Download Stewart Landers - Institute of Medicine

The Role of Federal and
State Agencies in
Supporting Integrated HIV
Care Services
Presented to IOM Panel
Stewart Landers, Senior Consultant
June 21, 2010
Context
• HIV as a disease of impoverishment
• Service providers struggle with a
panoply of needs for many clients
• Ryan White HIV/AIDS Program
addresses most essential access to
care (primary care and medications)
– This is threatened by current fiscal crisis
– Health Care Reform may add to threat
Systems of Integration
• Integration of HIV/AIDS with closely related
infectious conditions including Sexually
Transmitted Infections (STIs), Viral Hepatitis
and Tuberculosis (TB)
• Integration HIV/AIDS Medical Services with
case management, mental health and
substance use treatment, transportation,
translation services, dental care
Systems of Integratoin (cont’d)
• Integration of HIV/AIDS with “upstream”
services that impact social determinants such
as housing, education, job training, legal
services and refugee and immigrant services
• Integration of HIV/AIDS into mainstream
health care, and in particular, the chronic care
model
Functions of Integration
•
•
•
•
Referral and navigation functions
Payer functions
Data functions
Client-centered functions
Each of these functions may take place
within an organization/institution or
across a network of separate institutions
Role of Government
• Supports quality standards for care
delivery
• Supports networks
• Provides funding streams to support
systems and functions
• Requires data collection and supports
this function
Federal Support for Quality
Standards
• Ryan White Program requires implementation
of quality assurance programs
• Functions of coordination and integration in
standards not explicit
– Support of federal and state government is
necessary (Roy,1995)
• Evidence of effectiveness unproven
– Title III (Part C) QA study found minimal impact
(Landon, 2004)
Federal Support for Network
Development
• Ryan White supports networks through
Part A Eligible Metropolitan Areas
(EMAs) and their Planning Councils
• Has often created rift in community
• Consortia conducted “outreach” to
communities of color (McKinney, 1993)
• Some evidence against effectiveness of
networks (Mor et al., 1993)
Federal Support for Network
Development (Cont’d)
• Study of Part A EMAs (n=324)
– Perceived quality of services high for
primary care and case management
– Perceived quality of services lower for
mental health, substance abuse,
transportation, housing, dental and
translation/interpretation (Hirshhorn, 2009)
Federal Support for Network
Development (Cont’d)
• Relationship between Primary Care
Providers and Case Managers
– Both report high levels of contact with each
other
– Grantee support for communication
between them not rated highly (Hirshhorn,
2009)
• Patient navigators found to be effective
in maintenance in care (Bradford, 2007)
Federal Role in Funding
Streams
• Some funding streams integrated;
others are not
– Prevention of HIV closely linked with
prevention of STDs and viral Hepatitis
– When non-HIV infected individuals are
identified, they are not eligible for services
that may support care and prevention such
as housing or benefits counseling or even
case management
Federal Support for Data
Collection
• Support for Information Technology (IT) by
local government grantees seen as limited
– A little more than 70% of Medical Directors and
Case Management Directors thought there was
support for IT
– Less than 50% of Medical Directors or Case
Management Directors said common intake forms
are supported by grantee (Hirschhorn, 2009)
Integration of HIV Care with
STIs, Viral Hepatitis and TB
• Integration of HIV and Hep C care has been
and is being studied
– Costs found to be higher
– Model being studied at UCSF
• Reductions in state funding may force
integration
• Health Care Reform in Massachusetts
reduced/eliminated stand-alone STI and TB
Clinics
Pilots by Feds to Support
Integration Encouraged
• Programs could enhance integration on
a limited basis by supporting integration
of care services for people with HIV,
STIs, Hep C, or TB
• Programs could enhance integration on
a limited basis by supporting integration
of care services for populations (i.e.
gay/bi/MSM; refugees/immigrants; etc.)
Integration with Mainstream
Care – The Chronic Care Model
Integration with Mainstream Care
– The Chronic Care Model (cont’d)
• Implemented as framework for addressing
chronic conditions including obesity and
smoking and chronic diseases such as
asthma, cancer, cardiovascular disease,
diabetes and sleep disorders
• Model may look different for HIV/AIDS based
on socio-demographics despite advances in
treatment
Health Care Reform
• Greatest danger is lack of perceived need
and reduced constituency for safety net
services
• As the perception of “full coverage” occurred
in Massachusetts, lawmakers reduced
funding for STI, TB, Family Planning, Sexual
Assault and Health Promotion programs
• ADAP will be a major concern
Health Care Reform (cont’d)
• Barriers under health care reform include:
– Co-pays; deductibles; premiums; other out-of-pocket costs
– Shortage of primary care providers
– Lack of support for case managers, interpreters, patient
navigators
• Equity remains a challenge: ethnic minorities, nonEnglish speaking, immigrants (legal and not), low
income still experience disparities
• People who are newly insured experience unique
challenges (Fairchild, 2009)
Acknowledgments
• Kevin Cranston, Director, Bureau of
Infectious Diseases (BID),
Massachusetts Department of Public
Health (MDPH)
• Dawn Fukuda, Director, Office of
HIV/AIDS, BID, MDPH
• Pat Fairchild and Lisa Hirschhorn, JSI
Bibliography
• Bradford, J. et al., (2007) HIV System Navigation: An
Emerging Model to Improve HIV Care Access, AIDS
Patient Care and STDs, 21(s1): S-49-S-58.
doi:10.1089/apc.2007.9987.
• Fairchild, P. (2009) Care Beyond Coverage, Report to
The Boston Foundation
• Hirschhorn, L. et al., (2009) Reported care quality in
federal Ryan White HIV/AIDS Program supported
networks of HIV/AIDS care. AIDS Care, 21(6), 799807
• Landon, B.E. et al., (2004) Effects of a quality
improvement collaborative on the outcome of care of
patients with HIV infection: the EQHIV study. Annals
of Internal Medicine, 140(11), 887-896.
Bibliograpy (cont’d)
• McKinney, Martha M. (1993) "Consortium
approaches to the delivery of HIV services under the
Ryan White CARE Act," AIDS and Public Policy
Journal 8(3): 115125
• Mor, V. et al., (1993) “Developing AIDS Community
Service Consortia,” Health Affairs 12, no. 1: 186-99
• Roy, B. et al., (1995) “Building Community Networks
to Increase Access to Services for Women, Children,
Youth and Families,” HIV Infected Women
Conference 22-24, p.72