Disclosures

2. Lessons Learned from the Implementation of System-level Workforce Capacity Building for Integrating HIV Primary Care in Community Health Care Settings Initiative (Institute) • Mary Correa, J.R. De La Garza, Marisol Gonzalez, Ernesto Guevara, Alison O Jordan, Kimberly Koester • Representatives from Workforce Capacity Initiative Demonstration Sites and the Evaluation and Technical Assistance Center

3. Disclosures Presenter(s) has no financial interest to disclose. This continuing education activity is managed and accredited by AffinityCE/Professional Education Services Group in cooperation with HRSA and LRG. PESG, HRSA, LRG and all accrediting organization do not support or endorse any product or service mentioned in this activity. PESG, HRSA, and LRG staff as well as planners and reviewers have no relevant financial or nonfinancial interest to disclose. Commercial Support was not received for this activity.

4. Learning Objectives At the conclusion of this activity, the participant will be able to: To understand common challenges that may occur when implementing practice transformations, and to learn ways that these challenges can be overcome. To identify the best practices for successfully implementing practice transformations in a variety of settings (e.g., from large academic medical centers to smaller community health centers). To learn how practice transformations can be integrated into standard practice to ensure long term sustainability.

5. Obtaining CME/CE Credit If you would like to receive continuing education credit for this activity, please visit: http://ryanwhite.cds.pesgce.com

6. Funding Acknowledgment This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U90HA27388 and title "System level Workforce Capacity Building for Integrating HIV Primary Care in Community Health Care Settings" for grant amount $2,200,000 (0% financed through non-governmental sources). This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

7. HRSA/SPNS: System-level Workforce Capacity Building for Integrating HIV Primary Care in Community Health Care Settings Initiative

8. Workforce Initiative Overview In 2014, SPNS funded 15 sites in 7 states, and the District of Columbia as part of the Workforce Initiative demonstration project; UCSF served as the evaluation and technical center. Basic premise of the initiative: to address the reality that HIV care and treatment workforce is declining at the same time the demand for HIV care continues to grow.

9. Goals of SPNS Workforce Initiative • To enhance the capacity and readiness of funded organizations to adapt and re-align their workforce systems to improve the provision of quality care to people living with HIV • Support organizations to promote the design, implementation, and evaluation of system-level changes in staffing structures that improve health outcomes along the HIV care continuum

10. Implementation Lessons Learned Demonstration Sites: • Mary Correa, Brightpoint Health • J.R. De La Garza, Coastal Bend Wellness Foundation • Marisol Gonzalez The Ruth M. Rothstein CORE Center • Alison O. Jordon The NYC Health + Hospitals • Ernesto Guevara Special Health Resources for Texas Evaluation and Technical Assistance Center: • Kimberly A. Koester University of California San Francisco

11. Cross-Site Evaluation Qualitative Findings from the of the Implementation of Workforce-related Practice Transformations • Kimberly A. Koester, PhD • University of California, San Francisco: Evaluation and Technical Assistance Center

12. SPNS Workforce ETAC: Qualitative Evaluation Objectives • To characterize demonstration sites’ practice transformations. • To identify factors operating at institutional, clinical, provider, or patient levels that help facilitate or constitute barriers to transformation.

13. Methods • Key Informant Interviews • Semi-structured interviews conducted by telephone • Sample included essential PTM team members at each site e.g., PI, Project Director/Coordinator, other key stakeholders including PTM implementers *Patient interviews were part of a focused-study and were conducted in 3 sites during Spring 2016

14. Analysis • Verbatim transcripts coded by a primary & secondary coder. • We use Dedoose, an online program to facilitate the organization and management of our data set. • We analyzed all text associated with the co-occurrence of the “Implementation” and “Facilitators” and ”Implementation” and “Challenges” codes.

15. Participants • Total of 60 baseline interviews with participants across 15 sites • Project leaders n = 33 • Interventionists n = 16 • Stakeholders n = 11

16. Workforce Development Projects Span three distinct areas to address the imbalance in supply and demand: • Increase capacity of providers to treat PLWH and/or increase access to primary care providers for PLWH • Share the care – task shifting/sharing • Engage patients into routine care

17. Expand = 8 Share = 11 Engage = 8 *Site 15 has not completed baseline data collection and is not included in the following analysis

18. ‘Reach’ of Practice Transformation: Inside, Outside or Inside and Outside the HIV Clinic • “Take down the walls” transforming beyond the HIV clinic • Driven by workforce shortages and a desire to change the status quo in HIV care management • Training primary care providers to treat HIV or to treat primary care needs of PLWH and medical residents • Working “in a more integrated fashion” within our clinic • Driven by consensus that “it’s just where care is headed” -implicit sense that team-based care was becoming normative • Optimize efforts to work as a team, rather than working in isolation and performing duplicative tasks without an overview of patients’ health.

19. Why These Practice Transformations? • “Historically, our Part C program, has operated - for better or worse - in a very tight bubble or silo. So, if I am an HIV patient, I'm defined by my HIV diagnosis. And if I need my Pap, I don't go to one of our OB-GYNs - I have my Pap done by my HIV provider. If I am diabetic, I am not referred to our comprehensive diabetes education program - I work with the HIV department staff, who are all amazing and wonderful and very knowledgeable individuals. But there are so many more resources available within the organization, that historically our HIV patient has not been properly linked to. And so, in an effort to improve access to care and, obviously, improve health outcomes overall, we're trying to establish those partnerships with other departments within the organization.”

20. Assessing Implementation Difficulty • How hard is it to implement practice transformation? • What does it take to implement these changes? • “On a scale of 1-10, with 1 being very easy and 10 being very difficult, how would you say it’s been to launch the PTM at your facility?”

21. Ease of Implementation • Variation across key informants within sites when assigning a numeric value, but consistent articulation of similar barriers and facilitators • Using the numeric ratings in combination with a qualitative assessment of implementation ease, we concluded ease fell in the middle of the scale • Participants rated ease/difficulty of implementation as “Fair to Middling” • Very Easy Somewhat Easy Somewhat Difficult Very Difficult (n=3) (n=6) (n=4) (n=1)

22. What does it take to implement? • Sites reporting implementation ease had a high degree of buy-in, shared vision. • Participants reporting a common vision did not describe change as a hardship. • Sites who interpreted stakeholder ‘resistance’ as manifestations of vulnerabilities saw training opportunities • Sites capitalized on existing relationships among health care professionals in separate departments • Projects utilizing a ground-up approach to determine where transformation was needed have a strong foundation upon which to implement transformations.

23. Summary • Workforce development required pulling together numerous stakeholders, gaining buy-in and securing willingness to change • Practice transformation is essentially a process in developing relationships. • Establishing/strengthening relationships requires time and energy. • Practice transformation projects are iterative by nature and implementers must be flexible throughout the process • It is not necessary to have all the pieces in place or barriers addressed right at the start. Elements will change and evolve over the arc of the project. • Processes are dynamic & iterative –requires a particular mindset, demands flexibility.

24. Brightpoint Health Special Projects of National Significance (SPNS)Practice Transformation Model • Mary Correa, MS • Senior Director, Grant Programs • DarnelleDelva, MPH, Evaluator

25. Acknowledgements The SPNS project is/was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number and title for grant amount (H97HA27427, for Special Projects Of National Significance( SPNS),$300,000.00 and 0% financed with nongovernmental sources). This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.” Thank you Evaluation and Technical Assistance Center (ETAC), University of California, San Francisco team for providing technical support SPNS Initiative: Dr. Steve Bromer, Valerie B. Kirby, MPH and Emma Botta, MS, Stuart Gaffney and Mary Guzé, MPH. John Hannay, Public Health Analyst and Project Officer for strategically overseeing and monitoring SPNS PTM project at Brightpoint Health.

26. About Us: BrightpointHealth, a member of the Hudson River Healthcare Family, has effectively responded to the evolving health needs for New Yorkers. Over 25 years. Federally Qualified Health Center (FQHC) 23 Operational Sites located in all five boroughs Serving homeless population, mental illness, formerly incarcerated and low income families. PTM located at Inwood clinic provides primary care for 3,919 patients annually. PLWHA - 827 patients. (Reporting period Jan 1, 2017 to June 22, 2018) As of today, we are the second largest in the country. 2000 staff members, serving 225,000 patients in the Hudson Valley, NYC and Long Island regions.

27. Healthcare Services Provided: HIV Adult Day Treatment Health Homes Dental Services Medical Case Management Grant Funded Health/ Care Management Services Primary Care Behavioral Health Onsite Pharmacy 340B Drug Program

28. Practice Transformation Model (PTM) Intervention Identification of resources and workflow solutions to formalize communication structures. Promote Collaboration among Providers. Improve Care Coordination. Prevent High-risk HIV Positive patients from falling out of care.

29. PTM Objectives The following are the four key components of the Practice Transformation Model (PTM): • Standardized systems for identifying and engaging high-risk HIV-positive patients, including the development of a patient registrythat stratifies HIV-positive patients based on level of risk. • Formalized communication among primary care and behavioral health providers to establish daily huddles within the primary care team and monthly HIV case conferences between a representative from the primary care and behavioral health team. • Enhanced Health Information Technology (HIT) Infrastructure that created a more streamlined process for providers to arrange referrals internally, as well as a cross-provider care plan for all HIV-positive patients. • Client self-management program established to educate and empower patients to take a more active role in managing their health and to mitigate barriers to treatment adherence.

30. Practice Transformation ModelImplementation Processes Standardized systems for identifying and engaging high-risk HIV-positive patients, including the development of a patient registry that stratifies HIV-positive patients based on level of risk. • The patient registries identified clients with three consecutive months of unsuppressed viral loads and those patients medically unstable as defined by clients with multiple co-morbidities and who have upcoming Primary Care (PC) and Behavioral Health (BH) appointments. • The patient registries also allowed the Registered Nurse, Patient Navigator and Peer Educators (PT) to flag patient charts on appointment dates, such that the patient can be referred to the team for engagement and intervention. • PT facilitated warm-hand offs to engage clients that were typically lost to care.

31. Practice Transformation ModelImplementation Processes Formalized communication among primary care and behavioral health providers to establish daily huddles within the primary care team and monthly HIV case conferences between a representative from the primary care and behavioral health team. • Retrospective huddles were a better mode to conducting pre-visit planning. • Operational changes to the Inwood PC clinic morning meeting schedule, such that huddles, case-conferences and training times were carved into the provider and staff schedules. • The use of Plan Do Study Act cycles (PDSAs)

32. Practice Transformation ModelImplementation Processes Enhanced Health Information Technology (HIT) Infrastructure that created a more streamlined process for providers to arrange referrals internally, as well as a cross-provider care plan for all HIV-positive patients. • To maintain communication, PT sticky notes, telephone encounters, upload client care plans and case conferencing notes were implemented, as methods to care coordinate and share important patient clinical information.

33. PTM Integration Timeline:

34. Sample Training Model

35. Practice Transformation ModelLessons Learned Client self-management program established to educate and empower patients to take a more active role in managing their health and to mitigate barriers to treatment adherence. • Results from the pre and post assessments showed participant improvement with regards to general health, confidence doing things, cognitive symptom management and use of medical care. • The peer led groups were effective in the HIV treatment cascade as it promotes self-efficacy, health literacy, motivation and shared experiences. • PLWHA peers play an especially important role in a patient’s multidisciplinary care team, as medication-adherent role models with lived shared experience.

36. PTM- Lessons Learned The formulated self-management workshop incorporated well received aspects such as:  • Action planning activities • Shorter Group Sessions (clinic setting) • Comprehensive group materials to facilitate activities that discuss barriers for treatment adherence i.e. • Problem-solving • Symptom cycle • Decision making • Purpose of medication usage

37. PTM- Lessons Learned • Early communication with ancillary staff highlighted opportunities for improvement in patient flow. • Staff training included that the proper documentation was entered in eCW by the call center to facilitate efficient communication between clinic staff and patients at the time of visit. The use of Plan Do Study Act cycles (PDSAs) to attain staff buy-in PTM. • Retrospective huddles were a better mode to conducting pre-visit planning. • PLWHA peers play an especially important role in a patient’s multidisciplinary care team, as medication-adherent role models living with a shared experience. • The formulated self-management workshop incorporated well received aspects of the PSMP and WHAM workshops and similar peer groups.

38. PTM- Lessons Learned • Incorporate additional groups for patients with multiple comorbidities within clinic setting. • Develop organizational capacity for Direct Observation Therapy (DOT.) • Continue with an integrated model of care to address social determinants of health. • Create an agency-wide culture around ending the AIDS Epidemic with ongoing patient-centered initiatives.

39. Brightpoint Health . Thank you!

48. https://nrg.e-compas.com/pr/