A Coordination of Care Quality Impact Project

1. A Coordination of Care Quality Impact Project “Straight from the Heart” : A Client Based Rapid Cycle Intervention Presented to The NYS AIDS Institute Quality Improvement Learning Network for Ryan White Case Management Providers Carla Lewis, Ph.D. & David Pulli, LMSW of Project Hospitality December 16, 2005

2. I. Identified Areas for Improvement Targeted Continuous Quality Impact Goals: • To increase access and coordination with mental health providers for HIV positive Title I Case Management consumers that present with mental health symptoms (24/30). Baseline data indicated that one third (8/24) of this subgroup were not engaged in mental health services in September 2005. • To enhance front line staff’s capacity to identify clinical needs by increasing awareness, confidence, and ability to identify useful psychosocial variables related to behavioral health outcomes. • To enhance cross-fertilization between programs, raising the salience of mental health screening, barriers, and referrals for case managers.

3. II. Organize Improvement Team • Dr. Carla Lewis, Agency wide Director of Planning, QI Council, and Evaluation (conceptualization, instrumentation, design, training, process and outcome evaluation, report writing) • David Pulli, LMSW Program Director (programmatic/service delivery elements, staff and client coordination, CQI project oversight and access) • Case management team (Krasimira Dobrinska, Pamela Williamson) Pilot sample identification, intervention implementation, data collection, evaluation, documentation, and follow-up) • Peer Volunteers (craft vignettes) • Mental Health Service Providers (special thanks to Dr. Maxine Ain, Staff Psychiatrist) Peer recruitment, support with vignettes, clinical/creative support

4. III. Review of Current Process • Measurement: Quantification/Aggregation of mental health non-engagement rate was 33-1/3%; Content Analysis of charts of non-engaged clients (client factors, length of time since infected, prior mental health services, circumstances, support networks, activities, change in biomarkers, housing, cultural influences) revealed contextual and clinical indicators for mental health services (ranging from supportive counseling through mental health harm reduction). • Hypothesized Root Causes of Non-Engagement:Low Outcome Expectancies, Denial, Cultural Myths ,Constraints (“stiff upper lip”, help seeking perceived as weakness) Unfamiliarity/Awareness, Fear (stigma, judgment, meds), Adaptation, Self Care, Systemic Attitudes (“Us” vs. “Them”), Screening Factors/ Acuity • Root Causes: (See empirically derived “Lessons Learned” Section VI)

5. IV. Select and Test Improvement Strategies Phase I • Blend elements from Community Identification and Social Cognitive Theory viz. Bandura’s Social Learning Elements --Role Modeling, Observational Learning, Outcome Expectancies and create and disseminate peer quotations e.g., “How Services Changed My Life”. • Volunteer peer testimonials for low literacy and culturally competent flyers crafted by peer volunteers were used by case managers in one-on–one intervention with the subset of resistant clients. The flyers, titled by the team as “Counseling and Me: Straight from the Heart” were also posted on the walls of the mental health offices, at their request. A byproduct of the implementation was the cross fertilization of mental health and case management teams (such as collaboration in collecting peer vignettes, discussing project mission) • Reactions to the flyer (client feedback survey) and mental health engagement rate will be evaluated post intervention.

6. IV. Select and Test Improvement Strategies (continued) Phase II • Mindfulness/Enrichment Training: Through consciousness raising training with Project Hospitality’s Social Psychologist/Planner, case managers will be able to “widen the net” and screen for more nuanced psychosocial dimensions such as social adequacy, resiliency, and event impact that may reflect critical variation in need for clinical and supportive mental health services. • Resiliency/attitude scales, Impact of Event Scale, social support, Self Esteem, psychological maltreatment, and coping style inventories were used as a point of lively discussion. Items, indicators and correlates were used to illustrate contextual influences and how they may play out clinically to inform/enrich service decisions. • Formative (iterative) process feedback with case management staff on training, administration of flyer, evaluation instrumentation, and client feedback is built into the design.

7. 1. How did you feel when you got to share your peer’s feelings on the “Straight from the Heart” Flyer? 2. Does what they wrote make you feel like you might consider (reconsider) getting support? If No, Why Not? If Yes, ____Wanted to be introduced to mental health team ___ Expressed interest/intentions but wanted some time. I am here whenever or whatever you decide! Quantitative Results (n=8) 75.0% (6/8) Yes 12.5 1/8 wanted introduction to MH 62.5 5/8 Expressed interest/intentions 25.0% (2/8) No 12.5 1/8 strong support networks 12.5 1/8 client “liked the flyer” and looked touched but surprised and frightened by such intimate sharing. “Not for me” was relieved when CM stopped evaluation. V. Measure Results of Improvement Strategies: Phase I

8. V. Results (Continued) Phase I Post Intervention Behavioral Outcomes • Non-engagement rate of clients presenting with mental health needs decreased from 33-1/3% (8/24) to 12.5% (3/24) at one month follow-up. • Engagement of those presenting with mental health needs increased from 66-2/3% (16/24) to 87.5%.( 21/24) at one month follow-up. Figure 1: Pre-Post intervention Engagement Rates in Mental Health Services (N=24)

9. Case Managers Evaluation 1. Since our training are you: (always, much more likely, more likely, about the same, less likely) to discuss/or screen for mental health issues? 2. Can you estimate the percent of time you are mindful/screen for mental health needs since the intervention? Two Ryan White Case Managers reported that they were “50% more likely” and “always conscious of mental health issues” since the project. V. Results of Improvement Strategies (continued) Phase II

10. V. Results (continued)Mindfulness, Coordination and Social Contagion • There is strong evidence that the salience of the project has diffused to neighboring COBRA staff which shares the same Project Director. • Since the start of this project, Harm Reduction Mental Health Services received twice as many referrals in October than usual. Supportive Counseling has admitted 6 new clients over October/November—20% of its most current caseload! • All Mental Health Staff including the Area Director, our Psychiatrist, Harm Reduction Mental Health, DOH AI Mental Health, and Supportive Counseling staff requested that the “Straight from the Heart” Flyer be posted on their walls. • Case Management staff have “enjoyed” more informal visits with Mental Health Staff since the project and the CM QI Team has decided to use the community identification tool for future clients as indicated.

11. VI. Lessons Learned Grassroots Gems • The flyer served as a window from which to explore underlying ambivalence. Our follow up results show that clients may be “sitting on the fence” initially but the opportunity to process concerns, coupled with case manager’s gentle support appears to be a catalyst for positive change. As indicated below, immediate reactions to “Straight from the Heart” peer quotes differed significantly from ultimate behavioral outcomes. • My first thought is ….identification. Yes, I can identify with the quotes…I feel it. It is touchy. I cannot say anything else at the moment. [Expressed interest/intentions but wanted some time] • They remind me that I need help. [Wanted to be introduced to Mental Health Team] • Yes I will think about it but have no time. Tell me when I will have a kitchen table…. [Expressed interest/intentions but wanted time] • They are right…but I am not like them. I am a strong man. I do not want to discuss my feelings. With you, it is enough. You are my case manager .I do not want to cry next door. ….Does what they wrote make you feel like you might reconsider getting support? …If you insist….[Expressed interest/intentions but wanted some time]

12. VI. Lessons Learned (continued) • The psychology of the environment, especially sharing space with COBRA staff and sharing an adjoining building with Mental Health staff was not fully utilized before the project. There is an exciting ripple effect on organizational culture when teams are committed to QI initiatives. • Hypothesized root causes of resistance or non-engagement require empirical validation so interventions can be crafted to penetrate actual barriers such as those generated through intervention using peer quotes as a stimulus. • Logistical Interference (time pressures, “taking care of business” housing appointments, insurance, getting the lights turned on, MHS engagement viewed as a luxury) • Privacy, Shyness, Embarrassment, cultural constraints about sharing feelings • Pseudo independence, machismo, views help seeking as a weakness, “me” vs. “them” • Strong social/alternate support networks

13. VII. Next Steps 1. Debrief results, disseminate, and acknowledge team success! 2.Level the Divide/Normalize by continuing to work strategically with social influence flyer to penetrate client isolation (“me vs. “them”) and fears about becoming a consumer of mental health services. 3. Screening Acuity: Continue to increase knowledge and awareness of psychosocial influences on well-being through “brown bag” rap sessions with staff social psychologist/Planner. 4. Keep track of resistant clients using a Stages of Change/readiness consciousness. Document where client fell on the continuum ( no interest, some interest, maybe later, after detox, refer now) on post-intervention treatment orientation questionnaire. 5. “Connecting the Dots” by leveraging client strengths, health efficacy beliefs, self care, and help-seeking more explicitly and interactively. Crafting mini treatment planning interventions, highly specific per client with quantifiable goals. 6. Diffuse culturally competent QI initiatives/interventions like this to identify/penetrate other service/behavioral barriers through ongoing collaboration with the Director of Planning/Evaluation.