Ask, Screen, Intervene 4 Cities Project

1. Ask, Screen, Intervene 4 Cities Project Training Exchange June 20, 2013 For Audio dial: 1-800-591-2259 Passcode: 959325 Please remember to mute your speakers

2. Training Exchange Objectives • Discuss updates to the Ask, Screen, Intervene (ASI) curriculum • Review the ASI Four Cities Project • Identify lessons learned from the implementation of the ASI framework in community health clinics • Describe preliminary results from the evaluation of the project

3. Agenda • Welcome and Call Purpose --- Joanne Phillips • Ask, Screen, Intervene (ASI) Curriculum Updates 2013 --- Helen Burnside • Ask, Screen, Intervene Four Cities Project --- Joanne Phillips • Introduction of the project • Collaborators • Timeline

4. Agenda • Four Cities Updates • Needs Assessment: process and findings • Training Design • Training Evaluation Data: barriers and anticipated practice changes • Lessons Learned • Clinic Experience • Plans for Sustainability • Baltimore • Chicago • Miami • Los Angeles

5. Agenda • Evaluations of the curriculum implementation --- AETC NEC • Evaluation Design • Data Collection • Data Analysis • Results • Summary of the Project --- Helen Burnside • Question and Answer --- Joanne Phillips

6. ASI Curriculum Updates • 2012 4 modules→ 3 modules • Risk assessment & screening for STDs • Prevention Interventions • Partner Services • 2012-2013 Revisions completed from DHAP and DSTDP Clearance • Contact National Resource Centers for access to DRAFT curriculum

7. http://www.cdc.gov/hiv/prevention/programs/pwp/index.html

8. Project Overview • MAI-funded project through HRSA HAB • Supports National HIV/AIDS Strategy goals • Began Fall 2011 • 2 year project • Project activities • Planning and implementation • Training and on-going technical assistance • Program assessment and evaluation

9. Project Objectives • Enhance clinician ability to conduct effective risk screening, conduct prevention counseling, and refer for services • Increase the number of HIV-positive persons who receive information about transmission risks and regularly receive risk reduction counseling • Increase the number of HIV-positive persons who are screened for STDs • Assist in strengthening linkages to referral services

10. Collaborators • HRSA HAB • CDC • 4 regional AETCs and 4 PTCs • National Resource Center for NNPTCs • AETC National Resource Center • AETC National Evaluation Center • 8 Ryan White Part C clinics/FQHCs in 4 cities

11. 4 Cities and Clinics • Baltimore • Chase Brexton Health Services (3 sites) • Total Health Care, Inc. (10 sites) • Chicago • Access Community Health Network • Erie Family Health Center, Inc. • Heartland Health Outreach, Inc. Selected based on ECHPP designation and application review

12. 4 Cities and Clinics • Los Angeles • Alta Med Health Services Corporation • Miami • Jessie Trice Community Health Center, Inc. • Miami Beach Community Health Center

13. Project Activities • Planning & Implementation (Fall 2011 - Winter 2012)

14. Project Activities • Training (Spring 2012- Summer 2012) • Tailor to clinic needs • Clinic project coordinator help facilitate and monitor • Assessment & Evaluation (Spring 2012 –Summer 2012) • Training Data • FTCC PIF • Training Evaluation Summaries • NRC for the NNPTCs

15. Project Activities • Ongoing Training and Technical Assistance (Fall 2012-June 2013) • Program level (feasibility, fidelity, impact) • AETC National Evaluation Center

16. Four Cities Updates AETCs and PTC updates on: needs assessment process, training design, training evaluation data, lessons learned, clinic experience, and plans for sustainability

17. Chicago Ricardo Rivero: Midwest AETC Deyanira Flores: ACCESS Clinic

18. Chicago: Needs Assessment • Meeting with clinic leadership and key staff • Specific needs related to 3 ASI modules: • What’s in place already • Who would be involved • EMR • What needs to be covered from ASI curriculum • Plans for sustainability

19. Chicago: Training Design • All 3 training modules were tailored … • Audience • Local information • Time • Training / TA beyond ASI: • STI: Overview & What’s New • Motivational Interviewing Bootcamp • Filling Your Prevention Tool Box • Risk screeners

20. Chicago: Practice Changes • Risk screening (e.g., paper and iPad tools, etc.) • Screening of STDs • Delivering prevention messages • Use of behavioral counseling • Referral to more intense prevention interventions

21. Chicago: Barriers Time (per encounter and for training) Lack of confidence in skills Competing priorities Changes in leadership Staff turnover

22. Chicago: Lessons Learned Clinic leadership and providers buy-in Needs assessment Single contact at the clinic Clinic-centered trainings and TA Periodic site visits Partner services … the weakest link?

23. Chicago: Clinic Experience Deyanira Flores, Project Coordinator ACCESS Community Health: Overall experience Major accomplishments Barriers worth mentioning

24. Chicago: Plans for Sustainability All 3 sites will continue implementation at different levels: ACCESS Community Health will expand to another site as of July 1, 2013 Erie Family Health Center and ACCESS will continue working with the PTC to conduct risk assessments with iPads Heartland Health Outreach … new leadership and programmatic staff

25. Los Angeles Tom Donohoe, UCLA Pacific AETC Linda Creegan, CA HIV/STD Prevention Training Center Ardis Moe, UCLA Pacific AETC Alberto Perez, CA HIV/STD Prevention Training Center

26. HIV Clinic in Los Angeles, California Main HIV Clinic, Commerce, California

27. Los Angeles: Needs Assessments/ Training Design • Initial Assessments: Winter-Spring 2012 • Scheduling: Spring 2012 • ‘Overview’ session • Modules I, II, III delivered May-June 2012 • ‘Implementation’ session June 2012 • “Wrap up” in-person session May 2013

28. Los Angeles: ASI Training Design • All ASI modules delivered at clinic and utilized Turning Technologies ARS • Overview session was important to review what ASI implementation project was/wasn’t (i.e., exit interviews) • Draft clinic signage was used to facilitate training experience and discussion of clinic specific implementation of ASI

29. Bilingual signs for HIV waiting room Bilingual HIV Waiting Room Signage Pin: “Ask me about Sexual Health”

30. Los Angeles: Training Evaluation • Barriers • Existing Secondary Prevention Programs • Existing ideas of ideal clinic flow for prevention • EMR implementation/trainings during project • Practice changes • Increased STD testing/partner services referral • Increased sharing of patient risk information • Enhanced discussion of hard-to-reach patients

31. Los Angeles: Lessons Learned • Important not to make patients feel like they are public health hazards---that assessing sexual health and prevention needs is part of high-quality HIV care • Combine ASI questions and protocols with existing prevention and STI screening procedures to enhance patient experience (without repeating sensitive questions) • Clinicians and support staff need to share prevention information and screening information, ideally through the EMR • Changing clinician/staff ‘routines’/beliefs may be harder than changing the EMR

32. Los Angeles: Sustainability of ASI • PAETC/PTC will work with clinic to assist with future ASI-related training needs, including options for dealing with ‘condom refusers.’ • The clinic now doing six month RA screening, with some staff more frequently • Partner Services always offered as standard of care (not always accepted, but increased) • Increased rectal and pharyngeal testing

33. Los Angeles: Sustainability of ASI Increase interactions within HIV staff groups (front office/back office, clinicians, mental health, case managers) EMR key for future sustainability (billing) More specific questions about prevention needs helped change exam room interaction but this is long term process Might be helpful to have level III observational experience for each discipline

34. Los Angeles: ASI-related trainings needs PAETC, PTC or other (PS ATTC) will offer: PrEP Brief Mental Health Screenings for non-mental health clinicians Billing for Prevention in the ACA Era SBIRTS Medical Marijuana and HIV Crack Cocaine and HIV Meth and HIV Alcohol and HIV

35. Baltimore Terry Hogan: Johns Hopkins PTC Abby Plusen: Pennsylvania/Mid-Atlantic AETC Jennifer Kunkel: Total Health Care

36. Baltimore: ASI Collaboration • Introductory Meetings • Training Centers’ Staffers • Clinics’ Staffers • Training Centers’ Responsibilities • Technical Assistance Training • Clinics Operations • Total Health Care, Inc. • Chase Brexton Health Services • Needs Assessments

37. Baltimore: Needs Assessment • Conducted face-to-face meetings with key stakeholders at each clinical setting • Collected needs assessment data with stakeholders • Used format developed in partnership with full ASI, 4-Cities Project Group • Prepared full report • Shared with clinic partners • Sent reports to ASI, 4-Cities Project

38. Baltimore: ASI Trainings • Scheduled trainings based on clinic schedules • Chase Brexton – held trainings on several different dates to accommodate all staff • Total Health Care – held one training to coincide with full clinic meeting • Collaborated with BCHD faculty for Module 4 • Assured sustainability through TOT for selected staff • Recognized that traditional TOT not best for staff resource

39. Baltimore: Clinic Perspective Implementation • Key components • What clients need to know • Am I at risk • What puts me at risk • What can I do to prevent risk • What providers and support staff need to know • How can I implement ASI in a high volume primary care setting • What does it take to document ASI activities • How to evaluate the impact of ASI on affected population

40. Baltimore: Barriers & Lessons Learned • Primary Care Settings • Not offering exclusive HIV services • Diverse clinic census • Electronic medical records • Already established • ASI risk questions • HIV Care Patients • Total Health Care – separate clinic visits • Many HIV-specific visits • Some chose to stay with primary care providers • Chase Brexton – incorporated into clinic

41. Baltimore: Clinic Perspective/Outcomes • Primary Care Side and Meaningful Use Questions • Brief ASI intervention • Imperative in high volume setting • Incorporate ASI intervention into Electronic Medical Record is ideal • Coordinate HIV Medical Services with Primary Care • Clinic Accomplishments • Total Health Care, Inc. • 398 HIV-positive clients screened/documented – 2012 • Chase Brexton Health Services • 933 Clients screened/documented – 09.2012-05.2013 • Ongoing collaboration between clinics

42. Baltimore: Sustainability • TOT model • TA • Linkage • Reverse Preceptor? • AETC + PTC as a resource • Collaboration between two large service providers

43. Miami Yvette Rivero: Florida/Caribbean AETC Richard Meriwether: AL/NC PTC Ruth Duval: Jesse Trice Clinic Coordinator

44. Clinics in Miami, Florida • Jessie Trice Community Health Center (JTCHC) 5361 NW 22nd Avenue, Miami, FL 33142 • Miami Beach Community Health Center (MBCHC) 710 Alton Road, Miami Beach, FL 33139

45. Miami: Needs Assessments • Initial Assessment • March 2012 • 2nd Assessment • October 2012 (sites requested training on HPV, Mental Health in HIV, STD, Substance Abuse, and Cultural Sensitivity) • 3rd Assessment • April 2013 (Sexual Health survey has been implemented as part of Primary Care and updates on STD will be provided yearly) • Last assessment pending June 2013

46. Miami: ASI Training Design • Modules delivered monthly in a previously scheduled training slot • Training slot was 3-5:00pm to avoid overtime pay and cutting into clinic hours • Training conducted in conference rooms at clinics • All clinic staff attended trainings

47. Miami: Training Evaluation Practices • Barriers • Time constraints of clinic visit • Client refusal to take Sexual Health survey • Practice changes • Allocating more time to provider • Allowing a Medical Assistant (MA) to assist provider • Providing education to clients that refuse to take Sexual Health survey

48. Miami: Supplemental Trainings • Cultural Sensitivity – • MBCHC, May 22, 2013 • JTCHC, tentative for June • HPV and HPV Vaccines – • JTCHC, May 3, 2013 • STD updates – • MBCHC, Feb. 21, 2013 • JTCHC, May 17, 2013 • Mental Health and HIV – (pending) June 2013

49. Miami: Additional trainings • Module I training provided on March 29, 2013, to: • Community Health Centers of South Florida, Inc. • Borinquen Medical Centers of Miami

50. Clinic posters for waiting area, provider’s office