homeless hiv health, outreach. and mobile engagement
TRANSCRIPT
Homeless HIV Health, Outreach and Mobile Engagement (HHOME)
Building a Medical Home for Multiply Diagnosed HIV Positive Homeless Populations Initiative
Deborah Borne, MD-MSW San Francisco Department
of Public Health
Miguel Ibarra, MPH San Francisco Community
Health Center
August 15, 2018
Disclaimer
This project was supported by the Health Resourcesand Services Administration (HRSA) of the U.S.Department of Health and Human Services (HHS)under grant number H97HA24957, SPNS SystemsLinkages and Access to Care Initiative, awarded at$750,000 over five years, with 0% non-governmentalsources used to finance the project. This informationor content and conclusions are those of the authorand should not be construed as the official positionor policy of, nor should any endorsements beinferred by HRSA, HHS or the U.S. Government.
Presentation Outline
● Back Ground Data for SF● HHOME Intervention: System, Program, and Client ● Lessons learned: Challenges and What worked● Sustainability – “Spin OFFS”
Homelessness in San Francisco 16/17
Homeless Homeless> 10 Years
TAY18-24 Women Age 60+
Top1-5%High
Utilizers
TotalNumber 11,239 3,699 790 2,717 1,622 1,351
Percent HIV
5.2%(584)
8.6%(318)
1.0%(8)
3.3%(89)
4.4%(72)
7.7%(104)
SF DPH FY 16-17 Coordinated Case Management System (CCMS) Homeless Client DataIndividuals who have ‘touched’ system in FY 16-17
The HHOME Intervention The System, Program, and Client Experience
System Change: Partners in Health
HHOMETeam
SFDPH Primary CareClinics
Housing and Urban Health
Direct access to Housing &
Respite
SF General HospitalPHAST
& Social Service
Homeless Outreach
Team/Placement
Project Homeless Connect
HIV Prevention: LINCS
SF Community HealthDrop -In
Forensic AIDS Project(Jail )
Levels of Support for PLWHA Experiencing Homelessness
• Homeless: Shelter and Housing– PHAST– Clinic-based social work
• Navigation– LINCS-CHW– COE-Ryan White Center of Excellence
• Case Management and Behavioral Health Care– Homeless Outreach Team– Intensive Case Management
• Mobile Medial– HHome
Engage in Primary Care:
Undetectable Viral Load!
Acuity and Chronicity Assessment
● Acuity scale is used to asses: o Current severity of the cliento Needs and chronicity of each client
● Domainso Ability to:
Engage in primary care Adhere to medication regimen Achieve, adjust to and maintain
housing Identify basic needs Navigate health and supportive services Engage in mental health treatment Impact of substance use and level of
recovery
SF HIV Care Management Continuum
Levels Of Primary Care for People Living with HIV and Experiencing Homelessness
The Program InterventionLeveraging Staff, Resources, and Cultures
HHOME Team: Program Design
SF Homeless Outreach (Mobile Care Culture)
● Shelter beds/Stabilization Rooms
● Permanent Housing
SF DPH Medical(Health Care for the Homeless Culture: One stop for Medical, Addiction Medicine, Mental Health Tx)
● Medical Clinic
● Medicine/Supplies
● Insurance Support
SF Community Health Center (Structure to Complexity)
● Drop in Clinic
● Drop in Center
Transitions (Community Based Culture)
● Placement
● Stabilization Rooms
HHOME Target Population: The ‘Hardest’ To Serve
● PLWHA not currently engaged in HIV treatment or failing the current level of care, with: o Detectable Viral Loado CD4 < 200
● Active substance abuse disorder● Diagnosed with severe mental Illness, or mental health
condition impairing functioning● Experiencing Homelessness● HIV-positive pregnant women● HIV-negative partner of HIV-positive individual● Partner meets HHOME criteria and needs PrEP● Transitional Age Youth (TAY), ages 18-25 and young
adults ages 25–30 aging out of TAY● Newly diagnosed with HIV ● Eminent risk of eviction
Some Results
79%
11.5%
83.6%
70.5%
6.6%
66.0%
9.4%
62.3%
12.3%
0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%
100.0%
Achieved viralsuppression
Deceased PermanentlyHoused
Discharged Lost to follow-up
Study, N=61 Total, N = 106HHOME Study Results 2017
Successes, Challenges, and Sustainability
Program Challenges
● Staff retention and turn-over o programmatic and city wide
● Lack of support available for newly housed individuals● Not enough Peer Navigation or RN time● Data Issues:
o Referral process is not centralized nor computerizedo We have different data systems
● Applying “QI” principles to a moving target is tricky● Maintaining calm focus in the midst of chaos
o “If we weren’t meditating before this, we certainly meditate now.” -Janell
● Addressing short term goals and long term goals simultaneously
System Challenges
● City-wide reorganization, affecting homeless health care and service accesso Political environment constantly changing
● Lack of support available for newly housed individuals● Not enough stabilization or supportive housing ● Discharging clients from program is difficult:
o No permanent/long-term care equivalento No palliative care for substance userso High risk of eviction & disengagemento Lack of trauma informed programs and providers
What Works?!
● Multi dimensional care:o Trauma informedo Client centered o System supported - system-wide coordination
● Flexible treatment planso “If they want pills, they get pills; if they want hugs, then they
get hugs.” —Deb Borne● Starting treatment anywhere, anytime, especially points of
transition● Integrated team-based navigation ● Community pharmacy● Support of lead agencies
Unexpected Successes and Sustainability
● City is supporting the ongoing funding for the programo Using Ryan White and general Fund dollarso Plan to use some state care coordination funding (Health homes
and whole person care) ● System-Wide Coordination
o Creation of the SF HIV Care Coordination Task Force System-wide referrals and linkages for PLWHA that are timely
and appropriate● Championing palliative care and advanced care planning● Recognized as a leader in trauma-informed medical care!
o Training faculty, medical students, residents, and fellows
HHOME Spin-Offs
● New Getting to Zero intensive case management programs● HHOME Life Skills
o Peer led program designed to retain PLWHA in housing● Encampment Health
o Low barrier PrEP, STI testing, and HIV testing and rapid treatment for encampment communities in SF
● Pregnant women mobile care● Social determinants of health consult
o Social medicine
HHOME Partnerships
● Safety net medical clinics● Medical and psychiatric emergency rooms and inpatient
hospitals● Surveillance and linkage organizations● SF county jail health program● HIVE – services for pregnant women living with HIV/AIDS
and/or discordant couples ● Project Open Hand – nutritional services and meal delivery for
people living with disabilities and/or chronic illnesses
The HHOME Model proves the hypothesis that systems fail, not the patient
A HHOME clients’ success comes from their resiliency coupled with pooling resources, integrating care between agencies, and
clearly defining and addressing system gaps
SustainabilityResources
● National Healthcare for the Homeless: https://www.nhchc.org/● SAMHSA: Homeless Programs Resources● Matthew Bennet: https://connectingparadigms.org/● San Francisco HIV Epidemiology Report:
https://www.sfdph.org/dph/comupg/oprograms/HIVepiSec/HIVepiSecReports.asp● San Francisco Point in Time Homeless Count: Report● Getting to Zero Initiative: https://www.gettingtozerosf.org/
o Retention and Re-engagement: Retention Committeeo HIV Care Options: Resourceso HIV Navigation Options: Materials
● SFDPH Population Health-Disease Prevention and Control: https://www.sfcdcp.org/● San Francisco Community Health Center: http://apiwellness.org/
SustainabilityContact Information
Deborah Borne, MD-MSWSan Francisco Department of Public Health
Miguel Ibarra, MPHSan Francisco Community Health Center