amber rossman, lmsw
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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
CDC ARTAS: ARTAS = Antiretroviral Treatment Access
Study Objective: link persons living with HIV to
medical care 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. 8th CROI 2001; AbstractS21, Gardner et al. AIDS 2005;19:423-431
Linkage to Care: CDC ARTAS
Findings: Compared to the standard of care group,
people in the ARTAS case management were more likely to have visited their HIV provider:– 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 careSource: Gardner et al. AIDS 2005;19:423-431
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(during ARTAS II study)Kansas City EMA
Historical HIV Positivity Rates
230 dx HIV+, 33% engaged in medical care
161 dx HIV+, 32% engaged in medical care
168 dx HIV+, 43% engaged medical care
167 dx HIV+, 60% engaged in medical care
193 dx HIV+, 68% engaged in medical care.
2001
Objective is to increase the engagement in care among newly diagnosed HIV+ individuals from 43% to 60-80% per year.
Source: Kansas City Health Department. Percentages rounded to the nearest whole.
2002
2003
2004
2005
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LTC: Eligibility Guidelines (adapted)
HIV+ newly diagnosed Not more than 2 HIV medical appointments
and never been on treatment (i.e. ARVs) Other HIV+ Considered:
– “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)
Now…
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Today LTC: From Referrals to Active Handoff
Positive Result
Outside Positive Result Referral: LTC paged before, at, or immediately after
result. LTCs are mobile and respond w/in 20 min, starts partner elicitation, coordinates
confrmatory result.
90 day LTC service, beyond "linked" date; support w/ partner notification; attends medical appointments; orients to HIV system, confirm HIV payer source; initiates
RW services; weekly case conference on progress toward care goals & graduation
90 Days & Engaged in Care = Active handoff:graduate to -> RW Case Manager or self management
General or Lost to Care Referral: LTC paged at contact w/ new-to-care client. Mobilizes to meet or contact, confirms HIV+, collaborates w/ D.I.S. and RW to confirm not
in care or services
Now…
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Results :Kansas City ARTAS II Project
94% linked to care* within 90 days
89% retained in care* at 6 months
199 referred, 91 participated
84% engaged in care* at 12 months
*“care” = attended appointment with a prescribing provider M.D., D.O., N.P. et al
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HIV Diagnosis
Page Linkage to Care – 20m response
Initial Response – meet with patient and diagnosing provider
Linkage to Care - 90 Day, intensive intervention of LTC Case Management (continuation w/ referral to CM services)
87% COMPLETE:
Graduate to long term HIV Case Management Services, continue engagement in care
5% NOT COMPLETE:
Lost to Care, Unable to Contact, Disengaged from Program; cont’d attempts re-engagement
8% COMPLETE:
Graduate to self-sufficiency, continued HIV care with own resources
84% of graduates still in care after 12 months.
Referring Sites
•Hospitals
•Health Depts (KC, Jx, Jo, Wy, MO)
•Publicly Funded Testing Sites
•Free Clinic (KCFHC)
•Med Offices/Other
•Self Referral
Intervention - Enrollment or Referrals
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Terms Important to Our LTC Program
“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)
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KC ARTAS Referral Sources
05
1015202530354045505560
Who's Referring?
KC Free Health Clinic
Truman Medical Center
KC Health Department
Other Medical/SocialServices
MO Dept of Health (NWDistrict)
Wyandotte Health Dept.
Self Referral
Referrals include ALL referrals screened by ALCMs regardless of eligibility form completed or enrollment status.
In the beginning (first 2 years)
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Recruiting, Retaining, Sustainability
Linkage to Care
Linkage to Care
816-990-2411
Contact Linkage to Care Coordinator for a confidential
appointment and to learn about treatment options – get lin
ked
to care. This program is confidential and free of charge
Your appointment is _______________ on _____________
Your A
ppoi
ntm
ent
Your A
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Administrative Set up for LTC
• Setting the Stage
• Preparing your System
• Accountability to LTC Standards
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Incoming (referrals in to LTC)
Linkage to Care
Linkage to Care
816-990-2411
Contact Linkage to Care Coordinator for a confidential
appointment and to learn about treatment options – get lin
ked
to care. This program is confidential and free of charge
Your appointment is _______________ on _____________
Your A
ppoi
ntm
ent
Your A
ppoi
ntm
ent
Your a
ppoi
ntm
ent i
s __
____
____
____
_ on
___
____
____
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Call S
arah
Goo
dwin
at 8
16-9
920-
2411
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www.k
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Setting the stage
• Commitment of System Supervisors
• Buy-in from Testing sites
• Integrating into procedures of multiple systems
• Developing tools for easy referral
Strong standards & results!
• 20 minute pager response
• Reinforce “active referrals”
• ALCM gives available at delivery of positive results
Preparing the system
• Training D.I.S./Public Health
• Communication: Reminders of Program / LTC staff presence at meetings
•Commitment to opt-out referrals
Pre-intervention recruitment
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Outgoing (referrals out of LTC)
Linkage to Care
Linkage to Care
816-990-2411
Contact Linkage to Care Coordinator for a confidential
appointment and to learn about treatment options – get lin
ked
to care. This program is confidential and free of charge
Your appointment is _______________ on _____________
Your A
ppoi
ntm
ent
Your A
ppoi
ntm
ent
Your a
ppoi
ntm
ent i
s __
____
____
____
_ on
___
____
____
__
Call S
arah
Goo
dwin
at 8
16-9
920-
2411
sch
edul
e yo
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appo
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ent.
www.k
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16-7
53-5
144
Setting the stage
• Commitment of Supervisors
• Buy-in from Case Management sites
• Integrating into CM system standards
Strong standards & results!
• Perform “intake” tasks/documentation
• Reinforce “active referrals” to long term CM system
• Continuum of care goals
Preparing the system
• Coaching Case Managers
• Clear, deliberate documentation
• LTC presence at system meetings
Post-intervention graduation
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Success Checklist: Implementing a Linkage to Care program
Existing, strong working relationships with 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)
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Checklist: Defining Your Program’s Linkage to Care
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
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Checklist: Active Referrals Activity
Client readiness to accept or act on a referralHighlight motivator – attuned to what client wants (motivational interviewing)
Preparing, using both didactic and experiential education
Visualizing goals and outcomes
Attending appointment with client
Active “hand off” and follow up
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Checklist: Active Referrals Tools
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
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LTC Staff: An Advanced Skill-Set
Previous experience in RW or hospital case management
Previous experience with homeless, SA, youth populations
STRONG expertise in HIV/AIDSBSW or MSW (strengths model experience
or understanding)(continued)
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LTC Staff: An Advanced Skill-Set
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
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Commitment to the LTC Process
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)
Using LTC short-term Case Management model (ARTAS adapted)
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Craw, J., Gardner, L (2010), Rossman, A., et al. Structural factors and Best Practicesin 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 EntryInto HIV Medical Care: Results of the Antiretroviral Treatment Access Study II(ARTAS II). JAIDS / J Acquir. Immune Defic Syndr 2008; 47:597-606.
Recommendations for Case Management Collaboration and Coordination inFederally Funded HIV/AIDS Programs. Federal Interagency HIV/AIDS CaseManagement Work Group: US Department
Further Reading:
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Questions:Questions:Amber Rossman, LMSW
www.kcfree.org
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