AIDS Leadership Foothills-area Alliance and Fairgrove Primary Health
AIDS Leadership Foothills-area Alliance and Fairgrove Primary Health
- Catawba Valley Medical Center/Fairgrove Primary Health, Hickory, NC
Please note that all data below was derived from the collaboration's nomination for the Collaboration Prize. None of the submitted data were independently verified for accuracy.
A gentleman with end-stage HIV/AIDS returned to the Appalachian foothills to seek the support of his family as he dealt with his condition. He found few HIV/AIDS services available in the area and little or no community education focusing on prevention. From the trunk of his car and a personal commitment to teach others how to avoid HIV/AIDS infection, a grassroots effort began then and is today known as the AIDS Leadership Foothills-area Alliance (ALFA). Recognizing the importance of education and support in preventing the spread of HIV/AIDS, Catawba Valley Medical Center’s (CVMC) CEO provided free office space and utilities, as well as volunteer leadership for ALFA.
In 2002, CVMC and ALFA collaborated to explore the possibility of launching a medical clinic for individuals living with HIV/AIDS. This collaborative planning included a multi-county community services assessment involving Social Services, Public Health, and other potential referral agencies throughout the region. Significant needs were identified and the two partners wrote a grant application for an interdisciplinary medical services program -- Fairgrove Primary Health (FPH). CVMC opened the medical clinic in January 2003.
In 2009, FPH and ALFA leaders identified another gap in HIV care and services. The missing component was the focus of medical care in the case management model. Operating separately, ALFA’s case management had traditionally focused on social and emotional support. However, for patients with HIV/AIDS, medication adherence, maintaining active medical care, and prevention of the spread of HIV are vital components to holistic medical case management. A new approach with an even more collaborative partnership has resulted in empowerment of CVMC and ALFA staff to participate in a more concentrated multidisciplinary team approach to care, new integrated position descriptions and supervision structure, as well as a comprehensive evaluation of all services available in the region.
Together, FPH and ALFA formed the Region II Network of Care and share a mission to identify, medically treat and provide assistance to patients living with HIV/AIDS in a nine-county region of the Appalachian mountains/foothills of Northwestern North Carolina.
Interdisciplinary Treatment Team Model- Interdisciplinary staff members from both agencies work together on goals and patient outcomes. Staff work to address barriers to care, assure necessary linkages to social support services, and assure medical adherence to maximize patient success. Weekly team meetings are held with all medical and Medical Case Management staff.
Leadership Model- Leaders from the two agencies are in constant communication and work to ensure quality medical care and referrals. FPH and ALFA leadership meet routinely to assess programs and services with the goal of monitoring successes and positive outcomes. The agencies have developed a “client first” approach with honest and constructive feedback of all aspects of services.
CVMC staff members serve on the ALFA Board of Directors and participate on agency committees including strategic planning, marketing, and event committees. ALFA staff assist CVMC with grant writing, program evaluation, internal education, marketing, Continuous quality Management and community outreach.
Program and agency evaluations- FPH and ALFA partner to evaluate services and programs of each agency. Staff members develop and implement annual needs assessments and evaluation of services for each agency and the region.
Community and medical staff outreach- FPH and ALFA partner to provide innovative educational events and programming for hospital staff and the public.
FPH and ALFA collaborate on evaluation, quality management, and performance improvement to determine program effectiveness and opportunities to continuously adjust and improve the HIV program for the region. Measurements to evaluate the program are based on the network goals: early detection of HIV, early entry into care and maintaining patients in care.
A program enhancement developed by the shared leadership team is in prevention. Prevention for Positives is an educational initiative that targets persons living with HIV/AIDS to reduce secondary infections. Staff at both agencies developed alternate testing sites targeting high risk individuals. The collaborative process has changed ALFA’s testing goals from focusing on the number of tests administered to focus on a 1% positive rate. The region benefits from early diagnosis and quicker entry into care. Next steps include addressing barriers to testing in our rural mountain counties and adding comprehensive STD testing.
ALFA testers now follow a client from a positive test result to their first medical appointment. This change further completes both agencies’ goals for customer service and early entry into medical care.
A newly created bridge-counseling program called Maintenance In Care (MIC) was developed to initiate non-compliant patients re-entry to care. Staff review patients in the MIC program weekly, and then contact these patients using numerous methods. Once they reach the patient, staff uses a tool to assess the patient’s needs and barriers to routine medical care. The success of MIC has been significant.
The advice for others is to include an interdisciplinary approach (including an infectious disease physician) to all aspects of care. Without involving key stakeholders and getting their buy-in, a merger of medical care and social case management could not occur. Medical providers, case managers, and administration from all organizations must participate in the planning, daily activities and evaluation of the program for success. Consumer involvement is vital to the success of our program and patients should be involved in decisions about their individual care. Patients are involved in the planning and evaluation of the program. They give input through satisfaction surveys, serving on consumer advisory boards and the ALFA Board of Directors.
Staff must expect and adapt to change easily. Change and collaboration is a constant factor in the continuum of care for people living with HIV/AIDS. The medications and treatments change as best evidence based practices are discovered. Patients change as they cope and live with the disease. Funding sources change as the economy fluctuates.
Agencies should choose staff that are passionate about their work. They must be firm, but compassionate. They should be intuitive as well as innovative. They must enjoy breaking down barriers and sharing successes. Success in assessing a non-adherent patient back into treatment is a shared accomplishment and one that is never the result of a single individual, but rather an interdisciplinary team never afraid of crossing two organization’s boundaries for the good of the client.
The collaborative partnership to form the Region II Network of Care (ALFA and FPH) has positively impacted patient care and health outcomes, as well as, increased revenue and created a service delivery system that is more efficient through the utilization of staff and volunteers to decrease expenses.
The “Patient First” methodology has changed how services to HIV positive individuals is delivered to individual patients. This process focuses on meeting patient needs from the receipt of diagnosis, throughout the care and treatment they subsequently receive. Key tools used in creating change comes through a series of meetings and supervision for the network: Interdisciplinary Treatment Team, Medical Case Management Supervision, Continuous Quality Improvement Team, Network Evaluation and Needs Assessment.
Interdisciplinary Treatment Team: This weekly meeting brings together staff of both agencies to address individual patient goals, outcomes, barriers to care and addresses risks for non-adherence leading possible secondary infection. By reviewing patients scheduled for medical visits, the Treatment Team reviews a core set of indicators to monitor a patients success with medical treatment. Core indicators include: labs such as CD4 count and viral load, medication needs and barriers, pap smears, dental visits, missed appointment rates.
Medical Case Management Supervision: Weekly clinical supervision of ALFA’s Medical Case Management (MCM) is provided by the Medical Case Management Supervisor from FPH. Thought the cross agency supervision, MCMs have a clearer understanding of patients interaction with medical providers and implementation of the medical model of care keeping the patients health as the focus of case management.
Continuous Quality Improvement Team: FPH leads a monthly continuous quality improvement (CQI) team. This team includes medical providers, clinic staff and ALFA leadership. This monthly CQI team is focused on medical indicators, such as labwork, pap smears, and dental exams. This team provides an update the quarterly network meeting, which includes all staff from both agencies. As a team, areas of weakness are identified and solutions are discussed.
Network Evaluation and Needs Assessment: Joining forces as a regional provider, the network has developed a comprehensive approach to assessment. Two new components were added to the regional needs assessment by surveying regional medical providers of specialty services for HIV positive patients and to social service agencies providing patient services. This yearly assessment will set new goals and identify strengths and weakness in our service delivery.
In a difficult economy, the cost saving benefits of our collaboration has pleased both Boards of Directors and administration of the network. Increase in revenue to both organizations were quickly realized through funding by the NC AIDS Care Branch. The new comprehensive model of care and patient focused approach to treatment awarded the network at grant of $400,000, an increase over previous years. This funding enhanced patient services and the networks ability to assist patients with additional specialty care visits, medication assistance, emergency finical assistance, and medications not covered by insurance or other funding sources.
Options for funding for each agency had been limited to their areas of specialty. Through the formation of the network, new funding opportunities opened with the comprehensive approach to care. The NC AIDS Fund awarded the network funding to increase services to northwestern NC and our counties in the Appalachian Mountains. Starting in the fall of 2010, HIV testers, MCM and medical providers will take network services to the northwest region reducing patients drive to medical appointments by an hour and a half each way.
Operating of FPH is not profitable for Catawba Valley Medical Center. The clinic operates at a financial loss every year. The new leadership program of the network and open communication between staff has generated cost savings for CVMC and potential revenue streams that are being discovered. Through contracting with ALFA to provide medical case management services to all FPH patients, the hospital gained four highly qualified medical case managers and a substantial cost savings to the hospital by subcontracting instead of hiring full-time staff.
Recently, a patient was admitted to a hospital with a diagnosis of AIDS and pneumonia. Because of the intense medical care needed, the patient’s hospital stay was 70 days and the cost was over $440,000. The patient was uninsured and the cost of this care will go unpaid. This is one example of an undiagnosed case and the cost of the care. By offering early detection and on-going outpatient medical care,the patients and hospitals are spared this expense.
New programs that have developed from the network collaboration:
Bridge Counseling: Bridge counseling is a program designed to identify and overcome barriers to care. MCMs work with medical providers to identify patients who are chronically missing appointments and assess barriers to treatment. MCMs have developed home visit assessment tools and have developed a program (MIC) to prevent clients from falling out of care.
Non-Traditional Testing Sites: New to the network is the expansion of HIV testing into the community targeting areas of high morbidity. At network meetings agency partners discuss “hot spots” of new infections, provide suggestions of testing sites to target individuals most at risk for HIV. The network currently has 15 Non-traditional Testing sites in indigent care clinics, substance abuse facilities and colleges/universities.
Partner Testing: Testing is the only way to know your HIV status, through expanded HIV testing program FPH staff and ALFA’s MCM have been trained to provide partner testing instead of referring partners to a health department or different staff members.
Staff and Community Continuing Education: Our region is hosting a free CE course focused on HIV care for medical providers in our region. The network is also offering joint training for ALFA/FPH staff keeping everyone up-to date on medical trends, risk factors of substance abuse and mental health. Quarterly training is provided to MCMs on topics which are pertinent to provision of care to patients we serve.
Our primary focus is on the impact to medical care and treatment of HIV positive individual in our region. Through the network, 100% of patients receive free Medical Case Management allowing them access to emergency financial assistance, free or reduced medications. Currently, 80 patients (36%) have no health insurance coverage, primary and specialty care must be covered with grant funding or be absorbed by CVMC. These patients receive drug assistance through ADAP; the network has helped 75% of patients with other free/reduced price pharmaceutical programs.
Patients are benefiting from a new approach with holistic care. Weekly treatment team meetings with medical providers and medical case management design and implement individualized treatment plans to meet individual needs and concerns. Patients are healthy and will live longer because of this collaboration. They become less reliant on the public system of funding and locate both employment and means of self-support to decrease the overall economic burden.
Stigma surrounding HIV status is a huge barrier to testing and medical care for many individuals in our rural mountain community. Joint continuing educational events with medical providers increases awareness to offer testing and quickly refer patients into care, 50% of the individuals participating in an educational event receive and HIV test.
With the network standards, new patients have entered care in less than 15 days from diagnosis. Staff members follow new patients from preliminary diagnosis to confirmatory to their first medical appointment providing support through the process. Additionally, the general public benefits from the reduction in secondary infections by working with patients in our Prevention with Positives Program.
In 2009, leaders from CVMC and ALFA, with guidance from the North Carolina AIDS Care Unit identified another gap in HIV care and services. The missing component was the focus of medical care in the case management model in the nine-county region served by ALFA and FPH.
Operating separately, ALFA’s case management had traditionally focused on social and emotional support such as housing, food, utilities and referrals to mental health and substance abuse providers. However, for patients with HIV/AIDS, medication adherence, maintaining active medical care, and prevention of the spread of HIV are vital components to holistic case management. The previous service model required a new approach with additional collaboration between existing agencies. The new approach has resulted in CVMC and ALFA staff participation in a more concentrated multidisciplinary team approach to care, new integrated position descriptions and supervision structure, as well as a comprehensive evaluation of all services available in the region.
With a new direction set, ALFA’s Board of Directors, with consultation from CVMC, transitioned from a traditional AIDS Service organization to medically-focused non-profit and the two separate agencies collaborated to re-enforce a loose connection and share visions to provide more comprehensive services to HIV patients in this region.
As the new collaboration grew, members of both organizations and clients took on leadership roles with both organizations serving on committees. Once fully implemented, the two agencies now act as one network with shared patients, information/data, training, tools,financial resources and a shared leadership model focused on patient care.
The collaborative structure works because of the shared focus. When a client enters the network, the process is seamless. Although the agencies are housed in different, yet close facilities, the individual entering care has access to all the services provided by both agencies. The staff interaction occurs regarding each patient’s medical care and treatment, partner testing and notification, and social support which include services such as housing and financial assistance. One patient, David, comments about this collaborative process to be a system which has kept him alive. He felt assured that he could obtain medications without an interruption in treatment and would be able to receive additional services as needed whether for emotional or physical needs.
While both partners agree this collaboration is best for our clients and community, there have been challenges in implementing this model. The largest hurdle was the shift to shared leadership and implementation of the medical model. This process has taken over a year in pre-planning with key staff and both organizations’administration.
After implementation, constant communication was required by senior staff members to assess conflicts, develop policies and procedures and document agreements. In creating the network, substantial changes were made at ALFA including rewriting position descriptions for all staff members and a new supervision plan. The transition was eased due to the commitment of staff to the issue and focus on client care.
Applying for joint funding as a network requires one agency to be the lead fiscal agency. Since CVMC is the medical provider and the larger of the two agencies bringing staff, structure and funds, they have become the lead agency in joint funding. In assuming the fiscal responsibility, the decision making process becomes weighted to the hospital and ALFA staff voiced concern over giving up this power. This issue has been resolved in the joint grant writing process. Senior leaders of both agencies develop grant budgets with full disclosure of the other financial status including salary and program budgets.
Developing stronger relationships and trust between the two staffs has been a major challenge. This issue has been resolved with key leadership presenting a united front to all staff and a patient centered focus. Senior level decisions were debated and resolved in management meetings and rolled out to staff as a unified plan. Leadership always allows time for staff members to describe concerns, voice frustrations and question decisions, however changes in policies are made from rational decisions rather than emotional response to change. Clear organizational plans and policy and procedures have made the transition easier for everyone.
Meeting patient needs across a diverse geographic area is complicated, the reality of extreme poverty and lower education levels of our patients complicates medical adherence. Our answer to this complicated challenge is to take medical treatment to our most isolated clients by opening a satellite clinic in the mountain, rural area of Boone, NC. Our goal is to decrease barriers to attend medical appointments by making it easier to receive medical care in a facility in closer proximity to these outlying counties.
The collaboration has completely changed the HIV service delivery system in our region making it stronger and clearly focused on the health outcomes of our patients. The Interdisciplinary Treatment Team has brought together a comprehensive view of individual patients needs addressing physical, emotional and finical barriers to care. The goal of each staff member is clear and focused on our patients’ health.
The impact of the collaboration with staff resulted in a renewed passion for this work. Staff have challenged each other with decision making and helping develop treatment plans to ensure patients adherence to medical regiments and care plans. Network staff report an affection for this change and note personal growth through this process.