 

Cost:

$

 

Type:

Other Lit

Inputs:

Staff and training materials

Outputs:

Trained and empowered men

New Horizons (based on CDC EBI Horizons) for young women

Details

Run onsite at the host organization. A booklet is provided for the girls to follow along and keep (summary of activities). Recruit from testing sites, county jail, halfway houses, health fair. Try to keep session to 10 participants

 

Population:

MSM of Color

Care Continuum Stage:

Retention, Viral Load Suppression

Intervention Type:

Capacity Building

Duration:

5 session intervention over 2 days (was been dropped to 3 sessions over 2 days. Now its one 5 hour intervention on 1 day). A Booster session is available for folks who have done the original more than 6 months back.

 

Cost:

$

 

Type:

Other Lit

Inputs:

Staff and training materials

Outputs:

Trained and empowered men

Navigation Services Coupled with Client Ed and Stigma Reduction

Details

Stigma reduction, client education, navigation and referral services bundled into one!

 

Population:

Youth, Transgender Women, MSM of Color, African American & Latina Women

Care Continuum Stage:

Retention, Viral Load Suppression

Intervention Type:

Case Mgmt

Duration:

6 months to 1 year

Cost:

$

Type:

Other Lit

Inputs:

EMR, navigator

Outputs:

healthier clients

Kids Xmas Project – for kids who otherwise would not have one

Details

Kids enrolled in case management with good retention are added to the roster to receive a gift

Population:

Youth

Care Continuum Stage:

Retention, Viral Load Suppression

Intervention Type:

Patient Focused

Duration:

annual for 1 month

Cost:

$

Type:

Other Lit

Inputs:

EMR, case manager, toys/clothes/gifts

Outputs:

Happy kids and parents, fulfilled staff, rapid word of mouth leading to greater engagement

Baby Shower – for poor women who otherwise would not have one

Details

Women who are pregnant (or who they find out are pregnant) are invited to have a baby shower at the clinic if they have had good retention in care

Population:
African American & Latina Women
Care Continuum Stage:
Retention, Viral Load Suppression
Intervention Type:
Patient Focused
Duration:
Second trimester of preg
Cost:
$
Type:
ShareLab, Other Lit
Inputs:
EMR, case manager, toys/clothes/gifts
Outputs:
Happy moms, better retention, MTCT prevention improved

Co-located Behavioral Health, Housing, and Treatment Services

Details

Engagement site has intensive colocated BH and CM servcies. Transition to other transitional living programs on graduation

Population:

Youth

Care Continuum Stage:

Retention, Viral Load Suppression

Intervention Type:

Health Systems

Duration:

6 Months

Cost:

$

Type:

Other Lit

Inputs:

EMR, case manager, counselors, housing/beds

Outputs:

Happier kids, more stable kids

Transgender Linkage to Care Program

Details

Gender affirming care had association w/better outcomes (hormone therapy, provider competencies, perceived support)

Population:

Transgender

Care Continuum Stage:

Retention

Intervention Type:

Capacity Building, Experience Evals, Patient Focused

Duration:

Ongoing

Cost:

$

Type:

Other Lit

Inputs:

Gender-affirming care (hormone therapity, compentency training

Systematic Monitoring of Retention

Details

Entry into care after HIV diagnosis, defined as a visit with an HIV care provider authorized to prescribe ART, has been associated with improved survival. Within a given jurisdiction or service area, providers of testing services, local public health institutions, and medical clinics have a shared responsibility to monitor entry into HIV care. Roles and accountability should be clearly established on a local level. Integration of multiple data sources, including surveillance data, administrative databases, and medical clinic records, may enhance monitoring of initial entry into HIV care.
Population:
Youth, Transgender Women, MSM of Color, African American & Latina Women
Care Continuum Stage:
Retention
Intervention Type:
Info Systems
Duration:
Ongoing
Cost:
$
Type:
IAPAC
Inputs:
EMR Capability, staff trained on EMR data entry, staff trained on EMR data extraction, synthesis, and analysis

Intensive Outreach for Those Out of Care

Details

In a sample of 104 individuals in whom HIV was diagnosed within 6 months before enrolling in the U.S. Special Projects of National Significance Outreach Initiative, 92% attended medical appointments within 6 months of enrollment. At study baseline, 14% of individuals had undetectable HIV-1 RNA, which increased to 45% after 12 months of follow-up. This observational demonstration project used a variety of approaches, focusing on individuals considered underserved by the health care system (such as women, youth, and people with a history of substance use or mental illness).

Population:

Youth, Transgender Women, MSM of Color, African American & Latina Women

Care Continuum Stage:

Retention

Intervention Type:

Outreach

Duration:

6-12 Months

Cost:

$

Type:

IAPAC, ShareLab

Inputs:

case managers and other providers are trained in early intensive outreach and stigma management. Case managers and other providers trained in barriers and facilitators cataloguing

Peer or Paraprofessional Navigators

Details

Patient navigation has been described as a model of care coordination and is largely based on peer-based programs established for patients with cancer. Patient navigators are trained to help HIV-infected patients facilitate interactions with health care. In an analysis of 4 patient-navigation interventions from the U.S. Special Projects of National Significance Outreach Initiative, involving more than 1100 patients who were inconsistently engaged in care, the proportion with at least 2 visits in the previous 6 months increased from 64% at baseline to 87% at 6 months and 79% at 12 months in the intervention group (26). In addition, the proportion of patients with undetectable HIV-1 RNA was 50% greater at 12 months than at baseline.

 

Population:

Youth, Transgender Women, MSM of Color, African American & Latina Women

Care Continuum Stage:

Retention

Intervention Type:

Patient Focused

Duration:

6-12 Months

Cost:

$

Type:

IAPAC

Inputs:

Patient Navigators trained to assess and address patient barriers to care. Patient Navigators trained to

Brief, Strengths Based Case Management

Details

The Antiretroviral Treatment and Access Study evaluated entry into and retention in care as part of a multisite RCT in several U.S. care sites comparing strengths-based case management sessions (up to 5 in a 90-day period) with passive referrals for local care among patients with recently diagnosed HIV infection. Trained social workers helped clients to identify their internal strengths and assets to facilitate successful linkage to HIV medical care. A significantly higher proportion of the case-managed participants visited an HIV clinician at least once within 6 months (78% vs. 60%) and at least twice within 12 months (64% vs. 49%). However, availability of resources may impede implementation in a given jurisdiction or service area.

Population:
Youth, Transgender Women, MSM of Color, African American & Latina Women
Care Continuum Stage:
Retention
Intervention Type:
Case Mgmt
Duration:
90 Days
Cost:
$$
Type:
IAPAC
Inputs:
Case managers trained in ARTAS

Peer-driven Out of Care Reach

Details

•We have an Peer Outreach Coordinator, and there are three more waiting to start soon. One will work with our partners to tackle MSM, the other will work as a bilingual Case Manager and also target the Hispanic population. The third will go out into the areas covered under our grant.

•Patients who have been gone for years, and reconnected to care by their primary care providers when they come into the Health Center for primary care needs.

•We are providing transportation via bus passes to make sure that those in care are able to come for appointments. We have been averaging two no shows a month for HIV clinic appointments.

Population:
MSM of Color
Care Continuum Stage:
Retention
Intervention Type:
Experience Evals, Outreach
Duration:
6 months
Cost:
$$
Type:
ShareLab
Inputs:
Peer outreach workers are available and trained to provide field outreach, cultural competency, and field safety. Outreach workers are trained to distribute and track transportation vouchers for individuals coming back into the program.

Exit Surveys and Interviews for Patients Transferring Out

Details

We have created “exit surveys” for Matthew 25 to get a better grasp on why the patients that are leaving care with M25 are leaving. We are hoping this will give us the data we need to make possible improvements in patient care.
M25 also conducts client satisfaction surveys to help identify any concerns clients may have. The results are given to staff, M25’s Board of Directors, and consumers involved in the CQI client group. Now, with electronic medical records and eClinical Works, our schedulers have been keeping track of missed appointments electronically. We are currently trying to find a way to measure the effectiveness of this change. We are re-evaluating our scheduling policy and procedures based on what to do if a client no-shows (call client the same day to try to schedule another appt, etc.).

Population:
Youth, Transgender Women, MSM of Color, African American & Latina Women
Care Continuum Stage:
Viral Load Suppression
Intervention Type:
Experience Evals, Patient Focused
Duration:
Ongoing
Cost:
$
Type:
ShareLab
Inputs:
Training for front end staff on interviewing patients who are exiting. Data collection tool and electronic analysis capacity needed.

Homeless Youth Support

Details

Larkin Street’s Engagement Programs provide homeless and runaway youth with a refuge from the streets. These programs serve a young person’s basic needs for food, shelter, and medical care. Larkin Street provides safety and encourages youth to move off the streets and indoors, where they can begin the transition from crisis to stability.

  • Street Outreach: Trained workers provide hygiene kits, referral cards, and counseling in San Francisco’s neighborhoods where homeless youth are most likely to gather.
  • Engagement & Community Center: Located in the Tenderloin, this drop-in center provides meals, showers, laundry, and counseling five days a week.
  • Haight Street Referral Center: Located in the Haight neighborhood near Golden Gate Park, this drop-in center provides counseling, snacks, and referrals five days a week.
  • The Michael Baxter Larkin Street Youth Clinic: Co-located with the Engagement & Community Center and run in partnership with the San Francisco Department of Public Health, the clinic provides primary health care, confidential STI testing, and benefits enrollment five days a week.
  • Diamond Youth Shelter: One of only two emergency shelters in San Francisco for runaway youth ages 17 and under, Diamond Youth Shelter provides up to 21 days of safe shelter and critical support to reunify youth with family or find alternative housing.
  • Lark-Inn for Youth Shelter: San Francisco’s first and only shelter for transitional age youth between 18 – 24, the Lark-Inn provides 40 beds of short-term housing and support services to keep youth safe as they make a plan for the future.

 

Population:

Youth

Care Continuum Stage:

Retention

Intervention Type:

Case Mgmt, Patient Focused

Duration:

Ongoing

Cost:

$$$

Type:

SPNS

Inputs:

Outreach workers, drop in spaces, outreach vans, patient navigators, cultural competency training, enhanced medication access

Outputs:

Healthier, more stable youth

VIRAL LOAD SUPPRESSION

VIRAL LOAD SUPPRESSION

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SAMHSA YMSM Training

Details

Stigma reduction, making services fun/engaging for kids, strategies for behavioral change leading to patient engagement
Population:
Youth, MSM of Color
Care Continuum Stage:
Retention, Viral Load Suppression
Intervention Type:
Case Mgmt, Experience Evals
Duration:
1 day, FU based on links back to resources for further education
Cost:
$
Type:
Other Lit
Inputs:
F2F training including support (online version coming eventually), website resources too
Outputs:
trained professionals

Practice-based Evidence Seminars

Details

Call for applications across the US based on innovative YMSM activities. Focus groups were formed to discuss and describe what work is occuring in the field. By service, how are patients brought in and retained? How are the service needs of a population different from the needs of other populations.
Population:
Youth
Care Continuum Stage:
Retention, Viral Load Suppression
Intervention Type:
Capacity Building, Experience Evals, Patient Focused
Duration:
2 day summit and lots of followup

Cost:
$$

Type:
Other Lit
Inputs:
SMEs and indivduals interested in making a difference. Need to have strong recording
Outputs:
white paper to categorize and rate the various methods to engage YMSM LGBT pops in BH services

Brothers Saving Brothers (based on CDC EBI Many Men Many Voices)

Details

Didactic series – 6 subcomponents to each section/group (ie. Comfort with my sexuality). Highly interactive. Video (10min) to seed more discussion. Standardized curriculum, but advise more listening than talking for the person delivering. Outreach via facebook, palm cards, condom drops at bars, peer-led (recruit from friend/network bases). Try to keep to 10 clients

Population:
MSM Of Color
Care Continuum Stage:
Retention, Viral Load Suppression
Intervention Type:
Capacity Building
Duration:
5 session intervention over 2 days (was been dropped to 3 sessions over 2 days. Now its one 5 hour intervention on 1 day). A Booster session is available for folks who have done the original more than 6 months back.

Cost:
$

Type:
Other Lit
Inputs:
Staff and training materials
Outputs:
Trained and empowered men

New Horizons (based on CDC EBI Horizons) for young women

Details

Run onsite at the host organization. A booklet is provided for the girls to follow along and keep (summary of activities). Recruit from testing sites, county jail, halfway houses, health fair. Try to keep session to 10 participants

 

Population:

MSM of Color

Care Continuum Stage:

Retention, Viral Load Suppression

Intervention Type:

Capacity Building

Duration:

5 session intervention over 2 days (was been dropped to 3 sessions over 2 days. Now its one 5 hour intervention on 1 day). A Booster session is available for folks who have done the original more than 6 months back.

 

Cost:

$

 

Type:

Other Lit

Inputs:

Staff and training materials

Outputs:

Trained and empowered men

Navigation Services Coupled with Client Ed and Stigma Reduction

Details

Stigma reduction, client education, navigation and referral services bundled into one!

 

Population:

Youth, Transgender Women, MSM of Color, African American & Latina Women

Care Continuum Stage:

Retention, Viral Load Suppression

Intervention Type:

Case Mgmt

Duration:

6 months to 1 year

Cost:

$

Type:

Other Lit

Inputs:

EMR, navigator

Outputs:

healthier clients

Kids Xmas Project – for kids who otherwise would not have one

Details

Kids enrolled in case management with good retention are added to the roster to receive a gift
Population:
Youth
Care Continuum Stage:
Retention, Viral Load Suppression
Intervention Type:
Patient Focused
Duration:
annual for 1 month
Cost:
$
Type:
Other Lit
Inputs:
EMR, case manager, toys/clothes/gifts
Outputs:
Happy kids and parents, fulfilled staff, rapid word of mouth leading to greater engagement

Baby Shower – for poor women who otherwise would not have one

Details

Women who are pregnant (or who they find out are pregnant) are invited to have a baby shower at the clinic if they have had good retention in care

Population:
African American & Latina Women
Care Continuum Stage:
Retention, Viral Load Suppression
Intervention Type:
Patient Focused
Duration:
Second trimester of preg
Cost:
$
Type:
ShareLab, Other Lit
Inputs:
EMR, case manager, toys/clothes/gifts
Outputs:
Happy moms, better retention, MTCT prevention improved

Co-located Behavioral Health, Housing, and Treatment Services

Details

Engagement site has intensive colocated BH and CM servcies. Transition to other transitional living programs on graduation
Population:
Youth
Care Continuum Stage:
Retention, Viral Load Suppression
Intervention Type:
Health Systems
Duration:
6 Months
Cost:
$
Type:
Other Lit
Inputs:
EMR, case manager, counselors, housing/beds
Outputs:
Happier kids, more stable kids

Self-reported Adherence Assessment by Patients

Details

Self-reported ART adherence has consistently been associated with HIV-1 RNA levels. Although it commonly overestimates adherence, self-reported nonadherence has a high predictive value. Self-report is less strongly associated with treatment response than are EDM- or pharmacy-based measures, but relative ease of implementation further supports its use in clinical care. Careful attention must be paid to collecting self-report data in a manner that makes reasonable demands on memory. Therefore, questionnaires should inquire only about specific doses taken over a short time interval (for example, in the previous week or less) and about global measures of adherence over a somewhat longer time (for example, in the previous month).

Population:
Youth, Transgender Women, MSM of Color, African American & Latina Women
Care Continuum Stage:
Viral Load Suppression
Intervention Type:
Case Mgmt
Duration:
Ongoing
Cost:
$
Type:
IAPAC
Inputs:
Providers trained in patient self-reporting: Visual Analogue Scale (VAS) and Swiss HIV Cohort Study Adherence Questionnaire (SHCS-AQ).

Pharmacy Refill Data Review by Providers

Details

Many observational studies across the globe have demonstrated the validity of pharmacy refill data as an ART adherence measure, including medical records, claims data, and ad hoc pharmacy contact. Pharmacy measures are useful for as long a period as the refill records are maintained. The interval over which refill records can be used depends on the days’ supply (that is, the length of time the medication dispensed is intended to last).

Population:
Youth, Transgender Women, MSM of Color, African American & Latina Women
Care Continuum Stage:
Viral Load Suppression
Intervention Type:
Health Systems
Duration:
3-6 months
Cost:
$
Type:
IAPAC
Inputs:
Train providers, pharmacists, and quality managers / data specialists in pharmacy-based measures for adherence (time to refill defined adherence)

Switching to Once Daily Regimens

Details

Several studies have demonstrated successful switching to once-daily dosing for patients with suppressed virus on a multiply-dosed regimen. Often, studies are limited by small sample size, short follow-up, or changes in ART regimens accompanying the switch to a once-daily regimen, so factors including toxicity, tolerability, and related considerations may contribute to observed findings. Treatment history and prior ART resistance are particularly important considerations when switching regimens for treatment-experienced patients.

 

Population:

Youth, Transgender Women, MSM of Color, African American & Latina Women

Care Continuum Stage:

Viral Load Suppression

Intervention Type:

Patient Focused

Duration:

Ongoing

Cost:

$

Type:

IAPAC

Inputs:

Training for providers on the importance of prescribing the easiest regimens to take (one pill once daily)

Pill Reminder Devices

Details

An adherence benefit of dose-time reminder alarms has been reported. Strategies using cellular technology (short message service communication) have demonstrated improvement in adherence and HIV-1 RNA. Methods ranged from texting dosing reminders with or without requesting a response to texting weekly check-ins from the clinic with telephone follow-up for those requesting it. One study found better ART adherence was achieved with use of texting with expected reply (interactive) than simple 1-way reminders.

 

Population:

Youth, Transgender Women, MSM of Color, African American & Latina Women

Care Continuum Stage:

Viral Load Suppression

Intervention Type:

Patient Focused

Duration:

20 weeks

Cost:

$$

Type:

IAPAC

Inputs:

Train providers and patients on the use of reminder devices. Train providers to identify patient barriers to adherence for discussion and work around.

Specific Adherence Discussion Tools

Details

The available literature suggests that some tools may be more beneficial to patient adherence when combined with education or counseling. Seven studies (Appendix Table 2) evaluated a particular adherence tool (pill organizer, dose planner, reminder alarm device, or EDM) as distinguished from general one-on-one education and counseling. All but 1 demonstrated an effect on adherence, and 3 of the 6 that investigated effects on biological markers found significant positive effects. Three studies from the Netherlands and China that used EDMs with counseling about missed doses showed improvement in adherence, and 2 showed improvement in biological markers. A factorial-design RCT and an RCT from Kenya showed the inferiority of using a reminder device without counseling and suggested that tools may be most successful when offered as part of a comprehensive support package.

 

Population:

Youth, Transgender Women, MSM of Color, African American & Latina Women

Care Continuum Stage:

Viral Load Suppression

Intervention Type:

Capacity Building

Duration:

5 Months

Cost:

$

Type:

IAPAC

Inputs:

Weekly pill counting and counseling for patients on the importance of adherence. Medical information from other providers and external hospitals for comparison.

Group Education and Adherence Counsel

Details

The evidence base included 7 studies of group-based education and counseling programs targeting general clinic populations (Appendix Table 2). Although some studies have demonstrated significant improvements in ART adherence, HIV-1 RNA, or CD4 cell counts and 1 study demonstrated effects in specific subsets of participants, other studies showed no significant improvements in adherence. Notably, studies targeted diverse patient groups and used a wide range of interventions, so the evidence does not clearly converge to support one particular approach to offering group education and counseling. Characterizing these interventions as “group” interventions designates their main modality, but several interventions also used an individual component or support for group members.

 

Population:

Youth, Transgender Women, MSM of Color, African American & Latina Women

Care Continuum Stage:

Viral Load Suppression

Intervention Type:

Capacity Building

Duration:

1 Months

Cost:

$

Type:

IAPAC

Inputs:

Training of providers in provision of group adherence counsiling and peer support. Weekly sympton management groups for patients, Continuity and telephone counselnig picks up when the weekly groups end.

DAART for Patients with substance use disorders

Details

Four RCTs and 3 prospective cohort studies of DAART showed significant HIV-1 RNA or CD4 cell count improvements compared with self-administered therapy. Follow-up data from 1 trial, however, failed to demonstrate persistent effects on biological outcomes after DAART was discontinued.

Population:

Youth, Transgender Women, MSM of Color, African American & Latina Women

Care Continuum Stage:

Viral Load Suppression

Intervention Type:

Case Mgmt

Duration:

6 Months

Cost:

$$

Type:

IAPAC

Inputs:

Providers trained to provide DAART to non-suppressed patients 5 days a week. Mobile clinics are helpful, but not required.

Together, we can improve HIV/AIDS care.