CASE STUDY: SPECIAL HEALTH RESOURCES OF EAST TEXAS Longview, Texas

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1 CASE STUDY: SPECIAL HEALTH RESOURCES OF EAST TEXAS Longview, Texas This project was funded by a grant from the Health Resources and Services Administration, U.S. Department of Health and Human Services, grant #4H97HA Disclaimer: Permission is granted for non-commercial use of documents so long as form of the document is not altered, the copyright is not removed, and a proper citation is made to the document. Non-commercial use of a document is use by a not-for-profit organization in which the document is not sold. If you have questions about appropriate and proper uses, contact the Health and Disability Working Group.

2 Background Special Health Resources of East Texas, Inc. (SHRET) is a non-profit agency based in Longview, Texas. SHRET is comprised of three main divisions. The Substance Abuse Services Division serves the 11 counties of East Texas. The HIV Division provides HIV services in 23 counties. These two divisions emerged from predecessor community agencies to form SHRET in The third division is Wellspring Recovery Center, an 18-bed inpatient substance abuse treatment program for people with HIV. Wellspring is the only inpatient facility in Texas exclusively treating HIV positive substance abusers. Although the HIV division and Wellspring are entirely dedicated to working with HIV, the substance abuse division works very closely with the other two divisions to provide substance abuse treatment and trauma counseling to people with HIV. All HIV Division services are available to HIV positive individuals in the 23 counties without regard to income. In addition, Wellspring is available to any HIV positive substance abuser in the state. SHRET serves approximately 900 HIV positive individuals annually and estimates that 25-50% are substance abusers. In the year 2000, 41% of the clients were Caucasian, 53% were African American, and 6% were Hispanic. Women represented 34% of the total population served. Among substance abusers, the primary drugs of choice were: 69% cocaine, 16% alcohol, 6% cannabis, and 78% poly-drug use. Approximately 59% have a history of IV drug use. Service Delivery Model Counseling, Testing and Outreach The HIV Division consists of six programs: the HIV Prevention Program, HOPWA/HOME Housing Program, Prevention Case Management, the Emerging Populations Program, the HIV Services Program, and the HIV Early Intervention Program. Two programs offer counseling and testing, among other services. The HIV Prevention Program provides counseling and testing for HIV and Hepatitis C. Individuals may come to the offices for testing but there are also nine outreach workers who do counseling and testing in the community. Although the outreach workers are trained in using Orasure, they usually do blood testing so that they can also test for Hepatitis C and Syphilis. The outreach workers go out to housing projects, bars, streets, parks and any areas where they feel they are likely to meet individuals at risk. The Emerging Populations Program provides oral and written information as well as outreach services in Spanish to the Hispanic community. A staff member, known as the Promotora (promoter of pubic health) also provides case management and referral for Spanishspeaking support services. Outpatient Services The HIV Services Program provides medical care, dental care, medication, insurance assistance, massage therapy, individual and group mental health treatment, housing and utility assistance, food vouchers, transportation assistance and case management services. These services, including dental care, are available at 4 separate clinics: in Longview, Texarkana, Paris, and Tyler. The only public transportation system in East Texas is the train. Clients are offered a 50% 2

3 discount on train fare to all appointments. There are 4 SHRET vans and drivers to provide transportation when needed. All individuals who are HIV positive and live within the 23 counties are entitled to use the services regardless of income. Referrals come to this program from the other divisions and programs as well as area hospitals, the local mental health clinic, and private medical care providers. Approximately 80% of the clients have concurrent mental health disorders, and most are medically compromised and in need of dental, nutritional and prescription medication services. Approximately 50% of the clients tested positive for Hepatitis A, B or C, and 5 clients suffered from significant complications due to Hepatitis C. Staffing of the HIV Services Program includes a physician, nurses, a certified acupuncturist, detoxification (acudetox) technicians, case managers, social workers, licensed chemical dependency counselors, and licensed professional counselors. The agency also has subcontracts with massage therapists, mental health providers, a psychologist, and alternative therapists. Because the service area is so vast, the agency maintains formal contracts with other agencies to ensure collaboration. They also have an extensive informal network ranging from the Louisiana state line to Dallas, and from the Oklahoma border to the Arkansas border in order to cover their entire service area. The HIV Early Intervention Program (HEI) provides intensive case management to HIV positive substance abusers. Specialized case managers work closely with clients to assess their health care needs and work hard to address the barriers of care for this population. Caseloads for the intensive case management program are limited to clients per case manager. Case managers conduct support groups and field trips. They see clients in the clinic, but they also travel to their homes and often provide transportation to care. Clients are seen as often as necessary to maximize recovery and adherence to care. HEI is one of 18 HIV Early Intervention Programs in the State of Texas and is, along with the other 17 HIV Early Intervention programs in the state, a major referral source for Wellspring Recovery Center. Case conferencing takes place on an informal basis every day, and formally once a week. Difficult situations are discussed, new information is shared, medical updates are given, policies and procedures are reviewed and changes are made as necessary. These meetings often include staff from other programs in the agency. A representative from the medical clinic, the substance abuse program and all the case managers attend all case conferences. Residential Substance Abuse Treatment The third main division of SHRET is Wellspring Recovery Center, a 60-day residential program for HIV positive substance abusers. The Wellspring staff consists of one part-time physician who shares time with the HIV Services Program, nurses, a licensed professional counselor, a licensed chemical dependency counselor, substance abuse clinicians, a case manager, and cooks. Most of Wellspring s clients do not have health insurance. A small percentage of patients have Medicare or other third party reimbursement sources. The program is funded by the Texas Commission on Alcohol and Drug Abuse (TCADA), the state agency that funds, licenses and regulates substance abuse treatment. 3

4 Wellspring provides medical and psychological evaluations, medical care and substance abuse treatment, social stabilization, crisis intervention, and case management. Nurse monitoring of clients is provided 24 hours per day. The program offers an array of therapeutic options including traditional individual and group counseling, support groups, life skills groups, and skills necessary to manage addiction while following a prescribed medical regime. Additionally, some less traditional treatments are incorporated into their programs. Group and individual sessions of Acudetox (auricular acupuncture) and neuro-feedback are offered daily to clients. Other therapies include yoga, massage therapy and other bodywork techniques known to enhance the immune system and general health, wilderness experiences, equestrian therapy, and additional outings which promote socialization and cooperation. In addition to these therapies, Wellspring provides classroom sessions using curriculum designed by the Hazelden Educational Series. Clients learn about the negative effects of substance abuse and strategies for avoiding relapse. Classes are followed by process groups where clients exchange information and experiences, share their feelings and insights, and engage in problemsolving skills. At the time of intake, clients are usually quite medically compromised due to a range of medical, psychological and social conditions. The intake goal is to welcome individuals into a safe setting where they can be stabilized and intensively treated while basic community resources are explored for them upon discharge. Complications such as unemployment, substandard housing, medical problems, poor diet and hygiene, noncompliance with medications, and loss of relationships with family and friends are common. The 18 Texas HEI programs are not only a major source of referral for Wellspring, they also serve as vital points of entry and discharge for the inpatient program. In fact, all initial assessments are completed by the HEI programs where uniform assessments, designed by Wellspring, are used. In addition, the HEI programs arrange detoxification and transportation to the Longview, Texas site. The training and programming is extensive. For example, in response to the high incidence of trauma in this population, clinicians train at the National Institute for Trauma and Loss for Children in Gross Pointe, Michigan. The training is applicable to adult populations. In the past few years there has been a growing body of research which indicates that alternative therapies such as auricular acupuncture, neuro-feedback, yoga, massage therapy and other bodywork are positively related to symptom relief in PTSD and positive feelings about health for HIV positive individuals. In light of these findings, the inclusion of alternative therapies are reflective of cutting-edge services for HIV positive substance abusers. Adherence and Retention Through Wellspring, clients learn about important medical therapy and address possible barriers to medical adherence. Wellspring teaches adherence strategies such as using alarms and tailored scheduling regimes to promote self-sufficiency for their individual medication programs. 4

5 Throughout stays at the facility, Wellspring and the local HEI staff do careful discharge planning. The HEI team provides intensive case management and support services upon discharge. Follow-up assessments are done by Wellspring staff at 30 day, 60 day, and one year intervals following completion of the program. Many clients have formed such a strong sense of community while at Wellspring that they choose to remain in East Texas and under the care of SHRET s outpatient services. In addition, all outpatient case managers are trained to follow up on clients lost to care. At intake, clients are asked to provide the name and phone number of someone who might know where they are if the agency cannot locate them. In addition, all case managers carry pagers and cell phones, and can be reached at any time through an 800 number. Harm Reduction Although abstinence is a central issue for any inpatient unit, Wellspring has some latitude around alcohol and drug slips. Patients are not always discharged because of relapse. Staff takes into consideration individual situations and treatment readiness whenever problems occur. Adherence to medical care, regardless of drug use patterns, is emphasized. When patients are discharged to the HEI programs around the state, continued abstinence is the goal but adherence to medical care through a harm reduction approach is the priority. Recovery is viewed as a process. Antiretroviral therapy is offered to anyone who is medically appropriate, independent of substance abuse patterns. The patient s ability to adhere to treatment is assessed according to behavior, not addiction status. Cultural Issues Due to Wellspring s intensive treatment modality, cultural issues (including gender, race/ethnicity, age, socioeconomic status, sexual orientation, alcohol/drug use, and various lifestyle choices), are addressed daily in the multitude of experiences and spectrum of therapies offered. The staff believes that diversity training, both for themselves and clients, is beneficial for the healthy functioning of a recovery community. Over the past few years, the treatment team has found that by working on their own personal biases, they are better prepared to clearly confront prejudice or cultural conflicts on the unit. SHRET has provided a significant amount of cultural diversity training for all direct service employees. The agency has seen a considerable increase in the Latino population in the area. SHRET recently received a grant for emerging populations and hired a physician from Mexico to work in the clinic as a case manager while she works on her medical certification. They are attempting to hire bilingual case mangers. However, it has been difficult to find bilingual case managers, nurses, and other staff. Thus far, most of their Spanish-speaking clients also speak English, but an increasing number of clients who speak only Spanish are anticipated. Summary Special Health Resources of East Texas, Inc. houses two divisions dedicated to working with HIV, one of which is dedicated only to serving HIV positive substance abusers. This division, 5

6 Wellspring Recovery Center, is the only facility in the state of Texas that provides inpatient residential treatment to men and women who are HIV positive substance users. Clients may be referred from any area of Texas. Wellspring staff is trained to treat clients who are triply diagnosed with HIV, substance abuse and mental health disorders. Wellspring provides a wellrounded array of traditional and nontraditional health care. The program structure is most conducive for teaching and instilling healthy medical, social and behavioral self-care skills for the HIV positive substance abuser. Furthermore, the program provides a sufficient amount of treatment time to help most clients stabilize and practice these new skills. For those who need more time to integrate new skills, SHRET is currently trying to find funding to create a transitional living facility. For further information, you may contact: Wendell Hicks, Executive Director Special Health Resources of East Texas Phone: (903) Jhicks0262@aol.com 6