Tools for Grantees:
"Retention
of Homeless Clients in HIV Care"
FINAL
REPORT
HEALTH
RESOURCES AND SERVICES ADMINISTRATION
HIV/AIDS BUREAU, DIVISION OF TRAINING AND TECHNICAL ASSISTANCE
RYAN
WHITE CARE ACT
TECHNICAL ASSISTANCE CONFERENCE CALL
SERIES
Thursday,
August 18, 2005
2:00 - 3:00 PM EST
Arranged by:
Health Resources and Services Administration,
HIV/AIDS Bureau, Division of Training and Technical Assistance
I.
Executive Summary
On August 18, 2005, the Health Resources and Service Administration's
(HRSA's) HIV/AIDS Bureau (HAB), held a conference call with CARE Act
grantees to discuss approaches for engaging homeless clients in HIV
care. The call was moderated by Steven Young, M.S.P.H., Director of
the Division of Training and Technical Assistance, and also featured
HAB Deputy Associate Administrator Laura Cheever, M.D., Sc.M.
Call
Presenters Included those working in community-based agencies that
serve the homeless, as well as two Title I grantees that offered
a systems-wide perspective. Participants highlighted key strategies
for working with homeless clients, including combining HIV care
with other services, building strong relationships to promote trust,
and delivering services according to the clients' readiness.
The
call was one in a series of technical assistance conference calls
aimed at providing grantees with assistance and guidance in planning,
implementing and managing their CARE Act programs.
II.
Welcome and Introductions
- Steve
Young, M.S.P.H., Director, Division of Training and Technical
Assistance, welcomed participants to the technical assistance
conference call entitled "Retention of Homeless Clients
in HIV Care." He noted that more than 875 individuals and
sites had signed up to participate in the call, including staff
of Health Care for the Homeless programs, and those representing
the Department of Housing and Urban Development's Housing Opportunities
for People with AIDS (HOPWA) program.
- Mr. Young
said that while the call would focus on homeless clients, the
issue of retention in HIV care for all clients was one that
merited greater attention by the Bureau and CARE Act providers,
given that many individuals with HIV face multiple barriers
to accessing care and services.
- Mr. Young
provided some data on HIV and homelessness. The prevalence of
AIDS among those using public shelters for housing is estimated
to be 10 times greater than the general population. HIV infection
rates among homeless individuals are estimated to be anywhere
from 3% -62%, depending on the particular subpopulation or geographic
area. Some of the highest rates are found among homeless injection
drug users. Duplicated CARE Act data from 2003 indicates that
at least 11% percent of CARE Act clients are non-permanently
housed and roughly 42,000 clients received housing related services.
About 10% of CARE Act services are focused on homeless clients.
III.
Federal Perspectives
Laura
Cheever, M.D., Sc.M.
Deputy Associate Administrator
HIV/AIDS Bureau
- Laura
Cheever, M.D., Sc.M., Deputy Associate Administrator of HAB,
said that the majority of those affected by HIV in the U.S.
come from medically underserved populations and face multiple
barriers to care.
- In addition
to lack of housing, many homeless clients are also dealing with
substance abuse and mental health issues, as well as other challenges
that complicate their ability to access care. Dr. Cheever stated
that "Overall, as a nation, we're really not doing a very
good job at getting people into care and helping them stay there"
and mentioned that homeless clients were especially hard to
serve in this regard.
- The Centers
for Disease Control and Prevention (CDC) estimates that a quarter
of all people with HIV are unaware of their status, and a third
of those who know they are HIV-positive are not receiving care.
That means that only about half of those with HIV are getting
consistent medical care.
- To assess
and examine current outreach efforts, HAB held a consultation
in Spring 2005 with grantees and representatives of other Federal
agencies. Traditionally, HAB's outreach efforts have focused
on clients that know they are HIV-positive but have never been
in care, or those who do not know they are HIV-positive. HAB
is not satisfied with the impact of these activities, explained
Dr. Cheever, and is seeking more effective approaches for serving
homeless persons.
- Dr. Cheever
said the consultation helped identify some effective strategies:
1) bring the services to the client, for example, have storefront
locations in places where homeless people congregate or live;
2) maintain operating hours that accommodate the lifestyles
of the population being served; and 3) co-locate medical services
with other support services that clients use. She emphasized
the fact that homeless persons often need intensive support
services to help keep them in care.
- Most CARE
Act grantees have experienced level funding in the past few
years while their caseloads have continued to grow, said Dr.
Cheever. "So the question becomes whether they choose to
invest a lot of resources and energy into a few patients that
are hard to reach," she said, "or whether they provide
a less intensive level of service to more clients." Every
program must analyze what balance is right for them, but the
expectation is that they will do both, based on local needs.
In addition, HAB is promoting greater collaboration among providers
to ensure the availability of services to homeless and other
clients.
- HAB's
housing policy states that CARE Act funds can be used for housing-related
services, including housing referral to short-term and emergency
housing, that support the client in gaining access to primary
care. Funds cannot be used for long-term housing.
- Dr. Cheever
explained in her experience as a clinician, medical providers
are often the crucial link to the system for homeless clients.
In that regard, doctors have a responsibility to help clients
get services that meet their basic needs. CARE Act programs,
she said, fund case managers and other staff that can help in
establishing those linkages.
- Dr. Cheever
also mentioned a document entitled Adapting Your Practice, developed
in collaboration with the National Health Care for the Homeless
Council. The document provides recommendations and innovative
strategies for serving homeless clients. Its available online
at www.nhchc.org.
- Mr. Young
said that the report from HAB consultation would be posted on
the HAB web site in the coming weeks.
IV.
From the Field
Leah
Holmes, L.I.C.S.W.
Senior Project Director and Principal Investigator
Miriam Hospital
Providence, Rhode Island
Alison
Frye, M.P.H.
Program Manager, Client Outreach and Assessment
Cascade AIDS Project
Portland, Oregon
Kristin
Durell
St. Mary's McAuley Health Center
Grand Rapids, Michigan
Xiomara
Llaverias
St. Joseph's Mercy Care Services
Atlanta, Georgia
- Project
Bridge, a program of Miriam Hospital in Providence, provides
outreach to HIV-positive offenders preparing to be discharged
from the corrections system. The program follows clients for 18
months after prison release to help ensure continuity of medical
care through social stabilization.
- Project
Bridge provides intensive case management using teams of professional
social workers and paraprofessional outreach workers or case assistants.
Social workers accompany clients to medical appointments to help
facilitate communication with doctors and address barriers to
care. Both clients and doctors regard this aspect of the program
as crucial.
- The program
employs harm reduction along with an approach called "motivational
interviewing." This technique tries to help the client determine
what about their lifestyle is working for them, what isn't and
where they feel they can make changes. Constant reinforcement
is a critical piece of working with homeless clients, says Leah
Holmes, Senior Project Director.
- Ms. Holmes
explains that homeless clients can leave their HIV medications
on site in a locked closet. That helps bring clients in on a daily
basis, where they can meet with an adherence nurse and receive
beverages and snacks to take along with their medications. Homeless
clients take a class called "Life Skills," which teaches
them about the importance of adherence, side effects, what they
can expect during the course of treatment, and other related issues.
- Peer
Link, a program of the Cascade AIDS Project in Portland, helps
identify and connect people living with HIV to the already existing
service continuum that consists of medical case management and
HIV primary care. The program also operates based on a harm reduction
model, which means that staff focus on delivering services according
to the client's readiness levels and what the client identifies
as his or her care and service needs. The program is very focused
on building relationships with clients, and uses intensive front-end
services to prepare clients for entry into care.
- Alison Frye
of the Cascade AIDS Project defined what it means to "meet
clients where they are at." She said it requires taking the
client's readiness and preferences into consideration when making
treatment decisions, and providing services on an unconditional
basis. For example, if the client is more concerned about having
a place to sleep rather than taking medications, explained Ms.
Frye, then her program would work on getting the client set up
with housing services.
- Kristin
Durell of the St. Mary's McAuley Health Center in Grand
Rapids, Michigan, provided an example of a harm reduction approach
from the substance abuse field: needle exchange. She said that
the goal of needle exchange is to reduce client risk while contributing
to positive, long-term health outcomes. This may mean different
things for different clients. As an example, she said that if
a client were using drugs with no intention of stopping, then
services would be organized around trying to provide the client
with HIV treatment that fits their lifestyle, rather than trying
to force them to change their behavior to accommodate an ideal
treatment scenario.
- Ms. Durell
said that many homeless are referred from emergency rooms or hospitals,
and most are ill when they come in to St. McCauley's for services.
The program generally starts clients on antiretrovirals immediately,
while simultaneously coordinating services to address other client
needs and working on development of a care plan. The program also
performs genotyping and phenotyping for all new clients, so that
treatment can be more tailored, and, in many instances, the number
of medications a client takes every day can be significantly reduced.
This, in turn, makes the regimen easier for clients to tolerate
and manage.
- Xiomara
Llaverias of the Title III-funded St. Joseph's Mercy Care Services
in Atlanta, Georgia, spoke about adherence with homeless clients.
She said that about 75% of the organization's homeless clients
are on treatment, and outlined several approaches that staff use
to help promote adherence. They call clients to remind them about
appointments, and use those calls to address adherence issues
the client may be facing. Staff regularly stress the importance
of keeping appointments and taking medications on time according
to their regimen. Doctors reinforce messages about adherence at
client appointments. In addition, the program uses case managers
and nutritionists to provide clients with adherence support and
information as they continue on their treatments.
- With regard
to support services, Ms. Llaverias explained that St. Joseph's
has had success with making a range of services available on site,
rather than trying to provide clients with referrals to other
agencies or organizations. She said the latter approach resulted
in many clients falling out of the system. She reiterated the
importance of follow-up in helping clients stay in care and keep
on their treatment schedules.
V.
System-wide Efforts to Serve Homeless Clients
Shelley
Stinson-Barron
Program Specialist
Alameda County Public Health Department
Office of AIDS Administration
Oakland, California
Derek Wilson
Program Analyst Supervisor,
AIDS Activities Coordinating Office
Philadelphia Department of Public Health
Philadelphia, PA
- Shelley
Stinson-Barron of the Alameda County Health Department,
a Title I grantee, explained that the health department contracts
with providers throughout Alameda County and also partners with
neighboring Contra Costa County to provide services to homeless
clients with HIV. The health department targets its efforts to
individuals who are not accessing care, those who are unaware
of their status, or those whose barriers are so severe that they
inhibit their ability to seek care. A major aspect of the program
is the provision of outreach services to bring clients into care.
- Ms. Stinson-Barron
said the health department also has core services targeted to
recently released or violent offenders with HIV. These include
transitional housing, substance abuse treatment, treatment advocacy,
and others.
- Derek Wilson,
a program analyst supervisor with AIDS Activities Coordinating
Office of the Philadelphia Department of Health, described
a network of onsite, street-level
storefronts that provide HIV care and services to homeless clients.
He said central to providing
service is the recognition that HIV is often not at the top of
the client's priority list. In order to
keep clients in care, the program offers a network of wraparound
services, including case
management, outreach, peer counseling, and primary care.
- Mr. Wilson
explained that storefronts are not identified specifically as
HIV programs because staff have learned that doing so quickly
stigmatizes them and causes clients to avoid them. They are, instead,
promoted as places that provide a range of services for homeless
clients, including HIV.
VI.
Measuring Success
- Mr. Wilson
explained that the Philadelphia Health Department has a strong
information systems unit that retrieves all kinds of data, including
units of service and Continuous Quality Improvement (CQI) results.
The health department is constantly reviewing data to assess its
progress in meeting goals. In addition, client feedback is sought
through, among other things, focus groups. Mr. Wilson explained
that Philadelphia's CQI program is aimed at building provider
capacity to deliver the highest quality of care and services,
and said technical assistance is used to support providers in
reaching CQI goals.
- Ms. Stinson-Barron
said that Alameda County requires all contractors to submit work
plans including quality indicators, and documentation from clients
to show that they are utilizing primary care and HIV services.
Staff reviewed results of client satisfaction surveys to identify
what is and is not working in provider programs.
- Ms. Durell
said that in addition to the tools Mr. Wilson mentioned, providers
at St. McAuley's Health Center have also developed an electronic
acuity tool that helps assess progress in addressing both psychosocial
and medical aspects of each client's care plan.
VII.
What's Not Working
- Mr. Young
asked the panelists to share their thoughts on approaches that
are ineffective in providing services to homeless clients.
- Ms. Frye
said that imposing really stringent program requirements has not
worked in the past with homeless clients of the Peer Link program.
She said that not taking the time to establish solid relationships
with clients also does not work.
- Ms. Llaverias
said that the use of group education sessions was unsuccessful
for St. Joseph's, so the program now conducts one-on-one education
with each client, which seems to make clients feel more comfortable.
- Ms. Stinson-Barron
said that her program is exploring more effective approaches for
reducing the rates of HIV among African American women, and bringing
them into care in greater numbers. She said that the ongoing rise
in new infections among African American women has made the health
department seek out new strategies for serving this community.
VIII.
Questions and Answers
| Question:
|
This
one is for Derek in Philadelphia. You mentioned needing to
build in some creative ways for minimizing HIV stigma. What
other services are you providing at the storefronts?
|
| |
|
| Mr.
Wilson: |
Well,
each storefront is different because they are all located
in a variety of different places. We have a storefront, for
example, located in a neighborhood that is heavily Latino
and so, English as a Second Language classes are offered there.
All of the storefronts offer some kind of food program for
the general population.
We
have one storefront in a suburban county that has a great
best breakfast program, and that is what pulls clients in.
Homeless clients know they will get a good breakfast at the
AIDS CARE Group. The organization uses that as a way of building
relationships with the homeless.
Mostly,
we tell our storefront operators to look around their neighborhoods
to see what the needs are, and then we will help them figure
out a way to get those services incorporated into their centers.
|
| |
|
| Question:
|
The
name AIDS Care Group indicates that they are an HIV organization. |
| |
|
| Mr.
Wilson: |
Most
people actually know the AIDS CARE Group as an organization,
but the storefront is housed in the Catholic Social Services
building, so when most people think about where to go for breakfast,
they say they are going to the Catholic building. |
| |
|
| Question: |
What's
the link to care at the storefronts? |
| |
|
| Mr.
Wilson: |
Well,
the storefronts have peer counselors or outreach staff who talk
with clients, get to know them, and find out what their needs
are. By building relationships and trust, you get people to
open up. Usually what happens is that a staff person will get
pulled to the side and a client will tell them what's going
on. |
| |
|
| Question: |
Hi,
I was wondering how much time agencies are spending trying to
get people hooked up to benefits like Medicaid. We are finding
that it is necessary because we can't really do much without
these types of benefit programs. |
| |
|
| Ms.
Frye: |
I
can answer that. I think what has been helpful for us is that
we have a peer advocate who works in our program and is able
to accompany people to the food stamp office or to apply for
Medicaid. It does take a lot of time but we are finding that
it is a necessary first step in order to move the client into
other services. |
| |
|
| Ms.
Holmes: |
Yes,
I think that it does help if you have somebody on your staff
who can be dedicated to that kind of work because it does require
a certain skill set and the parameters for the programs are
sometimes very complicated, so I would encourage you to have
somebody on your staff develop the expertise. |
| |
|
| Ms.
Stinson-Barron: |
We
stress that our providers need to connect their clients to other
services, such as Medicaid and Temporary Assistance to Needy
Families (TANF), because Title I service dollars are funds of
last resort. We fund a couple of client advocacy programs and
a legal program, which assist clients with appeals to the agencies
that distribute SSI or SSDI benefits. |
| |
|
| Question: |
Hello.
I have a question for Leah about social workers that go to doctors'
appointments and facilitate conversations for the patients.
In Sonoma County, our funds are being cut, and so are our county
mental health services. How do you work with others to provide
those services? |
| |
|
| Ms.
Holmes: |
Actually,
we do a lot of referral to mental health services. We do have
a psychiatrist who works with our clinic and she sees clients
for medication evaluations, which is very helpful. One of
the ways I view this is that these are not systems, these
are fortresses and sometimes there is an inverse relationship
between the level of need that the client has and the ability
to access the service for them.
About
7% of our clients have chronic mental illness. Our social
workers are both trained, and one actually worked for a mental
health agency here for about 15 years, so he's very familiar
with what's available. We do a lot of advocacy and social
workers will go to appointments with clients to make sure
they get in there and meet with somebody and get started.
It is a challenge and having people who are trained at that
level is very helpful.
|
| |
|
| Question:
|
One
thing we want to do with our clients is offer financial management
classes. But one of the panelists was saying that group classes
do not work very well. Should I do individual sessions instead?
|
| |
|
| Ms.
Durell: |
First
of all, you may want to look at what resources are available
in the community. I know in Grand Rapids there are financial
management resources that are available to everyone and it
might be a matter of facilitating a referral to a program
like that, if one exists. At McCauley, we have a housing specialist,
funded through HOPWA, who goes to different community programs
and provide a life skills class that includes a financial
piece.
So,
for example, we might identify two clients that live in a
particular subsidized housing program or shelter. The housing
specialist would offer the class at the shelter, so the two
clients would actually count towards our HOPWA goals and then
others would have the benefit of hearing the information.
In addition, this approach helps remove some of the stigma
by partnering with other programs in the community.
|
| |
|
| Question:
|
How
many classes do you usually have for your financial management? |
| |
|
| Ms.
Durell: |
One
class is two-hours long. |
| |
|
| Question:
|
I
know Xiomara had mentioned the fact that they do follow up by
phone, but what if clients do not have phones, how do you reach
out? What other methods do you use? Also, does anyone have extended
program hours? |
| |
|
| Ms.
Llaverias: |
Most
of our homeless patients either have a relative or friend
or a counselor that can act as a contact person. Also, many
times they have a place where we can send letters to them
and we do that.
|
| |
|
| Ms.
Durell: |
In
Grand Rapids, clients must be in the shelter by 6:00 p.m.
to have dinner and stay for the night. When we had hours from
4:00 -7:00, we saw [less] clients than during our daytime
hours. A lot of this is trial and error, and some of its learning
what the client's priorities are.
We
have found that a complete walk-in schedule hasn't worked
for us, nor has a complete appointment schedule. So we've
been working towards an open access schedule, which blends
the two. And, again, that's part of meeting people where they're
at, because some people want to know they can come in around
the time of another appointment and be seen, so they like
to schedule, while others might come in after they've been
out of medication for three days, and are willing to wait
two to three hours for their turn in line.
|
| |
|
| Question: |
How
do you deal with the homeless, undocumented clients that might
be reluctant to come in for services, including transgender
clients?
|
| |
|
| Mr.
Wilson: |
Our
basic philosophy is that regardless of documentation status,
regardless of transgender issues, the same level of care and
level of respect is given to all those who seek services.
Obviously,
with undocumented persons and with transgender persons, there
are extra challenges as they tend to be more ostracized. We
work hard to provide peer counseling to help them navigate
through all of the obstacles they face, and that is really
the key. We work as hard as we can to get them to a place
of stability.
|
| |
|
| Ms.
Stinson-Barron: |
We
fund a translation program so we can communicate with the population
and pull some of those people into care that need to be there
and be comfortable with the care that they are receiving. |
| |
|
| Comments: |
Hi,
this is Carol Tobias from Boston University. I don't have a
question but I wanted to provide a little bit more information
about outreach to the homeless population. We work with the
SPNS outreach initiative that covers 10 different programs around
the country, including Leah's and Alison's. We just did all
the data collection for the program, and we're finding that
over 60% of clients enrolled in these outreach interventions
are unstably housed.
About
half of those people are doubled up or living with somebody
else, not in their own home or apartment, and the other half
are either in temporary housing or on the streets. What's
very interesting is that there were no real differences between
the people who were very unstably housed and people who have
their own housing, in terms of their healthcare utilization
or level of adherence.
We
did find that individuals who were either temporarily housed,
or completely homeless, were more likely to be older, to have
been HIV-positive longer, and to have had some actual drug
use in the past 30 days, either cocaine or heroin. They were
also more likely to be on medication for mental health conditions.
This
group was also much more likely to receive their HIV care
in hospital outpatient settings, as opposed to clinics. Two
things that made it difficult for them to get care was that
they had nobody to go with them, and they had no phones to
make appointments. I just thought that would reaffirm some
of the things that Leah and Alison were saying about how important
it is to accompany people to appointments, both to make sure
they get there and to help with communication.
|
| |
|
| Mr.
Young: |
Thanks
Carol for sharing that perspective. It is clear that there
are some important findings and experiences that we are learning
through that initiative. I'm sure there are some more questions
out there, but unfortunately we are coming to the end of the
hour and we did want to wrap this up and leave you with some
thoughts about the best ways to retain homeless clients in
care. Our six panelists, as well as Dr. Cheever, have provided
us with some big themes, such as meeting clients where they're
at, being non-judgmental, having good referral mechanisms
in place, making services as accessible as possible, developing
good relationships with clients, and following up with them
on a regular basis.
I'm
going to give each of our six panelists a chance to leave
us with any last thoughts.
|
| |
|
| Ms.
Frye: |
I
think that one of the most important things is to make homeless
clients feel welcome and establish strong relationships with
them from the "get-go." This helps them want to
come to you, if you can't find them.
|
| |
|
| Ms.
Llaverias: |
For
us, it's also about creating a welcome environment and providing
good "customer service." That's the key for us.
|
| |
|
| Ms.
Durell: |
Cultural
competency is a big one that was kind of alluded to but not
touched on today. Living in poverty has a cultural component
to it. If you have ways of educating your staff about that cultural
experience, that's a big benefit. |
| |
|
| Ms.
Holmes: |
Helping
your staff understand that progress is not linear and helping
them to look for small incremental changes I think is very helpful.
The cheapest thing you can do is to create a welcoming environment
and that means looking at your front-line staff and how they
are greeting people. |
| |
|
| Ms.
Stinson-Barron: |
My
first thought is to continue educating yourselves about who
you're serving, why and how, and to continue educating the clients
about services and what's available. I also encourage staff
to deal with burnout, because if you can't take of yourself,
you can't possibly take care of someone else. Also, I think
it's important to listen to the client's needs and address those
needs and not impose what you think or believe that their needs
should be. |
| |
|
| Mr.
Wilson: |
I
want to encourage everyone to be as creative as possible in
meeting the needs of the homeless. Please remember to respect
their journeys. Their decisions and priorities may not match
yours, but you have to learn to respect that, and if you do,
you'll find good success in working with homeless persons. |
IX.
Wrap Up and Closing
- Mr. Young
thanked the panelists for their insights and expertise.
- He reminded
participants to download the resources available on the conference
call
Web site and said they'd all be receiving a summary of the key
points shared
on the call.
- Finally,
he thanked participants for their time and their commitment to
serving those
living with HIV in communities throughout the country.
|
