Integration of Comprehensive HIV Medical Care with Addiction Services

The Cooper Health System’s Early Intervention Program Expanded Care Center (CEEC) has integrated comprehensive HIV medical care with addiction services and medication protocols for substance use disorder (SUD), as a treatment model for people with HIV. CEEC provides a “one-stop shop” for HIV primary care, wraparound services, and addiction medicine services. For clients with HIV and SUD, both retention in care and viral suppression increased.

Camden, NJ

Emerging Intervention
Clinical service delivery model
Retention in HIV medical care; Viral suppression
Treat
People who inject drugs (PWID)
RWHAP Part A; RWHAP Part C
Hospital or hospital-based clinic
Need Addressed

New HIV infections related to substance use disorder are increasing due to the opioid epidemic in Southern New Jersey. CEEC identified an outbreak of new HIV infections among persons who use substances, but had many challenges linking people with HIV and SUD to external agencies that offered addiction treatment. CEEC sought to improve access to addiction medicine services by integrating these services within their existing HIV program, with the goal also to improve rates of viral suppression and retention in care.

Core Elements
Integrated HIV program design using the Chronic Care Model and addiction medicine services

Following the Chronic Care Model, CEEC providers connect their patients to multiple services including addiction medicine at one location, for a "one-stop shop" approach to care. Services provided by the multidisciplinary team include:

  • Full patient-centered wraparound services from reception to clinical care to support care
  • HIV primary care provided by board certified physicians in internal medicine and infectious diseases with onsite phlebotomy services
  • A range of mental health and addiction medicine services

The mental health and addiction medicine services available at CEEC include:

  • Weekly to biweekly appointments with addiction medicine board certified physicians
  • Prescription of medication for OUD (MOUD)
  • Medication Therapy Management provided by clinical pharmacists
  • Licensed Certified Alcohol and Drug Counselor (LCADC) providing individual counseling  and group therapy sessions 
  • Behavioral Health Clinical Psychologists available daily for assessments and psychotherapy
  • Medical Case Managers providing case management services and treatment adherence counseling
  • Non-Medical Case Management services for housing, transportation, emergency financial assistance, food, urgent medications and linkage to subspecialty care
  • Clinical Outreach Navigation that includes transitional care coordination from jail to community medical care
  • Chronic disease self-management and nutrition workshops for patient education
Multidisciplinary staffing structure

The following staffing model supports the strategy:

  • Addiction Medicine Physician: 0.20 FTE
  • Licensed Certified Addiction Counselor: 1.0 FTE
  • Case Manager: 1.0 FTE
  • Data Analyst: 0.20 FTE
  • Administrator: 0.10 FTE
  • HIV Primary Care Physician: 1.0 FTE
  • Outreach Navigator: 1.0 FTE
Health system-wide opt-out HIV and HCV screening

In January 2018, there was a change in Cooper Health System’s protocols to include "opt-out" HIV and HCV screening for their hospital and physician practice locations. The electronic health record enhancements included best practice alerts prompting HIV and HCV screening. This led to the increased detection of new HIV infections among persons with SUD who inject drugs and people with HIV and SUD lost to care. CEEC Clinical Outreach Navigators facilitated direct connection to CEEC HIV care services.

Data-driven quality improvement

Rates of viral suppression and retention in care were continuously monitored for people with HIV and SUD. The quality improvement team includes CEEC directors, clinic nurses, outreach navigators, case managers, physicians, advanced practice nurses, licensed certified addiction counselor, clinical psychologist, a quality supervisor, data specialist, and data analyst.

“It can be hard to get primary care providers to want to do more than basic primary care and wanting to refer out. And then you have specialists that don't want to do primary care, so medical care can be very siloed. The model that we have, where we have integrated so many services, is very patient focused.”

Outcomes

Over a three-year period from 2017 to 2019, CEEC enrolled an increasing number of people with HIV and SUD in addiction medicine services. By the end of 2019, 83 patients were enrolled, an increase from six in 2017.

Category Information
Evaluation data Electronic health record data identifying people with HIV and SUD imported into CAREWare for evaluation of viral  suppression and retention in care
Measures Viral suppression, retention in care, enrollment in addiction medicine services
Results

For all clients with HIV and SUD:

  • Viral suppression increased from 61.5% (24/39) in 2018 to 72.2% (39/54) in 2019.
  • Retention in care increased from 33.0% (3/9) in 2017 to 38.4% (15/39) in 2018 to 79.6% (43/54) in 2019.

For a cohort of forty clients who have been receiving HIV primary care at CEEC prior to the introduction of addiction services in 2017, 77.5% had suppressed viral loads at the end of 2019.

  • 17 clients (42.5%) maintained viral suppression from 2017 to 2019.
  • 14 clients (35.0%) reached viral suppression.
  • 2 clients (5.0%) who had suppressed viral loads returned to a non-suppressed viral load.
  • 7 clients (17.5%) had no change in viral suppression from 2017–2019.
Planning & Implementation
  • The CEEC program built upon Cooper Health System’s well-established processes for HIV testing and care coordination/navigation.
  • The CEEC strengthened collaboration with Cooper Health hospital programs. Emergency Department physicians are now routinely conducting HIV testing, may prescribe MOUD, and often bridge the connection to HIV and SUD care at CEEC.  Hospitalists work collaboratively with the addiction medicine consult service and infectious diseases consult service to assure integrated outpatient care for patients upon discharge.
  • Ongoing staff training is provided, and primary care providers are supported in obtaining a DATA waiver to allow them to prescribe MOUD.
  • A staffing model was established that ensured that the CEEC multidisciplinary team is available full time during clinic hours.
  • Additional resources were sought and partnerships established to address urgent medication, food, transportation, and housing needs of patients with HIV and SUD.
Sustainability
  • The program is funded through third party payer reimbursements such as Medicare, Medicaid and private insurances (program income), Ryan White HIV/AIDS Program (RWHAP) Parts A and C, and 340B pharmacy services program income.
  • The CEEC clinic was renovated in 2017, which contributes to program success by improving care coordination and collaboration. The renovated provider office design groups physicians, nurses, clinical pharmacists, psychologists, and counselors side by side facilitating integrated and multidisciplinary care and treatment. The open office space provides a forum and opportunity for multispecialty provider education.
  • The CEEC clinic office design includes work stations and hybrid exam rooms for individual counseling, case management services, and HIV counseling and testing. 
  • Maintaining partnerships with community-based agencies, social services, mental health and addiction treatment services is essential for making referrals when more intensive services are needed and to ensure people with HIV and SUD are connected to HIV care and treatment.
Lessons Learned
  • The stigma associated with addiction is difficult to overcome even among providers. Addressing internalized stigma is a challenge and ongoing staff education is important.
  • Introduce the tools and resources to staff prior to implementation.
  • CEEC had to develop a ‘disruptive patient’ policy, and establish a patient agreement process to minimize inappropriate behaviors in the clinic.
  • Providing integrated HIV and addiction medicine services has been the most successful approach for treatment and support of people with HIV and OUD.

“The opposite of addiction is connection. The pandemic has just made things so much more difficult. And we can't terminate our connection. We have to be available. We have to be ready when they're ready, and to be able to help them navigate the path to their recovery.”

Resources & Tools
  • The Effect of Addiction Services on Viral Load Suppression in People With HIV with Substance Use Disorder (see video below)

Contact the Innovator
Cooper Health System Early Intervention Program
Pamela Gorman, RN, ACRN
Administrative Director

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