Addressing the HIV Outbreak among People with HIV and the American Indian Community: MATEC Minnesota's HIV Practice Transformation Project Successes
November 17, 2020
The Native American Community Clinic (NACC) in Minneapolis has been highly successful in integrating HIV care into their Federally Qualified Health Center (FQHC). Minnesota has eleven sovereign American Indian (AI) nations1, and the Phillips neighborhood of Minneapolis (where NACC is located) has the third-largest urban AI population in the United States2. In 2019, AIs in Minnesota were seven times more likely to die of a drug overdose than white, non-Hispanic persons, and had an HIV diagnosis rate of nearly eight times that of white, non-Hispanic persons3.
Native American Community Clinic’s Unique Position
There is a current HIV outbreak among people who inject drugs (PWID) in Hennepin and Ramsey counties where Minneapolis and St Paul are located, respectively. There are 26 cases currently, up from 18 cases when the outbreak was announced in February 2020. Typically, there are 0-3 cases of HIV in PWID per year in these counties, so this is a very significant increase. There is also evidence of recent transmission in those diagnosed June - September 2020. Many of these individuals are currently experiencing houselessness, are co-infected with hepatitis C, and/or identify as AI/Native American (NA)4.
Because of their patient population and position in the community, the NACC was asked by the Minnesota Dept. of Health and Human Services to take a large role in responding to the outbreak. The NACC provides care to 4,500 patients annually and about 85% of their patient population identifies as NA/AI. Their mission is to promote health and wellness of mind, body ad spirit in NA families. NACC employs principles of Harm Reduction in their care services including meeting people where they are at, accountability without termination, and treating substance use as a chronic disease. The clinic provides a multitude of harm reduction services including safe injection/use supplies and education materials, Medication-Assisted Treatment (MAT), outpatient treatment programming, support groups, outreach services, and staff competency in sex work/trafficking/trading. NACC is located in Minnesota’s American Indian Cultural Corridor, is geographically very near the city blocks most impacted by the George Floyd Uprising in Minneapolis; and additionally is close to a large homeless encampment associated with AI-centered activism for unhoused persons.
NACC has a unique model as an FQHC that has an outreach wing, MAT services, and works very closely with a Harm Reduction and Syringe Services Program. The outreach services NACC provides have allowed the clinic to do HIV screening/testing in the field as well as incentivize those at high risk (i.e. those experiencing houselessness and/or those who inject drugs) to come into the clinic to be tested for HIV. Those who come into clinic can be screened/tested for other infections like HCV and STIs, and receive support services like mental health counseling, dental services, nutrition, health insurance navigation, peer recovery support, MAT services on-site, and culturally specific services like spiritual care with Elders in Residence. The HIV outreach wing of the clinic was and continues to be instrumental in the advancement of the clinic’s high-risk HIV screening, testing, linkage to care, and re-engagement in care. The success of this model is largely due to the staff that take the time to go to the encampments and build relationships with the individuals staying there and those at local shelters, and with the community members and agencies involved in encampment work. Some of this relationship-building includes organizing street clean up days, creating and passing out hygiene and wound care kits, food and water, and making sure harm reduction supplies are always available. Building these relationships was the key to getting folks at high risk for HIV transmission into the clinic. It takes time, but now outreach staff at NACC are trusted individuals in the community and the clinic is able to provide healthcare to those who identify as AI/NA, those living in encampments, persons who inject drugs, and/or persons with unstable housing.
NACC staff, including the CEO, CMO, CIO, Nursing Manager, and outreach staff have been instrumental in setting up these services and making them as a low barrier as possible. They are true clinic champions in every sense of the word. They recognize the need in the community and understand that the clinic is a trusted (and often is the only) place patients feel safe going for their healthcare and other needs. These dedicated individuals have devoted an enormous amount of time and energy into shaping their HIV services, and continuously seek to expand and improve on their care and services. NACC staff have developed an HIV risk assessment and internal referral system embedded in their EHR so each staff member can feel confident in providing HIV screening/testing in-clinic as well as making sure these patients have access within the clinic to other services like counseling and MAT, if desired. They have also sought to make sure current HIV patients are retained in care by offering services such as keeping medications in a lockbox at the clinic so patients don’t have to keep track of them while living in encampments, or working with pharmacies for coordination of medications and adherence (as NACC does not have a pharmacy on-site). The importance of this HIV capacity-building work is further illustrated when considering that in the past year, when patients received an HIV diagnosis at NACC and were referred to an HIV specialty clinic for their HIV care, there was 0% engagement in care at the specialty clinic.
MATEC MN’s Involvement
The MATEC Minnesota site has been strategically positioned to support this work as the NACC was paired as our HIV Practice Transformation Project (HPTP) site. All of our work together is driven by clinic staff’s time, energy, and priorities. These priorities are tied to their understanding of the needs in their community and MATEC trusts that they have a better grasp of the clinic and community needs than we do.
To that end, MATEC Minnesota has provided several key services that have moved this HIV capacity building work forward and have honored the staff’s energy and priorities. We:
- Maintain an open line of communication. MATEC staff and NACC staff have a trusting relationship that includes weekly meetings, frequent texting/phone conversations, and lots of emails where we share and brainstorm and plan.
- Facilitate HIV expert clinical support through MATEC faculty- physicians, NPs, and PharmDs act as mentors, provide clinical consultations, and could potentially co-manage patients. The patients that receive their HIV and primary care at NACC often have co-morbidities, a lack of support services, and more pressing concerns on their hierarchy of needs that complicate their healthcare so having a consultation/co-management system is effective.
- Maintain an ongoing contract with a nurse specialized in harm reduction and HIV who is heavily involved in this clinic change work. This nurse is able to answer outreach questions, support system changes like EHR additions, and generally use his experiences and expertise to be an extra clinical liaison for the staff. Our current MATEC Minnesota staff do not have clinical backgrounds so having someone dedicated to this work and available to reach out to when needed has been a big component of our success.
- Assisted with the implementation of the 340B program so additional funding in the form of rebate dollars can be funneled back into the clinic for patient support. These funds cover copays, lab testing, and other patient services that aren’t otherwise covered by insurance.
- Provide technical assistance including updating clinic policies and procedures. Examples of updated policies and procedures include patient criteria for routine rapid HIV screening in the primary care setting, delivery of negative or indeterminate HIV confirmatory test results, delivery of positive HIV confirmatory test results and linkage to care, and managing primary care for patients living with HIV. MATEC Minnesota site has also provided workflows and informational sheets for different types of HIV appointments such as new patient 1st visit or HIV maintenance visit, and list of HIV labs needed at each visit, list of vaccinations for persons living with HIV, and anal dysplasia screening. These systemic additions make sure that this HIV work is sustainable, so it doesn’t depend on staff who may eventually leave the clinic. It also helps all clinic staff, not just those who are involved in our HIV project work, to feel confident and comfortable providing HIV-related care such as screening, testing, PrEP, and internal referrals.
- Create individual personalized education/professional development for each member of the NACC staff as they desire. This helps staff from the front desk to the grant manager to the Chief Medical Officer feel more confident providing services to patients with HIV. We provide general “HIV 101” type educational materials as well as topics of interest to providers and nurses including HIV and comorbidities, Antiretroviral Therapy, and HIV for special populations including pregnant women. We utilize the National HIV Curriculum for some of this individual education, as well as the AAHIVM, ANAC, and other excellent resources.
- Advocate for the clinic and clinic staff whenever possible. We connect them to other HIV experts and funders in the Twin Cities and seek to have the clinic be recognized as a clinic that provides excellent HIV and primary care.
Summary and Future Plans
Focusing on relationship and trust-building should be the initial and primary goal of any Practice Transformation Project. Because we established rapport and confidence with each other, the implementation of all the action steps detailed here fell into place much easier. This relationship-building component is time-consuming for both parties but essential to the work.
Other successes included providing clinical support in the form of our nurse contractor and other consultative relationships with HIV experts. AETCs often have special relationships with the HIV workforce that other entities do not have, and can pair PTP clinic staff with HIV expert providers. AETCs also often have relationships with funders, especially other Ryan White Parts. We used our connections with those funders to facilitate a series of meetings and advocated in the background and the clinic will now have funding for one FTE position for a Ryan White non-Medical Case Manager to start in January 2021. Additionally, focusing on both individual education/professional development and policies/procedures, workflows, and EHR changes allowed for staff to improve their HIV knowledge and skills but also make sure the HIV capacity was sustainable. Above all, the staff at Native American Community clinic prioritized this clinic change and capacity building work. They understand the needs of the community and their unique position and array of other services, and want to meet those needs, and are willing to dedicate an enormous amount of time and energy to do so.
We would be remiss not to mention how the COVID-19 pandemic has impacted MATEC MN and NACC’s collaboration. We have not been able to meet in person since March. The clinic went through a process of closing, doing telehealth, and opening back up all within a few months. This work included navigating PPE and staff safety protocols, reworking clinic flows to maximize separation of patients, utilizing telehealth for providers at home and in clinic, and putting together COVID-19 outreach testing events. The outreach team had to quickly adapt to a new model of providing socially distant services and support. It was very difficult to prioritize this HIV Practice Transformation work in the face of so many other pressing healthcare concerns. There was staff turnover. Yet despite all these curveballs, in the year that we have worked with this clinic, they have seen a rise in the number of HIV tests performed, doubled the number of HIV patients retained in care at NACC, and tripled the number of patients on PrEP.
There are a lot of plans for continued growth, and future goals include: receiving additional Ryan White funding for culturally specific HIV care, further increasing the number of people with HIV retained in care at NACC, get all their current patients with HIV virally suppressed, and expanding services to provide more PrEP. We have had a lot of successes but are always seeking to improve and expand. Native American Community Clinic has an overarching goal to become a culturally specific HIV and Primary Care Center of Excellence and we at MN MATEC are honored to be a part of this clinic change work.
- "Minnesota Indian Tribes." Minnesota.gov, https://mn.gov/portal/government/tribal/mn-indian-tribes/
- “American Indians in Minnesota: Common health equity issues for American Indian populations.” Stratis Health - Health Care Issues | Culture Care Connection, http://www.culturecareconnection.org/matters/diversity/americanindian.html
- "HIV/AIDS Statistics - 2019." (2020, September 9). Minnesota.gov, Minnesota Dept. of Health, https://www.health.state.mn.us/diseases/hiv/stats/2019/index.html
- "Health Advisory: HIV Outbreak in Persons Who Inject Drugs." (2020, February 6). Minnesota.gov, Minnesota Dept. of Health, https://www.health.state.mn.us/communities/ep/han/2020/feb3hiv.pdf