Minutes of the Meeting of the
Integration of Care Committee
Veronica Fortunato & Steve Hemraj, IOC Co-Chairs
Wednesday, December 18, 2024
10:05am-11:25pm
Minutes
Members Present: Ronnie Fortunato (Co-chair), Steve Hemraj (Co-chair), Raffi Babakhanian, Mitchell Caponi, Dorothy Farley, Billy Fields, Deborah Greene, David Klotz, Jeff Natt, Cesar Nuñez, Leah Richberg, John Schoepp, Scott Spiegler (for Guadalupe Dominguez Plummer, ex-officio), Gretchen Ty
Staff Present: NYC DOHMH: Michael Navejas, Doienne Saab, Scott Spiegler, Adrianna Eppinger-Meiering, Johanna Acosta, Nicki Harris, Gina Gambone, Grace Herndon, Marilyn Baculima
Guests Present: Staff and Clients from Elmhurst Hospital, Mount Sinai Hospital, Institute for Family Health
Agenda Item #1: Welcome/Introductions/Minutes/Public Comment
Mr. Hemraj opened the meeting followed by a roll call and a moment of silence. The draft minutes from the November 22nd meeting were approved with no changes.
Agenda Item #2: Medical Case Management/Care Coordination (CCR) Service Category
Literature Review
Ms. Harris presented a literature review of 79 peer-reviewed publications, most from the US, but also some international, including articles, government reports and abstracts. The review had a focus on aging PWH, who often have co-morbidities that make treatment adherence more difficult, particularly across a care system fragmented across a variety of care services, further complicated by medical, psychological, socioeconomic, and other complexities. The review attempted to determine the components of an effective care management program. Highlights of the findings include:
- Compared to PWH who were not enrolled in CCR, CCR clients who were newly diagnosed or consistently unsuppressed demonstrated higher rates of viral suppression (58.3% of clients vs. 49.3% of controls) and care reengagement (87.2% of clients vs. 48.2% of controls).
- Other studies revealed client preferences for telehealth visits and telehealth ART adherence support, with lower preference for intensive services such as direct observational therapy (DOT) and home visits.
- In contrast, providers favored programs that integrated intensive services such as DOT, home visits, accompaniment, and help with issues other than primary care. This may have been influenced by provider access to public transportation and supportive staff, as most agencies were located in geographical areas with multiple transportation options and sufficient home-visiting staff.
- There is a need to address psychosocial factors such as mental health issues and housing instability to achieve higher rates of viral suppression. These results indicate a need for client services that vary in intensity and location, flexible service delivery options for providers, and emotional support services in future CCR models.
- Current studies are exploring patient perceptions of long-acting injectable (LAI) ART to inform a trial of the effectiveness of patient education and structured decision aids for daily oral ART medication versus LAI ART.
- A well-designed HIV care model should meet the full range of clients’ medical and social needs while building self-management skills, through interdisciplinary team-based case management, patient navigation, and structured health education.
- Some program models employ a ‘medical home’ model combining interdisciplinary team-based case management, patient navigation services as well as services tailored to people aging with HIV that reduces fragmented care and minimize gaps along, the HIV care continuum.
- A key theme of all care recommendations was support for the application of the 5M’s of geriatrics for people aging with HIV: mind, mobility, medications, multi-complexity, and what matters most to the patient. Successful care for older PWH use multidisciplinary processes to screen and treat aging-related conditions for physical health, functional ability, frailty, cognition, cancer, mental health, and socio-environmental factors.
- As a result of the COVID-19 pandemic, telehealth, and group teletherapy has been increasingly researched and demonstrated to encourage group cohesion and reduce barriers to accessing HIV care for older PWH. Qualitative interviews with older PWH have recognized telehealth as beneficial to reducing barriers to care, however disparities in technology access, literacy, privacy concerns, and culture persist among older PWH.
- Combined HIV/geriatric multidisciplinary clinics were the most evaluated care models. Programs such as the Golden Compass Program, which informed the Council’s HIV & Aging (Ambulatory Outpatient Services) directive. Core program elements include a consultative geriatric clinic, consultative cardiac clinic, group physical and social sessions, and health insurance navigation.
There was a question about cost analyses of care coordination programs and a comment about the limited availability of training for non-clinical staff on geriatric issues. Mr. Caponi noted that NYU’s CCR program coordinated geriatric care and is able to link clients to appointments for specialty care within the NYU network.
Provider and Consumer Panel
Lisa Scaturro (Elmhurst Hospital), Diane Tider (Mount Sinai) and Engerly de la Rosa (Institute for Family Health) presented on their programs. Questions asked prior to the meeting included: most successful and most challenging elements of the program, barriers to helping clients achieve VLS, and changes in the service model that would enhance effectiveness. Successes cited included accompaniment, where patient navigators help solve problems and overcome barriers to care such as language barriers. There is promise cited for long-acting injectables for keeping patients undetectable. All providers stressed the importance of relationships built over time between navigators and clients. Also, staff who are social workers have had success providing mental health support and assessment.
A common challenge cited was access to technology, particularly for clients who are unstably housed. While programs have provided linkage to programs that provide free phone and Internet service, some clients have barriers to using technology to access CCR services. Providers cited the difficulties addressing barriers to care stemming from social determinants of health. Also, the fragmented care system can make it difficult for clients who need a wide range of medical care and social services. Newly arrived people to NYC may have problems arising from being in transient housing, and even arranging transportation can be difficult, despite the array of options in NYC. Client readiness to enter treatment is a challenge that can be addressed through motivational interviewing techniques. Getting clients to agree to DOT can be difficult, especially if it’s in-person. Documentation and reporting requirements can take away from time for direct services.
Two clients from Elmhurst and Mt. Sinai spoke movingly about their experiences receiving CCR services. Questions sent before the meeting included what they liked about the program, what helped them stay adherent to treatment, and what they would change about the program. They both praised the programs assistance with providing support for treatment adherence and navigating the care system. They spoke of the importance of the relationships they built with their care navigators, whom they can rely on consistently for support and assistance. The navigators have helped with a range of personal issues, including disclosure of HIV status. One client spoke of the challenges she faced dealing with her diagnosis, a pregnancy and the onset of the COVID pandemic simultaneously. CCR staff helped her navigate the care system, deal with feelings of being overwhelmed and side effects of medication. The staff’s active listening skills were essential in providing effective services.
In the ensuing discussion, the importance of staff retention in order to maintain provider-client relationships was stressed. Staff, who must be compassionate and dedicated, also need ongoing support and training. Clients who have caregiver duties for other family also need additional support. Peers can be effective delivering many services. The importance of specialized training in geriatric care was stressed again. While reassessment (typically done every 6 months) can be burdensome, it can also be helpful, as it may identify a client need that had not been addressed before.
Service Directive Draft Goals and Objectives
Ms. Saab presented draft revisions to the Service Category Goals, based on the discussions to date. The goals from the 2017 directive remain relevant, but there is an added goal to increase the proportion of clients started in immediate anti-retroviral treatment (iART). Also, language was added to include screening and treatment for co-morbidities. There was a consensus to shorten the time of entry into care for newly diagnosed from 30 days to the DOHMH/Sexual Health Clinic and HRSA standards of 15 days.
Service category goals must be aligned with the Statewide Integrated HIV Prevention and Care Plan (IP) goals and objectives to reflect the 2022-26 plan. The goals reflect the Plan’s use of four “pillars” similar to the NYS ETE and federal EHE plans. There was a consensus to eliminate the timelines for linkage to care and VLS as there will be a new IP for 2027-31. It was emphasized that the higher percentages for those goals are an aspiration for CCR, but not measurable program objectives.
There was agreement, as part of the service model revision, to consider integration of CCR programs with clinical providers, and how to ensure that clients have uninterrupted service even when there is staff turnover. These will be included in a compilation of data and discussion points that staff will compile before the next meeting.
The next IOC meeting will be held on Wednesday, January 22nd, 10-am-12pm. There being no further comment, the meeting was adjourned.
