Upper Manhattan Regional Group Learning Session January 16th, 2014 WEL

Transcription

1 Upper Manhattan Regional Group Learning Session January 16th, 2014 WELCOME Systems Linkages and Access to Care for Populations at High Risk for HIV Infection in New York State

2 Welcome For Today s Introductions... As a team, please complete the (Pink) Linkage and Retention Connections form Select a staff member to share the information after introductions. Time will be allotted for initial connections amongst agencies.

3 Welcome and Opening Remarks Clemens Steinbock, MBA

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5 Question 1: Who invents new ideas?

6 [NY Times, February 28, 2013]

7 Discovery - conference table not Question: What are the processes involved in scientific discovery and the importance of social context? Study: data for one year were collected from four leading molecular biology laboratories (initial background search, pre/post interviews, taping of lab presentations) Findings: a) use of negative evidence to discard their hypothesis; b) knowledge transfer from same/other disciplines; c) importance of social context microscope [Kevin Dunbar, How Scientists Really Reason, 1995, MIT Press]

8 If you want improvements, then you need interactions.

9 Question 2: Do I need all the information (or just a gut feeling) to start to improve?

10 Detroit or Milwaukee?

11 [Goldstein, Psychological Review 109, 75-90, 2002] Less is more effect Which city is bigger? Study: testing of German and American students which cities in Germany and the US are larger Findings: American cities got 71% of American cities right and 73% German cities right Conclusion: the more knowledgable group makes worse inferences than a more knowledgable group

12 Less knowledge is often more.

13 Question 3: When we improve, do we need those who disagree?

14 Video Postcard...

15 It takes one dissenter Study: groups of seven individuals (one subject and 6 study participants) to match a particular line with one of three comparison lines; first two rounds everyone agrees, last round 6 participants agree on an incorrect line Results: 37% of people erred in which group pressure supported the incorrect answer; existence of at least one voice of dissent dramatically reduced conformity and error (75% error reduction] [Solomon Asch, Opinions and Social Pressure, Readings about the Social Animal 13, 1995]

16 Remember: Quality improvement is a contact sport.

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18 Welcome - Introductions Steve Sawicki

19 Overview Susan Weigl

20 NYLinks - Regional Groups What are we trying to accomplish? Silos Belong on Farms To strengthen collaboration, accelerate learning and spread of effective strategies across the continuum of HIV testing, linkage, engagement and VLS. Ultimately, to reduce the transmission of HIV across the state.

21 Our Approach Bridge systemic gaps among HIV related services within a region/state. Improve systems for monitoring, recording, and accessing information about retention and linkage to HIV care in NYS. Evaluate/identify innovative linkage and retention interventions and disseminate successful findings for replication

22 Engagement in Care Continuum Non-Engager Sporadic User Fully Engaged [1] Health Resources and Services Administration, HAB. August Outreach: Engaging People in HIV Care Summary of a HRSA/HAB 2005 Consultation on Linking PLWH Into Care. [2] Eldred L, Malitz F. Introduction [to the supplemental issue on the HRSA SPNS Outreach Initiative]. AIDS Patient Care STDS 2007; 21(Suppl 1):S1 S2.

23 Today s Work...

24 What We Hope to Accomplish Today Consider the prospect of the End of AIDS. Use surveillance data to understand the HIV care continuum in the region, indentify gaps, and discuss ways to further impact the regional cascade. Assess individual agency progress in 2013 in key areas to assure progress in 2014 Learn more about existing linkage and retention strategies & NYLinks Interventions Manuals Refocus our efforts based upon the aforementioned work and plan for 2014 (agency QI team planning)

25 Day-At-A-Glance 8:30am 12:00pm Welcome Opening Remarks Meeting Overview Linkage and Retention Connections & Meet-Up The End of AIDS Impacting the HIV Treatment Cascade in Upper Manhattan 12:00 Lunch - Peer Resources, Response Team, New Member Meet-Up 1:15pm 3:30pm Consumer Involvement in QI/QM Reports From the Field NYLinks Interventions Team Assessment and Planning Moving Forward

26 Linkage and Retention Connections Susan Weigl

27 Linkage & Retention Connections A Staff member: Instructions Please, share one area of expertise or tool that your team sees as critical to its work in successfully linking or retaining PLWHA in primary care

28 Linkage & Retention Connections Instructions During Sharing... Consider the needs, gaps and concerns related to your linkage or retention QI work for which you would like assistance from colleagues. Keep notes of the agencies and people you are interested in speaking with. We will allow time for this initial connection.

29 Upper Manhattan Addiction Research and Treatment Corporation AIDS Service Center Boriken Neighborhood Health Center Center for Comprehensive Health Practice Community Healthcare Network Harlem United Institute for Family Health Iris House Lenox Hill Hospital Mount Sinai Medical Center - Jack Martin Clinic New York Presbyterian Hospital - Columbia University Medical Center - Comprehensive HIV Program New York Presbyterian Hospital Center for Special Studies NYC Health and Hosp. Corp. - Metropolitan Hospital Center Virology Clinic NYC Health and Hosp. Corp. - Harlem Hospital Center Settlement Health and Medical Services St. Luke's Roosevelt Union Settlement William F. Ryan Community Health Center Network

30 African Services Beth Israel Medical Center - MMTP Clinics NYC Health and Hosp. Corp. - Renaissance Healthcare Network Lenox Safe Horizon Upper Manhattan

31 Linkage and Retention Meet-Up! Compare notes with your team and divide-up to reach out to those agencies you are most interested to learning from and/or linking more strongly to. You will have 10 minutes to initiate contact and discuss the information that is of interest/importance to your team s QI work. Ideally, you will leave this meet-up with contact names, phone number/ and one next-step for follow-up at a later date.

32 Meet-Up Challenge! Two Winners! Agency that collects the most names and phone numbers Two agencies with concrete next steps for collaboration on linkage and retention QI project work Please be sure to hand in your pink slip. We will use these for future collaboration.

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49 THE END OF AIDS: HIV IN NYC Adriana Andaluz, MPH Director, External Affairs Bureau of HIV/AIDS Prevention & Control Upper Manhattan Collaborative Meeting --NY Links January 16, 2014

50 HIV/AIDS IN NEW YORK CITY, ,141 new HIV diagnoses 2,529 HIV without AIDS 612 HIV concurrent with AIDS (19.5%) 1,889 new AIDS diagnoses Includes 612 concurrent HIV/AIDS diagnoses 114,926 persons living with HIV/AIDS 1.4% of the population of NYC 1,578 deaths among persons with HIV/AIDS (14.9 deaths per 1,000 persons) As reported to the New York City Department of Health and Mental Hygiene by September 30, 2013.

51 AN IMPORTANT PRECEDENT IN NEW YORK: NEAR ELIMINATION OF MTCT Perinatally HIV infected children (N=3,983), by year of birth and current vital status, NYC *Data for 2012 is incomplete due to reporting lag. Data as of August, New York City Department of Health & Mental Hygiene, Bureau of HIV/AIDS Prevention and Control

52 TRENDS IN HIV/AIDS: NYC, New York City Department of Health & Mental Hygiene, Bureau of HIV/AIDS Prevention and Control

53 Poverty levels, NYC HIV diagnosis rates, NYC 2012 Poverty levels, NYC HIV diagnosis rates, NYC 2012

54 NEW DIAGNOSES AND INCIDENCE ESTIMATES NYC, * 2012 incidence data are preliminary. ¹Estimates generated September 2013, by the CDC Stratified Extrapolation Approach (SEA). New York: New York City Department of Health and Mental Hygiene. HV Surveillance Annual Report Released December 1, 2013.

55 ESTIMATED HIV INCIDENCE AMONG MSM, OVERALL AND BY AGE GROUP, NYC * 2012 incidence data are preliminary. ¹Estimates generated September 2013, by the CDC Stratified Extrapolation Approach (SEA). New York: New York City Department of Health and Mental Hygiene. HV Surveillance Annual Report Released December 1, 2013.

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57 ACUTE HIV INFECTION, BY TRANSMISSION RISK CATEGORY, NYC

58 ACUTE HIV INFECTION AMONG MSM, BY RACE/ETHNICIT Y AND AGE GROUP, NYC 2012

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60 HIV DIAGNOSIS RATES AMONG YEAR OLD FEMALES BY RACE/ETHNICITY, NYC 2012 HIV dx rates among black >3x than Hispanic and >12x higher than white in NYC >3x >12x

61 MAXIMIZING A COMBINATION APPROACH TO REACH AN END TO AIDS IN NYS Treatment of STIs Grosskurth H, Lancet 2000 Treatment as Prevention Donnell D, Lancet 2010 Cohen, NEJM, 2011 Condoms Behavioral positive prevention Fisher J, JAIDS 2004 PrEP Grant R, NEJM 2010 (MSM) Baeten J, 2011 (Couples) Paxton L, 2011 (Heterosexuals) HIV Prevention Tool Kit Post Exposure prophylaxis (PEP) Scheckter M, 2002 HIV Testing Coates T, Lancet 2000 Linkage & Retention

62 PRIMARY PREVENTION Biomedical Strategies Post-Exposure Prophylaxis (PEP) SBH clinics provision to uninsured persons STD clinics exploring strategies to expand access on-site Development of new health materials for distribution CME course for primary care/ed clinicians Pre-Exposure Prophylaxis (PrEP) STD PrEP Survey SBH clinics PrEP education and linkage on-site Development of new health materials for distribution CME course for primary care/ed clinicians.

63 ALL HANDS ON DECK

64 THANK YOU

65 DEFINING THE END OF THE AIDS EPIDEMIC IN NEW YORK STATE January 16, 2014 Johanne Morne Adriana Andaluz Carol-Ann Watson

66 Community Response New York State HIV/LGBT Advocacy and Service Provider Community June 3, 2013 Re: The future of the AI and End of AIDS Dear Gov. Cuomo: Revitalizing the response: What would be the key elements of a NYS Plan to End AIDS?

67 Cascade of HIV Care New York State, , , ,000 Estimated HIV Infected Persons Persons Living w/ Diagnosed HIV Infection Cases w/any HIV Care during the year* Cases w/continuous care during the year** Virally suppressed ( n.d. or <200/ml) at test closest to mid-year * Any VL or CD4 test during the year ** At least 2 tests, at least 3 months apart 60,000 74,000 85,000 55% of infected 65% of PLWDHI 48% of infected 57% of PLWDHI 131,000 39% of infected 46% of PLWDHI 71% of cases w/any care 154,000 85% of infected

68 AIDS Institute Priorities Priority 1 Increase HIV viral load suppression among PLWHA Priority 2 Maximize participation in health insurance programs Priority 3 Launch a coordinated effort to reduce new HIV and STD infections among gay men and men who have sex with men (MSM). Priority 4 Enhance statewide public health efforts addressing hepatitis C (HCV) Priority 5 Promote interagency collaboration to address sexual health awareness, education, and treatment and care options for sti(s).

69 Community discussions Six Defining the End of the AIDS Epidemic in New York State meetings held across New York State Over 300 participants New York City Capital District Syracuse Region [including Binghamton] Updates provided at State advisory and planning meetings AIDS Advisory Council Statewide AIDS Service Delivery Consortium Prevention Planning Group Interagency Task Force on HIV/AIDS Updates provided at community based meetings University at Albany Updates provided at AI staff meeting, AI management meeting

70 Priorities are from multiple sectors Key stakeholders Community members State, city and local governments Academia Health professionals Community based providers Public and private sectors

71 Key Framing Questions What is effective community messaging and media? Community messaging must be sensitive and targeted to each community/population. Think of community messaging as layers for each target population. Develop messaging for both high risk HIV negative and positive persons. Promote the use of phone applications and social networking to deliver community messaging. Utilize empowering community messages. Engage print and social media venues.

72 Key Framing Questions What is the community perception of End of AIDS? The phrasing End of AIDS promotes stigma. In some communities there is a perception that the state has achieved the End of AIDS making it no longer a priority. In some communities the End of AIDS is being confused with having an available vaccine or having an undetectable viral load. To achieve the End of AIDS, HIV can not be regarded as just another chronic disease. Community members are concerned that the End of AIDS will not protect or address the needs of individuals living with HIV/AIDS. To achieve the End of AIDS policy makers must identify and remove NYS laws that promote the criminalization of HIV/AIDS.

73 Key Framing Questions Who else needs to be at the table? Diverse consumer representation including members of the Latino community Behavioral health providers Union representatives Youth and Senior representatives Medical providers DOCCS representatives LGBT representation; Trans women of color Sex workers Members of the faith community Public and private sector representatives

74 Key Framing Questions What is the role of Prevention in the End of AIDS movement? Develop targeted prevention strategies to ensure access to safe, stable and affordable housing/homelessness as primary and secondary prevention Develop targeted prevention strategies to address homophobia Develop effective and innovative behavioral interventions; utilize a peer model Target prevention interventions to youth and seniors Promote sexual health education in NYS education systems Prioritize prevention interventions within DOCCS facilities Ensure prevention messages align across the board Prioritize human rights at the forefront of the conversation

75 Defining the End of AIDS Priorities Policy Simplified consent for HIV Testing Enhanced data sharing between the State Health Department and healthcare providers Removal of condoms as evidence in statute Decriminalization of syringes Affordable, safe and stable housing for low income individuals; 30% rent cap on total income spent towards rent for low-income PLWHA; expand NYC HASA eligibility requirements Enhanced DOH oversight of DOCCS (Department of Corrections and Community Supervision) for Hepatitis C and HIV treatment and care

76 Defining the End of AIDS Priorities Prevention Syringe Access programs Proposed Medicaid Redesign programs Health Homes Prevention and Outreach Services Treatment Adherence programs to target high risk populations [sub populations] Increased access to culturally and linguistically appropriate prevention and health care services for undocumented immigrants living with HIV/AIDS, women and women (of color) Prevention Continuum that prioritizes innovative behavioral interventions Additional HIV testing sites and enhanced integration of 4 th generation testing

77 Defining the End of AIDS Priorities Bio medical interventions Promote and ensure access to npep and PrEP in the community and within DOCCS facilities ARV access

78 Defining the End of AIDS Priorities Access to Care Special Needs Plans (Model) ADAP Medicaid Managed Care NY State of Health and insurance exchanges Health and Recovery Plans (HARPS) Medicare

79 Structural Barriers Transportation Food Security Vocational/ Educational Housing Stability Mental Health Social Support Substance Abuse Poverty Immigration Cultural

80 Defining the End of AIDS Priorities Enhance Data Sharing Surveillance Enhance data collection practices [LGBT]

81 METRICS Clinical Prevention Pharmacology Community Engagement Costs and cost savings Transmission rate of.5% [730 infections] Progression of HIV to AIDS Stigma and Discrimination Expansion of HIV quality indicators within the managed care setting

82 Markers Associated with Successful HIV Management Available from NYS Surveillance System Proportion of newly diagnosed persons with concurrent AIDS Median CD4 count at diagnosis Proportion of persons with late HIV diagnosis (AIDS within 1 year of HIV diagnosis) Proportion of newly diagnosed persons linked to clinical care within 3 months of HIV diagnosis Proportion of persons living with diagnosed HIV infection (PLWDHI) in continuous medical care Proportion of PLWDHI with viral load suppression Number and proportion of persons with a new AIDS diagnosis who had an HIV diagnosis at least 30 days prior to the AIDS diagnosis Available from other data sources Stable housing Antiretroviral (ARV) access ARV adherence Rates of HIV testing among the population Data not currently available Access to mental health services NYSDOH/AI/BHAE

83 Defining the End of AIDS Priorities Messaging Provider and consumer education Targeted messaging to HIV high risk negative and positive individuals Address stigma and discrimination Ensure messages are aligned Support prevention and clinical practices that are person centered

84 Defining the End of AIDS Priorities Resources Ensure ARV access for all Fund targeted prevention and health care practices Specialty services such as transition coverage for transgender men and women Review of existing funding and funding allocations

85 Developing the Plan/Statewide Input and next steps Priority points of all community meetings across New York State. Inform the State on community needs and priorities to achieve the End of AIDS in New York State by Potentially inform a Governor appointed Task Force to work in cooperation with state, city, local governments and the community to implement a statewide plan to achieve the End of AIDS in New York State by Continued collaboration and partnership. Bi monthly community calls to provide updates and seek input.

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87 Johanne Morne AIDS Institute

88 Break? Susan Weigl Group

89 HIV In Upper Manhattan: The HIV Treatment Cascade, Surveillance Data, and Our Collaborative Reach Susan Weigl Group

90 CDC Cascade 82% 66% 37% 33% 25% MMWR December 2, 2011 / 60(47);

91 * Any VL or CD4 test during the year ** At least 2 tests, at least 3 months apart Cascade of HIV Care New York State, , , ,000 Estimated HIV Infected Persons Persons Living w/ Diagnosed HIV Infection Cases w/any HIV Care during the year* Cases w/continuous care during the year** Virally suppressed ( n.d. or <200/ml) at test closest to mid-year 61,000 74,000 85,000 55% of infected 65% of PLWDHI 48% of infected 57% of PLWDHI 131,000 39% of infected 46% of PLWDHI 72% of cases w/any care 154,000 85% of infected

92 * Any VL or CD4 test during the year ** At least 2 tests, at least 3 months apart Cascade of HIV Care New York State, , , ,000 Estimated HIV Infected Persons Persons Living w/ Diagnosed HIV Infection Cases w/any HIV Care during the year* Cases w/continuous care during the year** Virally suppressed ( n.d. or <200/ml) at test closest to mid-year 61,000 74,000 85, , ,000 23,000 46,000 11,000 13,000 = 93,000

93 * Any VL or CD4 test during the year ** At least 2 tests, at least 3 months apart Cascade of HIV Care New York State, , , ,000 Estimated HIV Infected Persons Persons Living w/ Diagnosed HIV Infection Cases w/any HIV Care during the year* Cases w/continuous care during the year** Virally suppressed ( n.d. or <200/ml) at test closest to mid-year 61,000 74,000 85, , ,000 Testing Linkage/ Re-Engagement Retention Adherence

94 Cascade of HIV Care New York City, , , ,000 Estimated HIV Infected Persons Persons Living w/ Diagnosed HIV Infection Cases w/any HIV Care during the year* Cases w/continuous care during the year** Virally suppressed ( n.d. or <200/ml) at test closest to mid-year * Any VL or CD4 test during the year ** At least 2 tests, at least 3 months apart 48,000 67,000 59, ,000 56% of infected 65% of PLWDHI 49% of infected 57% of PLWDHI 40% of infected 46% of PLWDHI 71% of cases w/any care 120,000 86% of infected

95 HIV Surveillance Data for Upper Manhattan, 2011 Kelly Piersanti, MPH Denis Nash, PhD, MPH NY Links Evaluation Team, CUNY SPH

96 Aims of Presentation What surveillance can do for NY Links, and its limitations Mapping current interventions onto the cascade Who is missing, and who are they? Using surveillance to identify gaps, and to assess whether implemented interventions are successful at closing them

97 HIV care cascade for newly diagnosed PLWH in NYC and Upper Manhattan, Total newly diagnosed¹ N=394 N=3,205 Linked timely to care² 62% 62% Retained in care³ 41% 45% Viral suppression within 6 months of diagnosis⁴ 29% 27% Viral suppression within 12 months of diagnosis⁴ 41% 41% 0% 20% 40% 60% 80% 100% 1 As reported to the New York City HIV Surveillance Registry (NYC HSR) by June 30, Timely linkage to care is defined as 1 CD4/VL reported to the NYC HSR 8-91 days post diagnosis. 3 Retention in care is defined as 1 CD4/VL test reported to the NYC HSR during each 4 month period in the 12 months immediately following diagnosis. 4 Suppressed viral load is defined as a patient's most recent viral load quantity reported to the NYC HSR within 6 or 12 months of diagnosis was 200 copies/ml. Diagnosed by an UMRG NY Links provider Diagnosed by a non-ny Links provider, rest of NYC

98 HIV care cascade for newly diagnosed PLWH in NYC and Upper Manhattan, Total newly diagnosed¹ N=337 N=3,137 Linked timely to care² 67% 68% Retained in care³ 47% 49% Viral suppression within 6 months of diagnosis⁴ 33% 44% Viral suppression within 12 months of diagnosis⁴ 49% 57% 0% 20% 40% 60% 80% 100% 1 As reported to the New York City HIV Surveillance Registry (NYC HSR) by June 30, Timely linkage to care is defined as 1 CD4/VL reported to the NYC HSR 8-91 days post diagnosis. 3 Retention in care is defined as 1 CD4/VL test reported to the NYC HSR during each 4 month period in the 12 months immediately following diagnosis. 4 Suppressed viral load is defined as a patient's most recent viral load quantity reported to the NYC HSR within 6 or 12 months of diagnosis was 200 copies/ml. Diagnosed by an UMRG NY Links provider Diagnosed by a non-ny Links provider, rest of NYC

99 % of new diagnoses with a VL 200 copies/ml 100% Evidence of VLS within 6 months of Diagnosis 80% UMRG collaborative begins Jan % 47.3% 40% 39.0% 20% Patients diagnosed by UMRG NY Links provider Patients diagnosed by non-ny Links provider (rest of city) 0% Jan - Mar 2009 Apr - Jun 2009 Jul - Sep 2009 Oct - Dec 2009 Jan - Mar 2010 Apr - Jun 2010 Jul - Sep 2010 Oct - Dec 2010 Jan - Mar 2011 Apr - Jun 2011 Jul - Sep 2011 Oct - Dec 2011 Jan - Mar 2012 Apr - Jun 2012 Quarter diagnosed

100 % of PLWDHI in care in the time period who were retained in care Retention Among All PLWDHI in Care 100 UMRG collaborative begins Jan PLWH in care at UMRG NY Links provider PLWH in care at non-ny Links provider (rest of city) 0 Jan - Mar 2009 Apr - Jun 2009 Jul - Sep 2009 Oct - Dec 2009 Jan - Mar 2010 Apr - Jun 2010 Jul - Sep 2010 Oct - Dec 2010 Jan - Mar 2011 Apr - Jun 2011 Jul - Sep 2011 Oct - Dec 2011 Jan - Mar 2012 Time period

101 Limitations to Surveillance o Surveillance data reporting lag o Reporting of new diagnoses and HIV-related laboratory tests are considered complete after a 6 month lag time. Data becomes available to surveillance epidemiologists approximately 1-2 months following lag. o What surveillance data can provide and what it cannot o Tricky to compare between surveillance-based indicators and provider self-reported NY Links indicators because of different definitions/time periods o Surveillance provides a proxy measure of care o CD4/VL reported=care? o Lack of CD4/VL = lack of care? o No VL reported = not suppressed? o Can track patients across multiple providers o Inability to track out-migration of patients

102 Interventions aimed at Linkage, Retention, and Adherence

103 Interventions Aimed at Linkage Total newly diagnosed¹ N=337 N=3,137 Linked timely to care² Retained in care³ Viral suppression within 6 months of diagnosis⁴ Viral suppression within 12 months of diagnosis⁴ 33% 47% 49% 44% 49% 57% *Systematic Monitoring *Care Coordination *Case Management *Patient Navigation *Streamlining Referrals *Same Day/Expedited Services *Outreach for nonengaged *Linkage with other agencies 0% 20% 40% 60% 80% 100% 1 As reported to the New York City HIV Surveillance Registry (NYC HSR) by June 30, Timely linkage to care is defined as 1 CD4/VL reported to the NYC HSR 8-91 days post diagnosis. 3 Retention in care is defined as 1 CD4/VL test reported to the NYC HSR during each 4 month period in the 12 months immediately following diagnosis. 4 Suppressed viral load is defined as a patient's most recent viral load quantity reported to the NYC HSR within 6 or 12 months of diagnosis was 200 copies/ml. Diagnosed by an UMRG NY Links provider Diagnosed by a non-ny Links provider, rest of NYC

104 Interventions Aimed at Retention Total PLWH³ N=126,064 Diagnosed PLWH 86% N=108,415 Evidence of care in 2011⁴ Retention in care among PLWH with evidence of recent care⁵ 80% 84% Viral suppression among PLWH with evidence of recent care⁶ Sustained viral suppression among PLWH with evidence of recent care⁷ Viral suppression among all diagnosed PLWH⁶ Viral suppression among all PLWH⁶ 40% 47% 61% 63% 0% 20% 40% 60% 80% 100% All NYC PLWH NYC PLWH receiving care at an UMRG NY Links provider² NYC PLWH receiving care at a non-ny Links provider² 74% 75% *Appointment Reminders *Systematic Monitoring *Care Coordination *Patient Navigation *Peer Support *Multi-Staff Approach *Coordinated Messaging *Systems Development

105 Interventions Aimed at Adherence/VLS Total PLWH³ N=126,064 Diagnosed PLWH 86% N=108,415 Evidence of care in 2011⁴ Retention in care among PLWH with evidence of recent care⁵ 80% 84% Viral suppression among PLWH with evidence of recent care⁶ Sustained viral suppression among PLWH with evidence of recent care⁷ Viral suppression among all diagnosed PLWH⁶ Viral suppression among all PLWH⁶ 40% 47% 61% 63% 0% 20% 40% 60% 80% 100% 74% 75% *Care Coordination *Medication Adherence Education and Counseling *Peer Support *Multi-Staffed Approach *Coordinated Messaging All NYC PLWH NYC PLWH receiving care at an UMRG NY Links provider² NYC PLWH receiving care at a non-ny Links provider²

106 PLWDHI with evidence of care vs. PLWDHI with no evidence of care

107 NY Links HIV care cascade: all PLWH in NYC and Upper Manhattan, Total PLWH³ N=126,064 Diagnosed PLWH 86% N=108,415 Evidence of care in 2011⁴ 54% among all PLWH 63% among diagnosed PLWH Retention in care among PLWH with evidence of recent care⁵ Viral suppression among PLWH with evidence of recent care⁶ 74% 75% 80% 84% among diagnosed PLWH Sustained viral suppression among PLWH with evidence of recent care⁷ 61% 63% Viral suppression among all diagnosed PLWH⁶ Viral suppression among all PLWH⁶ 40% 47% All NYC PLWH NYC PLWH receiving care at an UMRG NY Links provider² NYC PLWH receiving care at a non-ny Links provider² 0% 20% 40% 60% 80% 100% 1 Persons diagnosed with HIV on or before June 30, 2010 and living as of December 31, As reported to the New York City HIV Surveillance Registry (NYC HSR) as of September 30, 2012 [PROVISIONAL DATA] 2 Receiving care at an UMRG NY Links provider or at a non-ny Links provider is determined by the ordering provider of the first CD4/VL reported to the NYC HSR January 1, December 31, NYC has a 14% undiagnosed HIV rate; for reference, see :Eavey JJ, Torian LV, Jablonsky A, Nickerson JE, Fettig JF, Leider J, Calderon Y. Undiagnosed HIV Infection in a New York City Emergency Room: Results of a Blinded Serosurvey, December 2009-January th International AIDS Conference, 2012, Washington, DC. Abstract# TUPE282 4 Evidence of recent care is define as 1 CD4/VL reported to the NYC HSR January 1, December 31, Retained in care is defined as the percentage of PLWH with recent care who had 2 CD4/VL tests reported to the NYC HSR January 1, December 31, 2011 that were at least 45 days but no more than 183 days apart 6 Viral load suppression is defined as the % of PLWH with evidence of recent care whose most recent VL reported to the NYC HSR January 1, December 31, 2011 was <200 copies/ml 7 Sustained viral load suppression is defined as the % of PLWH with evidence of recent care whose VL tests reported to the NYC HSR January 1, December 31, 2011 were ALL <200 copies/ml

108 NY Links HIV care cascade: all PLWH in NYC and Upper Manhattan, Total PLWH³ N=126,064 Diagnosed PLWH 86% N=108,415 Evidence of care in 2011⁴ Retention in care among PLWH with evidence of recent care⁵ Viral suppression among PLWH with evidence of recent care⁶ 74% 75% 80% 84% 37% no evidence of care in NYC in Sustained viral suppression among PLWH with evidence of recent care⁷ 61% 63% Viral suppression among all diagnosed PLWH⁶ Viral suppression among all PLWH⁶ 40% 47% All NYC PLWH NYC PLWH receiving care at an UMRG NY Links provider² NYC PLWH receiving care at a non-ny Links provider² 0% 20% 40% 60% 80% 100% 1 Persons diagnosed with HIV on or before June 30, 2010 and living as of December 31, As reported to the New York City HIV Surveillance Registry (NYC HSR) as of September 30, 2012 [PROVISIONAL DATA] 2 Receiving care at an UMRG NY Links provider or at a non-ny Links provider is determined by the ordering provider of the first CD4/VL reported to the NYC HSR January 1, December 31, NYC has a 14% undiagnosed HIV rate; for reference, see :Eavey JJ, Torian LV, Jablonsky A, Nickerson JE, Fettig JF, Leider J, Calderon Y. Undiagnosed HIV Infection in a New York City Emergency Room: Results of a Blinded Serosurvey, December 2009-January th International AIDS Conference, 2012, Washington, DC. Abstract# TUPE282 4 Evidence of recent care is define as 1 CD4/VL reported to the NYC HSR January 1, December 31, Retained in care is defined as the percentage of PLWH with recent care who had 2 CD4/VL tests reported to the NYC HSR January 1, December 31, 2011 that were at least 45 days but no more than 183 days apart 6 Viral load suppression is defined as the % of PLWH with evidence of recent care whose most recent VL reported to the NYC HSR January 1, December 31, 2011 was <200 copies/ml 7 Sustained viral load suppression is defined as the % of PLWH with evidence of recent care whose VL tests reported to the NYC HSR January 1, December 31, 2011 were ALL <200 copies/ml

109 Demographic Breakdown among PLWDHI with evidence, and PLWDHI with no evidence of care, in NYC and Upper Manhattan, New York City- Evidence of Care N=68,135 (63%) New York City No Evidence of Care N=40,107 (37%) Upper Manhattan- Evidence of Care N=8,037 (68%) Upper Manhattan- No Evidence of Care N=3,718 (32%) Gender (%) Male 69% 74% 68% 71% Race/Ethnicity (%) PLWDHI 2 in NYC, N=108,242 PLWDHI in UM, N = 11,755 Black 45% 43% 48% 48% Hispanic 33% 31% 33% 28% White 19% 23% 18% 22% Other 3 3% 3% 1% 2% Transmission Risk (%) Men who have sex with men 35% 34% 36% 35% Injection drug use 17% 20% 13% 11% Heterosexual 4 22% 16% 24% 21% Perinatal 2% 2% 1% 1% Other 0.2% 0.2% 0.3% 0.1% Unknown 23% 28% 25% 32% 1 As reported to the Bureau of HIV Prevention and Control at the NYS DOHMH as of June 30, Includes any diagnosed PLWH receiving care January 1, 2011 December 31, Care at NY Links provider was determined by patients first lab reported to NYC or NYS HSR in the time period. Note: Laboratory testing is incomplete after December 31, Includes Asian/Pacific Islander, Native American, Multiracial, and race/ethnicity unknown. 4 Includes persons who had heterosexual sex with a person they know to be HIV-infected, an injection drug user, or a person who has received blood products. For females only, also includes prostitution, multiple sex partners, sexually transmitted disease, crack/cocaine use, sex with a bisexual male, probably heterosexual transmission as noted in medical chart, or sex with a male and a negative history of injection drug use.

110 Percentage PLWDHI with No Evidence of Care in , by Sex at Birth % 74.1% % 25.9% Males Upper Manhattan New York City Females

111 Percentage 60 PLWDHI with No Evidence of Care in 2011, by Race/Ethnicity % 43.3% % 30.8% 22.5% 23.5% * * * * 0 Black Hispanic White Asian/Pacific Islander Upper Manhattan Native American New York City Multiracial Unknown * 1.0%

112 Percentage PLWDHI with No Evidence of Care in , by Age % 33.7% % 25.5% 23.1% 22.3% % 6.7% 2.3% 4.3% 3.4% 2.8% 1.8% 1.0% Upper Manhattan New York City

113 Percentage PLWDHI with no Evidence of Care in , by Risk of Transmission % 34.0% 32.3% % % 19.5% 20.6% 16.2% * 2.3% * 0 MSM IDU History Heterosexual Unknown Perinatal Other Upper Manhattan New York City * 1.0%

114 Summary of Who Was Out of Care 2011 Among those with no evidence of care, there was a higher proportion of males, Whites, and those with unknown risk of transmission compared to those with evidence of care, in both NYC and in Upper Manhattan. Lower proportion of heterosexuals among those not in care in both NYC and UM. 37% of persons living with diagnosed HIV in NYC had no evidence of care in % of individuals diagnosed in 2010 by an UM provider had no evidence of care anywhere in NYC in Of those with no evidence of care: Three-quarters were male. Almost half were Black, 28% were Hispanic, and 22% were White.

115 Summary of Who Was Out of Care 2011 Of those with no evidence of care Age was normally distributed, with those aged representing the highest proportion with no evidence of care. Those aged make up 83% of those without evidence of care. For risk of transmission, MSM represents one-third of the population with no evidence of care in Unknown represents one-third of transmission risk, making this data difficult to interpret. IDU History is nearly twice as large (20% vs 11%) in NYC compared to Upper Manhattan. Demographic proportions for sex, race/ethnicity, and age among those with no evidence of care in 2011 are similar in Upper Manhattan and in all of NYC.

116 Using surveillance to identify the gaps along the care cascade

117 HIV care cascade for newly diagnosed PLWH in NYC and Upper Manhattan, Total newly diagnosed¹ N=337 N=3,137 Linked timely to care² 33% Retained in care³ 47% 49% Viral suppression within 6 months of diagnosis⁴ 33% 44% Viral suppression within 12 months of diagnosis⁴ 49% 57% 0% 20% 40% 60% 80% 100% 1 As reported to the New York City HIV Surveillance Registry (NYC HSR) by June 30, Timely linkage to care is defined as 1 CD4/VL reported to the NYC HSR 8-91 days post diagnosis. 3 Retention in care is defined as 1 CD4/VL test reported to the NYC HSR during each 4 month period in the 12 months immediately following diagnosis. 4 Suppressed viral load is defined as a patient's most recent viral load quantity reported to the NYC HSR within 6 or 12 months of diagnosis was 200 copies/ml. Diagnosed by an UMRG NY Links provider Diagnosed by a non-ny Links provider, rest of NYC

118 HIV care cascade for newly diagnosed PLWH in NYC and Upper Manhattan, Total newly diagnosed¹ N=337 N=3,137 Linked timely to care² 33% Retained in care³ 53% Viral suppression within 6 months of diagnosis⁴ 33% 44% Viral suppression within 12 months of diagnosis⁴ 49% 57% 0% 20% 40% 60% 80% 100% 1 As reported to the New York City HIV Surveillance Registry (NYC HSR) by June 30, Timely linkage to care is defined as 1 CD4/VL reported to the NYC HSR 8-91 days post diagnosis. 3 Retention in care is defined as 1 CD4/VL test reported to the NYC HSR during each 4 month period in the 12 months immediately following diagnosis. 4 Suppressed viral load is defined as a patient's most recent viral load quantity reported to the NYC HSR within 6 or 12 months of diagnosis was 200 copies/ml. Diagnosed by an UMRG NY Links provider Diagnosed by a non-ny Links provider, rest of NYC

119 HIV care cascade for newly diagnosed PLWH in NYC and Upper Manhattan, Total newly diagnosed¹ N=337 N=3,137 Linked timely to care² 33% Retained in care³ 53% Viral suppression within 6 months of diagnosis⁴ 56% Viral suppression within 12 months of diagnosis⁴ 49% 57% 0% 20% 40% 60% 80% 100% 1 As reported to the New York City HIV Surveillance Registry (NYC HSR) by June 30, Timely linkage to care is defined as 1 CD4/VL reported to the NYC HSR 8-91 days post diagnosis. 3 Retention in care is defined as 1 CD4/VL test reported to the NYC HSR during each 4 month period in the 12 months immediately following diagnosis. 4 Suppressed viral load is defined as a patient's most recent viral load quantity reported to the NYC HSR within 6 or 12 months of diagnosis was 200 copies/ml. Diagnosed by an UMRG NY Links provider Diagnosed by a non-ny Links provider, rest of NYC

120 HIV care cascade for newly diagnosed PLWH in NYC and Upper Manhattan, Total newly diagnosed¹ N=337 N=3,137 Linked timely to care² 33% Retained in care³ 53% Viral suppression within 6 months of diagnosis⁴ 56% Viral suppression within 12 months of diagnosis⁴ 43% 0% 20% 40% 60% 80% 100% 1 As reported to the New York City HIV Surveillance Registry (NYC HSR) by June 30, Timely linkage to care is defined as 1 CD4/VL reported to the NYC HSR 8-91 days post diagnosis. 3 Retention in care is defined as 1 CD4/VL test reported to the NYC HSR during each 4 month period in the 12 months immediately following diagnosis. 4 Suppressed viral load is defined as a patient's most recent viral load quantity reported to the NYC HSR within 6 or 12 months of diagnosis was 200 copies/ml. Diagnosed by an UMRG NY Links provider Diagnosed by a non-ny Links provider, rest of NYC

121 Conclusions Surveillance data is providing NY Links with annual snapshots of linkage, retention, and VLS indicators (care cascades), and also allows us to monitor trends within those indicators over shorter time intervals.

122 Conclusions Measuring the gaps along the care cascades, and identifying who is in and out of care. Use the cascade to guide choices of which interventions can target these gaps within the UMRG collaborative. Over time, surveillance data will be able to use these combined tools to assess whether the interventions implemented in this region are successful in closing these gaps.

123 Next Steps Continue to update the trend graphs for all of the NY Links surveillance-based indicators on a quarterly basis. The 2012 care cascades for newly diagnosed persons and PLWDHI will be prepared in June/July when data is finalized Preparing for the analysis of the interventions from the NY Links menu

124 Thank You!

125 SMALL GROUP DISCUSSION #1 Impacting the Regional Cascade Susan Weigl Group

126 Goals: Impacting the Upper Manhattan Treatment Cascade Small Group Discussion #1 Use regional data to assess gaps in the HIV care continuum in the region; Discuss how/if the current work of our group intersects with the regional care continuum; Based upon this fuller picture, discuss ways in which the regional group (as a collection of individual agencies) can impact the cascade further. 126

127 Impacting the Upper Manhattan Treatment Cascade Small Group Discussion #1 Tools Small Group Discussion #1 - Instructions HIV Care Cascade for newly diagnosed PLWHA in NYC and Upper Manhattan Interventions Aimed at Linkage, Retention and VLS Demographic Breakdown of PLWDHI w/ and w/o evidence of HIV care in NYC & UM Upper Manhattan Intervention Grid and Caseloads

128 Impacting the Upper Manhattan Treatment Cascade Small Group Discussion #1 - Instructions Get Set! - Select a facilitator and recorder Go!: Small Group Discussion #1 Instructions guide your table discussion: I. Review & discuss the Upper Manhattan HIV Treatment Cascades and characteristics of individuals not engaged in HIV care. (15 mins) II. Review the current portfolio of linkage and retention interventions in upper Manhattan ( mins) III. Report Back: (5 mins)

129 Full Group Report Back (5 mins total) Are interventions appropriately aligned with the gaps in the HIV care continuum to reach highest number of individuals in need? Can we shift the regional HIV Treatment Cascade further? How...?

130 Report Back Can we shift the HIV treatment cascade further? If so, how...? Are there segments of the HIV population where we can make the most improvement? If so which segments? Are there particular categories of interventions or collaborations that you would recommend based upon what you see in the data? Who else needs to be at the table for us to impact the cascade further? How might we strengthen our collaborations to address what we are seeing in the region? Are there ways to hold our individual agencies more accountable in terms of reaching the goal of ending the AIDS epidemic?

131 Working Lunch Affinity Groups: New Members Welcome and Orientation Steve Sawicki Consumer Lens Dan Tietz TA/Follow-Up Susan Weigl/Nova West All Others: Improving Upper Manhattan s Provider Directory &/or Linkage and Retention Intervention Self Assessment

132 Involving Consumers in Quality Improvement Daniel Tietz Susan Weigl

133 Framework* for PLWHA involvement in QM/QI Routinely Solicit Input From PLWHA Engage CAB in QI Appoint PLWHA to QM teams Communicate QI activities to PLWHA Annually Assess PLWHA Involvement See Handout In meeting packet

134 The goal of the consumer involvement section of the OA is to assess the extent to which consumer involvement is formally integrated into the quality management (QM) program. Score 0 Getting Started 1 Planning and Initiation 2 Beginning Implementation 3 Implementation Consumer Involvement Stage 4 Progress Towards Systematic Approach to Quality 5 Full Systematic Approach to Quality Management In Place

135 Score Characteristics There is currently no process to involve consumers in HIV Quality Management program activities. Is occasionally addressed by soliciting consumer feedback, but no formal process is in place for ongoing and systematic participation in Quality Management program activities Is addressed by soliciting consumer feedback, with development of a formal process for ongoing and systematic participation in Quality Management program activities Includes engagement with consumers to solicit perspectives and experiences related to quality of care. Is formally part of HIV QM program activities through a formal consumer advisory committee, satisfaction surveys, interviews, focus groups and/or consumer training/skills building. However, the extent to which consumers participate in QM Program activities is not documented or assessed (meets HAB Requirements)

136 Score 4 Characteristics Is part of a formal process for consumers to participate in HIV QM program activities, including a formal consumer advisory committee, surveys, interviews, focus groups and/or consumer training/skills building Quality Improvement (QI) activities includes three or more of the following: 1. sharing performance data and discussing quality during CAB meetings 2. Membership on the internal QM team or committee 3. Training on QM principles and methodologies 4. Engagement to make recommendations based on performance data results 5. Increasing documentation of recommendations by consumers to implement QI projects Information gathered through the above noted activities is documented and used to improve the quality of care. However, staff does not review with consumers how their involvement contributes to refinements in QI activities

137 Score Characteristics Is part of a formal, well-documented process for consumers to participate in HIV QM program activities, including a consumer advisory committee with regular meetings, consumer surveys, interviews, focus groups and consumer training/skills building QI activities includes four or more of the items bulleted in E2#4 5 Information gathered through the above noted activities is documented, assessed and used to drive QI projects and establish priorities for improvement Includes work with program staff to review changes made based on recommendations received with opportunities to offer refinements for improvements, information is gathered in this process and used to improve quality of care Annual review by the QM team/committee of successes and challenges of consumer involvement in QM program activities to foster and enhance collaboration between consumers and providers engaged in QI

138 With your team: Consumer Involvement Self Assessment - Please use the Consumer Involvement in QI/QM to self-assess your agency. - Indicate why you scored your agency as you did - how is this score substantiated? - Group sharing - Please hand-in your assessments

139 Consumer Involvement Self Assessment Scoring and Recommendations Based upon the assessment what can you do to increase consumer involvement in QI/QM at your agency? Score <2: Prioritized for technical assistance from AI Score 3: Generate ideas - reach-out to NYSDOH-AI and/or programs with strong consumer involvement Score 4-5: NYSDOH will reach-out to you to learn more about your consumer involvement work and discuss ways to highlight your program s expertise.

140 Consumer Involvement Quality Improvement Resources

141 Engaging Consumers in QM/QI Program A Seat at the Table for Consumers Resources

142 Reports From the Field: Cynthia Lee Harlem Pride Peer Program

143 HIV CARE: MOBILE HEALTH SERVICE Adriana Andaluz, MPH Director, External Affairs Bureau of HIV/AIDS Prevention & Control Upper Manhattan Collaborative Meeting --NY Links January 16, 2014

144 OVERVIEW Campaign Goals Social marketing creative Services offered Sample of texting Staff-client communication

145 MOBILE HEALTH SERVICE FOR NEWLY DIAGNOSED

146 Mobile health service for newly diagnosed and out of care ACTIVITIES AND SETTINGS Hi, did you take your meds? Yes! Thanks! Primary Campaign Goals Help link newly HIV infected to care Improve HIV medication adherence Provide easy access to resources and support services Sample Services Offered: Provider locator Medication reminders Prescription refill reminders Appointment reminders Healthy living messages Includes new media and traditional social marketing components Opt-in texting campaign Online resource hub Posters, palm cards, etc. Promotional campaign materials will be available in clinical settings, CBOs, and other testing partners.

147 SUPPORTING DATA Pilot Study: Improving Adherence to Antiretroviral Therapy for Youth living with HIV/AIDS PILOT DESIGN: SMS/text reminders to improve adherence to ART among HIV year olds for 24-week period. RESULTS: Improvements in adherence measures seen as early as 6 weeks Sustained throughout the 24-week study period. No significant difference in CD4 cell count or viral load between baseline and the 12- or 24-week follow-ups BUT trend toward improvement of these biomarkers and a small to moderate standardized effect size (Dowshen N, et al, 2012) Dowshen, N et al, Improving Adherence to Antiretroviral Therapy for Youth living with HIV/AIDS: A pilot study using personalized, interactive, daily text message reminders. Journal if Medical Internet Research. 14:2 (2012)

148 SMARTPHONE OWNERSHIP BY INCOME/AGE GROUP % within each age/income grouping who own a smartphone Source: Pew Research Center s Internet & American Life Project, April 17-May 19, 2013 Tracking Survey.

149 MOBILE HEALTH Continues to climb in popularity, especially among smartphone owners % of cell phone owners within each group who use their phones to look for health 45 or medical information online

150 DISSEMINATION ACTIVITIES Initial Promotion: World AIDS Day launch Press release Social Media Manhunt Cares targeted blast Promoted/targeted Tweets Tumblr post Social Media Manhunt Message of the Day Targeted Facebook posts Mobile app ads Tumblr post Social marketing material distribution to STD clinics and other funded partners Phase II Development of Spanish language materials Urban panels in targeted zip codes Post cards and palm cards Continued use of targeted social media

151 The 5 Interventions Overview, Benefits and Expectations for Participation Steven Sawicki January 2014

152 Intervention Selection Process Meeting on June 20 Follow up meeting to pare down list of dozens of identified interventions to 6 or fewer Interventions were selected based on the following criteria: Number of existing providers utilizing intervention Where impact of intervention fell on continuum Resources required to implement intervention Diversity of target population impacted Evidence base supporting intervention Provider type associated with intervention

153 Intervention selection teams Each intervention had a team Teams were assigned to each intervention to: Develop a summary of the intervention Develop an intervention package Teams were comprised of: NYS DOH staff NYC DOH MH staff NYLinks staff Consumers Providers Members of each team were selected based on experience with the particular intervention they were assigned to Summaries and packages produced by the teams were submitted to HRSA and to the national evaluation team for SPNS--ETAC

154 The 5 Interventions Artas (Anti-Retroviral Treatment and Access to Services) Appointment Procedures Consistent Messaging Outreach/Return to Care Peers

155 Summary of Each Intervention Brief Description Intervention Impact Area Target population Best for agencies who provide Core Elements Duration Resource requirements Training needed

156 Anti-Retroviral Treatment and Access To Services (ARTAS) Brief Description--ARTAS is an individual-level, multi-session, time-limited intervention utilizing a strengths based case management model. Impact Area Linkage to Care/Retention in Care. Target Population--Newly diagnosed individuals or those returning to care after more than a 9 month lapse. For Agencies that Provide HIV testing, clinical, supportive services. Core Elements 1-5 structured sessions with each person, Focus on strengths of the individual, Development of step by step plan to connect to care, Service takes place in the environment of the individual, Advocacy of individual needs related to return to care.

157 Anti-Retroviral Treatment and Access To Services (ARTAS) Duration 1 to 90 days Resource requirements Staff trained in case management/engagement. Training needed ARTAS, Motivational Interviewing suggested

158 Appointment Procedures Brief Description Standardization of procedures to facilitate making appointments, reminding patients of appointments, and providing follow up after missed appointments. Impact Area Linkage to Care/Retention in Care. Target Population All individuals who are HIV+. Limited resources may require prioritization New diagnoses, Out of Care, frequency of no show, last lab status. For Agencies that Provide HIV testing, clinical, supportive services. Core Elements Patient enrollment, expanded patient contact info acquired, appointment reminders instituted, missed appointment follow up procedures developed, documentation of efforts.

159 Appointment Procedures Duration ongoing. Resource requirements Staff, time for training. Training needed Field safety training if outreach is to be used.

160 Consistent Team Based Messaging Brief Description Positively phrased and action oriented messages are delivered by all members of the care team. Impact Area Linkage to Care/Retention in Care. Target Population All HIV+ individuals who are newly engaging or reengaging in care. For Agencies that Provide HIV testing, clinical, supportive services. Core Elements List of newly engaging and re-engaging patients, brief care message delivered by all staff on care team, longer care message developed and delivered by specifically indicated members of care team, tool to track messages and delivery process.

161 Consistent Team Based Messaging Duration ongoing. Resource requirements Staff, time for training. Training needed Use of scripted messaging, teachback, motivational interviewing suggested.

162 Outreach/Return to Care Brief Description Systematic search for individuals who have been out of care for longer than 9 months. Engagement of those individuals back to care. Impact Area Retention in Care. Target Population HIV+ individuals with at least one HIV medical visit within the last two years who have not been seen in primary care for 9 months or longer. For Agencies that Provide Clinical, supportive services. Core Elements Maintained care roster to identify out of care patients, case finding efforts, field outreach, care determination process, re-engagement and case closure process.

163 Outreach/Return to Care Duration ongoing. Resource requirements Staff, time for training. Training needed Field safety training for outreach, Case finding training.

164 Peer Support Brief Description Utilizing the skills of peers to better engage patients in the system. Impact Area Linkage to Care/Retention in Care. Target Population HIV+ individuals who are newly diagnosed, transferring their care, or returning to care after not being seen for 9 months or longer. For Agencies that Provide HIV Testing, Clinical, supportive services. Core Elements Identification of new, transferring or returning patients, Peers trained in engagement, Use of standardized, consistent messages, Contact schedule and process recording.

165 Peer Support Duration 1 to 90 days. Resource requirements Staff, time for training. Training needed Confidentiality, engagement and communication.

166 How to Pick an Intervention Use of regional cascade along with individual organization data related to linkage and retention. Awareness of competing interventions. Organizational resources. Commitment and ability to track required data. Ability to test and measure change and outcomes.

167 1 Artas 2 Appointment Procedures 3 Consistent Messaging 4 Outreach/Return to Care 5 Peer support 1,2, 3,5 1,2, 3,4, 5

168 Timeline and Next Steps Introductory Webinars done in November Revision and finalization of interventions happening now Assessment package developed Individual webinars for each intervention???? Process within each learning session to look at best way to impact the regional cascades Providers select interventions and receive TA 3/14 Beginning of evaluation Statewide dissemination process begins Webinars, workshops, presentations, conferences.

169 Expectations

170 To participate agencies should have the following: A QI project team with clear roles and responsibilities (includes: Executive Sponsorship/Lead, Project Lead; Data Lead, and a Consumer). A performance measurement system that is used to routinely monitor the rate of linkage to and on-going retention in HIV primary care for patients. Demonstrated experience in applying quality improvement methods to identify and test system changes. Capacity to collect and submit monthly process and outcome measures related to the intervention selected Willingness to participate in regular meetings with the NYLinks staff assessing intervention fidelity Willingness to share learning and adapt interventions Commitment to work with the NYLinks team through August 2015

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179 MORE BENEFITS Data collection tools, protocols and support to implement interventions known to improve timely access and/or retention in HIV primary care Training resources specific to each intervention and for additional recommended strategies that can supplement NYLinks interventions Technical assistance and coaching that includes assessment of key elements for implementation and on-going fidelity monitoring for site specific refinement Expert input, data reports and tools from CUNY School of Public Health to assure a sound evaluation plan

180 EVEN MORE BENEFITS Guidance on developing a successful team Opportunities to strengthen cross-continuum teams and potentially bridge learning across diseases On-going peer exchange and a community of support from colleagues implementing interventions Opportunity to highlight your agency's progress and expertise in addressing the key issue of access to and on-going retention in care to funders and key stakeholders Access to all of the resources available to NY Links so you can be successful in this endeavor

181 STILL EVEN MORE BENEFITS Opportunity to be part of a very limited, nationally recognized process designed to improve linkage and retention. This SPNS funding exists in only 6 states Opportunities to be part of any material published related to the process or the particular interventions selected Potential national and international recognition Potential appearances on Jimmy Kimmel Live, Dave Letterman, Jay Leno, and Oprah

182 Team Assessment and Planning Susan Weigl

183 How has your Linkage and Retention QI work progressed? & What will be your next steps?

184 Team Assessment & Planning Tools Agency specific Linkage and Retention Assessment (Completed as Pre-Work) Linkage and Retention Improvement Plan (Blue)

185 1. Performance Measurement Data Access and Use The data needed to systematically monitor linkage/retention in care exists in our agencies data system. There are routine data reports that our staff can access to track linkage/retention. There is flexibility to customize reports for different time periods or different indicator definitions at our agency. Our agency has IT staff who are skilled at running reports against our data system. Our agency staff has confidence in the quality of the data that comes from our data system. Our agency database s do a good job keeping us informed of how are programs are doing. Our agency fully utilizes all of the information on our data system for program improvement.

186 1. Performance Measurement See Page 2 of Assessment How does your program use data to evaluate success and drive effective decisions... - Drilling down data - Using data to set goals and measure progress - Sharing data in a variety of ways and stakeholders - Integration of Linkage and Retention Data - Leadership review and ownership of data - Have you reached a place where data collection and submission for NYLinks is routine?

187 Metropolitan Hospital Center Data Analysis 9 Newly Dx Patients Not Linked to Care Testing Location: Testing in ED = 4 Testing in Outpatient Mental Health = 2 Testing in Inpatient Units = 3 B. Reasons for/barriers to Linkage: Left prior to receiving preliminary results (2 ED) 2 No appointment prior to discharge (1 Inpt) 1 Tested on Saturday (no counselor onsite) (1 ED) 1 DNKA (1 ED) (2 MH) 3 Unable to be contacted by phone (3 ED) (1 Inpt) (1 MH) 5 Refused linkage to care (1 ED) (1 Inpt) (1 MH) 3 Psychosocial and/or stigma (1 ED) (2 Inpt) (2 MH) 5

188 SEX Grand Total % LTF % Retained % Female % % % Male % % % Transgender 65 1% 4 1% 61 1% Grand Total % % % RACE Grand Total % LTF % Retained % Am. Indian or Alaskan Native 10 0% 0 0% 10 0% Asian 50 1% 3 1% 47 1% Black or African American % % % Hispanic or Latino(a) % % % More than one race 45 1% 3 1% 42 1% Native Hawaiian or Other PI 1 0% 1 0% 0 0% Unknown / unreported 55 1% 9 2% 46 1% White (non-hispanic) % % % Grand Total % % % INSURANCE Grand Total % LTF % Retained % ADAP Plus % 97 18% % Commercial Insurance % 70 13% % Medicaid % % % Medicare % 56 10% % Ryan White Coverage 1 0% 1 0% 0 0% Uninsured-Self Pay 15 0% 12 2% 3 0% Grand Total % % % RISK FACTOR Grand Total % LTF % Retained % Heterosexual % % % IDU 316 7% 33 6% 283 7% IDU & Heterosexual 143 3% 26 5% 117 3% MSM % % % MSM & IDU 78 2% 10 2% 68 2% Occupational 7 0% 1 0% 6 0% Perinatal 64 1% 8 1% 56 1% Sex Abuse 10 0% 1 0% 9 0% Transfusion 31 1% 2 0% 29 1% Unknown 176 4% 40 7% 136 3% Grand Total % % %

189 Tracking Interventions What does this tell us about sustainability? Pap screening results 90% 80% 70% 60% 50% 40% 30% Hired PA, Created pt need List - placed in visible location to incr provider awaress Lost PA patient education calls to Schedule appt Pap Squad NP created monthly tracking log and outreach phone protocol to contact pts not meeting measure and those in need of a Pap test in 3 mos Lost NP; Adhere to different Guidelines Program 1 Program 2 Program 3 20% New PA Hired; Program1 10% 0% Oct-09 Feb-10 Jun-10 Oct-10 Feb-11 Jun-11 Oct-11 Feb-12 Jun-12

190 Patients Newly Enrolled in Medical Care August 2012 through June /11-5/12-8/11-7/12 10/11-9/12 12/11-11/12 2/12-1/13 4/13-3/13 6/11 5/12 8/11-7/12 10/11 9/12 12/11-11/12 2/12-1/13 4/12-3/13 National %=mean 60% 55% 56% 59% 57% 51% In+Care n=patients 7,687 8,335 8,476 8,014 5,857 5,619 p=organizations ECMC %=mean 57% 65% 72% 76% 77% 89% n=patients p=organizations NYS %=mean 66% 66% 63% 60% 61% 60% n=patients 961 1,064 1, p=organizations Top 10% %=mean 96% 100% 100% 96% 100% 100% n=patients p=organizations Top 25% %=mean 83% 89% 88% 84% 86% 87% n=patients 1, , p=organizations Challenge Intake and follow up process/protocol was uniform for all patients entering care. After intake, patients worked with the case manager on call at time of visit or phone contact, with no protocol promoting consistency/continuity. Patient reminders were done manually by phone and inconsistently completed due to staffing. Intervention Immediately identify any need for additional support and refer to WICY team for intensive multi-disciplinary management. (October 2012) Devised system by which patients would immediately be linked with a consistent medical case manager, creating a treatment team with the medical provider. (August 2011) Invested in automated system that allows patients to choose text or voice reminders and to confirm receipt of call. Reminders are made regardless of staffing. (August 2012) HIV+ patients newly enrolled with a medical provider with prescribing privileges who had a medical visit in each of the 4-month periods in the measurement year improved from 57% in August 2012 to 89% in June 2013, entering the top 25% for In+Care and the top 10% for New York Links at same time national and state averages remained stagnant or decreased.