Discuss updates to the Ask, Screen, Intervene (asi) curriculum Review the asi four Cities Project


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  • Discuss updates to the Ask, Screen, Intervene (ASI) curriculum

  • Review the ASI Four Cities Project

  • Identify lessons learned from the implementation of the ASI framework in community health clinics

  • Describe preliminary results from the evaluation of the project



Welcome and Call Purpose --- Joanne Phillips

    • Welcome and Call Purpose --- Joanne Phillips
    • Ask, Screen, Intervene (ASI) Curriculum Updates 2013 --- Helen Burnside
    • Ask, Screen, Intervene Four Cities Project --- Joanne Phillips
      • Introduction of the project
      • Collaborators
      • Timeline


Four Cities Updates

  • Four Cities Updates

    • Needs Assessment: process and findings
    • Training Design
    • Training Evaluation Data: barriers and anticipated practice changes
    • Lessons Learned
    • Clinic Experience
    • Plans for Sustainability


Evaluations of the curriculum implementation --- AETC NEC

    • Evaluations of the curriculum implementation --- AETC NEC
      • Evaluation Design
      • Data Collection
      • Data Analysis
      • Results
    • Summary of the Project --- Helen Burnside
    • Question and Answer --- Joanne Phillips


2012 4 modules→ 3 modules

  • 2012 4 modules→ 3 modules

    • Risk assessment & screening for STDs
    • Prevention Interventions
    • Partner Services
  • 2012-2013 Revisions completed from DHAP and DSTDP Clearance

  • Contact National Resource Centers for access to DRAFT curriculum





MAI-funded project through HRSA HAB

  • MAI-funded project through HRSA HAB

    • Supports National HIV/AIDS Strategy goals
  • Began Fall 2011

    • 2 year project
  • Project activities

    • Planning and implementation
    • Training and on-going technical assistance
    • Program assessment and evaluation


Enhance clinician ability to conduct effective risk screening, conduct prevention counseling, and refer for services

  • Enhance clinician ability to conduct effective risk screening, conduct prevention counseling, and refer for services

  • Increase the number of HIV-positive persons who receive information about transmission risks and regularly receive risk reduction counseling

  • Increase the number of HIV-positive persons who are screened for STDs

  • Assist in strengthening linkages to referral services



HRSA HAB

  • HRSA HAB

  • CDC

  • 4 regional AETCs and 4 PTCs

  • National Resource Center for NNPTCs

  • AETC National Resource Center

  • AETC National Evaluation Center

  • 8 Ryan White Part C clinics/FQHCs in 4 cities



Baltimore

  • Baltimore

    • Chase Brexton Health Services (3 sites)
    • Total Health Care, Inc. (10 sites)
  • Chicago



Los Angeles

  • Los Angeles

    • Alta Med Health Services Corporation
  • Miami

    • Jessie Trice Community Health Center, Inc.
    • Miami Beach Community Health Center


Planning & Implementation (Fall 2011 - Winter 2012)

  • Planning & Implementation (Fall 2011 - Winter 2012)



Training (Spring 2012- Summer 2012)

  • Training (Spring 2012- Summer 2012)

    • Tailor to clinic needs
    • Clinic project coordinator help facilitate and monitor
  • Assessment & Evaluation (Spring 2012 –Summer 2012)

    • Training Data
      • FTCC PIF
    • Training Evaluation Summaries
      • NRC for the NNPTCs


Ongoing Training and Technical Assistance (Fall 2012-June 2013)

  • Ongoing Training and Technical Assistance (Fall 2012-June 2013)

  • Program level (feasibility, fidelity, impact)

    • AETC National Evaluation Center


AETCs and PTC updates on: needs assessment process, training design, training evaluation data, lessons learned, clinic experience, and plans for sustainability

  • AETCs and PTC updates on: needs assessment process, training design, training evaluation data, lessons learned, clinic experience, and plans for sustainability





Meeting with clinic leadership and key staff

  • Meeting with clinic leadership and key staff

  • Specific needs related to 3 ASI modules:

    • What’s in place already
    • Who would be involved
    • EMR
    • What needs to be covered from ASI curriculum
  • Plans for sustainability



All 3 training modules were tailored …

  • All 3 training modules were tailored …

    • Audience
    • Local information
    • Time
  • Training / TA beyond ASI:



Risk screening (e.g., paper and iPad tools, etc.)

  • Risk screening (e.g., paper and iPad tools, etc.)

  • Screening of STDs

  • Delivering prevention messages

  • Use of behavioral counseling

  • Referral to more intense prevention interventions



Time (per encounter and for training)

  • Time (per encounter and for training)

  • Lack of confidence in skills

  • Competing priorities

  • Changes in leadership

  • Staff turnover



Clinic leadership and providers buy-in

  • Clinic leadership and providers buy-in

  • Needs assessment

  • Single contact at the clinic

  • Clinic-centered trainings and TA

  • Periodic site visits

  • Partner services … the weakest link?



Deyanira Flores, Project Coordinator

  • Deyanira Flores, Project Coordinator

  • ACCESS Community Health:

  • Overall experience

  • Major accomplishments

  • Barriers worth mentioning



All 3 sites will continue implementation at different levels:

  • All 3 sites will continue implementation at different levels:

    • ACCESS Community Health will expand to another site as of July 1, 2013
    • Erie Family Health Center and ACCESS will continue working with the PTC to conduct risk assessments with iPads
    • Heartland Health Outreach … new leadership and programmatic staff




  • Main HIV Clinic, Commerce, California



Initial Assessments: Winter-Spring 2012

  • Initial Assessments: Winter-Spring 2012

  • Scheduling: Spring 2012

  • ‘Overview’ session

  • Modules I, II, III delivered May-June 2012

  • ‘Implementation’ session June 2012

  • “Wrap up” in-person session May 2013



    • All ASI modules delivered at clinic and utilized
    • Turning Technologies ARS
    • Overview session was important to review what ASI implementation project was/wasn’t (i.e., exit interviews)
    • Draft clinic signage was used to facilitate training experience and discussion of clinic specific implementation of ASI




Barriers

  • Barriers

    • Existing Secondary Prevention Programs
    • Existing ideas of ideal clinic flow for prevention
    • EMR implementation/trainings during project
  • Practice changes

    • Increased STD testing/partner services referral
    • Increased sharing of patient risk information
    • Enhanced discussion of hard-to-reach patients


Important not to make patients feel like they are public health hazards---that assessing sexual health and prevention needs is part of high-quality HIV care

  • Important not to make patients feel like they are public health hazards---that assessing sexual health and prevention needs is part of high-quality HIV care

  • Combine ASI questions and protocols with existing prevention and STI screening procedures to enhance patient experience (without repeating sensitive questions)

  • Clinicians and support staff need to share prevention information and screening information, ideally through the EMR

  • Changing clinician/staff ‘routines’/beliefs may be harder than changing the EMR



PAETC/PTC will work with clinic to assist with future ASI-related training needs, including options for dealing with ‘condom refusers.’

  • PAETC/PTC will work with clinic to assist with future ASI-related training needs, including options for dealing with ‘condom refusers.’

  • The clinic now doing six month RA screening, with some staff more frequently

  • Partner Services always offered as standard of care (not always accepted, but increased)

  • Increased rectal and pharyngeal testing



Increase interactions within HIV staff groups (front office/back office, clinicians, mental health, case managers)

  • Increase interactions within HIV staff groups (front office/back office, clinicians, mental health, case managers)

  • EMR key for future sustainability (billing)

  • More specific questions about prevention needs helped change exam room interaction but this is long term process

  • Might be helpful to have level III observational experience for each discipline



PAETC, PTC or other (PS ATTC) will offer:

  • PAETC, PTC or other (PS ATTC) will offer:

  • PrEP

  • Brief Mental Health Screenings for non-mental health clinicians

  • Billing for Prevention in the ACA Era

  • SBIRTS

  • Medical Marijuana and HIV

  • Crack Cocaine and HIV

  • Meth and HIV

  • Alcohol and HIV





Introductory Meetings

    • Introductory Meetings
      • Training Centers’ Staffers
      • Clinics’ Staffers
    • Training Centers’ Responsibilities
      • Technical Assistance Training
    • Clinics Operations
      • Total Health Care, Inc.
      • Chase Brexton Health Services
    • Needs Assessments


Conducted face-to-face meetings with key stakeholders at each clinical setting

    • Conducted face-to-face meetings with key stakeholders at each clinical setting
    • Collected needs assessment data with stakeholders
      • Used format developed in partnership with full ASI, 4-Cities Project Group
      • Prepared full report
      • Shared with clinic partners
    • Sent reports to ASI, 4-Cities Project


Scheduled trainings based on clinic schedules

    • Scheduled trainings based on clinic schedules
      • Chase Brexton – held trainings on several different dates to accommodate all staff
      • Total Health Care – held one training to coincide with full clinic meeting
    • Collaborated with BCHD faculty for Module 4
    • Assured sustainability through TOT for selected staff


Key components

    • Key components
      • What clients need to know
        • Am I at risk
        • What puts me at risk
        • What can I do to prevent risk
      • What providers and support staff need to know
        • How can I implement ASI in a high volume primary care setting
        • What does it take to document ASI activities
        • How to evaluate the impact of ASI on affected population


Primary Care Settings

    • Primary Care Settings
      • Not offering exclusive HIV services
      • Diverse clinic census
      • Electronic medical records
    • HIV Care Patients
      • Total Health Care – separate clinic visits
        • Many HIV-specific visits
        • Some chose to stay with primary care providers
      • Chase Brexton – incorporated into clinic


Primary Care Side and Meaningful Use Questions

    • Primary Care Side and Meaningful Use Questions
      • Brief ASI intervention
        • Imperative in high volume setting
      • Incorporate ASI intervention into Electronic Medical Record is ideal
      • Coordinate HIV Medical Services with Primary Care
    • Clinic Accomplishments
      • Total Health Care, Inc.
        • 398 HIV-positive clients screened/documented – 2012
      • Chase Brexton Health Services
        • 933 Clients screened/documented – 09.2012-05.2013
      • Ongoing collaboration between clinics


TOT model

    • TOT model
    • TA
      • Linkage
      • Reverse Preceptor?
      • AETC + PTC as a resource
    • Collaboration between two large service providers




Jessie Trice Community Health Center (JTCHC)

  • Jessie Trice Community Health Center (JTCHC)

  • 5361 NW 22nd Avenue, Miami, FL 33142

  • Miami Beach Community Health Center (MBCHC)

  • 710 Alton Road, Miami Beach, FL 33139



Initial Assessment

  • Initial Assessment

    • March 2012
  • 2nd Assessment

    • October 2012 (sites requested training on HPV, Mental Health in HIV, STD, Substance Abuse, and Cultural Sensitivity)
  • 3rd Assessment

    • April 2013 (Sexual Health survey has been implemented as part of Primary Care and updates on STD will be provided yearly)
  • Last assessment pending June 2013



    • Modules delivered monthly in a previously scheduled training slot
    • Training slot was 3-5:00pm to avoid overtime pay and cutting into clinic hours
    • Training conducted in conference rooms at clinics
    • All clinic staff attended trainings


Barriers

  • Barriers

  • Practice changes

    • Allocating more time to provider
    • Allowing a Medical Assistant (MA) to assist provider
    • Providing education to clients that refuse to take Sexual Health survey


Cultural Sensitivity –

  • Cultural Sensitivity –

    • MBCHC, May 22, 2013
    • JTCHC, tentative for June
  • HPV and HPV Vaccines –

    • JTCHC, May 3, 2013
  • STD updates –

    • MBCHC, Feb. 21, 2013
    • JTCHC, May 17, 2013
    • Mental Health and HIV – (pending) June 2013


Module I training provided on March 29, 2013, to:

  • Module I training provided on March 29, 2013, to:

    • Community Health Centers of South Florida, Inc.
    • Borinquen Medical Centers of Miami




Provider administered Sexual Health survey is more likely to be more comprehensive and/or complete than self-administered survey

  • Provider administered Sexual Health survey is more likely to be more comprehensive and/or complete than self-administered survey

  • Patients were more willing to discuss sexual history because they knew that the sexual survey would be administered

  • Implementation of the Sexual Health survey has helped staff to facilitate sexual health discussions

  • Local involvement is crucial to program implementation

  • Prior to training, clinic involvement is crucial to program implementation



F/C AETC Coordinator has committed to provide STD training updates to staff at both clinics yearly.

  • F/C AETC Coordinator has committed to provide STD training updates to staff at both clinics yearly.

  • The clinics have established the Sexual Health survey as part of their Primary Care visit, which can be accessed in the EMR.

  • The clinics have already made changes to have every patient screened at every visit for sexual history in order to reduce HIV transmission.



Tim Buisker, Julia James, Andres Maiorana, and Janet Myers: AETC National Evaluation Center

  • Tim Buisker, Julia James, Andres Maiorana, and Janet Myers: AETC National Evaluation Center



Evaluation Design Overview

  • Evaluation Design Overview

    • Risk Screener Data
    • Patient Exit Survey Data
    • Ryan White Services Report/Client Level Data
    • Qualitative Interviews
  • Preliminary Results







Patient Exit Surveys

  • Patient Exit Surveys

    • Min 30 patients every other month in 400+ patient clinics
    • Min 12 patients every other month in <400 patients
    • Procedures tailored to clinic
  • Clinical Record Risk Data

    • ½ from EMR, ½ extracted using paper form
  • RSR Data

    • Was HIV risk reduction screening/counseling conducted?
    • Syphilis, Hep C, Hep B screening over time.


Study Participants:

  • Study Participants:

    • At least one ASI trainer per clinic
    • Planned for at least 4 providers per clinic
  • Methods:

    • Semi-structured Interviews
    • 30-60 minutes conducted over the phone
    • Interviews were audio-recorded and transcribed using a transcription service
    • Transcripts were coded iteratively by two independent researchers using an open-coding process (Strauss and Corbin 1998)


















How has the way you talk to patients about prevention changed after using ASI compared to before using ASI?

  • How has the way you talk to patients about prevention changed after using ASI compared to before using ASI?

  • How did the ASI training prepare you to talk to your patients about STD screening and HIV prevention with their partners?

  • How integrated do you think ASI has become to clinic procedures or protocols?



ASI provided a formal structure for discussing PwP with patients

  • ASI provided a formal structure for discussing PwP with patients

  • Clinic procedure: EMR adapted to include questions from ASI

  • ASI led to discussions about capacity for screening at the clinic

  • Medical providers and other staff were involved in implementing ASI



“I guess that what I would say about it is that it is a good reminder of something that, for the most part, we’re doing.”

  • “I guess that what I would say about it is that it is a good reminder of something that, for the most part, we’re doing.”

  • -- Medical Provider



ASI served as a reminder for providers on the importance of PwP

  • ASI served as a reminder for providers on the importance of PwP

  • ASI raised awareness of oral and anal swab testing in STI screening for gonorrhea

  • The Risk Screener facilitated conversations between patients and providers

  • Improved communication among team members helped medical providers learn more about their patients



“I would say doing [ASI] has been pretty seamless because I couldn’t even differentiate. It’s not like we fill out a form that says, ‘Fill out this form that you’ve completed ASI.’ We have to do more. It’s just part of what you do with every patient.”

  • “I would say doing [ASI] has been pretty seamless because I couldn’t even differentiate. It’s not like we fill out a form that says, ‘Fill out this form that you’ve completed ASI.’ We have to do more. It’s just part of what you do with every patient.”

  • -- Medical Provider



Time

  • Time

  • Knowledge transfer to new hires

  • Need for ongoing training

  • Need for special services for high risk patients and for those with comorbidities



“What this project did was make us talk about [STD screening] and just figure out how to make it available. Because our last lab wasn’t able to process everything correctly, we changed labs. It made us really figure out the process. From that, we’ve been able to do more. It just got everyone on the same page in the clinic about doing routine screening.”

  • “What this project did was make us talk about [STD screening] and just figure out how to make it available. Because our last lab wasn’t able to process everything correctly, we changed labs. It made us really figure out the process. From that, we’ve been able to do more. It just got everyone on the same page in the clinic about doing routine screening.”

  • -- Medical Provider



“Now, as part of the HIV care team, we're not going to pull back on discussing people's risks and how to intervene for a particular patient. We have those conversations weekly and we're going to continue that. We will also develop new tools and approaches for helping people.”

  • “Now, as part of the HIV care team, we're not going to pull back on discussing people's risks and how to intervene for a particular patient. We have those conversations weekly and we're going to continue that. We will also develop new tools and approaches for helping people.”

  • -- Medical Provider



Faye Malitz, HRSA

  • Faye Malitz, HRSA

  • Janet Myers, AETC NEC at UCSF

  • Andre Maiorana, AETC NEC at UCSF

  • Tim Buisker, AETC NEC at UCSF

  • Julia James, Fellow, UCSF



Helen Burnside: NNPTC NRC

  • Helen Burnside: NNPTC NRC



Patients want to discuss sexual health/Patient reluctance as a provider barrier

  • Patients want to discuss sexual health/Patient reluctance as a provider barrier

  • Needs assessment with clinic prior to training

    • Lab needs
    • Clinic flow/process and responsibilities of staff
    • Documentation: use of EMR, risk screener integration, partner service protocol, & data sharing
    • Clinic and provider buy-in


Multidisciplinary approach/medical home model

  • Multidisciplinary approach/medical home model

  • Sustainability: increase implementation success

    • Booster trainings
    • Clinic champion
    • Referral process
    • Incorporate ASI framework into clinic routine
    • “Changing clinician behavior is harder then changing an EMR”


Contact your AETC or NNPTC NRC for the ASI curriculum

  • Contact your AETC or NNPTC NRC for the ASI curriculum

  • Clinic posters are under development by NRCs

  • ASI provider guide



Joanne Philips: AETC NRC

  • Joanne Philips: AETC NRC




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