Update from San Ysidro Health Center Jeannette L. Aldous, MD October 14, 2016 UCSD HIV & Global Health Rounds

2. AIDS ROUNDS
Update from SanYsidro Health Center
October, 2016
Jeannette L. Aldous, MD
Clinical Director of
Infectious Disease
San Ysidro Health Center

3. Outline
Part 1:
“Community HIV Medicine at the San Diego-
Tijuana Border”
Part 2:
“Workforce of the Future: Educating Primary
Care Residents through an FQHC-based
Community HIV Medicine Rotation”
2

4. Community HIV Medicine at the
San Diego-Tijuana Border
3

5. 4SYHC roots in the community
Founded 1969 -
Local Women’s Organization
“Founding Mothers”
Casita – First Clinic Site

6. SYHC is now a Federally Qualified Health Center (FQHC)
providing comprehensive primary care services and family support
programs to more than 89,000 registered patients residing in the
South and Central/Southeastern Regions of San Diego County
annually. SYHC’s patient population profile is predominately Latino
with high rates of poverty, uninsured individuals and families, low
education levels, and non-English speaking heads of households.
5
SYHCToday
The Mission of San Ysidro Health Center is to
improve the health and well being of our
community’s traditionally underserved and
culturally diverse people.

7. 6
Our Community: SYHC Patient Demographics
2015
 Total patients: 89,662
◦ 39% 0-19 yrs
◦ 52% 20-64
◦ 9% 65 & over
 Demographics: 83% Latino, 5% AA, 4% API, 8%White
 Income: 91% of SYHC patients live at or below 200% of FPL
 Insurance:
◦ 31% Uninsured
◦ 57% Medi-Cal
◦ 8% Medicare
◦ 4% Private (mostly Covered California)

9. SYHC Services Overview
8
Behavioral
Health
Mobile
Clinics (2)
WIC
(5 Sites)
Primary Care
(10 Sites)
Maternal
Child Health
Center
Oral Health
(4 Sites)
OB-GYN
Pharmacy (2)
ADHC
PACE
School Based
Clinics (3)
HIV/AIDS (2)
Mi Clínica
Embedded Family Medicine Residency Program focused on
Community Medicine

10. SYHC HIV Coordinated Services

11. History
 1990s South Bay AIDS Project - HIV Case Management
Services in the South Bay area
 1999 HIV Specialty Care integrated at SanYsidro Health
Center – once a week for 4 hours
 2001 UCSD Owen Clinic and SYHC collaborate to
provide full-time HIV Medical Specialists at SanYsidro
Health Center
 2008, SYHC acquired Comprehensive Health Centers
including 2 HIV clinics (Elm St. & Euclid St.)
 HIV Department currently has 50 staff members and
multiple programs across Southern San Diego County
 Only HIV specialty program in the South Bay
10

12. SYHC HIV Coordinated Services
Mission: To provide a continuum of
culturally sensitive medical, social and
supportive services free of charge that
enhance the health and enrich the quality
of life of people living with HIV/AIDS and
their families

13. Medical
Research
Prevention
Outreach and
Testing
Case
Management
Training
SYHC HIV Services Department Overview

14. SOUTHEAST:
• 350+ HIV patients
• Ethnically diverse
• Our Place drop in center
SOUTH BAY:
• 650+ HIV+ patients
• Latino population
• CASA drop in center

15. SYHC HIV Services Department
Clinic Services
14
 Comprehensive HIV specialty and
Primary Care
 Treatment and Adherence Counseling
 Medical Case Management
 Prevention Counseling
 Pre-exposure Prophylaxis Clinic

16. HIV Coordinated Services
at CASA and Our Place
 Mental Health Services
 Substance and Addiction counseling
 Prevention Services, Partner Services, PrEP
 Linkage to care
 Insurance enrollment
 Case Management
 Insurance, housing, food, transportation, legal
 Peer Advocacy and Support Groups
 Outreach &Testing
 Events & Activities
 Research & Clinical studies

17. 16
one of the busiest borders in the world: 29 million north-bound crossings at San Ysidro in 2014
San Diego County population 3.2 million & 2nd most populous County in CA
Population-wise, Tijuana is the sixth most populous city in Mexico, 1.5 million
Our Unique Community

18. 17
Binational patients
 Use of medical services in
Tijuana (communication
limitations)
 Social life on both sides of
border (Hillcrest-Tijuana night
life)
 Deportation/migration
Border health
 Sicker population
 Present later stage disease
 HIV/AIDS, STIs, Tuberculosis
Our Unique Challenges

21. 20
Our (not so) Unique Challenges

22. SYHC HIV Department: Current Priorities
 HIV 101 and reducing HIV stigma across the
organization.
◦ Increasing access to internal services
 Behavioral health/Substance abuse services
◦ Closer relationship with Behavioral Health Dept
 TargetingYouth (focus: young MSM of color)
 Expanding access to PrEP
 Hep C treatment
 TB treatment cascade (clinic-wide)
21

23. Part 2:
Workforce of the Future:
Educating Primary Care Residents through
an FQHC-based Community HIV Medicine
Rotation
22

24. Special Projects of National Significance
Workforce Capacity Grant
 HRSA RW Part F funded demonstration projects to
improve HIV service delivery (one of 15 sites nationwide)
 Evaluation partner: Mari Zuniga, PhD
 Second SYHC SPNS project in 12 years
Prior study documented socio-demographics and HIV
care access behavior of Latinos living with HIV in the
U.S.-Mexico border region
 Purpose of current funding:
 “Further the overall understanding of system-level
structural changes within the HIV workforce that
will optimize human resources while improving
health outcomes.”
23

25. SPNS:
THE BIG PICTURE
WHY ARE WE DOINGTHIS?

26. THE BIG PICTURE (WHY ARE WE DOINGTHIS?)
GROUP EXERCISE: PROVIDING HIV CARE INTHE PAST

27. HIV CARE INTHE PRESENT
87% Retention in care*
93% of patients Viral
suppressed*
* For pts in our Ryan White
funded clinic.

28. RyanWhite providers are experts in providing
comprehensive,
patient-centered,
culturally-sensitive,
data-driven,
high-quality,
outcomes-oriented,
care
for underserved populations with
chronic conditions.
27

29. HIV CARE INTHE FUTURE

30. HIV CARE INTHE FUTURE
• More than 32 percent of today’s HIV clinicians will [retire]
over the next 10 years.
• there are inadequate numbers of new providers to replace
them
• the number of people living with HIV in the U.S. continues
to grow, with more than 55,000 new HIV infections
occurring annually.

31. SYHC SPNS PROJECT
KEY COMPONENTS OF OUR DEMONSTRATION PROJECT
1. PracticeTransformation
 Improvements to our HIV CareTeams
2. “Project Connect”
 Increasing access to non-HIV services for HIV positive
patients through Patient Navigation, training, and
outreach within SYHC
3. Workforce Capacity Building
 Expanding HIV workforce capacity through training
residents and non-HIV providers

32. 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT
Workforce of the Future:
Educating Primary Care Residents
through an FQHC-based Community
HIV Medicine Rotation
Jeannette Aldous, MD
San Ysidro Health Center
María Luisa Zúñiga, PhD
San Diego State University
Building HIV Capacity in Primary
Care and Integrating HIV Care
within Federally Qualified Health
Centers

33. Funding Support: Health Resources and Services
Administration # 1 H97HA274210100
Study Authors
San Ysidro Health Center
• Jeannette Aldous, MD
Clinical Dir. of Infectious Disease
• Katie Panella
Manager, HIV Clinical Services
Scripps Chula Vista Family
Medicine Residency
• Marianne McKennett, MD
Residency Program Director
Professor of Family Medicine
San Diego State University
• María Luisa "Mari" Zúñiga, PhD
Professor
Director, Joint Doctoral
Program in Interdisciplinary
Research on Substance Use
• David Howard
Research Coordinator

34. HIV Workforce Trends
• Persons living with HIV/AIDS (PLWHA) are living longer,
healthier lives and require a clinical workforce capable of
meeting their evolving healthcare needs.
• CDC estimates an increase of 30,000 patients/year
requiring care in next five years (CDC, 2012, 2014)
• By 2019, projected workforce net growth of 190 more
fulltime equivalent HIV providers falls under the number
needed to keep pace with increased patient care capacity
(Weisner, et al., 2016)
• Increased workforce capability and HIV competency of
Primary Care workforce will be needed to address future
healthcare needs of PLWHA

35. HIV training for U.S. Primary Care Residents
AAFP Curriculum Guidelines list HIV core competencies
as a training priority. However:
•only 25% of Family Medicine Program Directors
felt their residency had adequate HIV training.1
•79% felt their program did not have faculty with
enough HIV experience to train residents.1
•AAHIVM lists only 10 Family Medicine Programs
with HIV tracks2 (US has approx. 477 FM programs)
1. Prasad et al. Fam Med 2014)
2. http://www.aahivm.org/trainingopportunities)

36. 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT
Goal 1: Provide seamless continuity of a full spectrum of care for PLWHA
a) HIV Team PCMH Transformation
b) Increasing access/utilization of health center services through patient
Navigation and education for non-HIV departments
c) Improved EHR Utilization
Goal 2: Develop a sustainable clinical workforce pipeline that secures
medical resident and non-HIV provider capacity to serve HIV-positive
patients
a) Train Medical Residents
b) Train Primary care providers
SYHC SPNS Project:
“System-level Workforce Capacity Building for Integrating HIV
Primary Care in Community Healthcare Settings”

37. Scripps Family Medicine
Residency Program
Scripps Mercy Hospital
Chula Vista
Sponsoring Institution
UCSD
School of Medicine
Academic Affiliate
San Ysidro Health Center
Chula Vista Family Clinic
FPC
Residency Continuity Clinic
AHEC
Project Setting: Scripps Chula Vista Family
Medicine Residency Program
Resident Demographics
• 50% Underrepresented Minorities
• 43% Latino, reflecting local culture
• Many have local roots in San Diego
• 60% of graduates work in
underserved setting
Residency Program Goals
• Train family physicians to provide
care for the underserved
• Improve workforce diversity
• Focus on the US-Mexico Border

38. HIV CURRICULUM
•The rotation formally launched July 2015 (demo 2014)
•8 Second Year residents rotate each year through a six-
week, hands-on HIV clinical rotation.
•3-4 AETC didactic sessions (previously in place)
•Self-directed learning (AETC modules)
•Evaluation through a structured, self-administered
pre/post survey.

39. 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT
Evaluation Methods
18-item self-administered clinician survey
assessed resident:
1) Familiarity with service integration for PLWHA
2) Knowledge of common co-morbidities of HIV
3) Knowledge of routine primary care needs of PLWHA
• Pre-survey completed prior to initiating HIV curriculum
• Residents were re-contacted and post-survey completed at
conclusion of HIV-related training – May 2016

40. 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT
Results: Pre-Survey (n = 5)
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Familiarity
with Service
Integration
Knowledge of
Common
Comorbidities
Knowledge of
Primary Care
Needs of
PLWHA
HIV Knowledge• 5 of 8 residents
completed consent
and pre-survey
• 3 female &
2 male
• Avg. age = 31 yrs.
(Range: 29-34 yrs.)
Low
knowledge
High
knowledge

41. 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT
Results: Pre-Post Change
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Familiarity with Service
Integration
Knowledge of Common
Comorbidities
Knowledge of Primary
Care Needs of PLWHA
HIV Knowledge
Low
knowledge
High
knowledge

42. 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT
Qualitative analysis is ongoing to
evaluate Resident’s perception of
the training experience.

43. 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT
• Re: opportunity to improve understanding of HIV primary care
“I had opportunity to see patients on my own first then
precept with Dr. Aldous or see patients together with
her. There was a wide variety of pathology including
AIDS, molluscum, h/o cocci meningitis, uncontrolled
diabetes, hypertension, CKD on dialysis, prostatitis,
Bells Palsy. I saw both well controlled patients with
undetectable HIV viral loads on therapy and
uncontrolled patients who were quite sick.”

44. 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT
Discussion: Qualitative Analysis
• Qualitative analysis is ongoing to evaluate Resident’s perception
of the training experience. Examples:
• Re: increased comfort treating HIV+ patients
“Much of HIV care is primary care, especially when
patient’s viral loads are undetectable and they are well
controlled on their medication. I will be more cognizant of
screening for HIV and STDs [in future primary care clinical
work].”
• Re: depth and integration of the care team at SYHC
“An integrated team including a nurse, health educator,
social worker, and MA is important. . . . This level of
support, while it would be useful for the general patient, is
crucial in the care of PLWH.”

45. Discussion: rewards and challenges
Rewards: “unintended consequences”
• Primary Care expertise into the HIV clinic
• HIV/STI expertise into Primary Care clinic
• Referral access for HIV+ patients to Family Medicine
Challenges: Time!
•FQHC model does not include dedicated teaching time
•Lack of funding for teaching in Community setting
• Utilize AETC and other local resources for curriculum support

46. Conclusions
•Partnerships between RW clinics and Residency
Programs may increase access to HIV training.
•A curriculum targeting Family Medicine residents
is feasible
•Further focus on training in FQHC settings is a
strategy to address current workforce capacity
needs
•Ongoing efforts are needed to evaluate the short
and longer-term efficacy of HIV training for Family
Medicine residents

47. HIV CARE INTHE FUTURE?
87% Retention in care*
93% of patients Viral
suppressed*
* For pts in our Ryan White
funded clinic.

48. Acknowledgements
Management team:
Sara King, MPH
Karla Torres
Katie Panella
Brenda Huerta
Collaborators:
María Luisa Zúñiga, PhD
Marianne McKennett, MD
Clinical staff:
Virginia Sanchez, RN
Juan Delgado
Cecilia Navarrete
Simon Ramirez
Daniel Park, MD, MPH
Rob Kiernan, PA-C
Bill Grimes
Herman Magana

49. ACKNOWLEDGEMENTS

50. 51
THANK YOU