Stephen Crowe, ATC Managing Director Liza Kasmara, Director of Program Evaluation

1. Increasing Access to Care (ATC) for Homeless Individuals Living with HIV/AIDS: Harlem Model Implementation Stephen Crowe, ATC Managing Director Liza Kasmara, Director of Program Evaluation Harlem United Community AIDS Center, Inc. HRC Conference 2012, Portland, OR

2. Learning Objectives By the end of the session, participants will be able to: • Identify barriers to linking and retaining patients in care • List essential elements in a patient navigation system to increase access to and retention in care • Understand the importance of care coordination

4. Agency Overview

5. Organizational Structure Integrated HIV Services Community Health Services Community-Based HIV/STI/HCV Testing Access to Care & Support Services Drug User Health Services (Syringe Access, Harm Reduction, Recovery Support) Black Men’s Initiative –integrated interventions for YMSM, YTG of color New Business Development & Outreach Services Adult Day Health Centers Food & Nutrition Supportive Housing (Women’s Housing, Transitional Housing, Congregate, etc. ) Health Homes (COBRA) Case Management Family Support Holistic Provider-Led, Patient-Centered Primary Care and Dental Services Behavioral Health Services Patient Navigation/Case Management Support

6. Access to Care (ATC) & Support Services

7. ATC Program Development • National HIV/AIDS Strategy • Reduce New HIV Infections • Increase Access to Care and Improve Health Outcomes for People Living with HIV • Reduce HIV-Related Health Disparities • Achieve a More Coordinated National Response to the HIV Epidemic in the U.S. • Access to Care (ATC) Model • Ensure access to and retention in medical care • Provide support services needed to achieve optimal health outcomes • Facilitate re-entry into care and support services

8. ATC Program Development

9. ATC Program Development

10. ATC Client Characteristics • 75% Male, 24% Female, >1% Transgender • 95% Black and Hispanic • Primarily 35-54 years old • 65-75% Homeless/Unstably Housed • 40% HIV+, 15-20% AIDS diagnosis

11. ATC Program Overview • SERVICES: • Supportive Case Management Services • Patient Navigation & Reengagement Activities • Support Groups (in English, Spanish & French) • Connection to Medical Care & Support Services • Psychosocial Assessments and Counseling (individual and group) • Health Education/Risk Reduction Counseling • Treatment Adherence Counseling (individual and group) • Housing Placement Assistance (individual and group) • Enrollment into ADAP/ADAP-Plus/APIC/Health Coverage • Entitlements Assistance GOALS: • To locate and engage out-of-care individuals into care and support services • To ensure access and retention to medical care and support services • To provide support services needed to achieve optimal health outcomes • To navigate through initial medical care and connect to comprehensive case management

12. ATC Program Current Model - Structure

13. ATC Program Overview Target Population(s): • HIV-Positive and HighRiskHIV-NegativeHomelessIndividuals • High utilizers ofemergency rooms anddetox facilities • Undocumented • Immigrants Target Area(s): • Harlem • South Bronx Program Flow1. Patient Navigation Services • 2. Supportive Case Management • 2a. Psychological Assessment

14. ATC Program Overview 2b. Entitlements 3. Supportive Services

15. ATC Program: Outcomes • Retention in care • ART Status

16. ATC Program: Outcomes

17. ATC and Primary Care

18. Care Coordination • Team meetings/daily rounds • Electronic Reports • Daily communication between outreach and office managers • PN/Provider Protocols • E-mails with daily reminders of appointment availability • Patient Navigation/Escorts • Case Management and Providers • Communication via electronic health record

19. Care Coordination Utilizing HU’s Electronic Medical Records, e-ClinicalWorks (eCW), to coordinate care:

20. Care coordination • Tickler system in eCW: • Action items in “Review Actions” feature • Serve as communication tool between PN and clinic • Useful for clients who have chronic no-show issues

21. Challenges • Difficulty locating clients who are transient or homeless • Staff training & development, buy-in, resistance to change • Paperwork integration (difficulty in minimizing duplication) • Program funded by 6 contracts (city and state) is challenging to manage since funders have different core requirements, deliverables, expectations, and constraints • Multiple points of entry • Multiple databases • Ensuring effective communication happens among all staff during process of program development • Data entry issues (timeliness, not enough data entry support)

22. Best practices & Lessons learned • Employing Harm Reduction model • Client-centered Approach • Using Motivational Interviewing techniques to engage clients • Low threshold services • Using Daily Rounds to case conference clients • Collaborations with internal programs and external agencies to recruit clients • Ongoing staff training and development • Minimizing duplication of intake and paperwork throughout entire process

23. Contact Info • Stephen Crowe, ATC Managing Director scrowe@harlemunited.org • Liza Kasmara, Director of Program Evaluation lkasmara@harlemunited.org

24. References • Baggett, T. P. et al. (2010). The unmet health care needs of homeless adults: A national study. American Journal of Public Health, 100(7), 1326-1333. • Barrett, B. et al. (2011). Assessing health care needs among street homeless and transitionally housed adults. Journal of Social Service Research, 37, 338-350. • Bunger, A. C. et al. (2010). Defining service coordination: A social work perspective. Journal of Social Service Research, 36, 385-401. • Carter, M. (2012). Majority of HIV-positive patients in US not receiving regular medical care. AIDS Map. Retrieved from www.aidsmap.com/Majority-of-HIV-positive-patients-in-US-not-receiving-regular-medical-care/page/2228542/ • Craw, J. et al. (2008). Brief strengths-based case management promotes entry into HIV medical care. Acquir Immune Defic Syndr, 47(5), 597-606. • Craw, J. et al. (2010). Structural factors and best practices in implementing a linkage to HIV case program using the ARTAS model. BMC Health Services Research, 10(246), 1-10. • Dudley, J.R. (2009). Social work evaluation: Enhancing what we do. Charlotte, NC: Lyceum Books, Inc. • Findley, S. E. et al. (2012). Building a consensus on community health workers’ scope of practice: Lessons from New York. American Journal of Public Health, 102(10), 1981-1987. • Frerich, E. A. et al. (2012). Health care reform and young adults’ access to sexual health care: An exploration of potential confidentiality implications of the Affordable Care Act. American Journal of Public Health, 102(10), 1818-1821. • Hwang, S. W. et al. (2010). Universal health insurance and health care access for homeless persons. American Journal of Public Health, 100(8), 1454-1461. • Torian, L. V. et al. (2011). Continuity of HIV-related medical care, New York City, 2005-2009: Do patients who initiate care stay in care? AIDS Patient Care and STDs, 25(2), 79-88.