Interventions tested and implemented under the end+disparities ECHO Collaborative.
Implemented cognitive-behavioral program (Choosing Life: Empowerment! Action! Results! or CLEAR, an evidence-based tool) to promote health and change behavior with patients, including MSM of color.
A designated medication planner nurse worked with patients to improve adherence/compliance to antiretroviral therapy, utilizing a medication planner provided to patients on a weekly basis.
Implemented U = U educational initiative with young clients, both new and existing, via education during clinic visits, educational materials, and social media.
U be U clinic-based campaign to motivate and support patients in achieving viral suppression.
In response to data that navigating the healthcare system was a key barrier to achieving viral suppression, patient text messaging to patient navigators enabled within the existing system of mobile device appointment reminders and check-ins.
An expedited intake process for newly diagnosed patients (MSM of color), featuring a provider role in making scheduling decisions, maximizing services provided in single visits, and flexibility in first visit encounters.
Peer navigation services offered to new patients at initial intake.
Script developed and used by front office staff to follow-up with no-shows by phone to assess reasons for missed appointments and respond accordingly
Collaborative medical case management team called Tri-Pod (registered nurse, a social worker, non-medical case manager) utilizes a psychosocial assessment to identify barriers to adherence (e.g., lack of support/other priorities), facilitating collaboration among the medical case management team and allowing the MCM to provide patient-centered care, promote health and wellness, and assist in removing barriers to accessing health care.
Pill bottle reminder alarms (e-pill) for youth patients new to the clinic and those with inconsistent medication routines, with the provision of clinic instructions on use of the e-pill devices and added support via an adherence video teach-back tool.
Uber Health transportation services provided to young clients experiencing transportation barriers in order to improve appointment experiences and health outcomes.
Intervention
Integration of medical nutrition therapy in routine HIV care via screening of patients for food insecurity and delivery of cooking classes and healthy grocerie