engaging hard-to-reach populations in hiv care: empowering the patient

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This Webinar was the last of a three-part series synthesizing some of the successful practices in engaging hard-to-reach populations from SPNS population-specific initiatives. Speakers included: Dr. Angulique Outlaw from Wayne State University and the SPNS Young Men who have Sex with Men Initiative, discussing motivational interviewing Dr. Nikki Cockern from Wayne State University and the SPNS Young Men who have Sex with Men Initiative, discussing enhanced case management Dr. Margaret Hargreaves from Mathematica and Principal Investigator for the Latino HIV Care Best Practices Study, discussing engagement and retention of Latinos in HIV care

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  • 1. Engaging Hard-to-Reach Populations: Empowering the Patient May 15, 2013

2. Agenda Introductionto SPNS Integrating HIV Innovative Practices (IHIP) project SarahCook-Raymond, Impact Marketing + Communications Presentationsfrom SPNS granteesAngulique Outlaw, Horizons Project Nikki Cockern, Horizons Project Margaret Hargreaves, Mathematica BriefQpost-Webinar questionnaire&A 3. IHIP Resources: Innovative Approaches to Engaging Hard-to-Reach Populations Living with HIV/AIDS into Care IHIP Tools on Engaging Hard-to-Reach Populations Training ManualCurriculumWebinar Series Outreach April 18; see archive recordingInreach May 1; archive recording to be up soon!Empowering the Patient - May 15 4. An Introduction to Motivational Interviewing (MI) Angulique Y. Outlaw, Ph.D. Assistant Professor Director of Prevention Services Wayne State University School of Medicine Horizons Project 5. Outline What Is MI? How Does MI Work? How Are We Using MI? 6. Why Is Change So Hard? Lack of motivation from within a person People are not motivated by nagging or fear Most people dont change for another person When pushed, people push back Ambivalence (pros and cons) Lack of confidence (self-efficacy) Lack of social support, role models Life gets in the way! 7. What Do We Do To Try To Make Other Change? Given them Insight if you can just make people see, then they will change Give them Knowledge if people just know enough, then they will change Give them Skills if you can just teach people how to change, then they will do it Give them Hell if you can just make people feel bad or afraid enough, they will change 8. What Is Motivational Interviewing (MI)? Evidenced based intervention to promote health behavior change *MI is Client-centered, Goal-oriented approach Focused on increasing intrinsic motivation for change by: Resolving ambivalence about different potential courses of action Increasing self-efficacy about change *Miller & Rollnick (2002, 2007) 9. What Is MI? A method of communication Not a specific session by session intervention Not a bag of tricks Good communication at a micro-level Making every word count Develop rapport, understand the clients view Elicit and reinforce any and every communication about behavior change 10. Advantages Of MI Client-centered intervention Can be performed by a variety of staff members Occurs in a natural setting Ambivalence is addressed 11. What Does The Conversation Look Like? Empathic and warm Listening and understanding Expressing optimism and hope Reinforcing specific strengths Emphasizing personal choice and responsibility Offering menu of options Discussing value-behavior incongruence 12. MI Elements MISpiritMI Methods (OARS)MIMIPrinciplesChange Talk 13. MI Principles Express Empathy Develop Discrepancy Roll with Resistance Support Self-Efficacy 14. The RULEs Of MI Resist the righting reflex Understand your clients motivation Listen to your client Empower your client 15. Spirit of MI Collaborative (vs. Coercive) Working jointly together Evocative (vs. Educational) Elicit motivation, perceptions, goals, and values Autonomy supportive (vs. Authoritative) Self-directing freedom (Choice) 16. MI Methods Open-Ended Questions Affirmations Reflective Listening Summaries 17. Change Talk Disadvantages of doing what you are doing Advantages of change Optimism about change Intention to change 18. Horizons Project Dedicated to providing HIV prevention services to at-risk youth and direct care services to youth living with HIV ages 13-24 Is the only comprehensive HIV/AIDS program in Michigan focusing on youth 19. Continuum Of Care Other Medical Sites Serving HIV+ YouthHIV+Horizons Community OutreachHorizons Field & Internet OutreachHorizons Peer AdvocacyC&T SitesHIV+Horizons C&T Horizons Case Finding: Agency/Field OutreachCommunity Agencies and ResourcesHorizons Clinical Care Team Primary Medical Care Medical Specialty Care Nursing Services Health Education Adherence Support Social Work Services Case Management Ongoing Advocacy Mentoring Consumer Involvement Therapeutic Activities Transportation Psychological Services Psychiatric Consultation Education and Training MI for Retention Prevention Services (MI and Group) 20. How We Use MI Single session (30 minutes) As part of field outreach to encourage HIV C&T Single session (30 minutes) At initial appointment or first return to care appointment focused on engagement and retention in care Focused on adherence to antiretroviral therapy (initiation and maintenance) Focused on risk reduction 21. MI Computer Applications *Motivational Enhancement System for Sexual Risk & Adherence MISTI (Sexual Risk)(Feasibility study) Single session face-to-face or computer delivered intervention MISTI-II (Sexual Risk) Two session computer delivered intervention (Baseline and 3 months) MESA (Adherence) Two session computer-delivered intervention (Baseline and 1 month) *adapted by Ondersma et. al 22. To Sum Up Remember MI Elements Spirit Collaboration, Evocation, & Autonomy Principles Express Empathy, Develop Discrepancy, Roll with Resistance, & Support Self-Efficacy OARS Open-Ended Questions, Affirmations, Reflective Listening, & Summaries 23. To Sum Up Remember MI Elements Change Talk Disadvantages of Staying the Same, Advantages of Change, Positive Things About Change, & Intention to Change 24. MI Resources Motivational Interviewing (2012, 2007, 2002) Miller and Rollnick Motivational Interviewing with Adolescents and Young Adults (2010) Naar-King & Suarez www.motivationalinterviewing.org 25. Thank You!! 26. Engaging & Retaining Youth in Care Engaging Hard To Reach Populations HRSA WebinarNikki Cockern, PhD Assistant Professor Clinical Care Manager Wayne State University School of Medicine Horizons Project May 2013 27. Issues of Adolescence Trust Often not ready to change, not motivated Lack of impulse control Rebel against prescriptive approaches educational, skills building, traditional counseling Physical Changes (thanks to puberty) Peak of peer involvement and peer norms Heightened experimentation 28. Whats Unique about Adolescents? Environment-vitally important Separation/individuation Identity formation as separate from authority figures Translating personal goals into behavior within a constrained environment Mood fluctuates Trying to figure out who they are and try different roles Communication skills are still developing 29. Horizons Project Dedicated to providing HIV prevention services to at-risk youth and direct care services to adolescents and young adults living with HIV (ages 13-24) Has continued to grow as the only comprehensive HIV/AIDS program in Michigan focusing on youth Wayne State University School of Medicine (WSU) and the Detroit Medical Center (DMC) serve as fiduciaries.30 30. Engagement Strategies One-stop shopping & multidisciplinary approach to HIV care, that is youth sensitive & culturally competent. Meeting youth where they are and focusing on building relationship Intensive Case Management Services Identification of needs (initial & ongoing) Development of comprehensive service plan, including strategies for implementation Coordination of care & services Mental Health/Psychosocial Services Client Advocacy Transportation Treatment Adherence Program Lost to Follow-Up (L2FU) Program Use of Multi-media tools 31. Horizons Project Enhancements Advocates assist youth in enrolling and remaining in care Rapid linkage into care Intake and medical appointments are provided within the first week of contact Youth often receive resources prior to their med visit Direct linkage & support to ancillary care services and resources Motivational Interviewing is offered Multi-modal contact to youth in preferred medium (i.e. phone, text, email, Facebook inboxes) Jam Sessions (support groups) Transportation to life critical services (DHS) Provide a link to advocacy services if youth do not want to enroll in medical care Actively Promote Consumer Involvement 32. Horizons Project Modifications Quickly establish and maintain rapport Highlight and vitally protect confidentiality, while treating each with dignity and respect Contact with youth is consistent, yet at varied times and amongst several staff Staff is available outside of typical working hours/days and can be reached via cell and email daily Patient advocacy is vital to keeping youth connected and meeting their needs Staff often accompany youth to other necessary medical and ancillary care appointments (i.e. DHS, colposcopy, Dental, GYN, etc.) Phone contacts for transportation to clinical and ancillary appointments, JAM sessions, other care related activities Decrease barriers to access services Increase frequency of medical clinics held, so more appointment slots are available (including separate day youth can come in for treatment) Reserved new patient and sick patient slots during each clinic session Combined mom/baby or family clinic sessions to decrease the frequency of visits parents have to keep Use of laptops in medical clinic in order to complete on-line applications for insurance and/or supplemental coverage programs Provide incentives for improved adherence i.e. keeping appointments, reducing drug use ,decreasing incidence of STIs, etc. (works with mental health team) Provide lost to follow-up outreach i.e. phone calls, letters, and home visits (MI) 33. L2FU Program Protocol MI @ point of contact & @ clinic appt.1. Maintain List Identify youth who missed clinic appt. & not able to reschedule5. Contact made w/ Client & clinic visit scheduled Or RepeatMI via phoneMI @ HV if contact made2. 1st month after missed clinic visit. Advocate attempts Contact via phone/text4. 3 month Home Vi

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