Comprehensive Healthcare
Work Group

Report produced by The Measurement Group
5811A Uplander Way, Culver City, California 90230

Acknowledgments

The efforts of the Comprehensive Healthcare Work Group were led by Trudy Larson, M.D., of the University of Nevada; Karen Richardson Soons, Ph.D., of the University of Vermont; and Karen Meredith, M.P.H., of Washington University in St. Louis. This short version of the full report was prepared at The Measurement Group with contributions by Lisa A. Melchior, Ph.D., George J. Huba, Ph.D., Natasha De Veauuse Brown, M.P.H., and Jacqueline Gelfand, M.A.

This publication is supported by Grant Numbers BRU 900113-03-0 (The Measurement Group—PROTOTYPES Evaluation and Dissemination Center), BRU 900121-03-0 (University of Nevada School of Medicine), BRU 900109-03-0 (University of Vermont & State Agricultural College), and BRU 900125-03-0 (Washington University School of Medicine) from the Health Resources and Services Administration (HRSA) Special Projects of National Significance (SPNS) Program. The publication’s contents are solely the responsibility of the authors and do not necessarily represent the official views of HRSA or HRSA/HAB's Special Projects of National Significance. Printing run of 07-23-97.

Introduction

As part of their involvement in the overall Cooperative Agreement Steering Committee, three projects which constitute the Comprehensive Healthcare Work Group—the University of Nevada, the University of Vermont, and Washington University—have developed an evaluation report to educate people about the comprehensive HIV care projects, their experiences, and the valuable lessons that they have learned. Issues discussed include program start-up and the initiation of an evaluation system, diverse activities, common barriers, and recommendations. This report examines these issues from the perspective of a mid-course look at the first two years of funding for these projects.

Background and Funding

On October 1, 1994, the Special Projects of National Significance (SPNS) Program of the Health Resources and Services Administration (HRSA) funded an HIV Innovative Model of Care Initiative consisting of 27 cooperative agreements, HRSA, and an Evaluation and Dissemination Center (EDC). The cooperative agreement funding mechanism was selected to encourage projects to identify shared goals and objectives; to enable projects to share technical expertise; and to establish a cross-cutting evaluation. At its first meeting, the Steering Committee created five project Work Groups. This report is the first joint report from the Work Groups and details the progress and start-up issues faced by three projects providing comprehensive HIV/AIDS services within the context of university-based medical institutions.

Comprehensive Healthcare Work Group

The three Comprehensive Healthcare projects—the University of Nevada School of Medicine’s Early Nutrition Intervention in HIV and AIDS project, the University of Vermont & State Agricultural College’s Rural HIV Service Delivery project, and Washington University School of Medicine’s Helena Hatch Special Care Center for Women—have developed specialized medical care models within the context of a continuum of services in a medical clinic.

The University of Vermont has developed community clinics throughout Vermont and is determining whether patients receive appropriate and consistent care at the satellite clinics, rather than not receiving care, or traveling great distances to a single central site located at the state medical center. The University of Nevada has added a nutrition component to its comprehensive AIDS care clinic and is studying the effects of adding nutrition assessment, objective measurements, counseling, and supplements to the treatment of wasting in AIDS patients. Both the University of Vermont and the University of Nevada projects are providing services to largely rural patient populations.

The Washington University project in St. Louis, Missouri, is providing a continuum of care to women with HIV and their children within a traditional medical clinic model, combined with aggressive community outreach and case management. The Washington University project serves a group of inner city women, most of whom are African American.

Project Start-up and Initiation issues

The three Comprehensive Healthcare projects have identified a number of issues that they have encountered in the initial period of program implementation. Many start-up issues are common to some or all of the projects in this Work Group, although others are unique to specific programs. These issues include:

• Pressure to start services immediately

• Identifying specific service model concepts

• Client recruitment/outreach

• Logistics in implementing new clinics

• Ensuring consumer participation

• Training

• Technology and information systems

Start-up issues common to these three programs include staff recruitment and training, client recruitment and outreach, ensuring consumer participation, integrating local and national evaluations, and other issues associated with starting up a program that offers comprehensive medical and psychosocial services. The Vermont and Nevada programs overcame the problems of maintaining unique consumer advisory boards by seeking input from consumers who serve on other existing advisory groups, such as the State Title II consumer advisory boards. Linkages with HIV test sites proved successful for recruitment of clients at Washington University.

Another Comprehensive Healthcare project discovered significant training issues for staff who were extremely experienced in clinical service delivery, but had difficulty learning how to use the computers needed for clinic management and information. Bridging the gap between clinical and technical knowledge is one that has been addressed by training in all three projects in this Work Group.

Many of the issues faced by these programs were often due to the context in which services are provided (e.g., rural vs. urban, working with existing staff vs. newly hired staff). Other programs attempting to initiate comprehensive healthcare services within university settings may face many similar issues.

Evaluation

Each of the Comprehensive Healthcare projects, as is true of other HRSA SPNS Cooperative Agreement Projects, has a significant evaluation component. The SPNS projects each have local evaluations that focus on the unique aspects of their service models

• The University of Nevada uses the CIPP model (Context, Input, Process, and Product), with the goal of full, continuing and cost effective integration of nutrition into the Early Intervention Clinic

• The University of Vermont uses initial and follow-up questionnaires, surveys, and pre- and post- mini-residency tests to evaluate their goals involving the development of a healthcare delivery model and HIV/AIDS education of medical providers

• Washington University incorporates the process and outcome aspects of the CIPP model and involves qualitative assessment of areas such as enrollment rates, continuity of care, client satisfaction with services and care received

The cross-cutting data collected by the Evaluation and Dissemination Center (EDC) includes demographic information, medical intervention services, psychosocial intervention services, medications, client satisfaction, health related quality of life, program discharge/departure, and medical health indicators. These outcomes are measured comparably so that the data may be pooled.

Selected Accomplishments

The Comprehensive Healthcare Work Group projects have undertaken a large number of activities to increase their capacity to provide services to individuals with HIV/AIDS living in their target populations.

University of Nevada School of Medicine’s Early Nutrition Intervention in HIV and AIDS (Reno, Nevada)

• A nutritionist has been made available more frequently to provide various patient services

• Project staff have instituted frequent nutrition screenings, routine counseling, and intervention with HIV-infected persons before their disease process worsened

University of Vermont’s Rural HIV Service Delivery Project (Burlington, Vermont)

• Three state-of-the-art rural HIV specialty clinics became operational

• Client referrals increased by 30-35 percent

• Program staff created HIV "mini-residency" trainings for primary care providers and medical students/residents

• Quarterly HIV/AIDS educational sessions designed for community service organizations, mental health counselors, clergy, and associate health professionals have been held

Washington University’s Helena Hatch Special Care Center (St. Louis, Missouri)

• A clinic was established at Washington University Medical School

• Enrollment increased from 25 to 215 in the first two years

• Personalized care was provided, including home visits prior to the first clinic visit

• Adult and pediatric primary care clinics were combined

Barriers Encountered and Project Resolutions

In the course of their activities throughout the first two years of program funding, the projects have identified a number of barriers to developing and implementing their models. Barriers discussed include: (1) lack of funding/resources; (2) cooperative agreements with agencies in the projects’ service network; (3) staff-related problems; (4) enrollment and maintenance of high retention rates; (5) competing agendas within and among institutions and communities; and (6) other barriers.

Suggested solutions to these barriers are:

• Working with Medicaid representatives and the Ryan White system to negotiate rates and to cover non-medical and supportive services

• Unifying existing outreach activities by forming collaborative initiatives

• Clarifying roles and identifying shared missions

• Building trust through joint projects

• Communicating with and listening to all members of associated networks

• Developing clear job descriptions with objective criteria for evaluation of staff

• Providing ongoing professional development/support for project staff

• Developing retention strategies based on client feedback

• Adjusting programs based on ongoing information to provide the full array of services

• Inform patients of mechanisms in place to protect confidentiality

• Provide technical assistance to staff in evaluation issues

• Matching tasks to people’s skills and interests

• Giving feedback to stakeholders on data quality and interim findings on an ongoing basis

Summary

The three Comprehensive Healthcare projects are diverse in the locations of their projects, the types of services they provide, the target populations they serve, and the types of issues they face within their programs. Although each program is unique, the Comprehensive Healthcare Work Group projects have been united by the primary goal of developing specialized medical care models within the context of a comprehensive service continuum in a medical clinic.

Each of the projects experienced program and evaluation start-up issues, including staff recruitment and training, client recruitment and outreach, local and national evaluation systems, and other issues associated with beginning a program that offers a wide range of medical and psychosocial services. The projects also achieved specific goals during the first two years, resulting in significant accomplishments, project outcomes, and improvements in their service networks and in the delivery of HIV care services to their target populations.

In an effort to supply other comprehensive HIV care programs with information about the valuable lessons they learned during the first two years of funding, a number of recommendations have been made by the Comprehensive Healthcare Work Group. These recommendations include:

• Conduct initial and ongoing assessments with target populations, the base institution, and the community regarding needs, barriers, and common goals and resources

• Develop a collaborative atmosphere—both internally and externally—in program development and implementation

• Develop service models that are responsive to client concerns and barriers

• Establish dynamic referral/recruitment mechanisms

• Define jobs, recruit the right person, and provide incentives and ongoing training

• Establish goal-defined qualitative and quantitative evaluation plans, sharing incremental results with clients, staff and other interested parties

• Communicate, communicate, and communicate!

All of the programs have found that flexibility and perseverance are key attributes in building the referral networks needed to achieve their goals. It is expected that these suggestions will prove extremely useful to other programs offering comprehensive care services to people living with HIV/AIDS.

For Additional Information

The complete report on the Comprehensive Healthcare Work Group Qualitative Evaluation Report is available by contacting:

The Measurement Group—PROTOTYPES

Evaluation and Dissemination Center

5811A Uplander Way, Culver City, CA 90230

-or-

The Health Resources and Services Administration,

Special Projects of National Significance Program

5600 Fishers Lane, Parklawn Building, Room 7A-08

Rockville, MD 20857.

This report is also available on the Internet at The Measurement Group web site (www.TheMeasurementGroup.com). Additional reports and presentations are also available.

HRSA/HAB's SPNS Steering

Committee Representatives

1996 – 1997

AIDS Healthcare Foundation (Peter Reis)

Center for Community Health, Education, and Research/Haitian Community AIDS Outreach Project (Eustache Jean-Louis, M.D.)

Center for Women Policy Studies (Leslie R. Wolfe, Ph.D.)

East Boston Neighborhood Health Center (Judith Steinberg, M.D.)

Emory University (Jacqueline Zalumas, Ph.D.)

The Fortune Society (Tracey Gallagher)

Health Initiatives for Youth (Ron Henderson)

Health Resources and Services Administration (Barney Singer, J.D.)

Hektoen Institute for Medical Research/Cook County HIV Primary Care Center

(Mary Driscoll, R.N., M.P.H.)

Interamerican College of Physicians and Surgeons (James P. Tierney, M.A., M.B.A.)

Johns Hopkins University School of Medicine (John G. Bartlett, M.D.)

Larkin Street Services (Anne B. Stanton, M.S.W., C.S.W.)

Missouri Department of Health (James M. Dempsey, M.S.W., L.C.S.W.)

New York State Department of Health/Health Research (Humberto Cruz)

Outreach, Inc. (Sandra S. McDonald)

PROTOTYPES (Vivian Brown, Ph.D.)

SUNY–Health Science Center at Brooklyn (Jill Rips, M.A., M.Phil.)

The Measurement Group-PROTOTYPES Evaluation & Dissemination Center

(George Huba, Ph.D.)

University of Colorado Health Sciences Center (Donna Anderson, Ph.D., M.P.H.)

University of Mississippi Medical Center (Harold M. Henderson, M.D.)

University of Nevada School of Medicine (Trudy A. Larson, M.D.)

University of Texas Health Science Center at San Antonio (Victor F. German, M.D., Ph.D.)

University of Vermont & State Agricultural College (Karen R. Soons, Ph.D.)

University of Washington (Karina K. Uldall, M.D., M.P.H.)

Visiting Nurse Association of Los Angeles (David A. Cherin, M.S.W.)

Washington University (Karen Meredith, M.P.H., R.N.)

Well-Being Institute (Geoffrey Smereck, J.D.)