Integrating HIV Prevention and Care Services

State: IL Type: Promising Practice Year: 2015

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HIV/AIDS is a significant public health issue in the United States. CDC estimates that 1.2 million people aged 13 years and older are now living with HIV infection, and an additional 50,000 new HIV infections occur every year. One out of five people with HIV are unaware of their infection. About one in four new HIV infections is among youth ages 13-24, most of whom do not know they are infected, are not getting treated, and can unknowingly pass the virus on to others. There are tremendous disparities in HIV prevalence and care. Gay, bisexual, men who have sex with men (MSM) and African Americans bear a greater burden of HIV.

As our understanding of HIV/AIDS grows and effective treatments are developed, more focus is put on the needs for new HIV prevention services. However, in current practice, HIV prevention and HIV care services are separate. This lack of integration is inefficient and compromises the quality of HIV services. To address the limitations of current practice, Champaign-Urbana Public Health District (CUPHD) aims to 1)increase program capacity, 2) increase access to partner services, and 3) increase linkage to medical care through a merger of prevention and care staff.  The ultimate goals are to 1) improve the quality and continuum of HIV care, 2) reduce the transmission of HIV and 3) achieve cost sharing through the integration of prevention and care services .

To successfully integrate prevention and care services, CUPHD developed a quality improvement plan based on the National Association of County and City Health Officials’ (NACCHO) strategic planning guide.  The primary activity of the merger was to cross-train staff to provide both HIV prevention and care services. Care coordinators received both onsite and IDPH training. Changes are made from both programmatic and cost perspectives.

 

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Champaign-Urbana Public Health District
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Integrating HIV Prevention and Care Services
CUPHD, recently accredited by the Public Health Accreditation Board in 2014, is the local public health authority for the Cities of Champaign and Urbana and Champaign County, Illinois. Champaign County is located in east central Illinois and is 998.39 square miles with a population density of 201.8 people per square mile. Champaign County is an exemplar micro-urban community and a statewide leader in progressive education, health care, government, high technology, light industry and agriculture. In 2013 the US Census Bureau estimated the population to be 204,897 residents, a 1.9% increase since 2010. CUPHD has a mission to improve the health, safety and wellbeing of the community through prevention, education, collaboration, and regulation. Currently, with a budget of over $11 million and a staff of 120, CUPHD has expanded to meet countless needs in the Champaign-Urbana community. CUPHD's multi-disciplinary program staff has expertise in program design, implementation and evaluation. CUPHD has very accomplished employees in outreach, health education, nursing, epidemiology, finance, information technology, social marketing, and public relations. HIV/AIDS is a significant public health issue in the United States. CDC estimates that 1.2 million people aged 13 years and older are now living with HIV infection, and an additional 50,000 new HIV infections occur every year. One out of five people with HIV are unaware of their infection. About one in four new HIV infections is among youth ages 13-24, most of whom do not know they are infected, are not getting treated, and can unknowingly pass the virus on to others. There are tremendous disparities in HIV prevalence and care. Gay, bisexual, men who have sex with men (MSM) and African Americans bear a greater burden of HIV. With advances in HIV treatment, more people are now living longer with the disease. This combined with a disproportionate number of people diagnosed with AIDS where were previously unaware of their status point towards the need to better reach HIV-infected individuals with information about taking care of themselves and to improve strategies to prevent transmission to others. As our understanding of HIV/AIDS grows and effective treatments are developed, more focus is put on the needs for prevention services. However, in current practice, HIV/AIDS prevention and care are separate. The lack of integration of HIV/AIDS prevention and care is inefficient and compromises quality of HIV services. To address the limitations of current practice, the current practice aims to 1) increase program capacity, 2) increase access to partner services, and 3) increase care linkage through a merger of prevention and care services. The ultimate goals are to improve the quality and continuum of care and achieve cost sharing through the integration, and reduce the transmission of HIV. To successfully integrate prevention and care services, the practice developed a quality improvement plan based on the National Association of County and City Health Officials’ (NACCHO) strategic planning guide. The primary activity of the merger was to cross-train care coordinators so that they can provide both prevention and care services. Care coordinators received onsite and outside training. Changes are made from both programmatic and cost perspectives.  Results/outcomes:  The current practice is a timely response to the CDC's goal of creating a future free of HIV. With the advances in HIV treatment, more people are now living longer with the disease. This combined with a disproportionate number of people diagnosed with AIDS who were previously unaware of their status point towards the need to better reach HIV-infected individuals earlier with information about receiveing treatment, managing their health and and to improve strategies to prevent transmission to others. This would not be achieved or would be difficult to achieve under the fragmented/separated prevention and care services system. Under the new coordinated HIV services, program integration will allow for more holistic, wrap-around care and to reduce new infections. The new coordinated care system is one step forward achieving a future without HIV.  CUPHD website is http://www.c-uphd.org    
HIV/AIDS is a significant public health issue in the United States. CDC estimates that 1.2 million people aged 13 years and older are now living with HIV infection, and an additional 50,000 new HIV infections occur every year. One out of five people with HIV are unaware of their infection. About one in four new HIV infections is among youth ages 13-24, most of whom do not know they are infected, are not getting treated, and can unknowingly pass the virus on to others. There are tremendous disparities in HIV prevalence and care. Gay, bisexual, men who have sex with men (MSM) and African Americans bear a greater burden of HIV. With advances in HIV treatment, more people are now living longer with the disease. This combined with a disproportionate number of people diagnosed with AIDS where were previously unaware of their status point towards the need to better reach HIV-infected individuals with information about taking care of themselves and to improve strategies to prevent transmission to others. The target client population of the practice goes beyond the jurisdiction of CUPHD and includes people in Region 6 of the Illinois HIV Care Connect Program. In Region 6, there are about 900-1000 people identified as HIV-positive. Males, African American, MSM, IDU, MSM+IDU, and high-risk heterosexuals (HRH) are overrepresented. The population with the highest risk for HIV transmission is young, African American MSM. This points to the direction of catering to high-risk populations to use resources more effectively. In Champaign County, although the confirmed incidence of HIV infection is low, the high percentage of young people (nearly half of its population is below the age of 24, with a quarter between 18-24) poses potentially high risk of growing HIV infection within this region. Over the past 3 decades, a portfolio of proven strategies have been developed to reduce the risk of HIV transmission, including HIV testing, partner services, antiretroviral therapy, substance abuse treatment, access to condoms and sterile syringes, and screening and treatment for other sexually transmitted infections (CDC, 2011). However, like the nation's health care system, the current HIV prevention and care delivery system is fragmented at best. These evidence-based approaches to HIV prevention and care are not well integrated or coordinated from both a programmatic and cost perspective. For example, prior to the merger, HIV prevention and care at the Division were completely separated: prevention specialists and care specialists worked separately with different client populations and there was little communication between groups. When a client came in, the prevention specialist would try to get the client tested and provide preventive services only. If the client tested positive for HIV, the preventive staff could not provide adequate follow-up care services due to program constraints and lack of training in care services. Because the two systems were not allowed to share information, it was impossible to know whether adequate follow-up care was administered to those who tested positive for HIV. The lack of coordination also makde it difficult to provide prevention services for those tested HIV+, again due to program constraints and lack of training in prevention services among care specialists. The inefficiency and lack of coordination of the current HIV prevention and care services has been recognized in the newest strategic plan of the CDC's of HIV/AIDS Prevention 2011-2015. In the strategic plan, the CDC highlighted the importance of prioritizing the allocation of prevention resources, careful monitoring and constant re-evaluation, and intensive and sustained collaboration and coordination with partners. It recommended a comprehensive approach to HIV care that emphasizes prevention with people living with HIV and linkage to and retention in care. Accordingly, the CDC's new mandates now require programs to document and report complete referrals and care linkages. In response to the CDC's strategic plan and based on a careful evaluation of the current service delivery at the Infectious Disease Division of CUPHD, we decided to merge the prevention and care services and developed a quality improvement plan based on the National Association of County and City Health Officials’ (NACCHO) strategic planning guide to successfully create a seamless services delivery system from HIV testing to entry into medical care for HIV positive clients. According to our knowledge, this merger is the only one of its kind in public health HIV services division. The current practice is better in several ways. The merged system improves efficiency and effectiveness, improves clients' retention in services, increases care linkages, and conforms better with the CDC's mandate. Integration of care is an evidence-based approach, recommended by leading health bodies such as the CDC, HRSA, The Henry J. Kaiser Foundations, NASTAD, and independent researchers across the United States (CDC, 2011; HRSA, 2011; Henry Kaiser Foundation, 2004).
Goals of the current practice include 1) increase program capacity, 2) increase access to partner services, and 3) increase care linkage through a merger of prevention and care services. The ultimate goals are to 1) improve the quality and continuum of care 2) reduce the transmission of HIV, and 3) achieve cost sharing through the integration of prevention and care services. CUPHD is the responsible agency that implements the practice. More specifically, the integration is carried out in the Division of Infectious Disease. CUPHD's administration is involved in the implementation. The current practice aims to 1) increase program capacity, 2) increase access to partner services, and 3) increase care linkage through the integration of prevention and care services. By creating seamless services from HIV testing to entry into medical care for HIV positive clients, our HIV care services are more efficient and effective. To successfully integrate prevention and care services, the practice developed a quality improvement plan based on the National Association of County and City Health Officials’ (NACCHO) strategic planning guide. The primary activity of the merger was to cross-train care coordinators so that they can provide both prevention and care services. A total of nine care coordinators went through __ days of training on site at CUPHD. In addition, selected care coordinators attended additional trainings outside of CUPHD, including the National Quality Center's training on coaching basics in Chicago and the IDPH Ryan White quality management training. We also plan to increase outreach testing and continue opt-out HIV testing in CUPHD's STD clinic to increase the number of persons tested for HIV in CUPHD program; provide the CDC Effective Behavioral Intervention ARTAS to eligible clients; and establish a peer-run program to engage HIV positive clients in medical care. Time frame:  The design and implementation of the practice involved a number of important stakeholders including program directors, prevention specialists and case managers from the division of Infectious Disease, administration of CUPHD, and community partners and clients. Peer navigators and staff from other agencies in the community who serve the same target population provided input on the current services, recommendations for change, and support to others in the community affected by HIV/AIDS. The Center for Disease Control and Prevention (CDC) and the Ryan White HIV/AIDS program will serve as the advising agencies that will assist in the plan’s implementation. They will offer training resources to cross-train staff in prevention and care strategies. Illinois Department of Public Health (IDPH) will also serve as an advising body offering recommendations on the processes of the plan. IDPH will have a special role as the funding body of the plan. Peer navigators will be recruited through case managers, HIV clinics in the community, and then interviewed to become part of the committee. They will be invited to participate in committee meetings and a monetary incentive will be provided for their participation in the planning process. Start-up costs:  Existing staff was incorporated into this new model of care. Existing grant funds were used to develop the staff skills needed for this merger.  Staff recorded the time spent in each discipline to the corresponding cost center in the on-line time management system.  No new staff were added in response to this merger. It was our intent to keep this merger low cost and sustainable to be able to replicate to other communities. A total of nine staff members spent approximately 20 hours of their time to develop new skills. This would amount to approximately $5000 worth of personnel time which was a one-time cost associated with this merger. We do not anticipate any additional on-going cost to this program. There were no indirect costs associated with this merger.    
The objectives of the current practice were to 1) increase program capacity, 2) increase access to partner services, and 3) increase care linkage through the integration of prevention and care services. At the time of writing this application, we have just competed the merger and we are still in the process of refining and collecting outcome measures. So far we have conducted a care coordinator survey to evaluate the merger process and perceived effectiveness from the staff perspectives. The survey was delivered via C-UPHD’s SurveyMonkey ® account and was completed by all 8 members of the care coordination staff. The overall perception of the merger has been positive. The majority of the responses to the survey showed positive attitudes towards cross-training, and perceived increase in communication/workflow efficiency. For example, in both the Likert-type scale questions in the sections covering perceived merger effectiveness and progress in working cooperatively among all of the care groups as been on average “agree”. Areas of note are the training session effectiveness. Most answers were between “agree” and “strongly agree” with statements regarding the perceived value of the training sessions and the way in they were delivered. In the free response question of this section, when asked how C-UPHD could improve the delivery of the training sessions, a majority of employees asked for more training sessions or follow-up/refresher training sessions to reinforce the ideas taught. There were areas that had a more mixed reception from the staff. Those include the integration of the peer staff into the overall merger. The Likert scale question for the peer staff’s integration into the care coordination staff was very mixed. Answers ranged across the scale, centered at “neutral/unsure”. In the free response question, the staff requested that there be more interaction with the peer staff to help understand what they do and how they can be incorporated into the work that the care coordination staff does. This perhaps can be the next step in the merger’s progress, acknowledging more of what the peer staff’s contributions are to the continuum of care. Another area of focus based on the free response questions was improving the fluidity and speed of communication between staff members. Common among the comments made were improvements for quicker replies to emails, presence of supervisors at meetings, and more open conversations about tasks in the prevention role and individual check-ins between staff and supervisors. Though to note, when asked if the staff believed the care coordination staff have NOT been working effectively together, most responses were in disagreement or strong disagreement.  Finally, in terms of staff reporting of client-level concerns, there was very little concern about the way services were being delivered as a merged model. Rather, it was focused on the general scarcity or delayed delivery of resources. For example, patients had to wait too long for results or the inability to offer resources when funding is scarce.  Overall, it would appear the merger is doing well in its first year of progress. The care coordination staff is generally pleased with the services they can provide and believes the merger has been effective in combining the prevention care and medical casework roles.
The merger is a more efficient use of resources and can theoretically achieving cost sharing. So compared to the old practice, the current practice is more sustainable since this was more efficient and no new staff or resources were added. We anticipate a cost saving from these programs in the long run, so these are definitely sustainable.
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