Engaging Hard-to-Reach Populations: Empowering the Patient

1. Engaging Hard-to-Reach Populations: Empowering the Patient May 15, 2013

2. Agenda • Introduction to SPNS Integrating HIV Innovative Practices (IHIP) project • Sarah Cook-Raymond, Impact Marketing + Communications • Presentations from SPNS grantees • Angulique Outlaw, Horizons Project • Nikki Cockern, Horizons Project • Margaret Hargreaves, Mathematica • Brief post-Webinar questionnaire • Q & A

3. IHIP Resources onTARGET Center Websitewww.careacttarget.org/ihip

4. IHIP Resources:Innovative Approaches to Engaging Hard-to-Reach Populations Living with HIV/AIDS into Care • IHIP Tools on Engaging Hard-to-Reach Populations • Training Manual • Curriculum • Webinar Series • Outreach – April 18; see archive recording • Inreach – May 1; archive recording to be up soon! • Empowering the Patient - May 15

5. An Introduction to Motivational Interviewing (MI) Angulique Y. Outlaw, Ph.D. Assistant Professor Director of Prevention Services Wayne State University School of Medicine Horizons Project

6. Outline • What Is MI? • How Does MI Work? • How Are We Using MI?

7. Why Is Change So Hard? • Lack of motivation from within a person • People are not motivated by nagging or fear • Most people don’t change for another person • When pushed, people push back • Ambivalence (pros and cons) • Lack of confidence (self-efficacy) • Lack of social support, role models • Life gets in the way!

8. What Do We Do To Try To Make Other Change? • Given them Insight – if you can just make people see, then they will change • Give them Knowledge – if people just know enough, then they will change • Give them Skills – if you can just teach people how to change, then they will do it • Give them Hell – if you can just make people feel bad or afraid enough, they will change

9. What Is Motivational Interviewing (MI)? • Evidenced based intervention to promote health behavior change • *MI is • Client-centered, • Goal-oriented approach • Focused on increasing intrinsic motivation for change by: • Resolving ambivalence about different potential courses of action • Increasing self-efficacy about change *Miller & Rollnick (2002, 2007)

10. What Is MI? • A method of communication • Not a specific session by session intervention • Not a bag of tricks • Good communication at a micro-level • Making every word count • Develop rapport, understand the client’s view • Elicit and reinforce any and every communication about behavior change

11. Advantages Of MI • Client-centered intervention • Can be performed by a variety of staff members • Occurs in a natural setting • Ambivalence is addressed

12. What Does The Conversation Look Like? Empathic and warm Listening and understanding Expressing optimism and hope Reinforcing specific strengths Emphasizing personal choice and responsibility Offering menu of options Discussing value-behavior incongruence

13. MI Elements MISpirit Change Talk MI MI Methods (OARS) MI Principles

14. MI Principles • Express Empathy • Develop Discrepancy • Roll with Resistance • Support Self-Efficacy

15. The “RULE”s Of MI • Resist the righting reflex • Understand your client’s motivation • Listen to your client • Empower your client

16. Spirit of MI • Collaborative (vs. Coercive) • Working jointly together • Evocative (vs. Educational) • Elicit motivation, perceptions, goals, and values • Autonomy supportive (vs. Authoritative) • Self-directing freedom (Choice)

17. MI Methods • Open-Ended Questions • Affirmations • Reflective Listening • Summaries

18. Change Talk • Disadvantages of doing what you are doing • Advantages of change • Optimism about change • Intention to change

19. Horizons Project • Dedicated to providing HIV prevention services to at-risk youth and direct care services to youth living with HIV ages 13-24 • Is the only comprehensive HIV/AIDS program in Michigan focusing on youth

20. Other Medical Sites Serving HIV+ Youth Primary Medical Care Medical Specialty Care Nursing Services Health Education Adherence Support Social Work Services Case Management Ongoing Advocacy Mentoring Consumer Involvement Therapeutic Activities Transportation Psychological Services Psychiatric Consultation Education and Training MI for Retention Prevention Services (MI and Group) Horizons Clinical Care Team Horizons Peer Advocacy Horizons Community Outreach C&T Sites Horizons Field & Internet Outreach Horizons C&T Horizons Case Finding: Agency/Field Outreach Community Agencies and Resources Continuum Of Care HIV+ HIV+

21. How We Use MI • Single session (30 minutes) • As part of field outreach to encourage HIV C&T • Single session (30 minutes) • At initial appointment or first return to care appointment focused on engagement and retention in care • Focused on adherence to antiretroviral therapy (initiation and maintenance) • Focused on risk reduction

22. MI Computer Applications • *Motivational Enhancement System for Sexual Risk & Adherence • MISTI (Sexual Risk)(Feasibility study) • Single session face-to-face or computer delivered intervention • MISTI-II (Sexual Risk) • Two session computer delivered intervention (Baseline and 3 months) • MESA (Adherence) • Two session computer-delivered intervention (Baseline and 1 month) *adapted by Ondersma et. al

23. To Sum Up • Remember MI Elements • Spirit • Collaboration, Evocation, & Autonomy • Principles • Express Empathy, Develop Discrepancy, Roll with Resistance, & Support Self-Efficacy • OARS • Open-Ended Questions, Affirmations, Reflective Listening, & Summaries

24. To Sum Up • Remember MI Elements • Change Talk • Disadvantages of Staying the Same, Advantages of Change, Positive Things About Change, & Intention to Change

25. MI Resources • Motivational Interviewing (2012, 2007, 2002) Miller and Rollnick • Motivational Interviewing with Adolescents and Young Adults (2010) Naar-King & Suarez • www.motivationalinterviewing.org

26. Thank You!!

27. Engaging & Retaining Youth in CareEngaging Hard To Reach Populations – HRSA Webinar Nikki Cockern, PhD Assistant Professor Clinical Care Manager Wayne State University School of Medicine Horizons Project May 2013

28. Issues of Adolescence • Trust • Often not ready to change, not motivated • Lack of impulse control • Rebel against prescriptive approaches – educational, skills building, traditional counseling • Physical Changes (thanks to puberty) • Peak of peer involvement and peer norms • Heightened experimentation

29. What’s Unique about Adolescents? • Environment-vitally important • Separation/individuation • Identity formation as separate from authority figures • Translating personal goals into behavior within a constrained environment • Mood fluctuates • Trying to figure out who they are and try different roles • Communication skills are still developing

30. Horizons Project • Dedicated to providing HIV prevention services to at-risk youth and direct care services to adolescents and young adults living with HIV (ages 13-24) • Has continued to grow as the only comprehensive HIV/AIDS program in Michigan focusing on youth • Wayne State University School of Medicine (WSU) and the Detroit Medical Center (DMC) serve as fiduciaries. 30

31. Engagement Strategies • “One-stop shopping” & multidisciplinary approach to HIV care, that is youth sensitive & culturally competent. Meeting youth “where they are” and focusing on building relationship • Intensive Case Management Services • Identification of needs (initial & ongoing) • Development of comprehensive service plan, including strategies for implementation • Coordination of care & services • Mental Health/Psychosocial Services • Client Advocacy • Transportation • Treatment Adherence Program • Lost to Follow-Up (L2FU) Program • Use of Multi-media tools

32. Horizons Project Enhancements • Advocates assist youth in enrolling and remaining in care • Rapid linkage into care • Intake and medical appointments are provided within the first week of contact • Youth often receive resources prior to their med visit • Direct linkage & support to ancillary care services and resources • Motivational Interviewing is offered • Multi-modal contact to youth in preferred medium (i.e. phone, text, email, Facebook inboxes) • Jam Sessions (support groups) • Transportation to ‘life critical’ services (DHS) • Provide a link to advocacy services if youth do not want to enroll in medical care • Actively Promote Consumer Involvement

33. Horizons Project Modifications • Quickly establish and maintain rapport • Highlight and vitally protect confidentiality, while treating each with dignity and respect • Contact with youth is consistent, yet at varied times and amongst several staff • Staff is available outside of typical “working hours/days” and can be reached via cell and email daily • Patient advocacy is vital to keeping youth connected and meeting their needs • Staff often accompany youth to other necessary medical and ancillary care appointments (i.e. DHS, colposcopy, Dental, GYN, etc.) • Phone contacts for transportation to clinical and ancillary appointments, JAM sessions, other care related activities • Decrease barriers to access services • Increase frequency of medical clinics held, so more appointment slots are available (including separate day youth can come in for treatment) • Reserved new patient and sick patient slots during each clinic session • Combined mom/baby or family clinic sessions to decrease the frequency of visits parents have to keep • Use of laptops in medical clinic in order to complete on-line applications for insurance and/or supplemental coverage programs • Provide incentives for improved adherence • i.e. keeping appointments, reducing drug use ,decreasing incidence of STIs, etc. (works with mental health team) • Provide lost to follow-up outreach • i.e. phone calls, letters, and home visits (MI)

34. 1. Maintain List Identify youth who missed clinic appt. & not able to reschedule 5. Contact made w/ Client & clinic visit scheduled Or Repeat 2. 1st month after missed clinic visit. Advocate attempts Contact via phone/text 4. 3rd month Home Visit 3. 2nd month Mail post Card sent L2FU Program Protocol MI @ point of contact & @ clinic appt. MI via phone MI @ HV if contact made

35. Social Media Tools • General Information and linkage to Horizons Project and Community Services • Horizons Project Website: http://peds.med.wayne.edu/horizons • Horizons specific information and events/activities • FaceBook • Twitter • Adherence to Appointments & ARV regimen • Text Messages (regular, timed texts for youth starting meds & those w/sig adherence problems) (appointment reminders & check ins) • Email invites on the spot for upcoming med visits w/alarm • Private inbox message through Facebook

36. Suggestions for Programs Working with Adolescents • Empowerment: Give youth an opportunity to be the “expert”; demonstrate mutual respect & partnership • Instill responsibility, allowing for choices when possible • Be respectful of where youth is in the moment & nonjudgmental • Use open-ended questions • Avoid power struggles and hidden agendas • Address stigma, assumptions, judgmental behavior within the care delivery system • Provide integrated peer driven medical and psychological support models • Address the ‘real affects’ of denial and depression while increasing hopefulness and opportunities for success • Be more of an advocate, than parent or judge • Listen first, focus on their concerns • Acknowledge safety issues (community intolerance, bullying, potential violence from others) • Develop cultural competence • Patience, Patience, Patience

37. Summary • One stop shopping, multi-disciplinary team approach to care • Clinical Services, including intensive case management • Psychosocial Services • Engagement & Retention Strategies include: • Rapid Linkage to Care • Multiple clinic sessions options • Practical and Concrete Support for accessing resources • Peer Advocacy, access to support outside conventional time • Transportation • Treatment Adherence Program • L2FU Program • Use of social media tools

38. Staff Acknowledgement Director of Medical Service and Research: Elizabeth Secord, MD Director of Prevention Services: Angulique Outlaw, PhD Consultant for Psychological Services and Research: Sylvie Naar-King, PhD ATN Behavioral Research Coordinator: Monique Green Jones, MPH ATN Clinical Research Coordinator: Charnell Cromer, MSN Clinical Care Manager: Nikki Cockern, PhD Clinical Nurse Practitioner: Debbie Richmond, NP Clinical Social Worker: Tiffani Hollowell, CMSW Care Coordinator/Case Manager: Keshaum Houston, BS Adolescent Consultant: Jessica Daniel, MPH MSM Prevention Coordinator: Jeremy Toney MSM Outreach Workers: Bre’ Campbell, David Perrett ATN C2P Coordinator: Emily Halden Brown, MPP ATN Research Assistant: Cindy Chidi, BS ATN Linkage to Care Specialist: Valentina Djelaj, LLMSW ATN 110/117 Outreach Coordinator: Bryan Victor, MSW Fisher HRH Prevention Coordinator: Te’Neice Dobbins, BS

39. Thank you!—Questions/Comments? Nikki Cockern, PhD; 313.745.4892; scockern@med.wayne.edu http://www.peds.med.wayne.edu/horizons

40. Latino HIV Best Practices: Improving Access, Engagement and Retention in Care May 15, 2013 Engaging Hard-to-Reach Populations – HRSA Webinar Margaret Hargreaves, Ph.D., M.P.P.

41. Study Methods • Review of the literature • Impact of HIV/AIDS epidemic on Latinos • Evidence of effective practices for engaging and retaining HIV-positive Latinos in HIV care • Site visits to 10 exemplary sites • 6 States selected for study • 10 sites selected across 6 states • 1 to 1.5 day site visits by bilingual teams • Analysis of sites’ 2009 RDR and 2010 RSR data • Racial/ethnic analysis of client characteristics, service use, and clinical outcomes

42. Selected Sites • CARE Resource, Miami, FL • CommWell Health, Dunn, NC • Elmhurst Hospital Center – ID Clinic, Brooklyn, NY • Centro de Salud Familiar La Fe, El Paso, TX • Miami Beach Community Health Center – Immune Support Program, Miami, FL • Mission Neighborhood Health Center – Clinica Esperanza, San Francisco, CA • Montefiore AIDS Center, Bronx, NY • San Ysidro Health Center – CASA, San Ysidro, CA • Valley AIDS Council, Harlingen, TX • West Side Community Health Center – Clinic 7, St. Paul, MN

43. Site Locations

44. Site Characteristics • 7 Federally Qualified Health Centers (FQHCs), 2 hospital outpatient departments, 1 AIDS service organization • RWHAP Funding: Parts A, B, C, D, F, MAI, SPNS • Populations served: Mexico, Caribbean, Central America, South America, Migrant farm workers • HIV clients served: 160 clients - 2665 clients • Percentage Latino clients: 20 – 80 percent

45. Sites’ Quality of Latino HIV Care • 9 providers prescribed HAART to Latino clients at same or higher rate than non-Latinos • 4 providers conducted CD4 counts for over 90% of Latino clients in the last year; another 3 providers conducted CD4 counts for over 80% of Latinos in the last year • 3 providers conducted viral load tests for over 90% of Latino clients in the last year; another 4 providers conducted viral load tests for over 80% of Latinos in the last year

46. Barriers and Strategies • Barriers to Latino access, engagement, and retention in HIV care identified at five levels • Individual • Clinician • Organization • System • Community • Total of 43 strategies were used by HIV providers to address identified barriers to Latino access, engagement, and retention in HIV care

47. Strategies to Address Individual-level Barriers • Help completing applications and obtaining eligibility documentation for Medicaid, Medicare, ADAP, SSA, Ryan White, SNAP (n=10) • Referrals for social services, including food and housing assistance, domestic violence services, legal aid, immigration services (n=10) • Transportation assistance, including vans and metro/bus cards (n=9) • Targeted Latino support groups for MSM, women, transgender, Spanish speakers, hepatitis C, treatment adherence, substance abuse, domestic violence, HIV education (n=8)

48. Individual-level Strategies, Cont. • Peer health educators, peer counselors, buddies, who provide health education, system navigation, social support, and client advocacy (n=7) • Reinforcement of treatment adherence messages geared to client literacy levels, using reminder calendars, pictures, symbols, color codes, pill boxes, key chains, directly observed therapy, literacy lessons (n=7) • Home or clinic delivery of HIV medications by pharmacy or clinic staff (n=3) • Client social groups, knitting, arts, crafts (n=3)

49. Strategies to Address Clinician-level Barriers • Knowledge of traditional home remedies, foods, cultural values, religious beliefs, differences among Latino subpopulations (n=10) • Showing warmth, respect, friendship to clients and their families; having a passion for the work (n=10) • Fluent Spanish speakers, interpreter lines, translation support from bilingual staff, certified interpreters (n=10) • Staff “willing to go the extra mile” for clients (n=7) • Home visits, hospital visits, long-term follow-up (n=7) • Mostly Latino/Hispanic staff (n=5) • Avoidance of culturally loaded terms such as gay, mental health, and psychiatry (n=5) • Training in cultural competency (n=3)

50. Strategies to Address Organization-level Barriers • Comprehensive one-stop shop of HIV ambulatory outpatient care and supportive services (n=10) • Flexible scheduling, double-booking, walk-ins, open slots for emergencies (n=10) • Clinic materials in Spanish (signs, notices, videos, website, brochures, medication labels, posters) (n=10) • Frequent appointment reminder calls, missed appointment follow-up calls, free cell phones to receive reminders (n=9) • Close tracking of visits, labs, medications, and contact information for treatment adherence and retention purposes (n=9) • Client confidentiality policies and practices (n=8)