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in+care CampaignWebinar

August 14, 2012

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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

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Agenda

• Welcome & Introductions, 5min• Substance Abuse and Retention, 30min• The UCSF Story, 10min• Data Review and Discussion of

Retention Strategies Collected Through the Campaign, 15min

• Q & A Session, 5min• Updates & Reminders, 5min

Strategies to Improve Health Outcomes and Treatment Retention

in HIV+ Substance Users

Chinazo Cunningham, MD, MS

Albert Einstein College of Medicine

Montefiore Medical Center

Objectives

• To review poor health outcomes observed in HIV+ substance users

• To examine treatment strategies aimed at improving health outcomes and treatment retention – Outreach

– Case management

– Integration of HIV & substance abuse treatment

– Support groups

– Patient navigation

– Harm reduction framework

National estimates of drug-related ED visits 2004-2010

SAMHSA, OAS, DAWN

Poor outcomes in HIV+ substance users

• Less access to care

• Less retention in care

• Less access to antiretroviral therapy (ART)

• Worse adherence to ART

• Slower decline in morbidity and mortality

Turner 2001; Kalichman 2002; Shapiro 1999; Celentano 1998; Strathdee 1998; Arnsten 2002; Tucker 2003; Golin 2002; Chesney 2000; Lucas 1999; Bouhnik 2002; Knowleton 2001; Chitwood 1999 & 2001; Cronquist 2001

Possible Reasons for Poor Health Outcomes

• Substance users:- Lack of trust in health care system

- Competing needs (housing, food, benefits, etc.)

- Co-morbid illnesses (mental illness, Hepatitis C, TB)

- Intermittent incarceration

• Providers:- Discrimination (substance use, race/ethnicity, poverty, HIV, homeless)

- Lack of education/training around substance use

• System:- Fragmented system addressing HIV & substance abuse separately

- Lack of support to address needs

- Lack of flexibility to address needs

- Philosophical framework not conducive to drug users

Strategies to Improve Health Outcomes & Treatment Retention

• Outreach

• Case management

• Integration of HIV & substance abuse treatment

• Support groups

• Patient navigation

• Harm reduction framework

Outreach

• Project Bridge – Intense CM for HIV+ recently released prisoners

– At 1 year, 82% were retained in HIV care

• Yale Community Health Care Van – Mobile van visiting needle exchange sites

– At 9 months, 77% with undetectable VL

• Montefiore/CitiWide Program – Doctors with outreach team targeting HIV+ SRO hotel residents

– After outreach, regular HIV care provider and taking ART

• HRSA multi-site outreach initiative # of outreach visits associated with gap in HIV care

Rich 2001; Cunningham 2005; Altice 2003; Cabral 2007

Case Management• One of the most widely used services in HIV programs• Lack of uniform definition of CM• Studies examining CM

– Several observational studies examine association between CM and HIV outcomes

• CM assoc with HIV health care utilization

• CM assoc with ART utilization and adherence

– Few RCTs of CM with conflicting findings• CM with drug users & non-users = HIV care utilization

• CM with drug users = no change in HIV care utilization

Katz 2001; Cunningham 2007; Kushel 2006; Lo 2002; Messeri 2002; Harris 2003; Gardner 2005 ; Sorenson 2003

Integration of HIV & SA Treatment

• Benefits of integration– Easier to access/utilize services

– SA treatment associated with positive HIV health outcomes

– Single health care provider can closely monitor and reduce risk of drug-drug interactions

– Likely more efficient and less costly

• 2 ways of integration– HIV treatment into SA treatment

– SA treatment into HIV treatment

Samet 2001

Integration of HIV treatment into SA treatment

• Several studies examined integration of HIV treatment into methadone programs– Feasible HIV care utilization high risk behavior opioid use– Improvement in education & employment

Selwyn 1993; Keen 2003; Samet 2001; Fiellin 2001; Novick 1988, 1993 & 1994; Salsitz 2000

Integration of SA treatment into HIV treatment

• Several studies examined buprenorphine treatment in HIV clinic

• HRSA multi-site study• Feasible opioid use HIV care utilization ART initiation VL, CD4 count

• International studies with consistent findings

O’Connor 1998 & 1996; Vignau; 2001 Fiellin 2002 & 2012; Sullivan 2006; Cunningham 2011; Altice 2012; Lucas 2010; Roux 2009

Support Groups

• Support groups are widely accepted to address needs of drug users not addressed elsewhere

• Few studies explicitly examine support groups– Attending support groups associated with:

utilization ART utilization HIV care services

Kang 2006; Cunningham 2008

Patient Navigation

• Patient navigation = emerging strategy to improve outcomes of marginalized HIV+ individuals

• Few studies have examined patient navigation• Evaluation pooling data from 4 “navigation-like”

programs– Blend of CM, care coordination, accompaniment to appts

– Patients who received navigation (vs. no navigation) HIV care utilization VL

Bradford 2007

Harm Reduction

• Principles:– minimize harmful effects of drugs

– some ways of using drugs are safer than others

– success not necessarily cessation of drug use

– non-judgmental, low threshold services

– “meet drug users where they are at”

Harm Reduction

• System approach– Flexibility in appointments– Missed and “walk-in” appointments– Wait times (in person, by phone)

• Individual approach

The reality of caring for HIV+ substance users

• Difficult and challenging work, yet can be very gratifying

• Time and PATIENCE

• Acknowledge own judgments, personal beliefs

• TRUST is critical

• Addressing the “hidden agenda”

Harm Reduction Treatment

• Shift in traditional philosophy

• Take several steps back and assess harms

• Patient vs. provider agenda

• Concrete actions – Prescriptions for syringes

– Refer for case management

– Redefine health, goals, and success/failure

Redefine Health• Health is NOT the absence of disease

• Biopsychosocial model AND…– drugs – housing– support system – finances – violence – criminal justice issues…

• Life priorities of HIV+ IDUs– Only 37% ranked HIV as most important– Top priorities: housing, money, safety from violence

Mizuno 2003

Redefine Success

• Success is NOT just: – Undetectable viral load– Abstinence from drug use

• Success also includes:– Making it to appointments– Preventative care (PAP smears, OI prophylaxis, PPD)

– Less, safer, more controlled drug use– Improvement in non-medical areas (housing, support

system, criminal activity, etc.)

Why Adopt a Different Definition of Success?

• Recognizes that success is not only about taking medications

• Actively engages patients in health care and treatment• Values the health impacts of “non-medical”

interventions (e.g. controlled drug use, stable housing, social supports)

• Improves patients’ self-efficacy • Provides more opportunities for success

Conclusion

• Reviewed poor outcomes in HIV+ substance users

• Examined treatment strategies improve health outcomes and treatment retention – Outreach

– Case management

– Integration of HIV & substance abuse treatment

– Support groups

– Patient navigation

– Harm reduction framework

Support for Drug Users

Jacqueline Tulsky M.D.Professor of Medicine, UCSF/SFGH

Positive Health ProgramSF AETC

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A Perspective on Addiction

“Most of us walk unseeing through the world, unaware alike of its beauties, its wonders and the strange and sometimes terrible intensity of the lives being lived about us.”

Rachel Carson (1907-1964)

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“Gaining some control”

34 yo man opioid addicted in jail Frequent in and out, but during longer

stay is approached by targeted testing project and found HIV+, CD4 110.

Referred to methadone at release, but comes 3 days later. No slot that day, told to come back next day

Disappears and arrested 3 weeks later.

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Continued -2

This time, HIV specialist in jail contacted us at the methadone program

Could we do intake while in jail and start patient on methadone?

Sheriff agreed, methadone agreed – pt started while in jail on 30mg methadone

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Continued -3 On release, pt came to methadone next

day where methadone dose confirmed with jail and increased slowly

Referred to HIV primary care clinic in the methadone clinic who used Motivational Interviewing, social worker, drug counselor for ADAP, food, housing and support

Over 3 months, stabilized on methadone, identified cocaine as problem and wanted HIV treatment

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Continued -4 Back in jail one more time, but

continued methadone through their program. Start HIV ART medications.

Arranged inclusion in methadone DOT program for HIV meds at when released from jail.

2 years later still struggles with cocaine, but no further jail stays, off street opioids, undetectable viral load.

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Lessons Learned

Multi modality for true recovery in most complex pts (addiction/medical/social)

They can’t do it alone, and neither can you

Motivational Interviewing was very useful in identifying (and creating) the patient’s priorities

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Lessons Learned

Connections between and across programs and providers are underutilized and often the only barrier is the lack of imagination, communication and persistence

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Improvement Strategies Exercise

Michael Hager, MPH MANQC Manager

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in+care Campaign National Data Snapshot

December – June Data as of 07/31/2012

Dec Average

(Patients)

Dec Sites

Feb Average

(Patients)

Feb Sites

Apr Average

(Patients)

Apr Sites

Jun Average

(Patients)

Jun Sites

Measure 1: Gap Measure 16.00% (122,473) 200 15.88%

(123,949) 191 14.74% (125,056) 197 15.33%

(106,837) 167

Measure 2: Visit Frequency Measure

64.40% (83,647) 151 65.47%

(83,996) 147 61.91% (99,496) 170 63.63%

(85,825) 154

Measure 3: New Patient Measure

57.23% (7,859) 190 58.19%

(8,641) 183 58.72% (8,227) 188 59.79%

(6,899) 163

Measure 4: Viral Suppression Measure

69.14% (132,539) 192 69.39%

(143,625) 185 70.31% (148,134) 190 71.80%

(130,584) 168

Coming Soon – new analyses!

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New Way to Submit Improvement Updates!

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Improvement Update Discussion

A) Interventions Related to Substance Abuse• Patient navigation services• Van services to pick up and drop off patients where they

are (can be non-HIV specific to reduce stigma)• Health van services to treat patients where they are• Flexible appointment times or same day appointments• Case consultation at provider meetings• Interdisciplinary teams• Target substance abusing patients issues for intensive

reminders• Mention substance abusing patients in QM Plan – make

a program priority to address these needs

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Improvement Update Discussion

B) Barriers Related to Substance Abuse• Health is often a lower priority for substance abusers• Can be difficult to communicate with patients• Very high no-show risk for on site appointments• Lots of supports are needed for these patients• Silo-ed funding streams for HIV and substance abuse

treatment• Patients often missing eligibility determination

paperwork• Intermittent incarceration makes finding patients

challenging• Declining local resources for substance abuse treatment

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Improvement Update Discussion

C) Lessons Learned Related to Substance Abuse• Screen, screen, screen for substance abuse and relapse• Providing transportation for patients OR doctors to

improve patient access to care• Relying on community partnerships to bolster efforts• Relying on peers or someone relatable (navigator) to

slowly link patients into consistent HIV care• Working with Local/Regional Departments of Health to

create communities of learning and working groups• Tiered approach to outreach intensity based on

demonstrated patient need

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Time for Questions and Answers

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MedScape Retention in HIV Care Series

• Technical Working Group working on articles for a new Medscape Today News Series.

• Bruce Agins, MD MPH, New York State Department of Health AIDS Institute Medical Director, wrote the opening article in the series

• We recommend that you subscribe to HIV/AIDS MedPlus to be informed of new and exciting articles in this series!

• http://www.medscape.com/viewarticle/768102

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Partners in+care

• Partners in+care Private Facebook Group is live! • Share tips, stories and strategies• Join a community of PLWH and those who love them• Email michael@nationalqualitycenter.org for more

details

• Partners in+care website is live!• http://www.incarecampaign.net/index.cfm/77453 • Join our mailing list (a list-serv version of the FB

Group)

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• Campaign Office Hours: Mondays & Wednesdays 4-5pm ET

• Data Collection Submission Deadline: August 1, 2012

• Next Campaign Webinar: Identifying Attrition Risk Patients To be announced

• Next Meet-the-Author Webinar: To be announced

• Next Partners in+care Webinar: To be announced

Upcoming Events and Deadlines

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Campaign Headquarters:National Quality Center (NQC)90 Church Street, 13th floorNew York, NY 10007Phone 212-417-4730incare@NationalQualityCenter.org

incareCampaign.orgyoutube.com/incareCampaign