New York Links Long Island Regional Group November

New York Links Long Island Regional Group November 7, 2019

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3 Link and retain persons diagnosed with HIV in care to maximize virus suppression so they remain healthy and prevent further transmission. BP 5: Continuously act to monitor and improve rates of viral suppression BP 7: Use client-level data to identify & assist patients lost to care or not virally suppressed BP 8: Enhance & streamline services to support the non-medical needs of persons with HIV. . . BP 29: Expand & enhance the use of data to track and report progress

4 NYLinks Overall Objectives • • Improve Linkage to Care Improve Engagement in Care Improve ART Adherence Improve Viral Load Suppression

5 Methods • • • Put our Public Health Hats on Involve Everyone Think in terms of Region and Community Use Data Identify Gaps in Care Identify Interventions to fill Gaps Use Quality Improvement Methodology Increase QI skill set Share with Everyone

HIV Pre-Exposure Prophylaxis (Pr. EP) 2020 Charles John Gonzalez, MD Medical Director NYS DOH AIDS Institute

7 Plan to End the AIDS Epidemic A 3 -Point plan announced by the Governor on June 29, 2014 1. Identify all persons with HIV who remain undiagnosed and link them to health care. 2. Link and retain those with HIV in health care, to treat them with anti-HIV therapy to maximize virus suppression so they remain healthy and prevent further transmission. 3. Provide Pre-Exposure Prophylaxis (Pr. EP) for high risk persons to keep them HIV negative.

8 Pr. EP Efficacy is Well Established • Multiple studies affirm Pr. EP efficacy, adherence is important. • Studies have shown that Pr. EP reduces the risk of getting HIV from sex by about 99% when taken daily. • Among people who inject drugs, Pr. EP reduces the risk of getting HIV by at least 74% when taken daily. The USPSTF recommends Pr. EP for persons at high risk of HIV acquisition. GRADE: A

9 Pr. EP - New York State Priorities ü Increase client awareness ü Increase clinical provider knowledge ü Increase number of clinicians prescribing Pr. EP ü Increase access to Pr. EP and healthcare ü Develop a system that can incorporate future developments ü Evaluation

10 Pr. EP Utilization By the end of 2020, increase the number of individuals filling prescriptions for Pr. EP to 65, 000. Year Target Actual n n 2016 * 17, 057 2017 * 24, 118 2018 34, 000 2019 48, 000 2020 65, 000 Measure: Number of individuals filling at least one prescription for Truvada within the calendar year. Data Sources: Symphony Data, Medicaid Data • 41% Increase 2016 -2017

11 Pr. EP Utilization ETE Goal: By the end of 2020, increase the number of Medicaid recipients filling prescriptions for Pr. EP to 30, 000 Year Target Actual Jun-2013 * 251 Jun-2014 * 650 2015 * 2, 244 2016 3, 359 4, 226 2017 5, 039 6, 026 2018 16, 000 * 2019 22, 000 * 2020 30, 000 * Data Sources: Medicaid 2017 Target | 5, 039 Actual | 6, 026 Measure: Number of Medicaid recipients filling at least one prescription for Truvada within the calendar year.

12 Comparing Current Pr. EP uptake to 2020 Targets Persons on Pr. EP in NYS: 2014 -2020* 70, 000 65, 000 60, 000 37% of 2020 Target Achieved 50, 000 40, 000 34, 000 20% of 2020 Target Achieved 24, 284 17, 368 20, 000 10, 000 48, 000 9, 324 * 3, 388 0 2014 2015 2016 2017 2018 Target 2019 Target 2020 Target * Medicaid Data Warehouse (MDW) *Source: Source Healthcare Analytics (Symphony) and replacement of Medicaid data from the Medicaid Data Warehouse (MDW) Run by: Health Care Finance and Analytics on January 30, 2019

Pr. EP Data Nassau & Suffolk Region

14 Increasing Client Awareness

15 Increasing Client Awareness Pr. EP and PEP Consumer Materials All materials are free and can be ordered by emailing: aipubs@health. ny. gov TITLES PEP Yourself Poster Pr. EP Yourself Poster PEP 4 HIV Safety Insert PEP 4 HIV Brochure Pr. EP Yourself Against HIV

16 Increasing Client Awareness Adding a Pr. EP Track for Peer Certification • • Steering Committee engaged in 6 month process to deliberate and develop needed materials Conducted a survey of Pr. EP programs that documented the need for this track as well as employment opportunities for prospective peer workers Developed Pr. EP peer worker competencies Defined needed trainings Established a certification test Final meeting of the Steering Committee; April 17 th AIDS Institute and Peer Certification Review Board will review Steering Committee recommendations and make a final determination

17 Increase Clinical Provider Knowledge • NYS AI Clinical Guidelines for Pr. EP and PEP are being updated

18 Increase Clinical Provider Knowledge User-Friendly Pr. EP Guideline Tools Prescription and Follow-Up Pocket Guides Checklists for Prescription , Patient Education, and Follow-Up www. hivguidelines. org

19 Full Meeting Reports at www. hivguidelines. org/prep-for-prevention/prep-implementation/

20 Increase Clinical Provider Knowledge Primer for Women’s Healthcare Providers https: //www. health. ny. gov/diseases/aids/general/prep/docs/fact_sheet_women_family. pdf

21 Increase Clinical Provider Knowledge Clinical Education Initiative (CEI) CEI PEP & Pr. EP Courses, 2018 • 14 live in person presentations given to 315 participants • 3 online webinars given to 61 participants • 258 healthcare providers claimed CE credits for online courses • www. ceitraining. org

22 Increase Access to Pr. EP and Healthcare Voluntary Provider Directory v All regions of the State are represented v 629 registered prescribing sites (4/2019) www. providerdirectory. aidsinstituteny. org • Provider locater - Users can search for nearest provider • Providers can manage their own information

23 PEP Initiation in the Pharmacy Setting Pilot Demonstration • Explore issues related to implementation • Began 3/1/18 • 17 demonstration sites • Pharmacy window decal, training and brochures provided to sites • Due to low uptake, 6 -month pilot was extended to 1 year Low uptake likely due to lack of funding for an awareness campaign to inform consumers of the service. Data from the Pilot Demonstration: • • 36 PEP initiations – 35 from one site that is a pharmacy associated with a clinic 33 people attended follow-up appointment and obtained full prescription Roughly 70% male and 70% Caucasian Data from consumer follow-up survey pending

What can NY Links members do to help increase awareness and access to Pr. EP?

25 New York State Department of Health AIDS Institute charles. gonzalez@health. ny. gov 25

Cognitive & Behavioral Therapy in Working with Young Adult, Adolescent, and Pediatric HIV Helena A. Roderick, Ph. D. Senior Psychologist, CCMC, A&I – CTC, CYAAPH November 7, 2019 26

Disclosures Dr. Roderick: None November 7, 2019 27

Who Am I? My Background… • Born in Generation X; she/her pronouns • Graduate of the Bronx High School of Science and Columbia University • Obtained a Ph. D. in Clinical Psychology at SUNY Albany • Scientist-practitioner model • Studied CBT & developmental psychopathology: risk & resilience • Worked at the community clinic • Postdoctoral fellowship at NYPH Westchester Division’s Anxiety Clinic • For 15 years, worked at Northwell’s school-based health center at Franklin K. Lane High School in Brooklyn November 7, 2019 28

Learning Objectives Participants will 1. Gain increased familiarity with evidence-based psychosocial treatment 2. Discriminate between a “cookbook” approach and the flexible use of cognitive behavioral strategies 3. Gain readiness to implement elements of cognitive behavioral work November 7, 2019 29

Effective Elements of Therapeutic Relationship ♦ Alliance ♦ Empathy ♦ Goal Consensus and Collaboration ♦ Positive Regard ♦ Congruence/ Genuineness ♦ Feedback

CBT Rapport-/ Alliance-Building Tools • Present a confident and hopeful view of the work ahead • Speak with assurance and in a matter-of-fact manner about sensitive topics • Tricky balance: • Validate the individual and their experience • Address their symptoms with composure as “intruders” to be dealt with

General Characteristics of CBT • Active & Collaborative • Teach skills • Facilitate practice • Goal-Oriented • Structured, planful • Present-focused • Patient Manuals, not “cookbooks”!

CBT Formula for Success = Engagement + Psychoeducation + Skills Training + Relapse Prevention

Psychoeducation Explains the physiological underpinnings of symptoms, such as: Rapid heartbeat Cold hands Dizziness Stomach Upset

CBT Skills: Toolbox & Key Components • Recognize feelings and somatic sensations • Clarify cognitions • Develop a plan to cope • Evaluate performance • Self-reward

What I Feel Pounding heart Rapid breathing Feeling of Choking Sweating Dizziness Nausea Tingling Unreality Chest pain Muscle Tension Hot or cold flushes What I Do Avoid dance/party Run out of the room Go to the school nurse Go to the bathroom What I Think What if I faint? What if I lose control? What if my friends notice? Something’s really wrong! Maybe I’m dying! What if I go crazy?

FACING MY FEARS What I Feel Pounding heart Rapid breathing Feeling of Choking Sweating Dizziness Nausea Tingling Unreality Chest pain Muscle Tension Hot or cold flushes BEING A DETECTIVE CHANGING MY What I Do Avoid dance/party Run out of the room Go to the school nurse Go to the bathroom BREATHING What I Think What if I faint? What if I lose control? What if my friends notice? Something’s really wrong! Maybe I’m dying! What if I go crazy?

Coping Strategies Do something enjoyable and distracting. Do something soothing and relaxing. Do something that expends energy. Find someone to talk to. Change the way you are thinking. 38

CBT for Depression: Taking Action (Stark & Kendall, 1996) Ø Always find something to do to feel better Ø Catch the positive Ø Think about it as a problem to be solved Ø Inspect the situation Ø Open yourself to the positive Ø Never get stuck in the negative muck Transgender Care: A Multidisciplinary Approach CME/CE Conference October 17, 2019 39

Cognitive Skills The two most common cognitive errors that result in anxiety are: Probability Overestimation • Calculate accurate probability (“What are the odds of something bad happening? ”), then reassess level of anxiety Catastrophizing • “So what? ” (Even if something bad happened, it would be time-limited and manageable) Barlow & Craske, 2007

List of Cognitive Distortions (Burns, 1980) Page Distortion Type 1 Definition 1 All or nothing thinking (black & white) Seeing things as absolute categories 2 Overgeneralization Negative events will always reoccur and many ways 3 Mental filter Ignoring positives to focus on negatives 4 Discounting the positives Insisting that achievements, good outcomes don’t count 5 Jumping to conclusions Mind reading – assume others react negatively to you and fortune telling – predicting negative outcomes 6 Magnification/minimization Blow things out of proportion; shirk them to inconsequential 11/7/19

Page 2 Distortion Type Definition 7 Emotional reasoning “If I feel X then I must be X” (e. g. an idiot, incompetent) 8 Should statements Criticizing self/others w/ absolute standards (Always/Never) 9 Labeling Identifying with mistakes (e. g. I AM a fool vs. I made an error) 10 Personalization & blame Taking too much blame, or blame others and overlook your contribution to the problem 11 Fallacy of change Our happiness depends on others, so we’ll be happy if we successfully pressure others to change 12 Heaven’s Reward Fallacy We expect self-denial, sacrifice, proactive moral/religious activities to pay off in our lifetime in an observable way 13 Always being right It is unthinkable that we are wrong, and we’ll convince anyone else that we’re correct 11/7/19

An Inspirational Tale of Practicing What You Preach (Tool: Expressive Writing) Last week, we staged an “intervention” among the interdisciplinary team for an African American young woman in her mid-20 s who had been having worsening symptoms due to medical nonadherence. In other words, she was dying, despite all that we did and all we could offer her. The intervention was a constructive dialog. I am so proud of how the team conveyed that we did NOT GIVE UP on her. I helped her open up about her thoughts and feelings, and articulate her commitment to FULL ADHERENCE in the days ahead. Now, her viral load is a remarkably low 111. It hasn’t been that low in at least 6 years. And she’s on the road to an undetectable viral load – her goal and ours. We can’t wait! November 7, 2019 43

Place holder: QI Updates by Northwell CYAAPH & CART 44

LUNCH 45

46 Quick Look Back on Variation. . HOW TO IDENTIFY AND UNDERSTAND VARIATION

47 Quick Look back on Variation • Variation can be either good or bad; its important to determine the type of variation you have in your system • Special cause variation is external to the system but effects it; the effect can be either good or bad • In healthcare, it is at times best to establish your own upper and lower limits to understand the behavior of your process or system • To use a more structured approach to variation, we need to use a control chart

48 Quick Look back on Variation cont. • The idea of variation was based on earlier works far back as the 1700 • Processes have inherent variations categorized as common cause and special cause variation • Run charts are an effective way of determining variation • Special cause variation can be present in a system and following the guidelines for run charts and analyzing variation will help identify variations • Deeper analysis of your data leads to a better understanding of what may need to be improved

49 Rules for Identifying Special Cause Variation There is special cause variation when: 1. There is a single point outside the control limit 2. There is a run of eight or more points in a row above or below the centerline 3. There are six consecutive points increasing (trending up) or decreasing (trending down) 4. There are two out of three consecutive points near (outer one third) a control limit 5. There are 15 consecutive points close (inner one-third of the chart) to the centerline

50 Summary of Five Rules • These rules are derived over time to further identify special cause variation • Data must be carefully plotted for these patterns to become evident • These five rules can be used in improvement projects to spur further investigation or to judge the effectiveness of your improvement activities

51 Variation Game Counting Candy

52 Learning Objective https: //www. youtube. com/watch? time_continue=135 &v=Z 5 h. Lrw. G 10 m 8 At the end of this activity, you will be able to: • Define common cause variation and special cause variation. • Discuss why knowledge of variation is important when working to improve a process or system.

53 Directions 1. Chose a designated group member to be reporter and plotter Count M&Ms as individuals. Do not tell your other group members how many M&Ms you have. When every group member has finished counting their M&Ms, report the number to the group’s designated reporter. The designated reporter will plot out each bag on M&Ms on a run chart. 2. 3. 4. • • The x axis will show the # of participants The y axis will show the # of M&MS per bag

Discussion Questions: 54 https: //www. youtube. com/watch? v=9 li. ODQloz. WQ • Think of a work process you’re familiar with. What would be an example of common cause and special cause variation in this process? • Why is understanding variation useful when you are trying to improve a process or system? • Imagine you’re working on an improvement project and you notice a data point that’s far outside the normal range of variation. What would be your first course of action?

Place holder: QI Updates by NUMC, SBM and HRHCare 55

56 Brainstorming Session IDENTIFY TOPICS FOR FUTURE NYLINKS LIRG MEETINGS

57 Leveraging Quality Improvement to Achieve Equity in Health Care How QI Can Reduce Disparities QI interventions can reduce disparities in at least three ways: (1) In some cases, standard QI interventions can improve quality more for those with the lowest quality, but this is unreliable; (2) group-targeted QI interventions can reduce disparities by preferentially targeting disparity groups; and (3) culturally competent QI interventions, by tailoring care to cultural and linguistic barriers that cause disparities, can improve care for everyone but especially for disparity groups. Guidelines for Culturally Competent QI A culturally competent approach to QI should (1) identify disparities and use disparities data to guide and monitor interventions, (2) address barriers unique to specific disparity groups, and (3) address barriers common to many disparity groups. Leveraging Quality Improvement to Achieve Equity in Health Care, Green, Alexander R. Tan-Mc. Grory, Aswita et al. , Joint Commission Journal on Quality and Patient Safety, Volume 36, Issue 10, 435 - 442

New York State Training of Consumers on Quality (TCQ) Plus Informational Webinar October 2019

Presenters Steve Sawicki Lead 59 Daniel Tietz Director Consumer Affairs AIDS Institute

Policy Clarification Notice 15 -02 In 2015, the HIV/AIDS Bureau published Policy Clarification Notice (PCN) 15 -02 – Clinical Quality Management (CQM) Policy Clarification Notice. The purpose of the PCN is to clarify the RWHAP expectations for clinical quality management programs. This training is written with PCN 15 -02 in mind and, in part, its purpose is to assist RWHAP recipients in meeting these requirements. https: //hab. hrsa. gov/sites/default/files/hab/clinicalqualitymanagementpcn. pdf 60

AIDS Institute Quality of Care Program Standards for Consumer Involvement in Quality Improvement Consumer(s): Are routinely asked to provide input/feedback in the selection of quality improvement (QI) priorities Participate in HIV quality management (QM) program activities, as members of the QM committee Provide feedback on the HIV QM program by responding to formal solicitations for public comment and by participating in an organization’s consumer advisory board. Are offered opportunities to participate in trainings in QI and are provided with an organization’s performance data results and findings. Experience is assessed at least annually and findings are formally integrated into QI activities and communicated back to staff and consumers, as specified in the guidance issued by the AIDS Institute 61

Consumer Involvement Cascade Guidance • Provide an explanation of how consumers were engaged in the process of developing the quality improvement plan based on the data in the cascad es. • Explain how consumers were given the opportunity to learn about the methodology used to define each indicator and to construct each bar on the treatment cascades, including how the numerator and denominator were derived. 62

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NY State TCQPlus Goals 64 • Foster a working relationship between consumers and HIV prevention and care providers to form TCQPlus training partners. • Plan and deliver local TCQ training programs by the TCQPlus training partners. • Develop regional training capacity among consumers and providers to deliver quality improvement trainings in local jurisdictions. • Increase the number of consumers and providers who attend a TCQ program training conducted by TCQPlus graduates • Increase the number of consumers who are active members of provider and NYLINKS regional level clinical quality management program activities

TCQPlus Learning Objectives • Provide overview of the Ryan White HIV/AIDS Program (RWHAP) and its CQM expectations for recipients/sub-recipients • Familiarize participants with basic principles of adult learning theory and increase capacity to apply these principles when designing and delivering training programs • Create a safe space for participants to discuss civic engagement, evaluate relationships, and to review frameworks to engage consumers in quality improvement activities • Familiarize participants with clinical quality management principles and terminology 65

TCQPlus Learning Objectives • Learn and demonstrate how quality management teams and committees make decisions to solve problems • Create space for participants to reflect on real life experiences to be change agents • Review concepts of health numeracy, performance measurement, and quality improvement • Provide planning tools and resources to design and deliver local TCQ programs 66

Pre-TCQ Participant Expectations • Identify and select NYLINKS regional group members to form up to training team(s) § Up to 2 teams per regional group § Each training team will include one staff from a provider organization and up to two consumers. • Complete pre-work assignments by participating in 3 webinars on topics that include: § Provide overviews of TCQPlus Program and Ryan White Program quality expectations § Familiarize participants with basic principles of adult learning and discuss how these principles relate to designing learning experiences § Read two essays on different methods of involvement including agitation, activism, and advocacy 67

Participant Expectations During TCQPlus § Attend actively participate in TCQPlus in- person session (travel, lodging and meals covered by AIDS Institute) • Approximately 2 ½ full days of training • March 22 -24, 2020 § Training Location • Capital Region (Schenectady or Albany, New York) 68

Post-TCQ Plus Participant Expectations 69 § Participate in follow-up webinar for networking and staying connected to members of TCQPlus training team § Design and deliver two (2) ½ day local TCQ Programs within 2 -4 months after attending TCQPlus § Identify and recruit consumers and providers to participate in local TCQ programs § Work with AIDS Institute staff to plan TCQ program logistics (i. e. , space, food, training materials, etc. ) § Report back to AIDS Institute staff on TCQ program(s) delivered and outcomes using survey monkey tool § Participate in future clinical quality management capacity building webinars

TCQPlus Participant Selection Process 70 § Each NYLINKS regional group should determine who has the time, energy, and commitment to participate in the TCQPlus program § Up to two PLWHA and one staff member can make up a training team § All members of each training team should be or plan to be actively engaged in clinical quality management program activities § Up to two training teams can be selected for each NYLINKS regional group § Provider staff must review and sign “Recipient Agreement” to participate in the TCQPlus on behalf of the training team § Agree to assist with logistical planning of regional TCQ program(s) § Serve as regional content experts and present on facility or regional level cascade data during regional TCQ programs. § The deadline to select NYLINKS regional training teams is January 31, 2020

TCQPlus Implementation and Delivery Timeline June 2018 Secure funding a schedule TCQPlus Overview Presentations within each NYLINKS regional group for outreach and recruitment Fall 2019 January 2020 Identify NYLINKS Regional team members (1 Provider and up to 2 consumers) per team. A maximum of 2 teams per regional group 71 June 2019 Schedule and deliver 3 Prework webinars (2 weeks prior to TCQPlus) Secure training venue (Capital Region) January 2020 October 2018 February 2020 March 2020 Identify TCQPlus faculty (TCQPlus graduates, content experts, and lead trainers) March 2020 TCQPlus program Follow-up evaluation activities and planning webinar booster sessions June 2020 Deliver 1 st NYS TCQPlus program

Questions?

Contact Information Daniel Tietz, Director of Consumer Affairs New York State Department of Health AIDS Institute (518) 486 -7302 (voice) daniel. tietz@health. ny. gov 73

Important Dates for NYLinks LIRG Upcoming Webinars: December 16 2019 - Northwell CART : Utilizing Heat Maps January 2020 – Expanding on Variations January 2020 - NYS DOH Department of HIV/AIDS Surveillance 2020 NYLinks LIRG Meetings • March, June, September and December 74

Contact Information Steve Sawicki, NYLinks Lead, steven. sawicki@health. ny. gov Regional Leads Upper Manhattan—Susan Weigl sweigl@yahoo. com Lower Manhattan—Susan Weigl Western NY—Steven Sawicki Long Island—Febuary D’Auria, febuary. dauria@health. ny. gov Central NY & Southern Tier—Laura O’Shea, laura. oshea@health. ny. gov Mid & Lower Hudson—Steve Sawicki Queens—Nova West, nova. west@health. ny. gov Brooklyn—Steven Sawicki & Zeenath Rehana zrehana@health. nyc. gov Bronx—Dan Belanger, dan. belanger@health. ny. gov Northeastern NY—Steve Sawicki Staten Island—Steve Sawicki Statewide TA for Consumer Involvement in Quality Improvement—Dan Tietz, Daniel. Tietz@health. ny. gov And Remember to visit the webpage at: www. newyorklinks. org 75