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									Developing a Peer-Based Early
Intervention Services Program
   Project Consumer LINC
       December 6, 2011
       Emily Gantz McKay
         Harold Phillips
            Hila Berl


  Sera Morgan
Emily Gantz McKay
       Webinar Objectives
• To familiarize participants with the
  components of an Early Intervention
  Services Program, as described by the
  HIV/AIDS Bureau
• To summarize the benefits of using peers
• To provide a step-by-step process for
  developing a peer-based EIS program
  appropriate for your service area


1.       Components of an Early Intervention
         Services (EIS) Program
     –     Questions/Discussion
2.       Benefits of the use of peers to help
         PLWH learn their status, enter or re-
         enter care, and remain closely linked to
3.       Steps and key questions for designing a
         peer-based EIS program
     –     Questions/Discussion

Components of an
Early Intervention
Services Program

Harold J. Phillips

       Components of Early
       Intervention Services

HIV Testing:
– Used to help the unaware learn their status
  and receive either referral to prevention
  services or referral and linkage to HIV care
– Cannot duplicate or supplant testing efforts
  paid for by other sources.
– Must be coordinated with other testing
  programs especially HIV prevention programs
      Components of Early
      Intervention Services

Referral Services:
Linkage Agreements (MOU/MOA) and referrals,
working with key points of entry to create
connections between services and funding
streams, Routine X-Provider meetings, face to face
contact, providing referral to additional services to
meet immediate needs
       Components of Early
      Intervention Services-
         Referral Services

Activity of Relationship/Trust building:
•Creating a bond of trust and safety with the
client that extends to the other care givers in the
HIV continuum.
•Instilling confidence in the client and in the
system of care
     Components of Early
    Intervention Services –
       Referral Services

Assessment of immediate
s regarding care/care system
•Assessment differs from case management
and focuses on changing view and knowledge of
HIV and care leading to care seeking behaviors
     Components of Early
     Intervention Services

Health Literacy/Health Education
•Education on the HIV service delivery system
•How to work with your clinicians
•How to handle problems and issues
•Disease progression and managing life with HIV
    Components of Early
    Intervention Services

Access and Linkage to Care:
•Primary Medical Care (3-4 visits)
•Medical Case Management
•Entry into Substance Abuse Treatment
•Treatment Adherence
•Bringing others into care
•System for monitoring and tracking referrals
(successful and unsuccessful)
     The Four Program
   Components of Early
   Intervention Services

2.Referral Services
3.Health Literacy/Health Education
4.Access and Linkage to Care
 The Four Service Elements
      Must be Present

• Early Intervention Services is a combination
  of all these service elements
• They must all be present and available to
  clients as an integral part of the program
• They do not all have to be Ryan White Part A
  or B funded
     Early Intervention Services v.
           EIS                            OUTREACH
Core Service                       Support Service
Can include HIV Testing            Does not include testing
                                   Targets activities in areas with a
Works with key points of entry     high probability of finding
                                   individuals who are positive
Combination of services            Only one service
Can assist in addressing unmet     Can assist in addressing unmet
need and the unaware               need and bring unaware to testing
Can use peers in paid staff        Can use peers in paid staff
positions                          positions
                                   Length of Service interventions are
Length of Service intervention a
                                   short term and often sporadic
averages 3-6 months
                                   (1-3 months)
       Components of Early
       Intervention Services

• Testing
• Referral Services
 –Linkage agreements to work with key points of entry
 –Relationship/Trust Building
 –Assessment of immediate need/ attitude
  /knowledge/behaviors/beliefs regarding care
 –Information dissemination
• Health Literacy/Health Education (Counseling)
• Access and Linkage to Care
 Early Intervention Services
   & Unmet Need& EIIHA

• EIS can be part of a strategy to address
  unmet need, and EIIHA
• EIS can focus on getting individuals in care
  who know their status
• Emphasis on working with points of entry
• Can resemble a models of case finding or
  patient navigation

Questions and Comments
 Benefits of the
  Use of Peers

Harold J. Phillips

         Why Use Peers?

Letter from HAB/DTTA (2-10-10) said:
 "Peers are uniquely positioned to
 effectively engage and help retain
 PLWH in care and treatment programs
 and, further, with appropriate training
 and supervision, they make remarkable
 contributions to the interdisciplinary

            Why Use Peers?
• Can develop a high level of trust with other
• Ability to share their own experiences
• Role models and proof that people can live
  productive lives with HIV
• Personal knowledge of system of care and
  challenges associated with accessing care
• Clinicians rarely able to spend significant time
  with PLWH
• Cost-effective
• Particular value with HIV+/unaware and
  PLWH with unmet need                               20
Demonstrated Value of Peers
Demonstrated effectiveness with other
diseases such as diabetes:
– Bring people into care
– Reduce missed appointments
– Improve treatment adherence
– Reduce complications
– Reduce emergency room visits
– Reduce hospitalizations
– Reduce health care costs
 Designing a Peer-Based
Early Intervention Services

    Emily Gantz McKay

    Purpose of a Peer-based EIS
• To help people with HIV/AIDS enter and
  become fully linked to and engaged in
  HIV/AIDS care
• Focus typically on populations that are likely
  to be hardest to reach –
   – Individuals who feel marginalized and
   – PLWH who have trouble navigating the HIV/AIDS
     service system – often because they have never
     had a “medical home”
   – PLWH who have had negative experiences with
     the care system                                  23
     Key Questions/Decisions

1. What will be the focus of your EIS program?
2. Should your EIS program pay for testing?
3. What services will peers provide? What won’t
   they do?
4. What points of entry will be the focus for your
   program? What about other relationships?
5. What will be the job title for your peers – will
   they be “peer community health workers”?
6. How will you match peers with PLWH clients?

     Key Questions/Decisions, cont.

7.  What characteristics, knowledge, skills, and
    experience should be identified as required?
8. What classroom and practical on-the-job
    training will you provide?
9. What will be the supervisory requirements?
10. Will you use a central agency for training and
11. Will you allow both full- and part-time peers?
    What about stipends?
   1. Program Focus Options
• HIV+/unaware: Early Identification of
  Individuals with HIV/AIDS (EIIHA) –
  immediate linkage to care after testing
• Unmet need: Finding people who know
  they are HIV+ but have been out of care for
  at least 1 year and helping them enter/re-
  enter care
• Retention in care: Working with PLWH
  who are loosely connected to care or have
  missed medical appointments – including
  recently diagnosed PLWH
     2. Use of Funds for Testing
Factors to consider:
•   EIS is the only service category under
    Ryan White Parts A and B that can pay for
•   Links to testing are essential
•   EIS funds should be used for testing only if
    existing testing resources are insufficient
•   Peers can be trained to do counseling and
    testing (even if you don't buy the test kits)
  3. Services Peers will Provide
• Outreach                  • System navigation
• Testing or testing        • Coaching/mentoring
  support                     and support
• Trust building            • Treatment adherence
• HIV literacy education:     counseling
  living with HIV           • Follow up
• Education about the       • Relationship building
  system of care            • Support to the clinical
• Intake support              team
     4. Points of Entry and Other
• Assignment of peers based on:
  – Specific points of entry
  – Types of entities (e.g., homeless shelters, testing
    sites, substance abuse treatment programs)
  – Location (e.g., county, neighborhood)
• Key importance of personal relationships:
  – Points of entry – to contact peer when a person
    needing help is identified
  – Providers (especially clinics and case management
    sites) – to inform peer when a client misses an
    appointment or seems to need peer support
              5. Job Title
• Make it descriptive of full range of
• Use a title that helps ensure respect for
  the peer's role
• Consider "community health worker" --
  now a Bureau of Labor Statistics-
  recognized profession
• Explore titles and certification used in
  your state
        6. Matching Peers with
• Matching factors:
  –   Gender, race/ethnicity, sexual orientation, age
  –   Location: specific community or neighborhood
  –   Life experience
  –   Use of a diverse peer team
• Other considerations:
  – Young men may relate well to an "older sister"
  – Stigma may mean peer should not be from the
    same neighborhood or nationality group

            7. Qualifications
Typical Requirements:
• Peer status
• Experience with local/regional system of care
• No excludable criminal convictions – e.g., sex-
  related felonies, serious violent crimes, recent
  convictions (within past X years)
• Education/literacy – can use demonstrated
  reading comprehension and writing skills needed
  for record keeping, etc. rather than diploma or
  degree requirement
           Things to Look For
Characteristics             Knowledge/Skills
• Commitment                • PLWH population
• Empathy                   • Geographic area
• Interpersonal relations   • How Ryan White
• Organization & multi-       programs work
  tasking                   • Strong, culturally
• Judgment                    appropriate
                              communications skills
  Decide what skills        • Mentoring, coaching
  are required for          • Boundaries
  selection, and            • Computers/record
  which ones you              keeping
  can teach                 • Working with providers
     8. Classroom & Practical
Consider 4 phases:
1. Pre-service classroom training (community
   college or project-developed and run)
2. On-the-job practicum combined with additional
   classroom training
3. Ongoing on-the-job training, with supervision
4. In-service sessions plus peer network

    Suggested Learning Topics
• Understanding HIV         • Problem solving & crisis
  disease                     management
• Ryan White programs –     • Confidentiality &
  legislation, services,      privacy, including
  policies, guidelines        HIPAA requirements
• Navigating the system     • Providing emotional
  of HIV care                 support
• Multicultural awareness   • Self-management
  and competence            • Self-disclosure
• Developing trust          • Communication skills
• Maintaining               • Medications and
  professional boundaries     treatment adherence
9. Supervisory Requirements
• Specified level of supervision – e.g., hours per
• Supervision must ensure:
  – Support for peer model
  – Understanding of EIS program components and
  – Consistently available supervision & support
  – Professional development opportunities
  – Help with relationship building
  – Links to testing
• Training for supervisors
• Establishment of supervisors support network       36
 10. Use of a Central Agency

Structure Options:
1. Centralized: hiring, training, supervision,
   monitoring and evaluation, with peers
   assignment to providers
2. Partially centralized: training, supervision,
   involvement in recruitment, assistance and
   evaluation; providers hire & supervise
3. Decentralized: multiple providers hire,
   train, supervise

  Value of Centralized or Partially
       Centralized Structure

• Training quality – larger group for training, likely to
  be more structured, with consistent quality
• Consistent implementation of model – staff
  understand program model
• Cost effectiveness – only one agency develops and
  delivers training
• Flexibility – peers supervised day to day (and often
  hired) by multiple providers, allowing for variations
  based on population needs and organizational culture
• Evaluation – single evaluator
   11. Full or Part Time Peers?
• Full time: Regular employee, easier to provide
  benefits, full caseload, good return on training
• Part time: May be needed to protect the health of the
  peer; allows smaller communities to hire several peers
  that match different populations or communities
• Limited Hours due to SSDI/SSI: Allows PLWH on
  disability to work 30-50% time and keep benefits; allows
  for a diverse peer team; but smaller individual
• Stipends: Peers tend to be hired away by other
  providers; level of work usually too great for stipends
           Typical Challenges
•   Training
•   Boundaries
•   Personal health issues
•   Compensation
•   Provider and partner attitudes
•   Understanding of EIS
•   Setting limits on work with a single client

  Example: Positive Pathways
     Pilot Program (DC)
• Assists HIV-positive African Americans to participate
  in HIV medical care; focus on women
• Funded through Social Innovations Fund
• Central agency (CommonHealth Action) manages
  program for Washington AIDS Partnership
• Training includes formal community health worker
  certificate program at community college plus HIV-
  specific training and practical experience
• CHWs placed community and medical organizations
• Peer support group
• Training and support for supervisors                    41
  Example: Design for New
Washington, DC Part A Program
• Central agency to provide training, oversight,
  assistance, & evaluation
• Individual providers to hire and supervise peer
  community health workers
• 160 hours of classroom training plus 800 hours
  of practicum over 6 months
• Peer and supervisor support networks
• Both full- and part-time employment
• Focus on unmet need and PLWH loosely
  connected to care
  Other EIS & Related Programs
• People to People (P2P) – started by African
  American AIDS Task Force, Minneapolis/Saint Paul
  Part B Program
• Michigan Programs:
   – Youth Link Program of AIDS Partnership MI – Detroit
   – MI Patient Navigator Program of Sacred Heart
     Rehabilitation Center – Saginaw
   – Wayne State Physician Group Peer Navigator Program
     – Detroit
• Hand in Hand – New Orleans
• Christie’s Place – San Diego
• Linking to Care, Positive Connections – Charlotte
  (no longer operating)                                43
    Resources from Consumer
          LINC Project

• "Designing a Peer-Based Early Intervention
  Program: Components, Strategies, and Key
• Other Consumer LINC project materials
• Links to other materials
• See http://www.mosaica.org/Resources/

               Other Resources
• Community Health Workers National Workforce Study
  - http://bhpr.hrsa.gov/healthworkforce/chw/
• Building Blocks to Peer Success - 2 toolkits - PEER
  Center, Boston University -
• Integrating Peers into Multidisciplinary Teams: 2
  toolkits - Cicatelli Associates - http://careacttarget.org/
• “The Utilization and Role of Peers in HIV
  Interdisciplinary Teams” - HRSA/HAB Consultation -
Questions and Comments

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