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in care Campaign Webinar

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Title: in care Campaign Webinar


1
  • incare Campaign Webinar
  • August 14, 2012

2
Ground Rules for Webinar Participation
  • Actively participate and write your questions
    into the chat area during the presentation(s)
  • Do not put us on hold
  • Mute your line if you are not speaking (press 6,
    to unmute your line press 6)
  • Slides and other resources are available on our
    website at incareCampaign.org
  • All webinars are being recorded

3
Agenda
  • Welcome Introductions, 5min
  • Substance Abuse and Retention, 30min
  • The UCSF Story, 10min
  • Data Review and Discussion of Retention
    Strategies Collected Through the Campaign, 15min
  • Q A Session, 5min
  • Updates Reminders, 5min

4
Strategies to Improve Health Outcomes and
Treatment Retention in HIV Substance Users
  • Chinazo Cunningham, MD, MS
  • Albert Einstein College of Medicine
  • Montefiore Medical Center

5
Objectives
  • To review poor health outcomes observed in HIV
    substance users
  • To examine treatment strategies aimed at
    improving health outcomes and treatment retention
  • Outreach
  • Case management
  • Integration of HIV substance abuse treatment
  • Support groups
  • Patient navigation
  • Harm reduction framework

6
National estimates of drug-related ED visits
2004-2010
SAMHSA, OAS, DAWN
7
Poor outcomes in HIV substance users
  • Less access to care
  • Less retention in care
  • Less access to antiretroviral therapy (ART)
  • Worse adherence to ART
  • Slower decline in morbidity and mortality

Turner 2001 Kalichman 2002 Shapiro 1999
Celentano 1998 Strathdee 1998 Arnsten 2002
Tucker 2003 Golin 2002 Chesney 2000 Lucas
1999 Bouhnik 2002 Knowleton 2001 Chitwood 1999
2001 Cronquist 2001
8
Possible Reasons for Poor Health Outcomes
  • Substance users
  • - Lack of trust in health care system
  • - Competing needs (housing, food, benefits, etc.)
  • - Co-morbid illnesses (mental illness, Hepatitis
    C, TB)
  • - Intermittent incarceration
  • Providers
  • - Discrimination (substance use, race/ethnicity,
    poverty, HIV, homeless)
  • - Lack of education/training around substance use
  • System
  • Fragmented system addressing HIV substance
    abuse separately
  • Lack of support to address needs
  • Lack of flexibility to address needs
  • - Philosophical framework not conducive to drug
    users

9
Strategies to Improve Health Outcomes Treatment
Retention
  • Outreach
  • Case management
  • Integration of HIV substance abuse treatment
  • Support groups
  • Patient navigation
  • Harm reduction framework

10
Outreach
  • Project Bridge
  • Intense CM for HIV recently released prisoners
  • At 1 year, 82 were retained in HIV care
  • Yale Community Health Care Van
  • Mobile van visiting needle exchange sites
  • At 9 months, 77 with undetectable VL
  • Montefiore/CitiWide Program
  • Doctors with outreach team targeting HIV SRO
    hotel residents
  • After outreach, ? regular HIV care provider and
    taking ART
  • HRSA multi-site outreach initiative
  • ? of outreach visits associated with ? gap in
    HIV care

Rich 2001 Cunningham 2005 Altice 2003 Cabral
2007
11
Case Management
  • One of the most widely used services in HIV
    programs
  • Lack of uniform definition of CM
  • Studies examining CM
  • Several observational studies examine association
    between CM and HIV outcomes
  • CM assoc with ? HIV health care utilization
  • CM assoc with ? ART utilization and adherence
  • Few RCTs of CM with conflicting findings
  • CM with drug users non-users ? HIV care
    utilization
  • CM with drug users no change in HIV care
    utilization

Katz 2001 Cunningham 2007 Kushel 2006 Lo 2002
Messeri 2002 Harris 2003 Gardner 2005
Sorenson 2003
12
Integration of HIV SA Treatment
  • Benefits of integration
  • Easier to access/utilize services
  • SA treatment associated with positive HIV health
    outcomes
  • Single health care provider can closely monitor
    and reduce risk of drug-drug interactions
  • Likely more efficient and less costly
  • 2 ways of integration
  • HIV treatment into SA treatment
  • SA treatment into HIV treatment

Samet 2001
13
Integration of HIV treatment into SA treatment
  • Several studies examined integration of HIV
    treatment into methadone programs
  • Feasible
  • ? HIV care utilization
  • ? high risk behavior
  • ? opioid use
  • Improvement in education employment

Selwyn 1993 Keen 2003 Samet 2001 Fiellin 2001
Novick 1988, 1993 1994 Salsitz 2000
14
Integration of SA treatment into HIV treatment
  • Several studies examined buprenorphine treatment
    in HIV clinic
  • HRSA multi-site study
  • Feasible
  • ? opioid use
  • ? HIV care utilization
  • ? ART initiation
  • ? VL, ? CD4 count
  • International studies with consistent findings

OConnor 1998 1996 Vignau 2001 Fiellin 2002
2012 Sullivan 2006 Cunningham 2011 Altice
2012 Lucas 2010 Roux 2009
15
Support Groups
  • Support groups are widely accepted to address
    needs of drug users not addressed elsewhere
  • Few studies explicitly examine support groups
  • Attending support groups associated with
  • ? utilization ART
  • ? utilization HIV care services

Kang 2006 Cunningham 2008
16
Patient Navigation
  • Patient navigation emerging strategy to improve
    outcomes of marginalized HIV individuals
  • Few studies have examined patient navigation
  • Evaluation pooling data from 4 navigation-like
    programs
  • Blend of CM, care coordination, accompaniment to
    appts
  • Patients who received navigation (vs. no
    navigation)
  • ? HIV care utilization
  • ? VL

Bradford 2007
17
Harm Reduction
  • Principles
  • minimize harmful effects of drugs
  • some ways of using drugs are safer than others
  • success not necessarily cessation of drug use
  • non-judgmental, low threshold services
  • meet drug users where they are at

18
Harm Reduction
  • System approach
  • Flexibility in appointments
  • Missed and walk-in appointments
  • Wait times (in person, by phone)
  • Individual approach

19
The reality of caring for HIV substance users
  • Difficult and challenging work, yet can be very
    gratifying
  • Time and PATIENCE
  • Acknowledge own judgments, personal beliefs
  • TRUST is critical
  • Addressing the hidden agenda

20
Harm Reduction Treatment
  • Shift in traditional philosophy
  • Take several steps back and assess harms
  • Patient vs. provider agenda
  • Concrete actions
  • Prescriptions for syringes
  • Refer for case management
  • Redefine health, goals, and success/failure

21
Redefine Health
  • Health is NOT the absence of disease
  • Biopsychosocial model AND
  • drugs
  • housing
  • support system
  • finances
  • violence
  • criminal justice issues
  • Life priorities of HIV IDUs
  • Only 37 ranked HIV as most important
  • Top priorities housing, money, safety from
    violence

Mizuno 2003
22
Redefine Success
  • Success is NOT just
  • Undetectable viral load
  • Abstinence from drug use
  • Success also includes
  • Making it to appointments
  • Preventative care (PAP smears, OI prophylaxis,
    PPD)
  • Less, safer, more controlled drug use
  • Improvement in non-medical areas (housing,
    support system, criminal activity, etc.)

23
Why Adopt a Different Definition of Success?
  • Recognizes that success is not only about taking
    medications
  • Actively engages patients in health care and
    treatment
  • Values the health impacts of non-medical
    interventions (e.g. controlled drug use, stable
    housing, social supports)
  • Improves patients self-efficacy
  • Provides more opportunities for success

24
Conclusion
  • Reviewed poor outcomes in HIV substance users
  • Examined treatment strategies improve health
    outcomes and treatment retention
  • Outreach
  • Case management
  • Integration of HIV substance abuse treatment
  • Support groups
  • Patient navigation
  • Harm reduction framework

25
Support for Drug Users
  • Jacqueline Tulsky M.D.
  • Professor of Medicine, UCSF/SFGH
  • Positive Health Program
  • SF AETC

26
A Perspective on Addiction
  • Most of us walk unseeing through the world,
    unaware alike of its beauties, its wonders and
    the strange and sometimes terrible intensity of
    the lives being lived about us.
  • Rachel Carson (1907-1964)

27
Gaining some control
  • 34 yo man opioid addicted in jail
  • Frequent in and out, but during longer stay is
    approached by targeted testing project and found
    HIV, CD4 110.
  • Referred to methadone at release, but comes 3
    days later. No slot that day, told to come back
    next day
  • Disappears and arrested 3 weeks later.

28
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29
Continued -2
  • This time, HIV specialist in jail contacted us at
    the methadone program
  • Could we do intake while in jail and start
    patient on methadone?
  • Sheriff agreed, methadone agreed pt started
    while in jail on 30mg methadone

30
Continued -3
  • On release, pt came to methadone next day where
    methadone dose confirmed with jail and increased
    slowly
  • Referred to HIV primary care clinic in the
    methadone clinic who used Motivational
    Interviewing, social worker, drug counselor for
    ADAP, food, housing and support
  • Over 3 months, stabilized on methadone,
    identified cocaine as problem and wanted HIV
    treatment

31
Continued -4
  • Back in jail one more time, but continued
    methadone through their program. Start HIV ART
    medications.
  • Arranged inclusion in methadone DOT program for
    HIV meds at when released from jail.
  • 2 years later still struggles with cocaine, but
    no further jail stays, off street opioids,
    undetectable viral load.

32
Lessons Learned
  • Multi modality for true recovery in most complex
    pts (addiction/medical/social)
  • They cant do it alone, and neither can you
  • Motivational Interviewing was very useful in
    identifying (and creating) the patients
    priorities

33
Lessons Learned
  • Connections between and across programs and
    providers are underutilized and often the only
    barrier is the lack of imagination, communication
    and persistence

34
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35
Improvement Strategies Exercise Michael Hager,
MPH MA NQC Manager
36
incare Campaign National Data Snapshot
December June Data as of 07/31/2012 Dec Average (Patients) Dec Sites Feb Average (Patients) Feb Sites Apr Average (Patients) Apr Sites Jun Average (Patients) Jun Sites
Measure 1 Gap Measure 16.00 (122,473) 200 15.88 (123,949) 191 14.74 (125,056) 197 15.33 (106,837) 167
Measure 2 Visit Frequency Measure 64.40 (83,647) 151 65.47 (83,996) 147 61.91 (99,496) 170 63.63 (85,825) 154
Measure 3 New Patient Measure 57.23 (7,859) 190 58.19 (8,641) 183 58.72 (8,227) 188 59.79 (6,899) 163
Measure 4 Viral Suppression Measure 69.14 (132,539) 192 69.39 (143,625) 185 70.31 (148,134) 190 71.80 (130,584) 168
Coming Soon new analyses!
37
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38
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39
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40
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41
New Way to Submit Improvement Updates!
42
Improvement Update Discussion
  • Interventions Related to Substance Abuse
  • Patient navigation services
  • Van services to pick up and drop off patients
    where they are (can be non-HIV specific to reduce
    stigma)
  • Health van services to treat patients where they
    are
  • Flexible appointment times or same day
    appointments
  • Case consultation at provider meetings
  • Interdisciplinary teams
  • Target substance abusing patients issues for
    intensive reminders
  • Mention substance abusing patients in QM Plan
    make a program priority to address these needs

43
Improvement Update Discussion
  • B) Barriers Related to Substance Abuse
  • Health is often a lower priority for substance
    abusers
  • Can be difficult to communicate with patients
  • Very high no-show risk for on site appointments
  • Lots of supports are needed for these patients
  • Silo-ed funding streams for HIV and substance
    abuse treatment
  • Patients often missing eligibility determination
    paperwork
  • Intermittent incarceration makes finding patients
    challenging
  • Declining local resources for substance abuse
    treatment

44
Improvement Update Discussion
  • C) Lessons Learned Related to Substance Abuse
  • Screen, screen, screen for substance abuse and
    relapse
  • Providing transportation for patients OR doctors
    to improve patient access to care
  • Relying on community partnerships to bolster
    efforts
  • Relying on peers or someone relatable (navigator)
    to slowly link patients into consistent HIV care
  • Working with Local/Regional Departments of Health
    to create communities of learning and working
    groups
  • Tiered approach to outreach intensity based on
    demonstrated patient need

45
Time for Questions and Answers
46
MedScape Retention in HIV Care Series
  • Technical Working Group working on articles for a
    new Medscape Today News Series.
  • Bruce Agins, MD MPH, New York State Department of
    Health AIDS Institute Medical Director, wrote the
    opening article in the series
  • We recommend that you subscribe to HIV/AIDS
    MedPlus to be informed of new and exciting
    articles in this series!
  • http//www.medscape.com/viewarticle/768102

47
Partners incare
  • Partners incare Private Facebook Group is live!
  • Share tips, stories and strategies
  • Join a community of PLWH and those who love them
  • Email michael_at_nationalqualitycenter.org for more
    details
  • Partners incare website is live!
  • http//www.incarecampaign.net/index.cfm/77453
  • Join our mailing list (a list-serv version of the
    FB Group)

48
Upcoming Events and Deadlines
  • Campaign Office Hours Mondays Wednesdays
    4-5pm ET
  • Data Collection Submission Deadline
    August 1, 2012
  • Next Campaign Webinar Identifying Attrition Risk
    Patients To be announced
  • Next Meet-the-Author Webinar To be announced
  • Next Partners incare Webinar To be announced

49
Campaign Headquarters National Quality Center
(NQC) 90 Church Street, 13th floor New York, NY
10007 Phone 212-417-4730 incare_at_NationalQualityCen
ter.org incareCampaign.org youtube.com/incareCamp
aign
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