using surveillance to link to care: effective implementation ... hiv conf...surveillance- based...

2016 Lake County Health Department and Community Health Center

Using Surveillance to Link to Care: Effective Implementation of Surveillance Based Services

Valerie Johansen, MPH

Sara Zamor, MPH

Lake County Health Department & Community Health Center

October 2016

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Prevention Services

Learning Objectives

All participants will be able to:

• Identify and develop new strategies for conducting Surveillance Based Activities.

• Understand ways to build relationships with individuals and community partners to successfully link and retain individuals in care.

• Recognize ways to maximize strengths and resources in their own agencies to increase reengagement and linkage to care for challenging populations.

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Prevention Services


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703,462 residents in Lake

County

Prevention Services


Federally Qualified Health Center & Local Health Department ‒ Provides comprehensive, coordinated, and continuous care for

patients who receive primary care through the Community Health Centers – 7 Clinical Locations

‒ Mental Health and Substance Abuse services

‒ Responding to the functions of a local health department: assessment, assurance, and policy development

Two Governing Bodies ‒ Community Health Center Governing Council

‒ Board of Health

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Prevention Services

STI Program STI Program bridges the divide between Prevention and Care by conducting activities such as:

‒ Counseling and Testing for STI, HIV, and HCV

‒ STI treatments

‒ Surveillance for Chlamydia, Gonorrhea, Syphilis, HCV & HIV

‒ Linkage to Care/Early Intervention Services

‒ Outreach/Data to Care/Surveillance Based Services

‒ PrEP/PEP Clinics & Navigation

‒ Medical Benefits Coordination & Navigation

‒ Medication Adherence and Risk Reduction Counseling in Ryan White Ambulatory Clinic

‒ QI for both Prevention and Care

‒ Social Media Outreach/Marketing

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Prevention Services

Surveillance- Based Services (SBS) Model

Bridges the gap between Prevention and Care

‒ Seeks out those who are newly diagnosed or those who have fallen

out of care

‒ Links individuals to services (not just medical care)

‒ Reduces the rate of HIV transmission

‒ Improves the Quality of Life for People Living with HIV

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Prevention Services

Lake County Health Department SBS Model

Our Philosophy:

Focusing on the individual in need rather than our roles, titles or job descriptions.

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100%

[VALUE]%

[VALUE]% [VALUE]%

[VALUE]%

% o

f P

eop

le

HIV Cascade *Bars are Percentages of Total # of People who are HIV+

HIV Care Continuum for Lake County 2015

HIV+ (a)

Diagnosed (b)

Linked to Care (c)

Prescribed ARTs (d)

Virally Suppressed (e)

972

848

Prevention Services


Utilizes Prevention experts in a Community Health Center setting to deliver the intervention

Cross-trained, Bilingual Staff

‒ DIS Workers

‒ EIS/Linkage Workers

‒ DASA QHEIC Certified Counselors

‒ IDPH Certified STI & HIV Counselors

‒ Medication Adherence Counselors

‒ Surveillance Staff

‒ Medical Benefits Navigators

‒ PrEP/PEP Navigators

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Prevention Services


Surveillance Based Services Process

1. Acknowledgement of Cases

2. Weekly “Cascade” Meetings

3. Case Disposition Completed

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Prevention Services

Cascade Meeting

Who Is There

‒ STI Program Staff

‒ Ryan White Medical Case Managers

What Is Discussed

‒ New SBS cases

‒ EIS/Linkage Clients

‒ New Syphilis and/or HIV+ Clients

‒ Partners of Syphilis and/or HIV+ Individuals

‒ Case Management Clients

‒ PrEP Clients

‒ Client Viral Load Suppression Data

‒ Retention Data

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Prevention Services

Cascade Meeting • Assignment of new cases to staff

• Review Current Caseloads

‒ SBS

‒ EIS/Linkage

‒ PrEP

• Review monthly viral load and gap in medical visit data

• Reassignment of cases based on staff strengths and/or relationship with clients

• Determine field visits – weekly

• Utilize the “checklist”

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Prevention Services

Cascade Meeting • The “Checklist” was developed to:

‒ Ensure consistency and thoroughness for each case/client investigated

‒ Ensure completeness of investigation

‒ Document work completed

‒ Track communication between STI Program and client (i.e. returned letters/returned calls)

‒ Capture information for required fields in PROVIDE

‒ Allow for quicker closure of case/client

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Prevention Services

Lake County Health Department SBS Model Inventory of Available Resources

• In House

‒ INEDDS

‒ Medi

‒ Electronic Medical Record

• Community/Agency Partners

‒ Pharmacies

‒ Veterans Affairs Hospital

‒ Military Services

‒ Substance Abuse Treatment Programs

‒ County Jail

‒ IDPH STI and HIV Section

‒ Local Hospitals

‒ Private Providers

‒ County/City Clerk

‒ Housing Programs/Homeless Shelters

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Prevention Services

Lake County Health Department SBS Model Useful Websites/Apps

‒ Advanced Background Check

‒ PIPL

‒ White Pages Reverse Lookup

‒ Zillow

‒ Google Maps

‒ Social Media

Facebook, Adam for Adam, GRINDR, TINDER, Mobile Patrol, etc.…

‒ Illinois/Wisconsin Department of Corrections

‒ County Corrections

‒ Google

Search for Obituaries, Professions, Other Contact Information

‒ Tax Assessor

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Next Steps…

Investigative Procedures

1. Phone calls

2. Letters

3. Field visits

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Prevention Services


Phone Calls

‒ Never mention HIV, right?

‒ Call Unblocked

‒ Leave a general message

Scenarios

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Prevention Services


Letters

‒ Agency Letterhead Only

‒ Give direct-line phone number

‒ Use Code Name

‒ Multiple Languages

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Prevention Services


Field Visits

‒ In Pairs

‒ County/Company Car

‒ Ask Questions

‒ Various Locations

Scenarios

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Prevention Services

Lake County Health Department SBS Model Additional Strategies for Networking

‒ Pharmacies

‒ Private Providers

‒ Local Hospitals

Emergency Departments

Case Managers

Grand Rounds

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Prevention Services


‒ Ryan White Case Management

‒ Early Intervention Services

‒ Dental Services

‒ Mental Health Services

‒ Medication Adherence Counseling

‒ Availability and Access to English, Spanish & LGBTQ Support Groups

‒ ACA, Medicare C & D and other Insurance Enrollments

‒ ADAP/PAP

‒ Pharmaceutical Patient Assistance Programs

‒ Partner Notification and Testing

‒ PrEP/PEP

‒ Housing Services

‒ Health Education/Literacy

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It’s More Than Just Medical… SBS activities have afforded the STI Program to offer not just Linkage to Care services to people living with HIV

Prevention Services

Lake County Health Department SBS Model Outcomes

Oh, do we have stories!

‒ Sensitive professions

‒ Phone calls from out of the country

‒ Individuals with aliases

‒ Individuals with stolen identities

‒ Immigration

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Lake County Health Department SBS Model Outcomes

Tied into our Program Key Performance Indicators and our Agency Strategic Plan

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Lake County Health Department SBS Model Successes

In 2015:

• 263 Services Provided

• 185 Unique Individuals Served

• 48 Linked/Relinked to Care

• 181 Offered/Accepted Partner Services

• 25 Risk Reduction Counseling Sessions Conducted

• 3 Found to be Deceased

• 21 Found to be Out of Jurisdiction

• 4 Found to be Negative

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Prevention Services

Lake County Health Department SBS Model Challenges

What isn’t a Challenge?

‒ Stigma

‒ Staff time

‒ Funding

‒ Out of date/incomplete information

‒ Utilizing social media

‒ Unresponsive Patients

‒ Being perceived as “Big Brother”

‒ Balancing public health outcomes and patient health with patient privacy and patient self determination

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Prevention Services

Lake County Health Department SBS Model Recommendations

Maximizing Limited Resources to Maximize Outcomes

‒ Stay client-centered: keep client needs first

‒ Partner with surveillance staff to introduce SBS workers to private providers and hospitals

‒ Make Friends

‒ Integrate Surveillance and Data to Care as much as possible

‒ Integrated Data Collection System

Go Beyond Integrated Planning to Integrated Working

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Prevention Services

Lake County Health Department SBS Model Recommendations

• Integrated Database

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Conclusion

What Is Your Experience?

• Successes

• Interesting Stories

• Challenges

• Different Approaches

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Prevention Services

Thank you!

• Sara Zamor, MPH STI Program Coordinator

• Valerie Johansen, MPH Community Health Specialist

Lake County Health Department

STI Program

2400 Belvidere Rd

Room 1132

Waukegan, IL 60085

847.377.8450

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3010 Grand Avenue Waukegan, Illinois 60085

847.377.8000 phone

http://www.health.lakecountyil.gov

2016 Lake County Health Department

using surveillance to link to care: effective implementation ... hiv conf...surveillance- based...

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