1. Campaign Webinar Los Angeles County Linkage and Re-engagement Programs March 5, 2014

2. 2 Ground Rules for Webinar Participation Actively participate and write your questions into the chat area during the presentation(s) Do not put us on hold Mute your line if you are not speaking (press *6, to unmute your line press #6) Slides and other resources are available on our website at incareCampaign.org All webinars are being recorded

3. 3 Agenda 1. Welcome & Introductions, 5min 2. Campaign Update, 10min 3. LA DPH, 35min 4. Question and Answer, 10min In the chat room, Enter your: 1. name, 2. agency, 3. city/state, and 4. professional role at agency Michael Hager, MPH MA NQC Manager, in+care Campaign Manager New York, NY

4. 4 Campaign Update

5. 5 in+care Campaign in 2014 Campaign database running through 2018! Campaign website running through 2018! Partners in+care Facebook maintained indefinitely Campaign Newsletter moves to quarterly Campaign Webinars move to quarterly Partners in+care Webinars move to quarterly Campaign Coaching integrates into NQC Continuous TA Portfolios Local Retention Groups that wish to continue meeting should do so – NQC will support where possible

6. 6 Disseminating Improvement Work Lightning Rounds! 1 or 2 slides that contain the most salient points of your retention projects Include information on patient target, rationale for target selection and baseline data from your measures (including the date) Include information on each improvement cycle (what was tried, what was the result per the data) – for early cycles short measures of change are not necessary, but add value! What are your conclusions? How are you sustaining improvement Simplicity and clarity are the idea!

7. 7 in+care Retention Improvement Strategies

8. 8

9. 9 Data Collection Submission Deadline: April 1, 2014

10. 10 Gap Measure Results (12/11 – 2/14)

11. 11 Visit Frequency Measure Results (12/11 – 2/14)

12. 12 New Patients Measure Results (12/11 – 2/14)

13. 13 Viral Load Suppression Measure Results (12/11 – 2/14)

14. Los Angeles County HIV Linkage-to-Care and Re-Engagement Programs: Preliminary Results and Lessons Learned Amy Rock Wohl MPH PhD Division of HIV and STD Programs Los Angeles County Department of Public Health March 5, 2014

15. 15 Navigation Program

16.  Background:  Goal is to re-engage lost HIV clinic patients in HIV care using enhanced locator techniques and modified strengths-based cm intervention (ARTAS)  Participants to-date are out of care (OOC) patients from 4 LAC publicly-funded HIV clinics  Eligibility includes HIV+ patients who have not had a primary care visit in the past 6 mos and last vl >200 copies/ml; or no HIV primary care visits in 12 mos; or newly-diagnosed and never in care  Current status:  Ongoing enrollment

17. Modified ARTAS Intervention Based on ARTAS model Consists of: 4-phases administered over a 90-day period instead of ARTAS 5-sessions Increase in the number of visits per phase to add flexibility (up to 10) Like ARTAS, sessions are 60-90 minutes Intervention PhaseTitle/Content Number of Sessions Maximum Timeframe Phase 1Building the Relationship1-21 week Phase 2Assessment1-21-2 weeks Phase 3Linking to Resources/Enhancing Strengths2-41-8 weeks Phase 4Disengagement1-21-2 weeks

18. Preliminary Data Disposition of 499/636 1 Lost Clinic Patients 1 137 lost clinic patients were found ineligible due to VL/last appointment date 18

19. Most Effective Data Source 1 for Contact Information (n=499) 1 Patient contact data searches were hierarchical starting with clinical medical records, followed by Ryan White Patient database, HIV surveillance, Lexis-Nexis, and Other until patient was successfully contacted 2 HIV Surveillance breakdown: iHARS-LAC=24%, eHARS-CA=15% 3 Includes LAC Inmate locator, CA Prison Locator, STD surveillance database 2 19

20. 20  Race: 13% African American, 77% Latino, 5% White, 2% Asian, 4% Other  Gender : 26% female, 70% male, 4% transgender  Age: 45% 40 yrs  Insurance Status: 61% Uninsured, 36% Public Insurance, 3% Unsure  Substance Use (past 6 months): 5% IDU; 23% any drugs  Current Housing: 90% stable, 8% temporary, 2% homeless  Education: 70% <High School, 30% High School/GED  Employment: 38% employed, 13% disability/SSI/public assistance, 41% unemployed, 8% other  Yearly Income: 52% $15,000 Demographics (n=61)

21. Main Barrier to HIV Care at Time of Enrollment in NAV Intervention (n=61)

22. Needed Services 1 at Time of Enrollment in NAV Intervention (n=61) 1 Participants listed multiple needs 22

23. HIV Testing, Care and Clinical History at Time of Enrollment (n=55 1 ) VariableMinMaxMedianMean Time Since Positive Result9 months17 yrs6.4 yrs7 yrs Time Since Last Medical Appt.21 days3 yrs308 days358 days Last Viral Load Prior To Enrollment (copies/ml) 201,011,6232,22158,046 1 Data pending for 6 patients

24. Intervention, Linkage and Engagement in Care (n=55 1 ) Avg # of NAV visits = 7 (range 3-10) Avg # of hours spent with NAV = 15 (range 2-44) 98% (n=54/55) linked to care (attended 1 HIV medical visit) following intervention enrollment 20 of 34(48%) patients who were enrolled in NAV for at least 6 months engaged in care; (i.e. attended 2 or more medical visits and were referred for long-term case management and retention) NAV patient referrals: housing, substance abuse treatment, mental health, nutrition, transportation, assistance w health insurance and ADAP enrollment 1 Data pending for 6 patients

25. Lessons Learned and Next Steps Preliminary Lessons Learned –More efficient to start with surveillance rather than clinic data to identify OOC patients –HIV surveillance and clinic data provided most useful contact information for finding OOC patients –OOC patients vary in the intensity of intervention needed; NAV needs to work with OOC patients longer to promote long-term engagement in care –Structural roadblocks LACDPH legal concerns with sharing surveillance information Clinic administrative requirements Next Steps –Incorporate lessons learned into county-based LTC program

26. 26 Navigation Program Version 2.0

28. 28 Project Engage

29.  Background:  Goal is to identify OOC HIV+ persons and link them to HIV care  OOC HIV+ persons (alters) are identified through social network referrals from seeds or direct recruitment by staff; alters may recruit OOC persons  Incentives: $40 for baseline survey for seed/alter; additional $40 for seed/alter when alter links to care  Seeds identified from: 1.HE/RR programs at CBOs for at-risk MSM (eg crystal meth support group) 2.HIV clinic patient populations 3.Flyer/pocket card recruitment  Current status:  Ongoing Enrollment 29

30. 30 Flyer Pocket Card

31. Preliminary Results

32. Study Screening and Recruitment  Screened  Seeds: 99  HIV+ Alters: 104 1  Enrolled  Seeds: 56  HIV+ Out of Care Alters: 29  8 (28%) have enrolled as recruiters  21 (72%) have linked to care  Site Specific Enrollment:  APLA: 8 seeds and 20 alters (12 linked)  OASIS Clinic: 12 seeds and 3 alters (all linked)  GLC Clinic: 30 seeds and 3 alters (all linked)  Direct Recruitment: 6 seeds 3 alters (all linked) 32 1 62% were ineligible/not HIV infected per HIV surveillance

33. 33  Out-of-Care Alters (n=29)  Race: 41% African American, 10% Latino, 28% White, 21% Other  HIV Status: 100% HIV-positive  76% MSM; 24% heterosexual  Insurance Status: 38% Insured, 62% Uninsured  Reported Sex Work: 24%  Incarceration History: 86% lifetime, 55% past 12 months  Recent/Current Homelessness: 79%  Illicit Substance Use:  IDU: 48% lifetime, 21% past 3 months  Non-IDU: 62% lifetime, 41% past 3 months  Seeds (n=56)  Race: 42% African American, 22% Latino, 25% White, 11% Other  HIV Status: 75% HIV-positive  96% MSM; 4% heterosexual  Insurance Status: 89% Insured, 11% Uninsured  Incarceration History: 51% lifetime, 4% past 12 months  Reported Sex Work: 7%  Recent/Current Homelessness:16% Demographics

34. Out-of-Care Alters (n=29)  Testing and Care History  Time since 1 st HIV+ test: Avg=10.8 years (range: 3 mos-29 yrs)  Time between 1 st HIV+ test and 1 st HIV doctor visit: Avg=12.8 months (range: 1d-6yrs)  Number of clinics attended: Avg=2.6 (range: 1-20)  ART use: Ever taken= 72%, Currently taking=17%  Readiness to Engage in Care Scale 1  11 “contemplative” about starting care  18 “ready for action” about starting care  Sexual Behaviors (last 6 mos)  # of sexual partners (n=20): Avg=6.5 (range: 1-40)  31% report UAI 34 1 Scoring based on Transtheoretical model of behavior change

35. Characteristics of Out-of-Care Alters  Linkage, Care, VL  Linkage and Care Avg time out of care (n=21): 9.7 mos (range: 0-26) Avg time to link to care (n=21): 12.4 days (range: 0-97) Avg staff time dedicated to link to care (n=28): 373.9 min/6.2 hours (range: 140-840 min)  Viral Load  Last reported vl before enrollment (n=27): Avg=50,184 copies/ml (range: 48-370,660)  Acceptability Survey  Out-of-care alters who linked to care (n=16) stated: Project Engage helped get them into care: 16 Were satisfied with the help they received: 16 Would recommend PE to friends who were out of care: 15  11/16 (79%) stated that without PE, they would not have entered care themselves 35

36. Unmet Needs and Barriers to Care for Out-of-Care Alters  Unmet needs (social & medical services)  Number of unmet needs: Avg=7.7 (range: 1-14)  Most reported not being able to obtain:  Regular HIV care (n=25)  Dental care (n=22)  Medical Case Management/Mental Health Counseling (n=21)  Barriers to Care  Did not know where to obtain services  Experienced disrespect from HIV clinic staff  Challenges completing needed paperwork 36

37. Case Study #1 Case 1 is an older homeless minority MSM who tested HIV positive in 2006. He has been out of care for 26 months. He is a crystal meth user and prostitutes for survival and sleeps in parks and alleys. He reported 5 sex partners in the last 6 mos and was the insertive partner for UAI with all 5 partners. He has been incarcerated several times due to his drug use and prostitution. His physical appearance suggested he was feeling the effects of both his medical and social situation (several lesions on his face and arms, frail body and missing teeth). After enrolling him into Project Engage, he was linked into care in one day (4 hrs PE staff time). He was very excited and happy that someone took such an interest in his situation. After his first treatment appointment, he went back to the park where he hangs out and told his friends about his positive experience. One week later his physical appearance had improved dramatically and he stated that he is on the medication and feeling much better. 37

38. Case Study #2 Case 2 is a 29 year old homeless minority MSM who tested positive anonymously in June 2013 but had never linked to care. His mother gave him and his two sisters up for adoption when he was a child. He became homeless at the age of 18 after his adopted parents passed away and he moved from the midwest to California. He is currently homeless and lives on the streets in Los Angeles. He is a crystal meth user but does not currently engage in prostitution. He has spent time in jail for stealing, drug possession and prostitution. He reported 5 sex partners in the last 6 months and was the insertive partner for UAI for all 5 and also receptive partner with 1 of the 5 partners. He was very well-spoken and was appreciative that a program was in place like Project Engage to help people with HIV link into care. After enrolling into Project Engage, he was linked into care within two days by Project Engage staff (6 hours PE staff time). He is currently working with the HIV clinic staff to secure housing and other needed social services. 38

39.  Preliminary Lessons Learned:  Agency-based recruitment more effective than clinic-based recruitment  A few productive seeds is critical to success  Labor intensive to identify OOC persons  Labor intensive to link OOC persons to HIV care  Capacity needed to help OOC alters obtain photo ID to enroll in medical care/ADAP  LTC intervention needed for some  Next Steps:  Scale up staff (currently 1 FTE); increase incentives?  Expand direct field recruitment at parks/street corners; enhanced recruitment at more CBOs, at- risk youth agency, mobile testing vans, skid row clinic  Add 3-tiered intervention option in next phase  Incorporate into county-based LTC program 39

40. Acknowledgments Saloniki James Rhodri Dierst-Davies Alla Victoroff Sonali Kulkarni Heather Northover Jeff Bailey Brian Risley 40

41. 41 Question & Answer

42. 42 Campaign Headquarters: National Quality Center (NQC) 90 Church Street, 13 th floor New York, NY 10007 Phone 212-417-4730 incare@NationalQualityCenter.org incareCampaign.org youtube.com/incareCampaign