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COMMUNITY HEALTH ADVISORY & INFORMATION NETWORK (CHAIN) PROJECT

COMMUNITY HEALTH ADVISORY & INFORMATION NETWORK (CHAIN) PROJECT. Needs Assessment Committee Angela Aidala, Maria Caban, and Maiko Yomogida February 3, 2011. Introduction: Planning Questions. What services do HIV+ persons need? Where do they go for care?

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COMMUNITY HEALTH ADVISORY & INFORMATION NETWORK (CHAIN) PROJECT

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  1. COMMUNITY HEALTH ADVISORY & INFORMATION NETWORK (CHAIN) PROJECT Needs Assessment Committee Angela Aidala, Maria Caban, and Maiko Yomogida February 3, 2011

  2. Introduction: Planning Questions • What services do HIV+ persons need? • Where do they go for care? • What are their unmet needs/ service gaps? • What populations are underserved? • What works well, what doesn’t work? • What are the barriers and access issues? • WHERE SHOULD WE PUT OUR MONEY?

  3. CHAIN PROJECT GOALS • To provide a profile of PLWH/A in New York City and the Tri-County Region • To assess the system of HIV care – both health and social services – from the perspective of people living with HIV • To report on unmet needs, service utilization trends, and outcomes to the Planning Council and its Committees

  4. History of CHAIN • Initially developed in 1993 as one of the Planning Council’s evaluation resources • Contract with Columbia University School of Public Health • CHAIN has recruited 4 cohorts of PLWH/A • NYC I (1994-2002, n=968) • NYC II (2002-present, n=1114) • Tri-County I (2001-2007, n=482) • Tri-County II (2008-present, n=360) • A Technical Review Team (TRT) which includes representatives of the Planning Council, Public Health Solutions, NYCDOHMH and WDOH oversees CHAIN

  5. 17 Year Highlights (1994 -2011) • 2000+ PLWHA completed ave. 4+ interviews • 850-item questionnaire • 120 trained interviewers • 150+ reports • Multiple presentations to Planning Council, Council Committees, PPG, HAWG, provider and community groups, professional conferences

  6. Steps in the Process • Develop a research strategy • Consult with stakeholders • Develop research infrastructure • Implement strategy • Analyze & report on research findings • Re-evaluate strategy • Consult with stakeholders

  7. Selecting CHAIN ParticipantsA 2-Step Process • Designed to enroll representative samples • 1st step: random selection of service sites from listing of all agencies serving HIV clients -- Medical and Social Service -- All Boroughs (or Counties) -- RW Funding vs. non RW • 2nd step: agency staff help with random selection of clients -- Random selection from client rosters -- Sequential enrollment

  8. Recruiting CHAIN ParticipantsUnconnected to Care • NYC CHAIN includes small samples of PLWHA unconnected to care • Unconnected: Aware, no medical care, no case management for 6+months • Referrals from CHAIN agency recruited participants • Accompany Outreach Workers • Open recruitment and screening in street and community settings • 1994 (n=48) 1998 (n=24) 2002 (n=25)

  9. Comparison of CHAIN Participants with Surveillance & RW Encounter Data Cohort composition closely tracks surveillance data/ RW client data

  10. Collecting Information by Speaking with PLWHA • Comprehensive in-person 2hr+ interview • Follow-up interviews approx. yearly • Interviews in homes or agency settings • Community-based interviewing team • $35 incentive for every interview + referral resource • Strong community support with 80% - 90% follow-up interview completion rate

  11. Topics Covered • Current health & mental health status • Sociodemographic background • Family life, housing, work, economic resources • Sexual behaviors • Outlook on life, stress, stigma • Substance use behaviors • History of medical and social services • Utilization of medical and social services • Medication use and adherence • Service needs, satisfaction with services, barriers • Social networks, social support • Quality of life

  12. Analyze & Report • Prepare data for analysis • Work with Council & staff to define topics • Consult with stakeholders - What emerging issues should be investigated? - What subgroup comparisons? • Prepare draft of reports and get feedback • Disseminate final reports

  13. Some ways of classifying PLWH/A • Gender - Male / female / transgender • Race / Ethnicity - White / Black / Latino / Other • HIV risk exposure group - MSM / PDU / MSM + PDU / Hetero & Other • Clinical indicators - Viral load undetectable/ detectable • Age - 20-34 yrs old / 35-49 yrs / 50+ yrs • Geography - Bronx, Brooklyn, Manhattan, Queens, Staten Island

  14. Types of Analyses • Descriptive (rates, percentages, trends, mapping) • Analytical -- Are there group differences? -- Do certain models of care, interventions, or policies make a difference? • Multivariate analyses – considering the effects of many factors taken together

  15. Assessing the System of Care Conduct studies to examine: • Medical care, health, mental health, QOL outcomes for PLWHA • Trend data – tracking change over time • Individual factors associated with outcomes • Service utilization associated with outcomes • Systemic factors associated with outcomes Key resource for needs assessment – can show service system strengths and weaknesses

  16. Outcome Measures • Appropriate medical care • ARV and HAART utilization & adherence • T-cell changes, viral load suppression • Resolution of service need • Health and mental health functioning • Reduction of sex and drug risk behaviors • Mortality

  17. CHAIN Service Needs and Utilization: NYC Summary • NYCDOH took lead in defining revised set of service domains, needs and utilization measures • “Need” includes those currently using service • “Gap” = % without adequate service utilization among those with need for service • Minor differences in need definition between Tri-County and NYC • Compare 2006-2009 with earlier interview period 2001-2006

  18. What is a Service Gap? • The difference between the “need” for service, and the receipt of service • Need may be “subjective,” in that client explicitly wants service (AKA “demand”) • --Ex: “In the last 6 months, have you had a problem or needed assistance with housing?” • Need may be “objective,” in that client’s circumstances suggest a need for a service, even if client doesn’t demand it • -- Ex: Client has had at least one episode of homelessness, being doubled up, or being unstably housed in past 6 mo.

  19. Domain: Ambulatory Health CareService : HIV Primary Care • Who Needs the Service? All Individuals living with HIV/AIDS • Measure of Adequate Utilization One or more visits to HIV Primary Care Physician in last six months

  20. Trends in HIV Primary Care Adequate Utilization Need for Service Always 100%

  21. Domain: Ambulatory Health CareService : ARV Treatment Support • Who Needs the Service? • 1. CD4 count< 200 & not on ARV • 2. Not completely adherent to ARV meds • or • 3. Receiving support services for ARV meds • Measure of Adequate Utilization • Receiving support services for taking ARV’s from professional providers

  22. Trends in ARV Treatment Support Need for Service Adequate Utilization

  23. Domain: Case ManagementService : Social Service C.M. • Who Needs the Service? 1. Poor mental health score on standardized measure 2. In the last 6 months had an inpatient, emergency room or mobile unit visit for psychiatric or mental health 3. Being homeless or in unstable housing in the last 6 months 4. During past year used cocaine, crack or heroin, OR 5. During past 6 months heavy or problem drinking • Measure of Adequate Utilization • A case manager did one or more of the following in last 6 months: -Revising or developing a plan for dealing with needs, -Referrals for social services, -Help filling out forms for benefits or entitlements

  24. Trends in Social Service C.M. Need for Service Adequate Utilization

  25. Domain: Case ManagementService : Medical C.M. • Who Needs the Service? 1. No HIV primary care in the last 6 months 2. Stopped going or no visit to provider in the last 6 months 3. Missed more than one appointment in the last 6 months 4. No CD4 or VL test in the past 6 months, OR 5. Had any of the above problems at prior interviews AND had a case manager helped in getting or referring for medical services in the last 6 months • Measure of Adequate Utilization • During the last 6 months a case manager helped in getting or referring for medical services

  26. Trends in Medical C.M. Need for Service Adequate Utilization

  27. Domain: Mental HealthService : Professional Mental Health Services • Who Needs the Service? 1. Poor mental health score on standard measure 2. In the last 6 month had an inpatient, emergency room or mobile unit visit for psychiatric or mental health, or • 3. In the last 6 months received counseling from a mental health professional - psychiatrist, psychologist, therapist, or clinical social worker • Measure of Adequate Utilization In the last 6 months received counseling from a mental health care professional or clinical social worker

  28. Trends in Mental Health Services Need for Service Adequate Utilization

  29. Service: Alcohol or Drug Treatment • Who Needs the Service? 1. During past year used cocaine, crack or heroin, 2. During past 6 months heavy or problem drinking, or 3. Reported receiving drug or alcohol treatment was important • Measure of Adequate Utilization • In last 6 months received any form of treatment for alcohol or drug use, including AA/NA

  30. Trends in Alcohol or Drug Treatment Need for Service Adequate Utilization

  31. Food and Housing Services Need for Service Adequate Utilization 2006-2009

  32. The Value of CHAIN • Patterns and proportions we see in the sample can be used as estimates for the broader HIV+ population • Over time data can show changes in needs as well as effects of services and system wide interventions • Provides broad range of evidence about service needs and outcomes from the point of view of persons living with HIV/AIDS

  33. ACKNOWLEDGMENTS A Technical Review Team (TRT) provides oversight for the CHAIN Project. In addition to Peter Messeri, PhD, Angela Aidala, PhD, Maria Caban, MA, Melissa White, MSSW, and Maiko Yomogida of Columbia University’s Mailman School of Public Health, TRT members include Mary Ann Chiasson, DrPH, (Chair), Roberta Scheinmann, MPH, Public Health Solutions, Inc.; Jan Carl Park, MPA, Nina Rothschild, DrPH, Office of AIDS Policy and Community Planning; Mary Irvine, DrPH, Yoran Grant, PhD MPH, Daniel Weglein, MD, and Fabienne Laraque, MD MPH, Office of Evaluation and Quality Assurance; Ellen Wiewel, PhD, HIV Epidemiology and Field Services Program and JoAnn Hilger, Director, Ryan White Services, New York City Department of Health and Mental Hygiene; Julie Lehane, PhD, and Tom Petro, Westchester County Department of Health;, and Gregory Cruz. CHAIN reports are solely the responsibility of the researchers and do not necessarily represent the official views of the U.S. Health Resources and Services Administration, the City of New York, or Public Health Solutions.

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