ACCESS = HEALTH A Conversation on Funding Access to & Retention in Care with AIDS United

1. ACCESS = HEALTHA Conversation on Funding Access to & Retention in Care with AIDS United July 10, 2013

2. Agenda • Welcome & Logistics • Sarah Hamilton, FCAA • Funding HIV Care: AIDS United’s Access to Care Portfolio • Vignetta Charles, AIDS United • Strengthening the Health & Resilence of Women, Children & Families Impacted by HIV/AIDS • Shannon Hansen, Christie’s Place • Who is Being Served by Access to Care? • David Holtgrave & Cathy Maulsby, Johns Hopkins University • Q&A

3. Logistics • This is intended to be a safe discussion space for funders! If you wear different hats at your organization, please bring your grantmaking one to the Q&A. • We will open Q&A after all presenters. • In the interim, you can send questions via the question function at your right, via email sarah@fcaaids.org, or via Twitter @FCAA. If you want to ask a question via the phone, please raise your hand to be unmuted. • The call will be recorded and available on www.fcaaids.org after the call.

4. Funding HIV Care: AIDS United’s Access to Care PortfolioVignetta Charles, PhDSenior Vice PresidentJuly 10, 2013

5. HIV Prevalence and IncidenceUnited States, 1980 - 2010 Number of people living with HIV has grown because incidence is relatively stable and survival has increased Hall HIet al. JAMA. 2008 Aug 6;300(5):520-9 Prejean Jet al. PLoSOne. 2011;6(8):e17502 MMWR Morb Mortal Wkly Rep. 2012 Mar 2;61(8):133-8

6. Stages of HIV Care(CDC data, July 2012)

7. Funding streams • Public-Private Partnership • Social Innovation Fund (Corporation for National and Community Service) • Matching Private Funders • Local matching requirement • Private funding • Retention in Care (MAC AIDS Fund) • Positive Charge (Bristol Myers-Squibb)

8. Grantees Boston, MA New York, NY Chicago, IL Pittsburgh, PA San Francisco, CA Philadelphia, PA St. Louis, MO Washington, DC Los Angeles, CA Los Angeles, CA Indianapolis, IN Charlottesville, VA Montgomery, AL Durham, NC San Diego, CA New Orleans, LA Birmingham, AL

9. Cohort Requirements • Rigorous evaluation • Local evaluator • Contribute to national evaluation • Convening • Technical assistance • Compliance • Organizational development • Programmatic needs • Social Innovation Fund grantees—local match fundraising

10. Common Themes • Evidence-based interventions • Care coordination thru multi-disciplinary teams that meet regularly to discuss patient/client progress • Collaborative partnerships that seek to make meaningful, sustainable systems-level change • Many employ social network recruitment strategies • Most have formal partnerships with a clinical partner

11. Unique models • Boston—self sufficiency goal achieved through treatment adherence groups, job readiness training, and employment • New York City—Insurance provider that uses mobile engagement teams to remain connected to enrollees • Montgomery—telemedicine in rural communities • Los Angeles and Philadelphia—focus on formerly incarcerated individuals • Washington, DC—8 month certificate curriculum for Peer Navigators offered through local community college

13. Strengthening the health and resilience of women, children and families impacted by HIV/AIDS

14. Christie’s Place is a leading nonprofit community based organization in San Diego County that provides culturally competent and comprehensive HIV/AIDS education, support, and advocacy. Our mission is to empower women, children, and families whose lives have been impacted by HIV/AIDS to take charge of their health and wellness.

15. San Diego County Need • In 2010, 69% of women living with HIV who knew their status were not accessing medical care • San Diego is the 2nd largest county in CA • 4,200 square miles • Includes City of SD (7th largest city in country) • Borders Mexico (TJ is most active international border) • No county hospital – rely on community clinics and UCSD • MSM EMA, as such services tend to focus on men • Overall lack of family and women centered care and competency • Women generally isolated from local HIV agencies and/or uncomfortable accessing care at traditional service locations

16. ClientProfile • Heterosexually infected • Woman of color • Child bearing age • Low-income or poor • Low education level • Single parent or head of household • Two or more children • Unemployment or lack of occupation • Relationship discord or domestic violence • Trauma or abuse during childhood • Low self-esteem or mental illness (depression or anxiety) • Substance abuse or partner with this problem • Chaotic home life

17. Network of Care Model – system wide collaborative care approach to address access and linkage to care • Involves multiple collaborating organizations • Coordinated array of strategies to provide care completion services • Targeted to low income HIV+ women • County-wide • Collaborative partners: • UCSD Antiviral Research Center • UCSD Mother, Child, and Adolescent Program • UCSD Owen Clinic • Casa Cornelia Law Center • American Friends Services Committee: US Mexico Border Project • Cardea Services (evaluation)

18. CHANGE for Women Strategies • Expand capacity of Peer Navigator network at new clinic sites and through mobile, home-based model • Medical Home via My Chart • Increase access to clinical care via enhanced transportation, food and childcare • “I Am More Than My Status” social marketing campaign • Center of Excellence in Women’s HIV Care & Research • Expanded hours and bilingual capacity • Integrated medical care and behavioral health services • Formalized linkages and partnerships with immigration rights and social justice organizations • Human rights education • Legal advocacy for undocumented women and/or detained women

19. Strategic Alliances • Why choose this option? ACA, funding, positioning in community, diversification of services • Staying true to our mission and expertise • Understanding and articulating what we bring to the table – the “value added”/ROI for clinical partners • Developed/developing strategic alliances with clinical partners • Co-location with primary care • Peer navigation • Behavioral health • Medical case management • Part of clinic health teams • Whole person care • Patient and family support • Social support services • Strengthening medical home models

20. Successes • The “partnership” - tactics are strengthening medical home model and improving coordinated care • Peer Navigation model has brought 212 out-of-care and sub-optimally engaged in care HIV+ women back into care • Improved health outcomes of clients • Expansion of Fem-Owen Clinic, • development of Center of Excellence • Co-location of services and integration with provider teams = enhanced culturally appropriate & person-centered care; comprehensive care management; care coordination • Since program implementation, local unmet need decreased from 69% in 2010 to 64% in 2011, and then to 57% in 2012. • Increased access to care for HIV+ women by 12%

21. Challenges & Discoveries • Obtaining the local funding match • California changes to healthcare (LIHP, Medicare HMO, etc.) present numerous challenges and care interruption • Findings that a higher percent of CHANGE for Women clients report sexual assault history than the general population • CHANGE for Women clients report current and past intimate partner violence, including 18% who are in a relationship currently where they do not feel safe • Clients reporting substance abuse were: • Less likely to report having ‘basic’ needs like food or money • More likely to report intimate partner violence during the year before entering C4W • More likely to report needing alcohol/other drug treatment or mental health services

22. CHANGE for Women Phase II: Retention in Care (RiC)

23. CHANGE for Women Phase II: RiC • Trauma-informed and gender responsive bio/psycho/social model • Program expands upon established access to care efforts by improving RiC and ART adherence for HIV+ women of color in San Diego County, with an emphasis on African Americans and Latinas, including documented and undocumented immigrants • Strategies target the well-documented co-occurring barriers that prevent effective engagement in care and RiC and necessitate access to ancillary services to augment HIV care: • mental health conditions • substance abuse • history of abuse/trauma • low health literacy • 175 women will be assessed and monitored for RiC services over the funding period • 60 women will receive onsite behavioral health services yearly • 30 women will receive onsite strength-based case management yearly • 150 women will engage in monthly educational Treatment Education Adherence (TEA) sessions yearly

24. Strategy I. Expand scope and impact of the existing CHANGE for Women program through innovative and replicable interventions that strengthen RiC and ART adherence • Create system-level change by establishing formalized RiC partnership with UCSD Owen Clinic via Retention in Care Specialist • Expand capacity of Christie’s Place and partner agencies to deliver trauma-informed RiC services through ongoing training on the principles and practices of trauma-informed service delivery • Expand Social Marketing Campaign, “I Am More Than My HIV Status” to increase messaging about RiC and the importance of ART adherence

25. Strategy II. Expand integrated treatment teams to assess, identify and treat specific RiC barriers • Expanded RiCtreatment team allows for thorough assessment of clients who need additional support to meet health outcomes • Bilingual RiC Peer Navigators • Retention in Care Specialist • MSW-level Medical Case Manager • Mental Health Clinicians (including Clinical Manager) • Primary Care Physician/Provider, Psychiatrist, and other service providers working with client • RiC treatment team will develop a tailored service plan for each client • RiC treatment team will engage in ongoing discipline-specific clinical training on the intersections of trauma, mental health and substance abuse • Empowerment focused, strength-based, collaborative, gender responsive, culturally competent, and positioned to promote transformative social change

26. Strategy III. Provide tailored services to address identified barriers that prevent retention & adherence to ART therapies • Trauma-Informed Client Orientation (fosters hope, informed consent and investment in program participation and ensures client understanding of her role as an active collaborator in the treatment process with the ability to make choices regarding treatment and services) • RiC Barrier Assessment (strength-based, trauma-informed mental health, substance abuse and support system assessment which ascertains the client’s current level of functioning, barriers to optimal engagement in care and RiC, and the level of social support currently available to the client) • Behavioral Health individual, family, and group counseling services (clients with significant scores on the aforementioned trauma, substance abuse and/or mental health measures will be referred to the on-site mental health counselor working under the supervision of the Clinical Manager for tailored behavioral health treatment) • Treatment Adherence Activities (monthly Afternoon TEA [Treatment Adherence and Education] workshops, eight-week Treatment Adherence support group)

27. Next Steps • Working with State partners on how to certify or credential Peer Navigation • can this become a reimbursed service? • Electronic Health Record technology • Public and commercial third party insurance reimbursement for behavioral health services • Becoming providers on the Health Exchange/Marketplace plans • Reimbursement through sub-recipient agreements

28. Acknowledgments/Contact Information • AIDS United • MAC AIDS Fund • Johnson & Johnson • Alliance Healthcare Foundation • Macy’s Foundation & Passport Fund • Janssen Therapeutics LINCC Initiative • Kaiser Permanente Foundation Hospitals, Southern CA Region • Qualcomm Foundation • San Diego HIV Funding Collaborative • The California Wellness Foundation • UCLA/Johnson & Johnson Health Care Executive Program • Broadway Cares, Equity Fights AIDS • Safeway Shannon Hansen, MSW Program Manager hansen@christiesplace.org Elizabeth Brosnan Executive Director brosnan@christiesplace.org (619)702-4186 www.christiesplace.org

29. Who is Being Served by Access to Care? July 2013 David Holtgrave & Cathy Maulsby With abundant thanks to our colleagues and to A2C participants!

30. Presentation Objectives • Brief overview of the national evaluation strategy • Discussion of the results: • Who are the A2C participants? • What are the barriers to care? • What are the trends in participant health outcomes? • How are organizations collaborating at each A2C site? • Are A2C programs ‘cost-saving’ or ‘cost-effective’? • Dissemination of A2C/national evaluation

31. National Evaluation • Aim to answer, at the national level, cross-cutting questions about identification, linkage, re-engagement and retention in care • Cross-cutting findings about the successes, challenges, and barriers of linkage to care will inform current and future programs • Cross-cutting findings will speak to the successes and challenges of the broader health care system, including policy

32. National HIV/AIDS Strategy

33. Blueprint for HIV Treatment -- Linkage and Retention in Care • Contextual Environment • Rural v Urban • Neighborhood • Dependent care • Predisposing Factors • Age • Race/ethnicity • Gender • Poverty • Education • Mental illness • Substance abuse • Enabling Factors • Insurance status • Transportation • Housing • Social support • Self-efficacy • Perceived Need • Symptoms • Health beliefs • Health Care Environment • Clinic factors • Clinic distance • Appointment availability • Waiting time • System factors • Mental health services • Substance abuse services • Case management • Provider factors • Trust • Experience • Concordance Linkage to Care Retention in Care ARV Receipt & Adherence • Clinical Outcomes • Quality of life • CD4 Count • Plasma HIV RNA • Opportunistic infections • Death Environmental Outcomes Patient Characteristics Health behavior (Ulett, 2009)

34. Three-Pronged Evaluation Strategy

35. National Evaluation Constructs • Developed in collaboration with stakeholders, AU and grantees • Identified 21 constructs (e.g. linkage to care, engagement in case management, PCP prophylaxis, adherence, etc.) • For each construct, identified 2-3 measures based on the literature and best practices • Feasibility exercise on the 21 constructs (feasibility and relevance) • 21 12 to be collected across all sites • Data collected at baseline and follow-up

36. Preliminary Results

37. Data Sources • 1st SIF cohort • July 1, 2011 - August 31, 2012 • Baseline & six months (NYC, St. Louis, Boston, Chicago) • Baseline only (Los Angeles, San Diego, Montgomery, Washington DC) • 2nd SIF cohort • Data not yet available

38. How many clients were served by SIF and what are the characteristics of those clients?

39. SIF1 Total Enrollment (N= 1,197) # of participants SIF

40. Demographic CharacteristicsAcross SIF1 Sites % of clients

41. Mean # Years Since First HIV Seropositive Diagnosis *Excluding Washington D.C. and Montgomery

42. What do we know about clients’ service delivery needs?

43. Most Frequently Reported Client Needs at Enrollment (not mutually exclusive) % of Clients San Diego Chicago St. Louis Boston *I am going to read you a list of services and resources. Please tell me which ones you currently need (not mutually exclusive). .

44. Most Urgent Need Baseline and T1: Chicago (n=45) Percent Participant needs *Other=job training, transportation, mental health, child care, dental & food

45. What Barriers are Clients Encountering in Accessing Medical Care?

46. Most Frequently Reported Client Barriers to HIV Care at Enrollment (not mutually exclusive) % of Clients San Diego Chicago St. Louis Boston Often people with HIV face barriers to getting HIV care. What factors make it hard for you to get care? (don’t read)

47. Most Urgent Barriers to CareBaseline and T1: Chicago (n=45) Percent Participant barriers *Other=drug use, fear, stigma, denial, perceived need, competing priorities, location of care. Of those barriers which is the most urgent for you now?

48. Stigma at Enrollment Percent *Sometimes or often avoided treatment because someone might find out about my HIV ** Excluding Washington D.C.

49. Linkage to Care

50. SIF Linkage to Care and Case Management Service Plans % of participants *Excluding MAO and Washington, DC