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in+care CampaignMeet the Author

August 6, 2013

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Welcome & Introductions Welcome & Introductions, 5min NYC Care Coordination Program, 30min Q & A Session, 20min Updates, Reminders & Evaluation, 5minIn the chat

room, Enter your: 1. name, 2. agency, 3. city/state, and 4. professional role at agency

Michael Hager, MPH MA NQC Manager,in+care Campaign ManagerNew York, NY

August 6, 2013

New York City Department of

Health and Mental Hygiene

Argus Community,

Inc.

Beth Israel Medical Center

PATIENT NAVIGATION:

A Network Perspective from the NYC HIV Care Coordination Program

PRESENTERSBeau J. Mitts, MPH

Director, Ryan White Technical Assistance NYC Department of Health and Mental Hygiene

Stephanie Chamberlin, MPH, MIA Evaluation Specialist, Research and Evaluation NYC Department of Health and Mental Hygiene

Maria Rodriguez, MPA Program Director, Care Coordination Argus Community, Inc.

Vanessa Haney, MFA Program Director, Care Coordination Beth Israel Medical Center

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DOHMH Care Coordination Program (CCP) Model Background Development Implementation

Argus Community ExperienceBeth Israel Medical Center ExperienceEvaluationTake-Home Messages

AGENDA

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BACKGROUND: The CCP ModelInf

ormati

on S

harin

g

Outreach

Assessment and Planning

Benefits and Services

Coordination

Navigation

Health Promotion

Treatment Adherence

Persons at high risk for suboptimal health care outcomes: newly diagnosed previously lost to care/never in care irregularly in care with recent adherence issues (e.g., viral rebound,

resistance)

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BACKGROUND: Target Population

Patient Navigators are key players on the Care team Most interaction with the clients Community Health Workers Bridge the gap between the clinic and the community Reflect the community they serve

Services provided (often in client’s home) include: Health promotion Accompaniment Treatment adherence Modified DOT

Caseloads Patient Navigators: 14 to 20 clients DOT Specialists: 7 clients

Required clinical supervision9

BACKGROUND: Patient Navigation

Models reviewed: Medical Home, Patient Navigation, Chronic Care, Community

Health WorkerPrevention and Access to Care and Treatment (PACT)

Project Partnership between Partners in Health (PIH) and Brigham

and Women’s Hospital in Boston, MARequests for Proposals (RFP)

2004: Treatment Adherence Program (TAP) 2006: Maintenance in Care (MIC) 2009: Care Coordination Program (CCP)

Bradford et al. HIV System Navigation: An Emerging Model to Improve HIV Care Access. AIDS Patient Care and STDs. 2007;21:S49–S58.

DEVELOPMENT: Research and Timeline

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Program Manual Version 4.0 released May 29, 2013

Each version evolved and adapted Recommended staffing plan Staff roles and responsibilities Guidance on program processes

Standardized forms Excel adherence calculator

eSHARE data reporting system

DEVELOPMENT: Tools

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Trainings 10-day Care Coordination training

National Development and Research Institutes (NDRI)

HIV 101, case management skills, program forms, etc.

Four-day Health Promotion Training of Trainers (TOT) PACT trainers along with NYC DOHMH

Project Officers Two trainers at each Care Coordination

program One-day trainings

Care Coordination Refresher Cultural Sensitivity Co-occurring Disorders (HIV, MH, and SA)

Technical Assistance NYC DOHMH Project Officers Bi-annual Provider Meetings Site visits and webinars

DEVELOPMENT: Training and TA

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28 agencies providing CCP in New York City (NYC) 16 hospital-based agencies 12 community-based agencies

Caseloads: Agency caseloads: 52 to 230 active clients

9 small programs 12 medium programs 7 large programs

~3,300 PLWH in the active portfolio caseload at any given time

4,986 unique PLWH served from March 2012 – February 2013

IMPLEMENTATION: Funded Programs

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IMPLEMENTATION: Client Demographics

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Grant Year (GY) 2012, Care Coordination Program (All Agencies),N = 4,986

AGE GROUP % GENDER %<25 6.9% Female 37.3%25-44 38.4% Male 60.9%45-64 50% Transgender 1.8%65+ 4.7%

RACE/ETHNICITY % BOROUGH %Hispanic 37.1% Manhattan 21.0%Black 52.6% Brooklyn 32.8%

Bronx 31.1%RISK %

MSM 28.3% INSURANCE %IDU 7.8% Public Insurance 80.2%Heterosexual 58.6% Uninsured 9.7%

760 East 160 th StreetBronx, NY 10456

718-401-5700

Maria Rodriguez, MPA

ARGUS COMMUNITY, INC.

www.arguscommunity.org

Founded in South Bronx in 1968 Began as substance abuse treatment provider

Expanded to address homelessness, AIDS/HIV, welfare reform

Received national and international recognition Programs replicated in Washington, DC; San

Francisco; Albany; Des Moines; and Belfast, Northern Ireland.

Program created in response to community needs and continues to respond to new emerging needs

BACKGROUND: Argus Community, Inc.

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ACCESS I Care ManagementACCESS II Care CoordinationArgus Career Training

InstituteArgus Client Money

ManagementArgus Community Re-Entry

InitiativeARU Outpatient CenterDWI Screening and

Assessment

Elizabeth L. Sturz Outpatient Center

Harbor House & Harbor House II

MEDAL ProgramPrometheus I and IIRESTART GED ProgramStriver HouseYouth Intervention and

Development

PROGRAMS: Argus Community, Inc.

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The 3 P’s In Care Coordination

Patients

Program StaffProviders

Support

andCoach

BecomeSelf-

SufficientLinkag

e To

Care

Maintain aStable Health Status

Home Based

NavigationCommunit

yCoordination

of Social

Services

TreatmentAdherence

Coordinationof

Medical Services

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Total Census as of June 2013: 125 Active Patients

Referred by 3 medical facilities, self-referrals, and/or our Health Home program.

Patients By Track Enrollment as of June 2013:

PATIENTS: Argus Community, Inc.

Track EnrollmentA (Quarterly, no ART) 5B (Quarterly, with ART) 18C1 (Monthly) 47C2 (Weekly) 36D (Daily Directly Observed Therapy) 19

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IMPLEMENTATION: Client Demographics

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GY 2012, Argus Community, N = 208

AGE GROUP All CCP Argus GENDER All CCP Argus

<25 6.9% 2.6% Female 37.3% 44.3%25-44 38.4% 26.3% Male 60.9% 55.6%45-64 50% 66.5% Transgender 1.8% 1.0%65+ 4.7% 4.6%

RACE/ETHNICITY

All CCP Argus BOROUGH All CCP Argus

Hispanic 37.1% 49.5% Manhattan 21.0% 9.3%Black 52.6% 45.4% Brooklyn 32.8% 2.1%

Bronx 31.1% 86.6%RISK All

CCP Argus

MSM 28.3% 16.1% INSURANCE All CCP Argus

IDU 7.8% 10.7%Public Insurance 80.2% 88.7%

Heterosexual 58.6% 62.4% Uninsured 9.7% 7.2%

ACCESS IICCP

STAFF

PROGRAM STAFF

Program Director

Data ManagerMedical Center Liaison

Care Coordinator

Patient Navigator

Patient Navigator

Patient Navigator

DOT Field Specialist

Care Coordinator

Patient Navigator

Patient Navigator

Patient Navigator

DOT Field Specialist 22

1. Montefiore Medical Group (MMG) – CICERO Program/Bronx Community Health Network 11 Clinics from the Montefiore Medical Group

CICERO Program

2. All Med and Rehabilitation of New York

3. The George and Eva Neil Barbee Family Health Center

4. The 151st Medical Center

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PROVIDERS

Argus ACCESS II CCP

Provider

Referral

Walk-in/

Word of

Mouth

Linkage to Care

Referrals

Health Home Referr

alsNew York City 311

THE MODEL: Referral Process

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1.Provider Website 2.Social Work Luncheon/Program

Presentations3.Clinical Rounds/Conferences4.CCP Patient Report for Providers5.Consumer Advisory Board Meetings

THE MODEL: Building Provider Buy-in

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THE MODEL: Services Provided

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Accompaniment Assistance with Entitlements and Benefits, Health Care,

Housing, and Social Services Care Plan Case Conference Directly Observed Therapy (DOT) Health Promotions Home Visits Intake/ Re-Assessment Outreach for Patient for Reengagement Treatment Adherence/Pill Box Count

Lisa was referred by her PCP on 7/15/11 Initial enrollment track was C2-weekly CD4 at the time of enrollment was 219 and VL was 29,492 She began DOT services on 11/16/2011. Her CD4 was 214 and

VL 30,494 CCP staff provided daily DOT services, weekly Health Promotion,

and case management until 3/23/2012 when patients lab reported her CD4 was 350 and VL undetectable.

On 9/17/2012 her CD4 was 375 and VL remained undetectable On 1/18/2013 her CD4 was 465 and VL remained undetectable. Her last lab report indicates that her CD4 is 397 and VL remains

undetectable.

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CASE STUDY: Lisa

10 Nathan D Perlman Pl, New York, NY 10003

212-420-2620

Vanessa Haney, MFA

BETH ISRAEL MEDICAL CENTER

PETER KRUEGER CENTER FOR

IMMUNOLOGICAL DISORDERS

www.wehealny.org/services/bi_aidsservices

1978-1979

Donna Mildvan, MD (Chief of Infectious Disease) notices enlarged lymph nodes in gay men studied for sexually transmitted intestinal infections

1980 Beth Israel sees its first AIDS patient, a 33-year old West German man

1981 Beth Israel’s Infectious Disease Clinic opens1988 BIMC is given Designated AIDS Center status

1989 Beth Israel’s Infectious Disease Clinic is renamed The Peter Krueger Center for Immunological Disorders

1993 The Robert Mapplethorpe Residential Treatment Facility is founded by the Robert Mapplethorpe Foundation

BIMC’S AIDS CENTER TIMELINE

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BACKGROUND: BIMC Inpatient

1,083 certified beds Emergency Department

Visits (Excluding Admissions) in 2011: 107,178

Admissions in 2011: 35,376

Methadone Maintenance Treatment Program Visits: 1,079,514

Ambulatory/Outpatient Visits: 371,083

The Peter Krueger Center Number of Unique Patients: 1,200 HIV Primary Healthcare Specialty Healthcare (Dermatology,

Gynecology, Pain Management) Dental Mental Health

(Psychiatry/Psychology/Counseling) Transgender Health Care Services Care Coordination Social Work and Case Management Harm Reduction: Project S.H.a.R.E. Nutrition

Since 2010, 298 people have been enrolled into BI’s CC Program

Total Census as of June 2013: 186 Active PatientsPatients By Track Enrollment as of June 2013:

PATIENTS: BIMC

Track EnrollmentA (Quarterly, no ART) 0B (Quarterly, with ART) 15C1 (Monthly) 102C2 (Weekly) 64D (Daily Directly Observed Therapy) 5

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IMPLEMENTATION: Client Demographics

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GY 2012, Beth Israel, N = 223

AGE GROUP All CCP

Beth Israel GENDER All CCP Beth

Israel<25 6.9% 3.1% Female 37.3% 41.3%

25-44 38.4% 21.1% Male 60.9% 56.1%

45-64 50% 70.0% Transgender 1.8% 2.7%

65+ 4.7% 5.8%

RACE/ETHNICITY

All CCP

Beth Israel BOROUGH All CCP Beth

IsraelHispanic 37.1% 43.5% Manhattan 21.0% 39.0%

Black 52.6% 44.8% Brooklyn 32.8% 30.9%

Bronx 31.1% 18.8%

RISK All CCP

Beth Israel

MSM 28.3% 21.5% INSURANCE All CCP Beth Israel

IDU 7.8% 29.1%Public Insurance 80.2% 89.2%

Heterosexual 58.6% 65.0% Uninsured 9.7% 1.8%

Peter Kruege

r Center: CCP

Providers

Inpatient Social Work

Project S.H.a.R.E

. Clinical Trials

Case Finding in EMR

THE MODEL: Referral Process

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CARE COORDINATION: Our Team!

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PROGRAM STAFF

Program Manager

Data Entry

Care Coordinator

Patient Navigator

Patient Navigator

Patient Navigator

Patient Navigator

Care Coordinator

Patient Navigator

Patient Navigator

Patient Navigator

Patient Navigator

Patient Navigator

Prior to En-rollment

QTR 1 (Jan-Mar 2011)

QTR 2 (Apr-Jun 2011)

QTR 3 (Jul-Sep 2011)

QTR 4 (Oct-Dec 2011)

0102030405060708090

47.92

72.9365.85

82.05

69.23

52.08

27.0734.15

17.95

30.77

CCP Quarterly Viral Loads: N=50Percent Undetectable Percent Detectable

EVALUATION: Outcomes

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Brenda is a 44 year-old woman test HIV positive in 2004 History of trauma, depression, and substance use

Enrolled in CCP April 2011 Viral Load of 100,000 copies and CD4 was 113

Throughout 2011 and 2012 Remained difficult to engage but kept on a weekly track Did not agree to pill boxing and self-reported 100% adherence

March 2013 Viral Load had risen to 659,892 copies and her CD4 dropped to 11

April 2013 Agrees to DOT during her PCP appointment

July 2013 Viral Load is <75 and her CD4 have risen to 43 Significant improvement in herpes lesions

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CASE STUDY: Brenda

NYC Department of Health and Mental Hygiene

Stephanie Chamberlin, MPH, MIA

CARE COORDINATION PROGRAM

EVALUATION

Cross-agency evaluation utilizing standard metrics, based on the well-defined CCP protocol

EVALUATION: Process and Outcomes

Process Outcomes

Barriers

Facilitators

Fidel

ity to

Pro

gram

M

odel

Quality Management

Cross-sectional (2010 – Present)

Pre- and Post-CCP Enrollment (2012-

Present)Short-Term

Long-Term39

Patient Navigators n = 350%

20%

40%

60%

80%

100%

0.220.490.781.22

1.99

2.67

Hours Worked per Day (7.37 Average )

Indirect Client ServicesDirect Client ServicesProgram Activi-tiesN/AAdministrativeBlank, Illegible, Missing

Background

MethodSample of six (6) Agencies

EVALUATION: Time And Effort Study

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Care PlanIntake and Reassessment

All Case ConferencesAll Accompaniment

DOT FieldAll Adherence Logs

Outreach for ReengagementAll Assistance w/ Activities

Health Promotion

Travel Time to/from Client Encounters

0 0.2 0.4 0.6 0.8 1 1.2 1.40.010.04

0.100.11

0.160.16

0.250.47

0.591.18

All Client Services (Direct and Indirect): Average Hours per Day

Patient Navigators n = 35

EVALUATION: Time And Effort Study

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EVALUATION: Engagement In Care

n/a

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EVALUATION: Viral Load Suppression

n/a

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NYC DOHMHCare CoordinationEvaluation Team

Patient Navigators do more than just navigation Health promotion, treatment adherence, modified DOT, etc.

Diverse Community Health Worker staff Cultural sensitivity and competency

Field safety training and protocol Means of communication

Clinical supervisionTechnical assistance

Provider meetings Peer to peer learning Best practices

Incorporate data collection and evaluation

TAKE HOME MESSAGES

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Beau J. Mitts, MPH NYC Department of Health and Mental Hygiene bmitts@health.nyc.gov

Stephanie Chamberlin, MPH, MIA NYC Department of Health and Mental Hygiene schamberlin@health.nyc.gov

Maria Rodriguez, MPA Argus Community, Inc. marodriguez@arguscommunity.org

Vanessa Haney, MFA Beth Israel Medical Center vhaney@chpnet.org

QUESTIONS

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To find Care Coordination tools online

visit:www.nyc.govSEARCH: Care Coordination

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Announcements

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Upcoming Webinars: ― Stay Tuned! Campaign staff is hard at work for you

Data Collection Submission Deadline: October 1, 2013

Improvement Update Submission Deadline: August 15, 2013

Upcoming Events and Deadlines

― October – Sex Work and Retention

― August – Transitory Populations and Retention

― September – Women and Retention

Upcoming Monthly Topics

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Campaign Headquarters:National Quality Center (NQC)90 Church Street, 13th floorNew York, NY 10007Phone 212-417-4730incare@NationalQualityCenter.org

incareCampaign.orgyoutube.com/incareCampaign