Health eNav: Developing a System of Digital HIV Care Navigation in San Francisco
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Health eNavigation or Health eNav is an innovative HIV care navigation model being tested by the San Francisco Department of Public Health. This session will explain how Health eNav will utilize comprehensive digital navigation strategies including text-messaging, social media and geo-spatial platforms to meet youth where they are. Health eNav will also extend the system of tailored, personalized support outside traditional hours of operation. Health eNav harnesses the promise of mhealth within the world’s most complex public health department to develop a system of digital HIV care navigation. Health eNav is your digital companion to help guide you through important decisions, whenever, wherever and however you want it. Health eNav will also extend the system of tailored, personalized support outside traditional work hours. Connection is health. Health eNav is bringing connection to those who need it most to improve health outcomes to create and connect a healthier San Francisco.
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Health eNav: Developing a System of Digital HIV Care Navigation in San Francisco
- 1. Health eNav: Developing a System of Digital HIV Care Navigation Dillon Trujillo, Sean Arayasirikul, Erin Wilson San Francisco Department of Public Health
- 2. HIV Epidemic in San Francisco Focused epidemics among MSM and transwomen, particularly racial/ethnic minorities. In 2012-2013, there were 426 new HIV diagnoses. 414 (89%) were linked to care within 3 months of their diagnosis. 297 (64%) were retained in care for 3-6 months after linkage 236 (51%) were retained in care for 6-12 months after linkage 316 (68%) were virally suppressed within 12 months among all new diagnoses. **From 2009 to 2012, viral suppression within 12 months has improved; however, other steps in the continuum appear to be relatively poor.
- 3. Unmet Need among Youth and Young Adults in the HIV Care Continuum, 2012-13 There were 111 new diagnoses among youth ages 13-24 years old and 309 new diagnoses among young adults ages 25-34. 83% of youth ages 13-24 and 89% of young adults ages 25-34 are linked to care within three months of their initial diagnosis 57% of 13-24 year olds and 66% of 25-34 years olds are retained in care 3-6 months after linkage. Retention continues to diminish where 41% of 13-24 year olds and 51% of 25-34 years olds are retained in care 6-12 months after linkage to care . Only 63% of 13-24 year olds and 69% of 25-34 years olds are virally suppressed 12 months after linkage to care.
- 4. Conceptual Framework The Patient-Centered Medical Home (PCMH) Model A care team approach to provide patient-focused and culturally relevant services; strong provider/patient relationships; the elimination of barriers to care; and increased efficiency and quality of care. The Chronic Care Model (CCM) High quality chronic care, care coordination, ongoing quality improvement, linkage to community resources, and the use of individual and group interventions that empower patients to take an active role in their health. Health eNav also leverages community health worker (CHW) and peer navigation approaches to foster continuous relationships.
- 5. Health eNav Overview Health eNav will develop and implement a digital HIV care navigation system to complement traditional HIV care navigation services in San Francisco. Our Digital HIV care navigation intervention is comprised of four main components:
- 6. Health eNav Overview Health eNav will develop and implement a digital HIV care navigation system to complement traditional HIV care navigation services in San Francisco. Our Digital HIV care navigation intervention is comprised of four main components: Digital Care Circle
- 7. Health eNav Overview Health eNav will develop and implement a digital HIV care navigation system to complement traditional HIV care navigation services in San Francisco. Our Digital HIV care navigation intervention is comprised of four main components: 7 days a week Daily Surveys
- 8. Health eNav Overview Health eNav will develop and implement a digital HIV care navigation system to complement traditional HIV care navigation services in San Francisco. Our Digital HIV care navigation intervention is comprised of four main components: X 90 days Daily Surveys
- 9. Health eNav Overview Health eNav will develop and implement a digital HIV care navigation system to complement traditional HIV care navigation services in San Francisco. Our Digital HIV care navigation intervention is comprised of four main components: X 90 days Daily Surveys
- 10. Health eNav Overview Health eNav will develop and implement a digital HIV care navigation system to complement traditional HIV care navigation services in San Francisco. Our Digital HIV care navigation intervention is comprised of four main components: Barriers to Care Daily Surveys Digital Navigation
- 11. Health eNav Intervention Components Digital Care Circle Barriers to Care Daily Surveys Digital Navigation
- 12. Target Population We are enrolling 120 youth and young adult MSM and transwomen (aged 18-34). Inclusion criteria for the target population include: newly diagnosed, out of care status, or not virally suppressed youth and young adult aged 13-34 identify as MSM or transwomen We recruited our first participant on January 5th, 2017. After 14 weeks of recruitment, we have enrolled 48 participants. 40 are MSM and 8 are transwomen of color
- 13. Access to information, referrals Treatment advocacy Motivational interviewing Longer-term follow-up Asynchronous navigation Asynchronous social support Digital Navigation Access to a phone, digital navigation Digital Navigation Components
- 14. EMA: Mood and Mental Health (5 items) EMA: Substance Use (6 items) EMA: Substance Use x Sex (6 items) EMI Reminders: Treatment Adherence (3 items) EMA: Sexual Risk Behavior (3 items) Daily EMA/EMI SMS Survey Domains 90-day Ecological Momentary Assessments and Interventions
- 15. Intervention Outcomes HIV CARE CONTINUUM HIV TEST/ DIAGNOSIS VIRAL SUPPRESSION LINKED TO CARE RETAINED & ENGAGED IN CARE ACCESSING TREATMENT +% +% +% +%
- 16. Digital Navigation to Address Barriers to Care Digital Navigator Poor Adherence Support Medical Mistrust and Negative Experiences Lack of personalized engagement Lack of access to HIV Care Increased stigma Helplessness and Lack of Knowledge Social Isolation
- 17. Digital Navigation to Address Barriers to Care Digital Navigator Poor Adherence Support Medical Mistrust and Negative Experiences Lack of personalized engagement Lack of access to HIV Care Increased stigma Helplessness and Lack of Knowledge
- 18. Digital Navigation to Address Barriers to Care Digital Navigator Poor Adherence Support Medical Mistrust and Negative Experiences Lack of personalized engagement Lack of access to HIV Care Increased stigma Helplessness and Lack of Knowledge Social Support 24/7*
- 19. Digital Navigation to Address Barriers to Care Digital Navigator Poor Adherence Support Medical Mistrust and Negative Experiences Lack of access to HIV Care Increased stigma Helplessness and Lack of Knowledge Social Support 24/7*
- 20. Digital Navigation to Address Barriers to Care Digital Navigator Poor Adherence Support Medical Mistrust and Negative Experiences Personalized engagement Lack of access to HIV Care Increased stigma Helplessness and Lack of Knowledge Social Support 24/7*
- 21. Digital Navigation to Address Barriers to Care Digital Navigator Poor Adherence Support Medical Mistrust and Negative Experiences Personalized engagement Lack of access to HIV Care Helplessness and Lack of Knowledge Social Support 24/7*
- 22. Digital Navigation to Address Barriers to Care Digital Navigator Poor Adherence Support Medical Mistrust and Negative Experiences Personalized engagement Lack of access to HIV Care Decreased Stigma Helplessness and Lack of Knowledge Social Support 24/7*
- 23. Digital Navigation to Address Barriers to Care Digital Navigator Poor Adherence Support Medical Mistrust and Negative Experiences Personalized engagement Lack of access to HIV Care Decreased Stigma Social Support 24/7*
- 24. Digital Navigation to Address Barriers to Care Digital Navigator Poor Adherence Support Medical Mistrust and Negative Experiences Personalized engagement Lack of access to HIV Care Decreased Stigma Knowledge and Empowerment Social Support 24/7*
- 25. Digital Navigation to Address Barriers to Care Digital Navigator Poor Adherence Support Medical Mistrust and Negative Experiences Personalized engagement Decreased Stigma Knowledge and Empowerment Social Support 24/7*
- 26. Digital Navigation to Address Barriers to Care Digital Navigator Poor Adherence Support Medical Mistrust and Negative Experiences Personalized engagement Access to HIV Care Decreased Stigma Knowledge and Empowerment Social Support 24/7*
- 27. Digital Navigation to Address Barriers to Care Digital Navigator Medical Mistrust and Negative Experiences Personalized engagement Access to HIV Care Decreased Stigma Knowledge and Empowerment Social Support 24/7*
- 28. Digital Navigation to Address Barriers to Care Digital Navigator Daily Adherence Reminders Medical Mistrust and Negative Experiences Personalized engagement Access to HIV Care Decreased Stigma Knowledge and Empowerment Social Support 24/7*
- 29. Digital Navigation to Address Barriers to Care Digital Navigator Daily Adherence Reminders Personalized engagement Access to HIV Care Decreased Stigma Knowledge and Empowerment Social Support 24/7*
- 30. Digital Navigation to Address Barriers to Care Digital Navigator Daily Adherence Reminders Trust and Positive Experiences w/ HIV care Personalized engagement Access to HIV Care Decreased Stigma Knowledge and Empowerment Social Support 24/7*
- 31. Approach to outreach and recruitment strategies SF DPH HIV testing Sites SF DPH System Navigation Data to Care Initiative Community System Navigation Web and social media presence to reach NIC patients Digital Navigator will be mobile for in person enrollments! Digital Navigation will utilize a non- traditional work schedule and asynchronous communication
- 32. Sample Snapshot (n=48) Acuity Eligibility High Low Newly Diagnosed Out-of- Care Not virally Suppresse d Mobile Phones 42% (20) 58% (28) 25% (12) 63% (30) 53% (25) 31% (15) 7 participants have been closed out of digital navigation for non-response 1 participant passed during their first month enrolled While we have provided 15 participants with mobile phone access, about half (n=8) have lost their phone. Some of these participants have been closed out of digital navigation and few have replaced their phones on their own.
- 33. Case Study and Lessons Learned Cece, 32 yo Black Trans woman Matthew, 25 yo White MSM
- 34. Challenges - Technology AWS outage in February
- 35. Challenges - Technology Service outages
- 36. Challenges - Technology Human error
- 37. Thank you!!! Collaborators and Partners Participants Co-authors: Sean Arayasirikul and Erin Wilson YTH!
- 38. Contact Information DillonTrujillo E: Dillon.Trujillo@sfdph.org P: 415-243-6956 Erin Wilson E: Erin.Wilson@sfdph.org P: 415-554-9061 Sean Arayasirikul E: Sean.Arayasirikul@gmail.com P: 415-554-9036 Center for Public Health Research San Francisco Department of Public Health
Editor's Notes
- Intervention Component 1: Provide short-term mobile phone access – free mobile phone and 1 year of service (unlimited SMS text messaging and phone service).
- Intervention Component 2: Create a Digital Care Circle - Deliver asynchronous, non-traditional digital navigation through text messaging [Digital care circle]
- Intervention Component 2: Create Digital Sensing Power - Collecting ecological momentary assessment (EMA) data and integrating that into the digital navigation system in real-time
- Intervention Component 2: Create Digital Sensing Power - Collecting ecological momentary assessment (EMA) data and integrating that into the digital navigation system in real-time
- Intervention Component 2: Create Digital Sensing Power - Collecting ecological momentary assessment (EMA) data and integrating that into the digital navigation system in real-time
- Intervention Component 2: Create Digital Sensing Power - Collecting ecological momentary assessment (EMA) data and integrating that into the digital navigation system in real-time Digital Sensing EMA modules - SMS short surveys - will be delivered participants to sense and detect early indicators of barriers and facilitators along the HIV care continuum. These data will then be applied to facilitate personalized referrals, prompt digital care circle discussions, and inform our understanding of early predictors in the HIV care continuum.
- Health eNav aims to improve outcomes along the HIV care continuum, specifically, increasing the % of those: 1) linked to care within 30 days of diagnosis or re-engagement; 2) engaged and retained in care at 6 and 12 months from diagnosis or re-engagement; and 3) who are virally suppressed at 12 months from diagnosis or re-engagement.
- Description: Client 3004 and DT were texting on 3/2/17. During text message session, client indicated their HIV medications were stolen. Client saw doctor about 2 weeks ago and is currently out of town visiting family in LA. Will not be back in San Francisco for about a month. DT suggested to client to call her primary care and see what the options were to get more meds. Client left a message with PCP. DT called a medical case manager at API and they directed DT to her provider at TWUHC. DT left a message with client’s PCP. DT followed up with client via phone call and client said their PCP called them back and was able to refill her meds and send them to Walgreens in LA. Client told DT they would pick up HIV medications sometime today 3/3/17. 3/16/17: Matthew initiated conversation with DT during his time sitting in a doctor’s waiting room before HIV care appointment. Matthew mentioned they experience trauma with doctor offices and sitting in the waiting room was a very triggering experience for client. DT provided emotional support to client during their wait time. DT used motivational interviewing and affirmations to support client through this experience.