Engagement in Care Toolkit: Which engagement in care interventions might work for your clinic?

February 2014

Developed by the AETC Engagement in Care Workgroup

Note: This Working Group was convened to gather information about interventions that may have some utility in the improvement of care entry and retention. It should be noted that there are few randomized clinical trials or robust observational cohort data with biologic outcomes to support many interventions at this time. Therefore this chart is not intended to constitute recommendations that these interventions should be implemented, but rather to display the range of available options and to convey some sense of their strengths and challenges in the context of available evidence. We encourage that interventions be structured in such a way that outcome data may be collected and evaluated to advance the knowledge base in these important areas. For help using this tool in your clinic, please contact your local AIDS Education and Training Center.

Markup
Evidence-based InterventionStrengthsChallenges
Clinic-Wide Messaging
  • Affirmations and warm, welcoming messages enhance relationships between patient and clinic/patient and providers.
  • Patient messages are tailored for new, inconsistent, or established attenders.
  • Repeated messages from multiple sources (receptionist, providers, social workers, case mgrs., etc.) may be more reinforcing than from a single source.
  • Use motivational interviewing techniques and language focusing on patient strengths and skills, not just deficits and pathology.
  • Such communications contain inherent philosophy that all patients know something, and can be motivated toward retention and healthier behaviors.
  • Messages assume patients are resilient, capable of change, and offer hope.
  • Behavior change is hard, including provider behavior. Providers may believe that even brief messages use up the limited time they have with patients. Difficult to be consistent over time in terms of message delivery, and messages need to be varied over time or they become stale to the patient. Value of messages may wear off over time.
Outreach Worker
  • Connection to the target population allows strong referral relationships in the community to engage individuals in care; enhances clinic team's youth-centered engagement in care services; essential in locating clients who have missed appointments (AIDS Alliance for Children, Youth, and Families, 2005).
  • Outreach workers typically have limited professional training, so they must be closely supervised by experienced professionals; some sites noted difficulty helping outreach workers to establish boundaries between work and private life which sometimes led to compromised confidentiality (Hildalgo et. al., 2011).
Patient Navigator
  • Principles of patient navigation are rooted in community (lay) health worker and peer-based intervention strategies;
  • Methodology of patient navigation is well described in the non-HIV literature and has been incorporated into a number of disease prevention and management models, including those for cancer, diabetes, asthma, CVD, and maternal and child health. In the context of HIV, longitudinal data from a HRSA SPNS demonstration grant (Bradford, 2007) found improved engagement in care and viral load suppression associated with patient navigation.
  • Patient navigation can be implemented by a clinic or in collaboration with community-based service organizations; can also be tailored to site-specific needs and resources.
  • Limited prospective evaluations and/or cost-benefit analyses of patient navigation for any disease, particularly related to morbidity and mortality outcomes.
  • Reimbursement sources may be limited.
  • Patient navigator responsibilities that overlap with other clinic staff may create confusion and billing difficulties.
  • Lack of standardized training programs for navigators.
ARTAS Linkage Case Management (ALCM)
  • Focuses on the linkage and engagement of PLWH into care as soon as possible (<1 year) after initial HIV diagnosis
  • Strengths-based or person-centered case management
  • More effective with those >25 years old, not currently substance (non-IVD) using, Hispanic-identifying, stably housed, and co-located HIV medical care and linkage case management services
  • Staffing, training (3-day initial training), and strong interagency collaboration necessary
Technology-based Interventions
  • Allows engagement in a familiar, culturally acceptable, user-friendly format for many vulnerable populations of HIV+ (like adolescents and young adults)
  • Real-time
  • "Quick and easy"
  • Convenience of use
  • Tool to facilitate relationship building for vulnerable persons
  • Allows for non-verbal communication
  • Meets meaningful use requirement for reimbursement
  • Increases patient satisfaction and communication with health care providers
  • Patient can access labs, notes, and task providers and case managers
  • Patients can access secure/protected EMR from any computer (can use the library computers) or hand held devices
  • Not available reliably for many due to costs
  • Relies on access and regular use of technological device
  • Inconsistent documented outcome evidence; technology use limitations (knowledge of use, familiarity and comfort level) of some providers
  • Training need for providers
  • Confidentiality risk associated with not logging off if using EMR access program on a public computer
  • Patients in rural areas may have access to computers at their support groups/PLWH meetings.
  • Provider(s) and Patients must both have cell to text and understand limitations
  • Possible confidentiality issues (i.e. text is sent to patient, but friend/parent/partner reads message instead of patient)
Traditional Case Management
  • Consistent relationship between one case manager and HIV+ person over time; one person coordinating care components (medical, psychiatric, and psychosocial needs)
  • Different Case Management Acuity Scales have been created to assist in identifying the level of case management services needed for an individual
  • May not be able to work outside of clinic/health center environment
  • Maintaining ongoing connection over time (drops out of care, misses appointments, contact information no longer works)

References:

  1. AIDS Alliance for Children, Youth, and Families. (2005). Finding HIV-Positive Youth and Bringing Them into Care. Washington, DC.
  2. Bradford JB, Coleman S, Cunningham W. (2007). HIV System Navigation: an emerging model to improve HIV care access. AIDS Patient Care STDS. 21: 49-58.
  3. Buscher, A, Mugavero, M. Westfall, A.O., Keruly, J. Moore, R. Drainoni, M.L. Sullivan, M; Wilson, T.E. Rodriguez, A. Metsch, L. Gardner, L. Marks, G. Malitz, F & Giordano, T.P. (2013). The Association of Clinical Follow-Up Intervals in HIV-Infected Persons with Viral Suppression on Subsequent Viral Suppression. AIDS Patient Care and STDs, 27(8), 1-8.
  4. Craw J.A., Gardner L.I., Marks G., Rapp R.C., Bosshart J., Duffus W.A., Rossman A., Coughlin S.L., Gruber D., Safford L.A., Overton J., Schmitt K. (2008). Brief Strengths-based Case Management Promotes Entry into HIV Medical Care: results of the antiretroviral treatment access study-II. Journal of Acquired Immune Deficiency Syndrome. 47(5):597-606.
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