CASE STUDY: CHICAGO HEALTH OUTREACH Chicago, Illinois

Transcription

1 CASE STUDY: CHICAGO HEALTH OUTREACH Chicago, Illinois 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 Chicago Health Outreach (CHO) is a community health organization providing physical health, mental health, and support services to the city s neediest citizens - individuals who are homeless, mentally ill, refugees and immigrants - regardless of their ability to pay. CHO was founded in 1985 as a homeless demonstration project funded by the Robert Wood Johnson Foundation. CHO began providing medical care for HIV positive individuals four years later. At that time, most community health organizations in Chicago referred HIV positive clients to the county hospital. CHO, on the other hand, took the approach of providing integrated HIV care with other medical services in the community and subsequently became one of the original Title III programs in the city serving the largest number of individuals living with HIV/AIDS in Chicago. CHO is part of Heartland Alliance for Human Needs & Human Rights, a larger non-profit organization with several separately incorporated non-profit subsidiaries. Chicago Connections, another Heartland Alliance subsidiary, provides human services, and Century Place Development Corporation provides supported housing services. The three organizations work together closely to provide services for HIV positive substance users and are described together in the case study below. Approximately 10% of CHO s 11,000 clients are HIV positive; nearly all of these individuals have a recent history of substance abuse. More than 50% of their HIV clients are African American, 25% are White, 12% are Hispanic, and the remainder are of other racial/ethnic backgrounds. Approximately 60% of their HIV-positive clients receive Medicaid benefits, but almost 40% are uninsured. A serious challenge for CHO and other providers serving the uninsured is limited substance abuse residential treatment. There are only five slots reserved for uninsured homeless individuals in Chicago. CHO became a federally-funded community health center in 2000, enabling the organization to maximize federal funds and Medicaid dollars as a Federally Qualified Health Center. CHO has developed relations with several managed care organizations, since from the consumer s perspective, managed care plans provide a source of payment for their medications. The majority of CHO staff are grant-funded, offering services to the uninsured and those with Medicaid benefits who need services that Medicaid does not pay for. Service Delivery Model Chicago Health Outreach has several service divisions. The primary care division provides health care services at the CHO clinic in Uptown, at three subcontracted community health centers, and at 44 homeless shelters across the city. HIV primary care services are provided at the CHO clinic through a multidisciplinary team of physicians, an infectious disease team, nurse practitioners, nurses, adherence educators, a prevention case manager and a psychiatrist. The CHO clinic recently added weekend hours, and the clinical staff also does home visits. When the primary care team goes out to the homeless shelters, they often bring a mental health case manager or housing case manager with them. Since most of the HIV services are provided at the CHO clinics rather than the shelters, clinicians try to develop a relationship with clients to get 2

3 them to come to the clinic for their HIV care. The case managers help them to establish this relationship. When clients with HIV first arrive at the clinic, the adherence educator completes an initial psychosocial assessment, which includes a comprehensive health history and a needs assessment. The adherence educator also screens for drug use. Treatment options and referrals to substance abuse treatment programs are considered. The adherence educator, a bachelor s level staff person, serves as a case manager and refers clients to services as needed. Once a patient of the clinic, the adherence educators encourage clients to engage in addiction counseling or to attend support groups, one of which is a substance abuse support group. A second division of CHO provides mental health services. Services include street outreach, day programming, psychosocial rehabilitation, long-term case management, individual and group counseling, residential treatment, drug treatment, and outpatient services. CHO s mental health program has two distinct populations: a refugee population and a homeless population. Most of the HIV positive clients are part of the homeless program, but there is some overlap with the refugee program. The refugee population is transforming from a primarily Bosnian population to predominately Asian and African populations. CHO recruited case managers from each of these refugee communities to assist with service coordination and translation. Some of the more recent immigrants have HIV in addition to mental health disorders. Interpreter services are available in 28 languages through CHO s Health Care Interpreting Services Program. Many homeless individuals are dually diagnosed with mental illness and substance abuse disorders. Pathways Home is a new CHO outpatient program for this dually diagnosed population, with 50 housing slots. Some clients in this program are also HIV positive. Staff at Pathways use the stages of change model for both mental health and addiction issues, using a comprehensive screening tool at intake to assess readiness for change. Clients often present with needs unrelated to health care or HIV, and staff is trained to move slowly to allow clients time to become familiar with the setting and become more trusting. HIV status at Pathways is selfreported. Therefore the intensive care management teams, also known as ACT Teams, try to get clients into medical care as soon as they learn their HIV status. Chicago Connections, Heartland Alliance s human services subsidiary, provides supported residential substance abuse services. One of the housing programs, the Rafael Center, provides a continuum of housing for HIV positive substance abusers. If a substance abuse problem is identified at housing intake, clients have the following housing choices: A 12-Step abstinence-based recovery home; A transitional abstinence-based program where substance abuse issues are focused on; A transitional housing program where clients do not have to focus on their substance abuse issues; A 90-day residential program; or A harm reduction program for active users known as EPOCH. The intake process to determine the appropriate type of housing is extensive and can take as many as four visits. Some consumers are very reluctant to disclose substance abuse. Some 3

4 believe the only way to address substance abuse is through abstinence. At the beginning, clients do not understand that there are a variety of ways to address substance abuse, and need information and education to understand their options. The Rafael Center employs certified alcohol and drug addiction counselors and a staff psychiatrist shared with CHO. Individual psychotherapy is provided. Service Integration CHO has always provided primary care, mental health services and support services using a multidisciplinary team approach to care. The integration of substance abuse treatment with these other services has not been easy to accomplish. Residents of the Rafael Center housing programs could not always receive their HIV primary care at the CHO clinic and conversely, clinic patients could not always access substance abuse treatment. This is partly due to limited treatment slots within the city. CHO has developed a number of strategies to address the substance abuse treatment needs of their clients. For several years, a certified addition counselor from the Rafael Center worked at the CHO clinic to provide counseling services. In addition, the CHO adherence counselors provide supportive counseling and referrals for substance abuse treatment when needed. Most substance abuse treatment still occurs through referral services. CHO is working with other service providers in the community to create a substance abuse treatment continuum of care, including outreach, detoxification, residential, and outpatient treatment, for individuals without insurance. The CHO staff meets informally each day to discuss clients. They also meet formally once each week for case conferences. At Pathways, there are fewer clients and more staff. Thus, each clinical team meets 3 times per week to discuss client care and all of the clinical teams meet together weekly. One of the challenges CHO faces, with all of it s program expansion, is how to integrate each new service with the other services offered by the organization. Treatment and Adherence Medical adherence is an important goal for CHO and they have consistently tried new strategies to help clients adhere to treatment. Half of CHO s HIV-infected clients are currently on antiretroviral therapy. Adherence is not easy for clients who are also homeless, often have mental illness, and actively use drugs. Staff works with clients to address their mental health and substance abuse issues as part of the adherence process. The adherence counselors perform multiple roles at CHO. They provide education about how to live with HIV, information about nutrition, and diagnostic tests. They also serve as health coordinators, referring clients to mental health and substance abuse treatment. Finally, they provide services to those clients who have not revealed their HIV status to anyone but their medical providers. The adherence counselors offer a $5 weekly incentive to clients to come in and refill their pillboxes for the next week. Their latest adherence strategy is providing a pager set up to go off at certain times, reminding clients to take their medications. 4

5 At the Rafael Center, 60% of clients are on antiretroviral therapy. A nurse at the Center educates clients about health issues, engages individuals in discussions about when to start medication, and does medication monitoring. The nurse also offers to prepare medication boxes to help people with adherence. Clients are given options about when to start their medications. Staff have found that most people who are active substance users do not want to take HIV medications, because they know they may not be adherent if they want to get high. Clients with serious mental illness also have difficulty with medications adherence. Harm Reduction Several years ago, CHO used a behavioral model that required clients to understand the importance of abstinence. Drug screening was an important requisite of the housing programs. Today, CHO embraces a more holistic approach to change, in keeping with its Hull House tradition and orientation towards the social needs of clients. Harm Reduction principles are adopted by this model well. Most people come to the clinic needing care for an injury or illness, not for HIV or substance abuse care. Staff work with clients who are in the pre-contemplation phase by focusing on building relationships. The first goal is to address the basic needs for food, shelter, clothing and other needs articulated by clients. Then, as those needs are met, a relationship is built between client and staff. Eventually, the HIV and substance abuse issues are addressed. Harm reduction is a consumer-centered approach where consumers are helped to identify their own goals for reducing risk in many areas including sex and substance use. The harm reduction model has been difficult for some staff, particularly the administrative staff and the peer staff at the housing programs. There is a mandatory 4-day harm reduction training for all the Rafael Center staff because many of them are in recovery and have achieved recovery through abstinence-based programs. They needs a great deal of ongoing individual supervision, mentoring and opportunities to vent their feelings about fostering harm reduction approach group discussions. The Rafael Center has brought in consultants to help with the staff training and continues to focus on the bottom line how they can best serve their clients. Although training and individual supervision in harm reduction has been provided for clinical staff at CHO, the administrative staff did not receive this training until recently. When clients arrive at the clinic under the influence, the reception staff is their first encounter. Often subjected to abusive behavior, the reception staff viewed providers as too forgiving of clients. To address this, CHO recently conducted a retreat on harm reduction, involving the entire staff as well as some clients. Relapse and relapse prevention are addressed differently in CHO s different programs. At the CHO medical clinic where many of the clients are actively using drugs, relapse is viewed as a given. At the Rafael Center, different housing programs handle relapse in different ways. There are formal relapse prevention groups at most of the housing programs. In the abstinence-based programs, if clients relapse, they are discharged. However, they are referred to detoxification and are able to re-enter the program after detoxification. Other programs are wet programs where people are not yet in recovery and therefore relapse is not even an issue. 5

6 Outreach and Retention in Care HIV positive clients come to the CHO clinic from a variety of referral sources. Many referrals come from the Rafael Center. Two of the housing programs at the Rafael Center are wet houses and during the course of their stay, many residents are encouraged to receive HIV counseling and testing. If clients test positive, they are referred to the CHO clinic. Another major referral source is the needle exchange program where CHO staff conduct HIV counseling, testing and prevention case management on-site. There are also teams of outreach workers who do street work, go to shelters throughout Chicago, and respond to crisis calls from other providers. Some HIV positive clients are referred to CHO through this mechanism. Because the CHO medical providers go to the shelters on a regular basis, they can provide follow-up services and look for clients who have dropped out of care. Medical providers ask some homeless clients to meet with the adherence educator once a week, so that they stay in touch. CHO recently started a new program that offers clients a $10 incentive if they bring in a new client to be tested for HIV. If the clients get tested, both the new and referring client receive the $10. Working with Other Agencies In the early days of the Ryan White Care Act, CHO applied for and received a Title III grant to work with other federally qualified health centers in Chicago to establish a community-based system of HIV care. CHO served as the lead agency and fiscal intermediary for this group, helping several participating health centers get to the point where they could apply for their own Title III grants as independent entities. CHO also has an entire division devoted to community planning. One focus of this division is to bring providers together to create systems of care for the mentally ill homeless population. The city has contributed funds to hire a staff person at CHO to develop a network of HIV providers for this population on the north side of Chicago. This staff person convenes meetings of providers and HIV-infected consumer to discuss how to strengthen the network of mental health, substance abuse, medical care, and support services for clients. Cultural Issues CHO has a division devoted to Multicultural Services. This division is an in-house resource that provides interpretation and translation services, speakers, and materials on cultural issues. It also serves as a resource to state and national providers. The interpreter program provides materials on cultural competency and language rights to all ethic organizations in the Chicago area. They have 110 interpreters (independent contractors) covering approximately 28 languages. CHO also has translation capacity in 20 languages. Language barriers are not a problem for Spanish speaking clients because CHO hires Spanish-speaking and bicultural staff. CHO provides all staff with an orientation that covers cultural issues. They also offer quarterly workshops addressing cultural issues and homelessness. CHO views cultural competence as an ongoing process as reflected in the following statement from an employee: You can be here ten years and still have lots to learn. 6

7 Homelessness has it s own culture. Individuals who are homeless suffer from a significant amount of stigma. Immigrants and refugees, who are often quite frightened of the prospect of becoming homeless themselves, are frequently uncomfortable being around homeless individuals. This presents a number of challenges for the staff as they attempt to work as sensitively as possible with these complex social differences. Consumer Involvement CHO hires consumers to work in all of its programs. In addition, the Community Health Center s Board is composed of a majority of consumers, including some who are HIV positive. Each program within CHO also has its own Consumer Advisory Board (CAB). CHO encourages consumers to be part of the coalitions in Chicago and nationally to help with advocacy work, including the Title I Planning Council and the Communities Advocating Emergency AIDS Relief (CAEAR) Coalition. In the mental health program, consumers have put on a breakfast for legislators. This CAB has participated in program development and has organized dances and social events. The housing programs have had more difficulty sustaining consumer involvement because the programs are transitional. Consumers come into the programs, stabilize, and then move on. Consumer focus groups and client satisfaction surveys are completed for each program. These two processes feed into the strategic planning process for Heartland Alliance. Quality Improvement Chicago Health Outreach has a quality improvement program comprised of three components: Structure: Includes client demographics, billing issues, information systems; Process: Examines how CHO follows Public Health Service guidelines; Outcomes: Measures nights spent on the street after x months in a housing program, quality of life, adherence, hospitalization rates, decrease in viral loads, CD4 counts, and disease progression. The CHO Quality Improvement (QI) committee consists of a director and program staff. Each of the programs conducts its own QI by developing process and outcome measures and reporting to the CHO QI committee, which then reports to the Community Health Center Board. Summary One of Chicago Health Outreach s strengths is their approach to care. They use a community service model, know their community and provide the care that is needed right there. They have been successful in removing many access barriers to care, in gaining people s trust and engaging them in care. Another program strength is the integration of their many programs. They provide many different services and are able to integrate clients within and across the spectrum of programs. 7

8 CHO also faces several challenges. With much program expansion, the program has grown so much that there is a new need to reintegrate services. Working with the neighborhood is also a challenge. The neighborhood is becoming gentrified and there is a growing not in my back yard sentiment toward programs for the homeless, substance abusers, and people with HIV. CHO is working actively with the neighborhood organizations to address these issues. Another challenge is the multiple funding sources and multiple reporting requirements. Different funding and eligibility requirements sometimes make it difficult to address the needs of all their clients. Although CHO receives funding from the federal government, Medicaid, the Ryan White CARE Act and the city of Chicago, the majority of their clients are uninsured. CHO must dedicate a great deal of effort to accessing the necessary medical care, prescription medications, mental health, and substance abuse treatment services not covered by insurance for clients with insurance, and work even harder to find these services for those without insurance. For more information, you may contact: Maria de Guzman, Administrative Director of Primary Care Services Chicago Health Outreach Phone: mdeguzman@heartland-alliance.org 8