Thursday, June 27, 2013

Insurance issues as a barrier to HIV care: using a newsletter to raise awareness

By Kathleen Xu, MPH & Ranjani Paradise, PhD 

“Take the test. Take control.” – National HIV Testing Day slogan

In honor of National HIV Testing Day, we are sharing our experience working with Cambridge Health Alliance’s (CHA) two HIV clinics, The Zinberg Clinic and Somerville Hospital Primary Care, on a Continuous Quality Improvement (CQI) Team. Our team consists of a nurse manager, a social work manager, a nurse practitioner, a community health worker, a program support director, and three Institute for Community Health (ICH) staff members. We meet regularly to track quality measures and strategize how to help the HIV clinics sustain high quality services. One of the issues we have been tracking is the relationship between health insurance coverage and access to care for HIV patients. Insurance policy changes and gaps in coverage impact patients’ ability to maintain ongoing HIV treatment, which is extremely important for reducing HIV viral load and minimizing HIV drug resistance. With 63% of CHA’s HIV patients on public insurance, and a large proportion of them affected by unstable housing and employment situations, their insurance coverage often fluctuates. Therefore, the CQI team has made an effort to better understand the main insurance issues and ongoing policy changes that most affect these patients, so that CHA providers can better support patients through the process.

Over the past few months, our CQI team gathered information and feedback from the two clinics’ case managers about challenges they have experienced with insurance policy changes when trying to maintain coverage for their patients. We learned that as a result of many policy changes over the last 4 years, including those that resulted from the Massachusetts health care reform, the time it took case managers to ensure each patient received adequate coverage quadrupled.  Much of the added time was attributed to extra paperwork and delays in insurers’ response time.

One particular challenge case managers and patients have faced in recent years is stricter proof of residency requirements. Since many of CHA’s HIV patients are of low socioeconomic status and have unstable living situations, they often do not have the documents required to prove MA residency (e.g., mortgage papers, utility bills, leases). As a result of this policy change, patients experience unexpected coverage termination and coverage gaps. Case managers must continuously monitor patients’ social and living statuses on a month-to-month basis, as any income, dependency, address or job status changes could disqualify patients for some insurance policies. In such cases, case managers must help patients identify and apply for a new insurance policy depending on the status change and also help them determine which pharmacies accept the new insurance.

Overall, obtaining insurance has become a time-consuming and complicated process for patients and case managers. CHA is fortunate to have dedicated case managers to help patients navigate the complex insurance system, as well as providers who also work hard to keep patients in care and adhering to their medication regimens, even when faced with these insurance barriers.

In order to support our case managers, providers, and patients, the CQI team focused the April 2013 issue of our newsletter, Facts for Action, on insurance and HIV. This newsletter was disseminated to all staff and patients in order to raise awareness about the effects of insurance issues on HIV care.

The first page displays a timeline and comprehensive list of insurance issues that case managers have been working hard to overcome, while the second page includes a list of recommendations for providers and patients about how they can work together with their case managers to avoid insurance issues. Especially in the multidisciplinary setting of CHA’s HIV clinics, the newsletter served as an important reminder for all staff to collaborate as a team and communicate with each other and their patients to provide the best care for their patients.

National HIV Testing Day is an important annual event promoting HIV testing and encouraging all people to learn their HIV status. Getting tested is only the first step to managing HIV. As we reflect on our work with the CQI team, we are reminded that in addition to encouraging testing, we must ensure that those tested positive have access to the medical care that they need.

Special thanks to the HIV Continuous Quality Improvement (CQI) team and the CHA HIV clinics' case management staff for their help in compiling the Facts For Action newsletter!

The views expressed on the Institute for Community Health blog page are solely those of the blog post author(s), and do not necessarily reflect the views of ICH, the author’s employer or other organizations with which the author is associated.

Friday, June 14, 2013

Making Data Useful, Making Data Meaningful: Participatory Evaluation in the Youth First initiative

By Jeff Desmarais, MA, Maeve Conlin, MPH, Nazmim Bhuiya, MPH

May was teen pregnancy prevention month, which is a chance to highlight the Institute for Community Health’s (ICH) partnership focusing on teen pregnancy prevention. Massachusetts has made great strides in reducing the teen birth rate in the past decade, as evidenced by 2010 community-level teen birth rate data recently released by the Massachusetts Department of Public Health. In 2010, Massachusetts teen birth rate was 17.1 per 1,000 adolescent females aged 15-19, the lowest birthrate on record, continuing the state’s downward trend. While progress has been made, strong racial and geographic disparities in teen birth rates persist among Massachusetts’ communities. These disparities must be addressed through collaborative, multilevel efforts, such as Youth First, an initiative that aims to reduce the teen birth rate in Springfield and Holyoke, two communities with some of the highest teen birth rates in Massachusetts. In 2010, Holyoke had the highest teen birth rate in the state and Springfield had the third highest.

Youth First, a 5-year CDC-funded initiative, seeks to address teen birth rate disparities through a community-wide collaborative approach to enhance access to quality sexual health education and reproductive health services. This collaboration involves the lead organizations, Massachusetts Alliance on Teen Pregnancy (MATP) and the Youth Empowerment and Adolescent Health (YEAH!) Network, as well as a host of Springfield and Holyoke-based clinical and community partners. These partners aim to mobilize the community, empower youth through engagement and enhance the quality of clinical and health education services for sexual and reproductive health.

Working in partnership as the evaluator for this initiative, ICH’s role is to facilitate data collection and help our partners utilize this data to drive program improvements and decisions. Since ICH utilizes a participatory research approach to guide the evaluation process, we are simultaneously building our partners’ capacity to collect, analyze, and interpret data for their current and future work. This data allows our partners to think about their programs’ impact—to see how their hard work is making a difference in the lives of the youth they serve and the community more broadly—and informs their services in the future.

As we reflect on this important partnership and the value it brings to the health of populations, we have several critical lessons to share as evaluators:

First, in order for data to be useful for our community partners, it must be meaningful to them. As an evaluator, you can’t assume that all partners will have an understanding of how to interpret and use data to improve their communities. Building an understanding of what data actually tells us and how it can be used to inform programs’ strengths, gaps, needs, and target populations is an important step in any partnership. Having these conversations early on in the collaboration will help you identify which capacities must be improved so that data can be collected and used effectively.

Additionally, as evaluators we must help build communities’ data collection infrastructure to enable partners to collect and use data independently, so that teen pregnancy prevention efforts can be continuously improved and sustained even after grant funding ends. With a strong data collection system in place, the partners can better understand and improve their programs and in turn, their communities.

The Youth First initiative’s multifaceted approach to teen pregnancy prevention is what makes the program distinctive. Our work as evaluators is a small but very important piece of the initiative. Erica Fletcher, Prevention Director at MATP, describes our strong partnership as a unique project element and states that ICH has been instrumental to the initiative’s planning, implementation, and ongoing quality improvement efforts. Given that May was teen pregnancy prevention month, it is an opportune time to highlight strategies and share tips with other evaluators aiming to reduce teen pregnancy.  Strong partnerships with the community and a participatory evaluation approach are key steps towards recognizing opportunities to address social, behavioral and environmental factors that impact teen pregnancy.

Special thanks to Shalini Tendulkar, ScD, ScM, and Jessica Waggett, MPH at ICH and Erica Fletcher, Ed.M. Prevention Director at the Massachusetts Alliance on Teen Pregnancy for their support and guidance. 
The views expressed on the Institute for Community Health blog page are solely those of the blog post author(s), and do not necessarily reflect the views of ICH, the author’s employer or other organizations with which the author is associated.