Linkage to Care: Linking newly diagnosed HIV-infected persons to Medical Providers through Linkage to Care Case Management (LTC)

Amber Rossman, LMSW

Kansas City Free Health Clinic

Linkage to Care: CDC ARTAS

CDC ARTAS: ARTAS = Antiretroviral Treatment Access

Study Objective: link persons living with HIV to

medical care Features: Strengths-based case management:

– Empowerment & self efficacy – Clients identify internal strengths & assets

Sources: Samet et al. AIDS 2001;15:77-85, del Rio et al. 8th CROI 2001; AbstractS21, Gardner et al. AIDS 2005;19:423-431

Linkage to Care: CDC ARTAS

Findings: Compared to the standard of care group,

people in the ARTAS case management were more likely to have visited their HIV provider:– At least once in 6 months (78% v. 60%)– At least twice in 12 months (64% v. 49%)

Additional steps needed to improve linkage to HIV careSource: Gardner et al. AIDS 2005;19:423-431

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(during ARTAS II study)Kansas City EMA

Historical HIV Positivity Rates

230 dx HIV+, 33% engaged in medical care

161 dx HIV+, 32% engaged in medical care

168 dx HIV+, 43% engaged medical care

167 dx HIV+, 60% engaged in medical care

193 dx HIV+, 68% engaged in medical care.

2001

Objective is to increase the engagement in care among newly diagnosed HIV+ individuals from 43% to 60-80% per year.

Source: Kansas City Health Department. Percentages rounded to the nearest whole.

2002

2003

2004

2005

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LTC: Eligibility Guidelines (adapted)

HIV+ newly diagnosed Not more than 2 HIV medical appointments

and never been on treatment (i.e. ARVs) Other HIV+ Considered:

– “Lost to Care” patients welcome (piloting)– Repeat clients (if lost) assessed for

appropriateness– New to area clients (in HIV care in other city and

risk being lost to care)

Now…

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Today LTC: From Referrals to Active Handoff

Positive Result

Outside Positive Result Referral: LTC paged before, at, or immediately after

result. LTCs are mobile and respond w/in 20 min, starts partner elicitation, coordinates

confrmatory result.

90 day LTC service, beyond "linked" date; support w/ partner notification; attends medical appointments; orients to HIV system, confirm HIV payer source; initiates

RW services; weekly case conference on progress toward care goals & graduation

90 Days & Engaged in Care = Active handoff:graduate to -> RW Case Manager or self management

General or Lost to Care Referral: LTC paged at contact w/ new-to-care client. Mobilizes to meet or contact, confirms HIV+, collaborates w/ D.I.S. and RW to confirm not

in care or services

Now…

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Results :Kansas City ARTAS II Project

94% linked to care* within 90 days

89% retained in care* at 6 months

199 referred, 91 participated

84% engaged in care* at 12 months

*“care” = attended appointment with a prescribing provider M.D., D.O., N.P. et al

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HIV Diagnosis

Page Linkage to Care – 20m response

Initial Response – meet with patient and diagnosing provider

Linkage to Care - 90 Day, intensive intervention of LTC Case Management (continuation w/ referral to CM services)

87% COMPLETE:

Graduate to long term HIV Case Management Services, continue engagement in care

5% NOT COMPLETE:

Lost to Care, Unable to Contact, Disengaged from Program; cont’d attempts re-engagement

8% COMPLETE:

Graduate to self-sufficiency, continued HIV care with own resources

84% of graduates still in care after 12 months.

Referring Sites

•Hospitals

•Health Depts (KC, Jx, Jo, Wy, MO)

•Publicly Funded Testing Sites

•Free Clinic (KCFHC)

•Med Offices/Other

•Self Referral

Intervention - Enrollment or Referrals

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Terms Important to Our LTC Program

“passive referrals” vs. “active referrals” “linked to care” vs. “engaged in care” On call (incoming referrals) Graduated disengagement Strengths Perspective (SBCM) LTC Coordinator vs. Case Manager (ALCM) First & second medical appointment Active handoff (strict standard)

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KC ARTAS Referral Sources

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Who's Referring?

KC Free Health Clinic

Truman Medical Center

KC Health Department

Other Medical/SocialServices

MO Dept of Health (NWDistrict)

Wyandotte Health Dept.

Self Referral

Referrals include ALL referrals screened by ALCMs regardless of eligibility form completed or enrollment status.

In the beginning (first 2 years)

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Recruiting, Retaining, Sustainability

Linkage to Care

Linkage to Care

816-990-2411

Contact Linkage to Care Coordinator for a confidential

appointment and to learn about treatment options – get lin

ked

to care. This program is confidential and free of charge

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Administrative Set up for LTC

• Setting the Stage

• Preparing your System

• Accountability to LTC Standards

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Incoming (referrals in to LTC)

Linkage to Care

Linkage to Care

816-990-2411

Contact Linkage to Care Coordinator for a confidential

appointment and to learn about treatment options – get lin

ked

to care. This program is confidential and free of charge

Your appointment is _______________ on _____________

Your A

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Setting the stage

• Commitment of System Supervisors

• Buy-in from Testing sites

• Integrating into procedures of multiple systems

• Developing tools for easy referral

Strong standards & results!

• 20 minute pager response

• Reinforce “active referrals”

• ALCM gives available at delivery of positive results

Preparing the system

• Training D.I.S./Public Health

• Communication: Reminders of Program / LTC staff presence at meetings

•Commitment to opt-out referrals

Pre-intervention recruitment

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Outgoing (referrals out of LTC)

Linkage to Care

Linkage to Care

816-990-2411

Contact Linkage to Care Coordinator for a confidential

appointment and to learn about treatment options – get lin

ked

to care. This program is confidential and free of charge

Your appointment is _______________ on _____________

Your A

ppoi

ntm

ent

Your A

ppoi

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ent

Your a

ppoi

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Setting the stage

• Commitment of Supervisors

• Buy-in from Case Management sites

• Integrating into CM system standards

Strong standards & results!

• Perform “intake” tasks/documentation

• Reinforce “active referrals” to long term CM system

• Continuum of care goals

Preparing the system

• Coaching Case Managers

• Clear, deliberate documentation

• LTC presence at system meetings

Post-intervention graduation

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Success Checklist: Implementing a Linkage to Care program

Existing, strong working relationships with City/State Health Departments Disease Intervention and C & T Services HIV Case Management Systems Medical Care facilities

Continuum of Programs - as much onsite as possible Experienced staff, strong in Case Management Demonstrated leadership in HIV services Major networking skills! Customer Service (view professionals as secondary client)

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Checklist: Defining Your Program’s Linkage to Care

Branding the service for entire system

Outreach to C & T referral sources

Outreach to medical referral destinations

Know points of entry of HIV+ individuals

Broad outreach to potential clients

Targeted outreach to potential clients

Market using client and system outcomes publically

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Checklist: Active Referrals Activity

Client readiness to accept or act on a referralHighlight motivator – attuned to what client wants (motivational interviewing)

Preparing, using both didactic and experiential education

Visualizing goals and outcomes

Attending appointment with client

Active “hand off” and follow up

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Checklist: Active Referrals Tools

Hotline or pager number for referrals “Where can I find you” form/tool Material without the word “HIV” or “AIDS” Maps, pictures, forms of care sites/services Offer to train HIV testing staff throughout service

area Report back on outcomes of referral Act as “sales representative” touching base w/

referral sites monthly

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LTC Staff: An Advanced Skill-Set

Previous experience in RW or hospital case management

Previous experience with homeless, SA, youth populations

STRONG expertise in HIV/AIDSBSW or MSW (strengths model experience

or understanding)(continued)

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LTC Staff: An Advanced Skill-Set

Harm Reduction understanding and practice application

Flexible hours to meet client needs (whatever it takes spirit)

Outcome focused (involved in all areas of project) Customer service attitude with both clients and

referring professionals

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Commitment to the LTC Process

graduated disengagement (90 day) active referrals (into program & in service

coordination) cross training staff LTC staff as trainers (outreach to professionals) active hand-off (graduating program) case conference (weekly)

Using LTC short-term Case Management model (ARTAS adapted)

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Craw, J., Gardner, L (2010), Rossman, A., et al. Structural factors and Best Practicesin Implementing a Linkage to HIV Care Program Using the ARTAS Model. BMC Health Services Research 2010, 10:246 (20 August 2010)

Craw, J., Gardner, L., et al. Brief Strengths Based Case Management Promotes EntryInto HIV Medical Care: Results of the Antiretroviral Treatment Access Study II(ARTAS II). JAIDS / J Acquir. Immune Defic Syndr 2008; 47:597-606.

Recommendations for Case Management Collaboration and Coordination inFederally Funded HIV/AIDS Programs. Federal Interagency HIV/AIDS CaseManagement Work Group: US Department

Further Reading:

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Questions:Questions:Amber Rossman, LMSW

www.kcfree.org