Integration of Care – Dec. 7, 2023 Minutes


December 7th, 2022

MEETING of the
Veronica Fortunato & Steve Hemraj, IOC Co-Chairs
Wednesday, December 7th, 2022
Zoom Meeting Recording


Billy Fields
Brenda Starks-Ross
Chris Joseph 
Claire Simon
Deborah J. Greene 
Dorothy Farley
Graham Harriman 
Gregg Bruckno
Gretchen Ty 
John Schoepp 
Karen McKinnon 
Michael J. Ealy
Raffi Babakhanian
Recipient: Scott Spiegler
Ronnie Fortunato 
Rose Chestnut
Timothy Frasca 


Adrianna Eppinger-Meiering 
Bryan Meisel
Cristina Rodriguez-Hart
Grace Mackson 
Ilana Newman
Jose A. Colon-Berdecia
Kimbirly Mack
Renee James 

Donald R. Powell
Agenda Item 1: Welcome, Roll Call & Moment of Silence
Co-chair Ronnie Fortunato opened the meeting with introductions and a moment of silence.
Agenda Item 2: Refresher: Implementation Science Foundations and Introduction to the Implementation Research Logic Model with Cristine Rodriguez-Hart, PhD & Grace Mackson
Dr. Rodriguez-Hart and Mackson presented a refresher on the Implementation Research Logic Model (IRLM). 
Key points from the discussion follow:
•       Implementation science is primarily concerned with how to make interventions be used in real world settings. Implementation often not thought of until late in the translational process, which causes problems
•       Implementation plans should address implementation context
•       “Context” includes factors that influence implementation of interventions -> also called “determinants”
•       If determinants influence for good= facilitators, for bad=barriers
•       When the context is not considered, we might use approaches that are inappropriate to the setting, leading to unsuccessful interventions
•       Outer Setting: HIV cases decreasing but outcomes inequitable, Complex and interrelated structural determinants of health, Social service system to support PWH, COVID-19, Medicaid and federal funders, Laws
•       Inner Setting: Comprehensive but complex HIV service system largely reliant on Medicaid, Wide variability in quality of services and staff, Strained workforce, More funding needed, Telehealth vs in-person services
•       PWH Characteristics: Commonly face stigma, Poverty, Comorbidities, Difficulty navigating service delivery system, Housing and Nutritional vulnerabilities, Aging, Trauma, Technology needs, Mental health and substance use
•       Process: HIV coalitions and networks, HIV surveillance data and Surveys, Programmatic and contractual data, EHE Plan, QI, Townhalls, Priority population focus, Tracking mostly HIV biomedical outcomes
•       Interventions are the “thing” you want to see adopted, implemented, scaled up, and/or sustained in order to improve health outcomes*
•       7 types of interventions often referred to as the 7 Ps:  
•       Programs, Practices, Principles, Procedures, Products, Pills, Policies 
•       Implementation strategies are methods or techniques used to enhance the adoption, implementation, and sustainability of a public health/clinical program or practice (the intervention)*
•       We can select from many types of strategies, but those we choose need to reduce barriers and leverage facilitators that we identified exist in the context
•       The Intervention: Routine monitoring of stigma in a facility  The Implementation Strategies:Conduct stigma surveys, Disseminate results and discuss
•       Traditionally, public health focused only on measuring client outcomes, largely ignoring the measurement of health system and provider actions
•       In IS we collect a broader diversity of outcomes 
•       Implementation outcomes are measured at the level of the setting and provider vs. health outcomes are measured at the level of the client 
•       Determinants reflect the context where implementation occurs
•       Strategies are activities or interventions directed at the system or provider to improve HIV-related care
•       Mechanisms might be a determinant, a short-term outcome, and/or an aspect of the implementation strategy
•       Implementation outcomes are the changes we expect to see in adoption, implementation, cost, feasibility, reach, and sustainment of effective HIV interventions delivered throughout the RWPA portfolio
•       Service outcomes reflect the extent to which services are safe, effective, client-centered, timely and equitable.
•       Implementation science distinguishes between 3 types of outcomes: Implementation, service and client outcomes
Agenda Item 3: Line-by-Line Editing of Draft Behavioral Directive
The directive was introduced by Melanie Lawrence, who walked the committee through the structure of the document. The committee was asked to read and critique the determinants of the document prior to line-by-line editing. Ms. Lawrence highlighted the importance of pulling in the current context of services in NYC, including the mayor’s announcement of a new program for people with serious mental illness (SMI).
The committee read through the document to identify changes/edits/interrogate the document.
Edits were submitted by committee members, and brief discussions of the contents ensued.
Mr. Joseph noted the difference between harm reduction and substance use services – RWPA traditionally categorizes such activities as harm reduction. Harm reduction has been used by the NY EMA in place of HRSAs substance use service category. Mr. Harriman suggested changing the name to better reflect the full spectrum of services – “harm reduction/substance use”. The portfolio currently doesn’t fund psycho-social rehab – which can provide great benefit to persons with mental health disorders – learning to live with a mental health disorder.
HRSA does fund community-based services that can possibly be used to fill this gap. Mr. Harriman will investigate.
Is psycho-social rehab the MH service, or something else?
Dr. Hart questioned the structure of the document and where information on the document is found. Ms. Lawrence explained her thinking in the structure. Dr. Hart asked if there will be separately funded contracts – however this is the purview of the recipient.
Mr. Harriman found a way to fund psycho-social rehab, which will require a new directive. 
Mr. Babakhanian noted that services should be available in consistent locations. People are more comfortable accessing services where they are familiar with staff and the space
Discussed difference between drop in and low threshold – no real meaning attributed to low threshold term
Drop-in is similarly undefined
Walk-in implies accessing a service
Improved language around supporting access to technology for service delivery for clients
Clarified language around client readiness and informed choice
Included language around navigating agency versus client choice/interests
Agencies should make it easier for clients to access services without burdensome data entry on the client
Data redundancy is also driven by multiple funders collecting data – burden on clients and agencies
MH and s/u service records are supposed to be kept separate – but goal of integrated care is blocked 
Data collection is often re/traumatizing
Changed language from psych eval to MH eval
Medicated assisted treatment (MAT) was added to pharmacological interventions for clarity 
No one is offered MAT without a clinical indication – added this language
Alcohol isn’t a problem for everyone, but must be assessed
Services should be offered when a client has a clinically indicated history. 
Agenda Item 4: New Business & Public Comment
No public comment. Happy Holidays!