create+equity Quality Improvement Interventions

Promising interventions focused on by the create+equity Collaborative. Each summary includes core components, tips and trick, links to additional resources (manuals, case studies), and suggested evaluation measures.

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Optimal Linkage and Referral (Active Referral Intervention)

Active Referral involves successful linkage of people with HIV to primary care as well as other services and supports. This may include newly diagnosed individuals, persons previously diagnosed who have never been linked to care, or persons who have fallen out of care and are being re-linked.

Patient Navigator Model (SPNS Project)

This model, tested and evaluated as part of a Special Projects for National Significance (SPNS) project, is a time-limited service delivery process that helps people with HIV (PWH) to obtain timely HIV-related care to optimize their health.

Staff Training on Motivational Interviewing Skills, Strategies and Tools

Motivational interviewing is a client-centered, directive therapeutic style to enhance readiness for change by helping clients explore and resolve am- bivalence. An evolution of Rogers’s person-centered counseling approach, Motivational Interviewing elicits the client’s own motivations for change.

The Undetectables Program

A stepped approach to ART adherence for people with HIV who have mental health issues, substance use issues and/or are experiencing homelessness.

Training on Continuous Improvement

Organizational leaders frequently make bold statements about their commitment to quality and its components (e.g., safety, efficiency, effectiveness, value and listening to their customer). However, the real test of whether an organization is making quality improvement its north star is how well it has prepared its leaders and staff to apply quality concepts, methods and tools to daily work. Building capacity and capability for continuous improvement, therefore, is a fundamental building block of this journey.

Trauma-Informed Approaches Improving Care for People with HIV

According to NASTAD’s Trauma-Informed Approaches Toolkit (see link below), being trauma-informed is an approach to administering services in HIV care that acknowledges that traumas may have occurred or may be active in clients’ lives, and that those traumas can manifest physically, mentally, and/or behaviorally.

Uber Health (or similar) Transportation Services

A number of studies have demonstrated that the lack of access to transportation has been consistently associated with sub-optimal ART adherence. Uber Health and similar medical transportation services can be an effective strategy for patients experiencing transportation barriers.

Use of Peer Navigators

Peer navigator services are often useful for new patients, patients who have inconsistent engagement and patients who have disengaged. Several organizations participating in the ECHO Collaborative as well as several controlled studies have showed the efficacy of peer navigators, particularly around engagement and re-engagement.

Waiting Room Milieu Manager

Using a Milieu Manager to manage the waiting area, welcome people, help manage the atmosphere of the waiting room, act as liaison between patient and clinic staff, and help people feel comfortable.

Walk-In Availability and Open Access to Care

Walk-in availability of and open access to Ryan White HIV/AIDS Program-funded clinics allow clients to come for services at a time that is convenient for them and be seen by appropriate providers within a reasonable period during normal business hours.

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Case Conferencing to Support ART Adherence

Case conferencing allows a multi-disciplinary team to review patients (either select patients or all patients), understand their challenges and assets, and develop customized strategies to stay in ongoing HIV care and improve viral suppression rates.

Collaborative Care Model

The integration of physical and mental health care is an important component in effective patient care for patients with co-morbid conditions. The Collaborative Care Model offers an evidence-based approach to integration in which primary care providers, care managers, and psychiatric consultants work together to provide care and monitor patients’ progress.

Cognitive Behavioral Therapy for Adherence and Depression (CBT-AD)

Cognitive Behavioral Therapy for Adherence and Depression (CBT-AD) for adults with HIV, follows a modular approach that addresses both depression and ART adherence in each session.

Optimal Linkage and Referral (Active Referral Intervention)

Active Referral involves successful linkage of people with HIV to primary care as well as other services and supports. This may include newly diagnosed individuals, persons previously diagnosed who have never been linked to care, or persons who have fallen out of care and are being re-linked.

Patient Self Care Plans

A Patient Self Care Plan is a patient-centered planning technique that recognizes a patient’s own strengths, assets and networks as part of their overall care plan.

Staff Training on Motivational Interviewing Skills, Strategies and Tools

Motivational interviewing is a client-centered, directive therapeutic style to enhance readiness for change by helping clients explore and resolve am- bivalence. An evolution of Rogers’s person-centered counseling approach, Motivational Interviewing elicits the client’s own motivations for change.

Tele-Health to increase ART Adherence

There is emerging evidence (see Citations section) that telehealth with patients can help address several barriers to care, improve health outcomes and can help improve ART adherence. There is also evidence to recommend the addition of tele-mental health for patients with a mental health issue.

The Undetectables Program

A stepped approach to ART adherence for people with HIV who have mental health issues, substance use issues and/or are experiencing homelessness.

Training on Continuous Improvement

Organizational leaders frequently make bold statements about their commitment to quality and its components (e.g., safety, efficiency, effectiveness, value and listening to their customer). However, the real test of whether an organization is making quality improvement its north star is how well it has prepared its leaders and staff to apply quality concepts, methods and tools to daily work. Building capacity and capability for continuous improvement, therefore, is a fundamental building block of this journey. In addition, not all aspects of a clinic’s work will have a specific evidence-based or evidence-informed practice to implement. By training clinic staff on how to improve any process, program, or system, they will have a way to systematically improve outcomes related to viral suppression, even in the absence of an evidence-based intervention.

Trauma Informed Approaches Improving Care for People with HIV

According to NASTAD’s Trauma-Informed Approaches Toolkit (see link below), being trauma-informed is an approach to administering services in HIV care that acknowledges that traumas may have occurred or may be active in clients’ lives, and that those traumas can manifest physically, mentally, and/or behaviorally.

Uber Health (or similar) Transportation Services

A number of studies5 have demonstrated that the lack of access to transportation has been consistently associated with sub-optimal ART adherence. Uber Health and similar medical transportation services can be an effective strategy for patients experiencing transportation barriers.

Download All Age - Core Interventions

Case Conferencing to Support ART Adherence

Case conferencing allows a multi-disciplinary team to review patients (either select patients or all patients), understand their challenges and assets, and develop customized strategies to stay in ongoing HIV care and improve viral suppression rates.

Collaborative Care Model

The integration of physical and mental health care is an important component in effective patient care for patients with co-morbid conditions. The Collaborative Care Model offers an evidence-based approach to integration in which primary care providers, care managers, and psychiatric consultants work together to provide care and monitor patients’ progress.

Optimal Linkage and Referral (Active Referral Intervention)

Active Referral involves successful linkage of people with HIV to primary care as well as other services and supports. This may include newly diagnosed individuals, persons previously diagnosed who have never been linked to care, or persons who have fallen out of care and are being re-linked.

Patient Self Care Plans

A Patient Self Care Plan is a patient-centered planning technique that recognizes a patient’s own strengths, assets and networks as part of their overall care plan.

Staff Training on Motivational Interviewing Skills, Strategies and Tools

Motivational interviewing is a client-centered, directive therapeutic style to enhance readiness for change by helping clients explore and resolve ambivalence. An evolution of Rogers's person-centered counseling approach, Motivational Interviewing elicits the client’s own motivations for change.

Tele-health to Increase ART Adherence

There is emerging evidence (see Citations section) that telehealth with patients can help address several barriers to care, improve health outcomes and can help improve ART adherence. There is also evidence to recommend the addition of tele-mental health for patients with a mental health issue.

Uber Health (or Similar) Transportation Services

A number of studies have demonstrated that the lack of access to transportation has been consistently associated with sub-optimal ART adherence. Uber Health and similar medical transportation services can be an effective strategy for patients experiencing transportation barriers.

The Undetectables Program

A stepped approach to ART adherence for people with HIV who have mental health issues, substance use issues and/or are experiencing homelessness.

Training on Continuous Quality Improvement

Train clinic staff on how to improve any process, program, or system so that they have a way to systematically improve outcomes related to viral suppression, even in the absence of an evidence-based intervention.

U=U Education Initiatives

A person living with HIV continues to use ART as prescribed gets to undetectable they can no longer sexually transmit the virus to other people. This is called Undetectable = Untransmittable or U=U. Communicating this to patients can help motivate ART adherence, reduce stigma and improve their well-being.

Use of Peer Navigators

Peer navigator services are often useful for new patients, patients who have inconsistent engagement and patients who have disengaged. Various studies have documented the efficacy of peer navigators, particularly around engagement and re-engagement.

Waiting Room Milieu Manager

Using a Milieu Manager to manage the waiting area, welcome people, help manage the atmosphere of the waiting room, act as liaison between patient and clinic staff, and help people feel comfortable.

Download All Substance Use - Core Interventions

Case Conferencing to Support ART Adherence

Case conferencing allows a multi-disciplinary team to review patients (either select patients or all patients), understand their challenges and assets, and develop customized strategies to stay in ongoing HIV care and improve viral suppression rates.

Cognitive Behavioral Therapy for Adherence and Depression (CBT-AD) for Injection Drug Users

Cognitive Behavioral Therapy for Adherence and Depression (CBT-AD) for HIV-infected adults that are injection drug users follows a modular approach that addresses depression, injection drug use and ART adherence in each session.

Implement Harm Reduction Principles for Healthcare Settings

Harm reduction refers to interventions aimed at reducing the negative effects of health behaviors without necessarily extinguishing the problematic health behaviors completely. Harm reduction strategies within HIV clinics have been associated with better patient outcomes.

Low-Threshold Buprenorphine Treatment

Medication Assisted Treatment (MAT) using buprenorphine has been established as the gold standard in treating opioid use disorders. But to ensure that more patients can benefit from this treatment, clinics (and communities) need to implement low-threshold treatment.

Optimal Linkage and Referral (Active Referral Intervention)

Active Referral involves successful linkage of people with HIV to primary care as well as other services and supports. This may include newly diagnosed individuals, persons previously diagnosed who have never been linked to care, or persons who have fallen out of care and are being re-linked

Patient Navigator Model

This SPNS-tested model is a time-limited (generally 12 months) service delivery process that helps people with HIV obtain care. The focus is on those who are newly diagnosed as well as those vulnerable to loss to care. The model may be particularly useful to patients with substance use issues and who require more intensive supports.

Staff Training on Using Basic Motivational Interviewing Skills, Strategies and Tools

Motivational interviewing is a client-centered, directive therapeutic style to enhance readiness for change by helping clients explore and resolve am- bivalence. An evolution of Rogers’s person-centered counseling approach, Motivational Interviewing elicits the client’s own motivations for change.

The Undetectables Program

A stepped approach to ART adherence for people with HIV who have mental health issues, substance use issues and/or are experiencing homelessness.

Training on Continuous Improvement

Train clinic staff on how to improve any process, program, or system so that they have a way to systematically improve outcomes related to viral suppression, even in the absence of an evidence-based intervention.

Trauma-Informed Approaches: Improving Care for People with HIV

Being trauma-informed is an approach to administering services in HIV care that acknowledges that traumas may have occurred or may be active in clients’ lives, and that those traumas can manifest physically, mentally, and/or behaviorally.

Uber Health (or similar) Transportation Services

A number of studies have demonstrated that the lack of access to transportation has been consistently associated with sub-optimal ART adherence. Uber Health and similar medical transportation services can be an effective strategy for patients experiencing transportation barriers.

Use of Peer Navigators

Peer navigator services are often useful for new patients, patients who have inconsistent engagement and patients who have disengaged. Various studies have documented the efficacy of peer navigators, particularly around engagement and re-engagement.

Waiting Room Milieu Manager

Using a Milieu Manager to manage the waiting area, welcome people, help manage the atmosphere of the waiting room, act as liaison between patient and clinic staff, and help people feel comfortable.

Walk-In Availability and Open Access to Care

Walk-in availability of and open access to Ryan White HIV/AIDS Program-funded clinics allow clients to come for services at a time that is convenient for them and be seen by appropriate providers within a reasonable period during normal business hours.