Project Consumer LINC Webinar December 6, 2011 Emily Gantz McKay Harold Phillips Hila Berl

1. Developing a Peer-Based Early Intervention Services Program Project Consumer LINC Webinar December 6, 2011 Emily Gantz McKay Harold Phillips Hila Berl 1

2. IntroductionsSera MorganandEmily Gantz McKay

3. Webinar Objectives To familiarize participants with the components of an Early Intervention Services Program, as described by the HIV/AIDS Bureau To summarize the benefits of using peers To provide a step-by-step process for developing a peer-based EIS program appropriate for your service area 3

4. Agenda Components of an Early Intervention Services (EIS) Program Questions/Discussion Benefits of the use of peers to help PLWH learn their status, enter or re-enter care, and remain closely linked to care Steps and key questions for designing a peer-based EIS program Questions/Discussion 4

5. Components of an Early Intervention Services Program Harold J. Phillips 5

6. HIV Testing: Used to help the unaware learn their status and receive either referral to prevention services or referral and linkage to HIV care services Cannot duplicate or supplant testing efforts paid for by other sources. Must be coordinated with other testing programs especially HIV prevention programs Components of Early Intervention Services

7. Referral Services: Linkage Agreements (MOU/MOA) and referrals, working with key points of entry to create connections between services and funding streams, Routine X-Provider meetings, face to face contact, providing referral to additional services to meet immediate needs Components of Early Intervention Services

8. Activity of Relationship/Trust building: Creating a bond of trust and safety with the client that extends to the other care givers in the HIV continuum. Instilling confidence in theclient and in the system of care Components of Early Intervention Services-Referral Services

9. Assessment of immediate needs/attitude/knowledge/behaviors/beliefs regarding care/care system Assessment differs from case management and focuses on changing view and knowledge of HIV and care leading to care seeking behaviors Components of Early Intervention Services – Referral Services

10. Health Literacy/Health Education (counseling) Education on the HIV service delivery system How to work with your clinicians How to handle problems and issues Disease progression and managing life with HIV disease Components of Early Intervention Services

11. Access and Linkage to Care: Primary Medical Care (3-4 visits) Medical Case Management Entry into Substance Abuse Treatment Treatment Adherence Bringing others into care System for monitoring and tracking referrals (successful and unsuccessful) Components of Early Intervention Services

12. Testing Referral Services Health Literacy/Health Education Access and Linkage to Care The Four Program Components of Early Intervention Services

13. Early Intervention Services is a combination of all these service elements They must all be present and available to clients as an integral part of the program design They do not all have to be Ryan White Part A or B funded The Four Service Elements Must be Present

14. Early Intervention Services v. Outreach

15. Testing Referral Services Linkage agreements to work with key points of entry Relationship/Trust Building Assessment of immediate need/ attitude /knowledge/behaviors/beliefs regarding care Information dissemination Health Literacy/Health Education (Counseling) Access and Linkage to Care Componentsof Early Intervention Services

16. EIS can be part of a strategy to address unmet need, and EIIHA EIS can focus on getting individuals in care who know their status Emphasis on working with points of entry Can resemble a models of case finding or patient navigation Early Intervention Services & Unmet Need& EIIHA 16

17. Questions and Comments

18. Benefits of the Use of PeersHarold J. Phillips 18

19. Why Use Peers? Letter from HAB/DTTA (2-10-10) said: "Peers are uniquely positioned to effectively engage and help retain PLWH in care and treatment programs and, further, with appropriate training and supervision, they make remarkable contributions to the interdisciplinary team." 19

20. Why Use Peers? Can develop a high level of trust with other PLWH Ability to share their own experiences Role models and proof that people can live productive lives with HIV Personal knowledge of system of care and challenges associated with accessing care Clinicians rarely able to spend significant time with PLWH Cost-effective Particular value with HIV+/unaware and PLWH with unmet need 20

21. Demonstrated Value of Peers Demonstrated effectiveness with other diseases such as diabetes: Bring people into care Reduce missed appointments Improve treatment adherence Reduce complications Reduce emergency room visits Reduce hospitalizations Reduce health care costs 21

22. Designing a Peer-Based Early Intervention Services ProgramEmily Gantz McKay 22

23. Purpose of a Peer-based EIS Program To help people with HIV/AIDS enter and become fully linked to and engaged in HIV/AIDS care Focus typically on populations that are likely to be hardest to reach – Individuals who feel marginalized and disenfranchised PLWH who have trouble navigating the HIV/AIDS service system – often because they have never had a “medical home” PLWH who have had negative experiences with the care system 23

24. Key Questions/Decisions What will be the focus of your EIS program? Should your EIS program pay for testing? What services will peers provide? What won’t they do? What points of entry will be the focus for your program? What about other relationships? What will be the job title for your peers – will they be “peer community health workers”? How will you match peers with PLWH clients? 24

25. Key Questions/Decisions, cont. What characteristics, knowledge, skills, and experience should be identified as required? Preferred? What classroom and practical on-the-job training will you provide? What will be the supervisory requirements? Will you use a central agency for training and support? Will you allow both full- and part-time peers? What about stipends? 25

26. 1. Program Focus Options HIV+/unaware: Early Identification of Individuals with HIV/AIDS (EIIHA) – immediate linkage to care after testing Unmet need:Finding people who know they are HIV+ but have been out of care for at least 1 year and helping them enter/re-enter care Retention in care:Working withPLWH who are loosely connected to care or have missed medical appointments – including recently diagnosed PLWH 26

27. 2. Use of Funds for Testing Factors to consider: EIS is the only service category under Ryan White Parts A and B that can pay for testing Links to testing are essential EIS funds should be used for testing only if existing testing resources are insufficient Peers can be trained to do counseling and testing (even if you don't buy the test kits) 27

28. 3. Services Peers will ProvideConsider: Outreach Testing or testing support Trust building HIV literacy education: living with HIV Education about the system of care Intake support System navigation Coaching/mentoring and support Treatment adherence counseling Follow up Relationship building Support to the clinical team 28

29. 4. Points of Entry and Other Relationships Assignment of peers based on: Specific points of entry Types of entities (e.g., homeless shelters, testing sites, substance abuse treatment programs) Location (e.g., county, neighborhood) Key importance of personal relationships: Points of entry – to contact peer when a person needing help is identified Providers (especially clinics and case management sites) – to inform peer when a client misses an appointment or seems to need peer support 29

30. 5. Job Title Make it descriptive of full range of responsibilities Use a title that helps ensure respect for the peer's role Consider "community health worker" -- now a Bureau of Labor Statistics-recognized profession Explore titles and certification used in your state 30

31. 6. Matching Peers with PLWH/Clients Matching factors: Gender, race/ethnicity, sexual orientation, age Location: specific community or neighborhood Life experience Use of a diverse peer team Other considerations: Young men may relate well to an "older sister" Stigma may mean peer should not be from the same neighborhood or nationality group 31

32. 7. Qualifications Typical Requirements: Peer status Experience with local/regional system of care No excludable criminal convictions – e.g., sex-related felonies, serious violent crimes, recent convictions (within past X years) Education/literacy – can use demonstrated reading comprehension and writing skills needed for record keeping, etc. rather than diploma or degree requirement 32

33. Things to Look For Characteristics Commitment Empathy Interpersonal relations Organization & multi-tasking Judgment Decide what skills are required for selection, and which ones you can teach Knowledge/Skills PLWH population Geographic area How Ryan White programs work Strong, culturally appropriate communications skills Mentoring, coaching Boundaries Computers/record keeping Working with providers 33

34. 8. Classroom & Practical Training Consider 4 phases: Pre-service classroom training (community college or project-developed and run) On-the-job practicum combined with additional classroom training Ongoing on-the-job training, with supervision In-service sessions plus peer network meetings 34

35. Suggested Learning Topics Understanding HIV disease Ryan White programs – legislation, services, policies, guidelines Navigating the system of HIV care Multicultural awareness and competence Developing trust Maintaining professional boundaries Problem solving & crisis management Confidentiality & privacy, including HIPAA requirements Providing emotional support Self-management Self-disclosure Communication skills Medications and treatment adherence 35

36. 9. Supervisory Requirements Specified level of supervision – e.g., hours per week Supervision must ensure: Support for peer model Understanding of EIS program components and requirements Consistently available supervision & support Professional development opportunities Help with relationship building Links to testing Training for supervisors Establishment of supervisors support network 36

37. 10. Use of a Central Agency Structure Options: Centralized: hiring, training, supervision, monitoring and evaluation, with peers assignment to providers Partially centralized:training, supervision, involvement in recruitment, assistance and evaluation; providers hire & supervise Decentralized:multiple providers hire, train, supervise 37

38. Value of Centralized or Partially Centralized Structure Training quality – larger group for training, likely to be more structured, with consistent quality Consistent implementation of model – staff understand program model Cost effectiveness – only one agency develops and delivers training Flexibility– peers supervised day to day (and often hired) by multiple providers, allowing for variations based on population needs and organizational culture Evaluation – single evaluator 38

39. 11. Full or Part Time Peers? Full time:Regular employee, easier to provide benefits, full caseload, good return on training investment Part time:May be needed to protect the health of the peer; allows smaller communities to hire several peers that match different populations or communities Limited Hours due to SSDI/SSI:Allows PLWH on disability to work 30-50% time and keep benefits; allows for a diverse peer team; but smaller individual caseloads Stipends:Peers tend to be hired away by other providers; level of work usually too great for stipends 39

40. Typical Challenges Training Boundaries Personal health issues Compensation Provider and partner attitudes Understanding of EIS Setting limits on work with a single client 40

41. Example: Positive Pathways Pilot Program (DC) Assists HIV-positive African Americans to participate in HIV medical care; focus on women  Funded through Social Innovations Fund Central agency (CommonHealth Action) manages program for Washington AIDS Partnership Training includes formal community health worker certificate program at community college plus HIV-specific training and practical experience CHWs placed community and medical organizations   Peer support group Training and support for supervisors 41

42. Example: Design for New Washington, DC Part A Program Central agency to provide training, oversight, assistance, & evaluation Individual providers to hire and supervise peer community health workers 160 hours of classroom training plus 800 hours of practicum over 6 months Peer and supervisor support networks Both full- and part-time employment Focus on unmet need and PLWH loosely connected to care 42

43. Other EIS & Related Programs People to People (P2P) – started by African American AIDS Task Force, Minneapolis/Saint Paul Part B Program Michigan Programs: Youth Link Program of AIDS Partnership MI – Detroit MI Patient Navigator Program of Sacred Heart Rehabilitation Center – Saginaw Wayne State Physician Group Peer Navigator Program – Detroit Hand in Hand – New Orleans Christie’s Place – San Diego Linking to Care, Positive Connections – Charlotte (no longer operating) 43

44. Resources from Consumer LINC Project "Designing a Peer-Based Early Intervention Program: Components, Strategies, and Key Decisions" Other Consumer LINC project materials Links to other materials See http://www.mosaica.org/Resources/ HIVAIDS/ProjectConsumerLINC.aspx 44

45. Other Resources Community Health Workers National Workforce Study -http://bhpr.hrsa.gov/healthworkforce/chw/ Building Blocks to Peer Success - 2 toolkits - PEER Center, Boston University -http://www.hdwg.org/peer_center/training_toolkit Integrating Peers into Multidisciplinary Teams: 2 toolkits - Cicatelli Associates -http://careacttarget.org/ library/peers/ToolkitForPeerAdvocateSupervisors.pdf “The Utilization and Role of Peers in HIV Interdisciplinary Teams” - HRSA/HAB Consultation -http://hab.hrsa.gov/newspublications/peersmeeting summary.pdf 45

46. Questions and Comments