Special Projects of National Significance
2005 Report to CARE Act Grantees

Outreach Initiative

Targeted HIV Outreach and Intervention Model Development and Evaluation for Underserved HIV-Positive Populations Not in Care

Background

Identifying effective models of outreach to underserved HIV-positive people not in care is a critical element in responding to the changing AIDS epidemic. Recent advances in the treatment of HIV/AIDS have slowed both AIDS death rates and the progression of disease for many individuals. However, certain vulnerable and marginalized groups of people, including people of color, women, substance users, the homeless, youth, men who have sex with men, and people who are incarcerated, are not benefiting as much from these advances. Populations with the highest HIV-infection rates have a correspondingly greater need for treatment, yet other behavioral and service delivery factors such as cultural and linguistic biases, racial and gender discrimination and lack of insurance have a profound influence on access to medical care. For instance, late HIV diagnoses and initiation of therapy are far more prevalent among African Americans, Latinos and intravenous drug users.

Creative and intensive outreach efforts are needed to assure early and continued treatment for people facing persistent access barriers. Outreach strategies that worked in the early years of the epidemic may not improve access for people who have been historically underserved and marginalized and who mistrust the medical care system. In response, medical and ancillary service

providers have developed innovative outreach strategies that they believe are effective in engaging and retaining underserved individuals in care. They use various outreach approaches, including street outreach and mobile vans, to reach affected populations in rural areas and specific out-of-care segments of the population such as racial and ethnic minorities and individuals released from correctional systems. Outreach approaches have emerged that seek to engage clients by addressing them on their own terms, providing them with tangible benefits that meet their subsistence needs before addressing health care needs. In these frontline approaches, each incremental step that brings an individual closer to primary HIV care is seen as progress. Harm reduction and the stages of change model of behavior change are two theoretical frameworks used by several projects that are based on this client-centered approach.

Although providers across the nation use locally-defined outreach strategies to improve access to care, there has been little systematic investigation of the effectiveness of local outreach efforts and their contribution to HIV outcomes. Thoughtful research is needed that operationally defines outreach within health service delivery systems and in relation to health outcomes. Many providers using outreach strategies need technical assistance so that they can participate in systematic evaluation activities. The SPNS Outreach Initiative (Targeted HIV Outreach and Intervention Model Development and Evaluation for Underserved HIV-Positive Populations Not in Care) is a direct response to this research need.

2005 REPORT outreach initiative

The outreach Initiative

The SPNS Outreach Initiative refines and evaluates outreach strategies to bring underserved people living with HIV into comprehensive continuum of care. The Evaluation and Program Support Center for the initiative is the Health and Disabilities Working Group at the Boston University School of Public Health. The Outreach Initiative was designed to be implemented in two phases. In Phase I, seventeen HIV service programs were selected to evaluate their existing outreach interventions and to identify enhancements. These programs ranged from small community-based organizations to large university-based medical centers. All of the projects targeted vulnerable and marginalized people living with HIV, but not in care. The initial funding period for these seventeen awards was two years.

During Phase I, each grantee collaborated with the Evaluation Center to carefully characterize its intervention, develop evaluation tools, build data collection capacity, conduct local evaluations of its existing outreach activity, and plan for enhancements of that intervention or the development of a new intervention. A principle objective was to collect baseline data about the current results of outreach activities in order to measure program improvement over the course of the initiative. Baseline data varies according to the focus of outreach, and may include the number of individuals who return for HIV test results, the number of individuals who make and keep their first medical appointment, the number of sporadic users, or the number of sporadic users who return to regular medical care. During the first year of Phase I, the Evaluation Center and the programs identified the basic evaluation questions, measures and indicators for local and multi-site analysis.

Programs that evaluated their Phase I interventions, developed enhanced or new interventions and met other program requirements were then eligible to apply for Phase II funding to implement and evaluate their enhanced or new outreach models over an additional three year project period. Ten demonstration sites and the Evaluation Center were funded for Phase II and participate in the multi-site evaluation. This report describes these 11 grantees.

This initiative targets HIV-infected individuals, particularly minorities and the underserved
that are in need of HIV services.

The goals of the Outreach Initiative are to:

· Evaluate proactive strategies for bringing minority and underserved populations into health care in the early stages of HIV disease;

· Identify and evaluate models that transform sporadic users of health care into regular and continual users of health care; and,

· Identify effective methods to support and retain clients in health care.

Contact Information

Evaluation and Support Center

Health and Disabilities Working Group
Boston University School of Public Health
Center for Outreach, Research and
Evaluation (CORE)
374 Congress Street
Boston, MA 02210
www.hdwg.org/projects/outreach.htm

Carol Tobias, MMHS, Principal Investigator
E-mail: tcarol@bu.edu
Phone: 617-426-4447

HRSA Project Officers

Special Projects of National Significance
5600 Fishers Lane, Rm 7C-07
Rockville, MD 20857

Moses B. Pounds, PhD
E-mail: mpounds@hrsa.gov
Phone: 301-443-2894

Robyn Schulhof, MA
E-mail: rschulhof@hrsa.gov
Phone: 301.443.0258

Melinda Tinsley, MA
E-mail : mtinsley1@hrsa.gov
Phone : 301.443-3496

2005 REPORT outreach initiative

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Multnomah County Health Department
(Portland, OR)

CareLink Outreach Intervention for Out-of-Care PLWH

Target Population: Traditionally underserved people living with HIV (PLWH) who are not engaged in HIV primary care or who are at risk for falling out of care

Goal: 1. To seek out and identify PLWH who are not utilizing medical care and case management services or who are at risk of falling out of care; 2. To link out of care/at risk PLWH to medical and case management services and provide them support to remain and be successful in care

Strategies: 1. A focus on three top-ranking processes of change: consciousness raising, self-liberation, and helping relationships; 2. Increase outreach worker staff, develop a peer advocate team, improve collaboration with case managers, counseling and testing, and HIV primary care

Evaluation: Four broad questions guide the CareLink evaluation: 1. What is the CareLink outreach intervention and implementation process? 2. What is the process a client goes through from initial contact with a CareLink Outreach Worker to enrollment or sustained use of health care services? 3. What are the characteristics of HIV-positive individuals who are out of care and who become enrolled in CareLink? 4. What are the short-term, intermediate, and long-term outcomes as a result of CareLink?

Contact Information:

Maureen H. Rumptz, PhD, Principal Investigator
1120 SW Fifth Avenue, 14^th Floor
Portland, OR 97204
email: maureen.h.rumptz@state.or.us
Phone: 503-731-4291

UCLA Division of Medicine and Health Services Research (Los Angeles, CA)

Intervention for Outreach and Access to Care in the Underserved with HIV

Target Population: Poor, minority and underserved persons with HIV

Goal: To reduce barriers to HIV care, improve service delivery, promote engagement and retention in care, and foster improved health outcomes

Strategies: 1. HIV testing and counseling provided by the Drew mobile HIV testing van program; 2. Enhanced case-management intervention to include intake, assessment, referral, and follow-up, based on the Motivational Interviewing and the Continuous Relationship Model

Evaluation: The evaluation will focus on the impact of the Phase II intervention on engagement and retention in care and health outcomes; periodic surveys will assess barriers, housing status, health insurance, use of health care and missed appointments, and medical record abstraction for CD4 count and viral load data

Contact Information:

William Cunningham, MD, MPH, Project Director
911 Broxton Avenue, Ste. 101
Los Angeles, CA 90095
email: wcunningham@mednet.ucla.edu
Phone: 310-206-1632

University of Miami School of Medicine (Miami, FL)

Caring Connections

Target Population: HIV-seropositive women, including those who are pregnant

Goal: To improve retention in and utilization of HIV primary and perinatal care services by pregnant and non-pregnant women

Strategies: 1. A theoretically-derived gender-specific intervention based on the Stages of Change Model, utilizing

2005 REPORT outreach initiative

a nurse educator approach; 2. Two face-to-face structured health education sessions plus two booster sessions designed to promote targeted health services utilization behavior change

Evaluation: Evaluation questions will include: 1. Does the Phase II intervention result in more improved outcomes compared to Phase I? 2. What is the relationship of potentially adverse factors and potentially beneficial factors to service utilization and health outcomes? 3. What is the structure of the program as it relates to client retention? 4. What is the process of program implementation that relates to the target population? 5. What are the outreach/retention outputs in the program that relate to the target population?

Contact Information:

Sally Dodds, PhD, LCSW, Principal Investigator
1695 NW 9^th Avenue, Room 3308 (D-21)
Miami, FL 33136
E-mail: sdodds@med.miami.edu
Phone: 305-355-9191

University of Washington Department of Psychiatry (Seattle, WA)

Outreach: HIV-Seropositive People Not in Primary Care

Target Population: HIV-seropositive people of color who are not currently enrolled in primary care or are sporadic users of primary care

Goal: To increase the percentage of clients that receive regular primary care and ancillary services such as mental health care or substance abuse counseling

Strategies: 1. An intervention that incorporates the Assertive Community Treatment (ACT) team approach to engaging people with multiple problems and linking them to appropriate care services; 2. Hire staff with chemical dependency and mental health expertise to provide culturally competent care to the target population

Evaluation: The evaluation will focus on: 1. Demographics of clients relating to mental health

problems, substance use issues, and/or homelessness; 2. The effects of the enhanced staffing and ACT approach on referrals and retention in primary care; 3. Barriers to engagement and retention in primary care

Contact Information:

Victoria Harris, MD, MPH, Principal Investigator
University of Washington
Box 356560
Seattle, WA 98195
E-mail: vharris@u.washington.edu
Phone: 206-680-9699

Wayne State University (Detroit, MI)

Evaluating Horizons Project Targeted HIV Outreach and Intervention to Enroll and Retain HIV-Positive Youth in Medical Care

Target Population: Youth that are not receiving primary medical care and youth already enrolled in medical care

Goal: To enroll and retain youth in HIV-oriented primary medical care

Strategies: 1. Agency and street outreach, outreach events, individualized case management/social work, mental health services, and peer advocacy and education; 2. Motivational Interviewing, which concentrates on the issues of motivation along the continuum of behavior change

Evaluation: Evaluation activities will focus on documentation of contacts, medical and psychosocial outcomes, and a qualitative evaluation of barriers to care

Contact Information:

Sylvia Naar-King, PhD, Project Director
Department of Psychiatry, Children's Hospital of Michigan
3901 Beaubien Boulevard
Detroit, MI 48201
E-mail: snaarkin@med.wayne.edu
Phone: 313-745-4875

2005 REPORT outreach initiative

Well-Being Institute, Inc. (Detroit, MI)

Detroit Access-to-Care Program

Target Population: HIV-infected persons in Detroit who are lost to follow-up in medical care, predominantly African American, at or below the poverty level, and experiencing barriers in accessing medical care

Goal: To improve the engagement and retention of the target population in medical care

Strategies: Focusing on direct improvement of participants' global well-being using the Personalized Nursing LIGHT Model intervention

Evaluation: Outcomes to be measured include well-being, participation in health care, client health status, adherence to medical treatment, and how improvement in adherence may be correlated with health outcomes

Contact Information:

Geoffrey Smereck, JD, CAC, Principal Investigator
3800 Woodward Avenue, Suite 218
Detroit, MI 48201
E-mail: gsmereck@pnc-wbi.com
Phone: 313-831-6000

Whitman-Walker Clinic, Inc. (Washington, DC)

Healthy Connections for Positive Living

Target Population: Ethnically diverse persons at high risk for non-retention in HIV-oriented primary medical care

Goal: To increase a client's self efficacy and improve health care access and retention

Strategies: 1. Integrating the Health Belief Model and Self-Care Deficit Theory 2. Assignment of a Retention Care Coordinator (RCC) to facilitate self-efficacy in self-care management

Evaluation: The primary evaluation questions to be answered are: 1. What is the effectiveness and required dose of an outreach retention intervention targeting high-risk persons for non-retention in HIV-oriented primary medical care? 2. What is the relationship between HIV-related stigma and utilization of HIV-oriented primary medical care?

Contact Information:

Michael Relf, PhD, RN, CS, ACRN, Principal Investigator
1407 S. Street NW
Washington, DC 20009
E-mail: mrelf01@georgetown.edu
Phone: 202-687-4647

Boston University School of Public Health, Health and Disability Working Group (Boston, MA)

Center for Outreach, Research and Evaluation (CORE)

Goal: 1. To coordinate and facilitate the evaluation of outreach strategies for bringing minority and underserved populations into healthcare in the early stages of HIV disease; 2. To identify and evaluate models that transform sporadic users of health care into regular and continual users; 3. To identify effective methods to support and retain clients in health care

Strategies: 1. Technical assistance provided to each grant site; 2. Grantee training on interviewing, data entry, and data submission; 3. Multi-site evaluation to include client level data analysis, aggregate agency-level quality improvement analysis, and qualitative analysis

Evaluation: Multi-site questions include: 1. What types of outreach strategies are associated with engagement and retention in medical care? 2. What are the characteristics of clients who are engaged and retained in medical care, versus those who are not? 3. Are there differences in barriers and facilitators among individuals engaged and not engaged in medical care? 4. Does engagement in case management facilitate engagement in primary care? 5. Is the level of retention in care associated with changes in CD4 and viral load? 6. Are individuals who are retained in medical care more likely to show improvements in overall functioning and quality of life?

Contact Information:

Carol Tobias, MMHS, Center Director
374 Congress Street, Suite 502
Boston, MA 02210
E-mail: tcarol@bu.edu
Phone: 617-426-4447