HIV substance abusers encouraged to use new case management program
Study shows program works
A strengths-based case management program for HIV-positive patients who are active substance abusers appears to have some success in directing such patients to HIV care and treatment, according to recent research.
For about 15 years, Ohio behavioral scientists have used a strengths-based case management model with substance abusers, having case managers meet with them over a nine month period with the purpose of improving their health care outcomes.
"What we found in summary is, indeed, case management did lead to better outcomes, including less involvement in criminal activity and lower levels of drug use," says Richard C. Rapp, MSW, assistant professor in the department of community health at School of Medicine, Wright State University in Dayton, OH. Rapp also is with the Center for Interventions, Treatment and Addictions Research (CITAR) in Dayton.
"Case management seemed to help keep people in treatment, and longer treatment led to better outcomes," Rapp says. "So that's our rallying cry for case management."
With encouragement from the Centers for Disease Control and Prevention (CDC) of Atlanta, GA, Rapp and co-investigators developed a model of strengths-based case management that was studied in the antiretroviral treatment and access study (ARTAS), which ran from 2003 to 2004.
What had been a nine-month case management program was condensed to five sessions with the case managers’ entire focus and goal being to link HIV patients to care, Rapp explains.
"Originally, the program was a source of ongoing support to individuals with substance abuse problems," Rapp says. "We went into this one with a very specific intent, and we told clients up front that it was our hope they'd get involved with health care services."
The idea is that the case managers can help them deal with any barriers they encounter, including referring clients to mental health services or drug treatment programs if necessary, he says.
While most of the patients involved in case management care in Dayton were HIV negative, the pilot studies focused on HIV infected substance abusers, Rapp notes.
The ARTAS trial had promising results, so the CDC has decided to expand it to make a demonstration project in 10 cities, and it will conclude late next year, Rapp says.
"We're recruiting 50 people at each of 10 sites, and their primary characteristic is being newly diagnosed with HIV," Rapp says. "Some are substance users, some are homeless, and some are people with alternative lifestyles."
Ideally, the demonstration project will confirm the positive results already seen and convince the CDC to build case management into the HIV continuum of care, Rapp says.
"Forty percent of the people who are HIV positive don't access health care within six months," Rapp says. "And there are huge implications at all levels for this, including people passing the virus to others, declining health, and having a disease that's more expensive to treat at a later time."
The faster HIV patients can be brought into case management, the better, he says.
"It's always ironic that what seems like a simple task of linking someone to care can have an amazing set of barriers," Rapp says.
"For a lot of people we work with it's not a straightforward process," Rapp adds. "If they're homeless, have no transportation, if there are waiting lists, people become exasperated and give up."
So that's what the case management model is about: having a skilled professional develop a relationship with the client and facilitate their linking to medical care, Rapp explains.
The demonstration project works this way: A person has been diagnosed with HIV in a health department clinic is told about this project, and if they're interested they are referred to one of the project case managers to see very quickly, Rapp says.
The case manager explains the program to the client and sees whether the person remains interested. If so, the client will schedule a first meeting and meet again up to five times, he adds.
Here is a breakdown of what happens at each session:
• First session: "The case manager gives clients a chance to talk about their feelings about being HIV positive in one-on-one sessions," Rapp says. "The case manager will focus very deliberately on the client's strengths and help clients identify times and situations where they've been successful."
Case managers focus on clients' assets and help them use these to take a first step in accessing care, Rapp says.
"Strength-based case management is used to engage people in talking about strengths and helps people move to that first step," he adds.
• Second session: "This is much more focused on strengths and helping clients identify what their most immediate barriers are," Rapp says.
The case manager helps clients develop a written plan to address barriers.
"We again make the assumption that many of the people we work with are living disorganized lifestyles, and we'll commit everything to writing when developing a plan about how the individual will deal with those barriers," Rapp says. "So if the barrier is 'I can't go to care because I haven't told my partner I'm positive,' then they develop a plan for how they can tell their partner or link to care without telling their partner."
Another barrier that the case manager could help the client overcome would be the lack of transportation. The case manager could arrange for the client to take public transportation or drive the client to the health care center, if necessary, Rapp says.
"Some case managers have taken pictures of the clinic and shown them to clients, saying, 'You'll walk down here and walk down this hall and talk with Nancy the intake nurse,'" Rapp explains. "They make it as easy as possible for the client to follow through."
• Third, fourth, fifth sessions: The case manager continues to look at barriers and helps the patient make a plan to deal with barriers and successfully link to care, Rapp says.
The written plans, called contact plans, are reviewed and updated with changes or additions, and these have turned out to be one of the most popular aspects of the case management sessions, Rapp notes.
"In follow-up interviews, we've heard how clients responded so positively to these written plans," he says. "That's always my bias to write it down and make sure the client has a copy of it."
Having a plan in writing gives clients a sense of order in what frequently is a disorganized life, Rapp explains.
"Many people in crisis don't think clearly or retain information very well, so this plan gives them the steps to follow," he says. "It will read: 'I talk with the case manager; here's what he does; here's what I'm supposed to do; here's my target date for handling that.'"
It serves as a gentle reminder, Rapp says.
Also, if the plan is revised because one strategy didn't work out, the case manager will explain that the change doesn't indicate a failure, but occurred simply because something was note anticipated, and now they must prepare for that, Rapp says.
"There's a cheerleading component to it," Rapp says. "We focus on strengths, and whatever goals the client sets are their own goals and not the case manager's."
At each meeting, the case manager is reminding the client that the meetings soon will come to an end, and that also might help motivate people to take the steps necessary to accomplish their goal, Rapp notes.
"At the last session, the goal is to have the patient walk out with a bundle of information so if the client decides to link with health care, the tools are there," Rapp says.
During the clinical trial, 78 percent of the people in case management visited an HIV clinician at least once in six months, while 60 percent of standard of care clients linked with an HIV clinician within six months.1
As a result of the program, some sites came up with system changes that helped to reduce barriers. For instance, one clinic would provide buffet food and child care for clients, taking care of the issue of finding a place to leave one's child while making an appointment, as well as acknowledging the reality that finding the next meal can be a financial issue for some clients, Rapp says.
"It's pretty minimal when compared with having someone who is untreated with HIV infection and then develops AIDS," Rapp adds.
Reference:
- Rapp RC, et al. Strengths-Based Case Management: Implementation of an Effective Intervention for Encouraging Health Care Linkage Among Newly-Diagnosed HIV-Positive Persons. Presented at the 2005 National HIV Prevention Conference, June 12-15, 2005; Abstract: M3-F0404.
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