Journal of Health Care for the Poor and Underserved

145 Pages·2002·0.48 MB·English

Journal of Health Care
for the Poor and Underserved
NATIONALEDITORIALBOARD
ABDELMONEMA.AFIFI,Ph.D.,ProfessorofBiostatistics,SchoolofPublicHealth,Centerfor
Health Sciences, University of California, Los Angeles, CA
MARYASHLEY,R.N.,M.P.H.,Director,CenterforCommunityandPreventiveMedicine,Rancho
Domingus,CA
CARLC.BELL,M.D.,PresidentandChiefExecutiveOfficer,CommunityMentalHealthCoun-
cil, Chicago, IL
DANIEL S.BLUMENTHAL,M.D.,M.P.H.,ProfessorandChairman,DepartmentofCommu-
nity Health and Preventive Medicine, Morehouse School of Medicine, Atlanta, GA
ROBERTN.BUTLER,M.D.,FoundingPresidentandChiefExecutiveOfficer,InternationalLon-
gevity Center, New York Academy of Medicine, New York, NY
WILLIAMA.DARITY,Ph.D.,ProfessorEmeritus,SchoolofPublicHealth,UniversityofMassa-
chusetts, Amherst, MA
VANESSANORTHINGTONGAMBLE,M.D.,Ph.D.,VicePresident,DivisionofCommunity
and Minority Programs, Association of American Medical Colleges, Washington, DC
M.ALFREDHAYNES,M.D.,M.P.H.,DeputyDirector(retired),CharlesR.DrewUniversityof
Medicine and Science, Los Angeles, CA
SUSANJENKINS,Ph.D.,R.N.,SeniorProgramOfficer,HitachiFoundation,Washington,DC
EDITH IRBYJONES, M.D., Past President, National Medical Association, Houston, TX
WILBERTC.JORDAN,M.D.,M.P.H.,MedicalDirector,OasisClinicandAIDSProgramand
AIDS Institute, Martin Luther King/Drew Medical Center, Los Angeles, CA
ROSALYNC.KING,Pharm.D.,M.P.H.,Director,OfficeofInternationalPrograms,Schoolof
Continuing Education, Howard University, Silver Spring, MD
LaSALLED.LEFFALL,M.D.,Professor,DepartmentofSurgery,HowardUniversityHospital,
Washington, DC
ROBERTG.ROBINSON,M.S.W.,Dr.P.H.,AssociateDirectorofProgramOperations,Officeon
Smoking and Health, Centers for Disease Control and Prevention, Atlanta, GA
WILLIAMA.ROBINSON,M.D.,M.P.H.,ChiefMedicalOfficerandDirector,CenterforQuality,
Health Resources and Services Administration, Rockville, MD
VICTORW.SIDEL,M.D.,DistinguishedUniversityProfessorofSocialMedicine,Montefiore
Medical Center/Albert Einstein College of Medicine, Bronx, NY
RUEBENC.WARREN,D.D.S.,M.P.H.,Dr.P.H.,AssociateDirector,UrbanAffairs,Agencyfor
Toxic SubstancesandDiseaseRegistry,DepartmentofHealthandHumanServices,At-
lanta,GA
Official Publication of Meharry Medical College
TheJournalofHealthCareforthePoorandUnderservedreceiveda1992AwardofDistinctioninthe
22ndAnnualAwardsforExcellenceProgram,sponsoredbytheAssociationofAmericanMedicalCol-
leges’Group on Public Affairs.
Journal of Health Care
for the Poor and Underserved
Volume 12, Number 4 • November 2001
Journal of Health Care
for the Poor and Underserved
Volume 12, Number 4 • November 2001
Brief Communications
Circle of Care: 381
Beyond HIV Counseling and Testing
CAROLA. PATSDAUGHTER,PhD,RN,ACRN
CATHERINE O’CONNOR,MSN,RN,ACRN
CECELIAGATSON GRINDEL,PhD,RN
PAULO TAVEIRA,MDIV
MICHAELA. MANCUSI,MSW,LICSW
Voices of Immigrant South Asian Women: 392
Expressions of Health Concerns
JOAN L. BOTTORFF,RN,PhD
JOYL. JOHNSON,RN,PhD
LISAJ. VENABLES,RN,BSc,MSN
SUKHDEV GREWAL,RN,BSN
NELEENAPOPATIA,RN,MSN
B. ANN HILTON,RN,PhD
HEATHER CLARKE,RN,PhD
PAULINE SUMEL,RN,BSN
SONIABILKHU,BA
GURPALSANDHU,RN,PhD
Original Papers
Access to and Use of Ambulatory Health Care 404
by a Vulnerable Mexican American
Population on the U.S.-Mexico Border
MICHAELPARCHMAN,MD
THERESABYRD,RN,DrPH
Behaviors, Attitudes, and Knowledge of Low-Income 415
Consumers Regarding Nutrition Labels
LAURAH. MCARTHUR,PhD,RD
VALERIE CHAMBERLAIN,PhD
ALAN B. HOWARD,MS
Whether and Where Community Health 429
Center Users Obtain Screening Services
KEVIN D. FRICK,PhD
JERRILYNN REGAN,RN,MS,MPA
Low-Income Californians’ Experiences 446
With Health Insurance and Managed Care
LISAI. BACKUS,MD,PhD
ANDREW B. BINDMAN,MD
Health Insurance Coverage-Enrollment 461
and Adequacy of Prenatal Care Utilization
VILMACOKKINIDES,PhD
Perspectives of Low-Income African Americans 474
on Syphilis and HIV: Implications for Prevention
JEBOSE O. OKWUMABUA,PhD
VINCENT GLOVER,MBA
DELOIS BOLDEN,BA
SHERON EDWARDS,BS
Impact of a Personal Response System 490
on Hospital Use by Low-Income
African American and White Elders
BRENDAF. MCGADNEY-DOUGLASS,MSW,PhD
Effectiveness of Reminder Systems 504
on Appointment Adherence Rates
SUSAN MAXWELL,RN,MBA
ROSE MALJANIAN,RN,MBA
SHERYLHOROWITZ,PhD
MARYANN PIANKA,APRN,MHSA
YOLANDACABRERA,BA
JOHN GREENE,MD
Acknowledgment of Peer Reviewers 515
Information for Authors 518
About the Institute 522
In the Next Issue 522
Readers’Services 523
Index to Volume 12 524
Subject Index 524
Author Index 526
Sage Publications Thousand Oaks • London • New Delhi
Brief communication 381
CPairtcsldea oufg Chaterre et al.
CIRCLE OF CARE: BEYOND HIV
COUNSELING AND TESTING
Overview
ManyHIVcounselingandtestingprogramsdonotlinkbothseropositive
andseronegativeindividualswithcomprehensiveservicesafterHIVtesting.
East Boston Neighborhood Health Center implements HIV counseling and
testinginfourprograms:(1)aconfidentialprogramforexistingclients;(2)an
anonymous test site serving inner-city residents; (3) a mobile unit serving
courts,methadoneclinics,andsubstanceabuseprograms;and(4)ascreening
clinicforimmigrants.Thispaperpresentscounselingandtestingdatafrom
theseprogramsfortwoperiods.Inaddition,dataonreferralsforbothsero-
positive and seronegative individuals from the anonymous test site and
mobileunitarereported.Personalizedreferralsensurethatnewlyseroposi-
tiveindividualsareimmediatelyengagedincomprehensiveHIVcare.Refer-
ralsforindividualswithhigh-riskbehaviorshelpmaintaintheirHIVnegative
statusaswellaspromoteearlyHIVdetectionandintervention.Inaddition,
referralsthatextendtofamiliesandsocialnetworkscompletethecircleofcare.
Background
TheriskofHIVinfectionisparticularlyhighamongsuchgroupsasinject-
ing drug users and their sex partners, sex workers and their partners, men
who have sex with men but are not gay identified, and minority women.
Althoughcounselingandtestingservicesareavailableinmostcommunities
toreachthesehigh-riskgroups,1,2mostprogramsdonotlinkbothseropositive
andseronegativeindividualswithcomprehensivehealthcareservicesafter
HIVtesting.Forsome(e.g.,insuredpersonswhohaveaprimarycareprovider
orpersonswithadequatefinancial,material,andsocialsupports),theselink-
ages may be unnecessary. However, disenfranchised populations may lack
resourcesandbeunabletoadvocateforthemselvestoobtainhealthcareand
social services. In addition, marginalized persons may be inhibited from
accessing care because of past negative experiences with bureaucratic sys-
tems. The advantages of linking seropositive individuals to health care ser-
vicesincludeprovisionoftreatmentandpreventionofnewinfection.Theless
obviousbutequallyimportantreasonsforengagingseronegativeindividuals
intocareincludeongoingopportunitiesforHIVeducationaswellasestab-
lishing a safety net for early detection and intervention in the event that
Received October 1, 1999; revised April 1, 2001; accepted June 6, 2001.
JournalofHealthCareforthePoorandUnderserved • Vol.12,No.4 • 2001
382 Circle of Care
infectiondoesoccur.Thepurposeofthispaperistwofold:(1)toreportHIV
counseling and testing data from four community-based programs at one
inner-cityhealthcenterand(2)todescribetypesofreferralsfromtwoofthese
programs to health and social services needed by seropositive and
seronegative persons who are generally not engaged in care.
HIVcounselingandtestingprogramsexistinmanycommunitiesthrough-
outtheUnitedStates.Thestructureoftheseprogramsvaries.Someprograms
focusonlyoncounselingandtesting,whileothersprovideparticipantswith
an educational program on HIV prevention.3 Most of these programs have
beenhousedinsinglelocationsorhavefocusedonsinglepopulations.4-10In
someinstances,counselingandtestingprogramshavebeentakentocommu-
nitysettingstoaccesshard-to-reachpopulations.3,11Theeffectivenessofedu-
cation,counseling,andtestingprogramsinreducingriskbehaviorsforHIV
infection has been documented.12-19 Two goals for these programs are clear.
The ultimate goal is the prevention of HIV infection. Secondarily, when an
HIVdiagnosisismade,personslivingwithHIV/AIDS(PLWHIVs)arelinked
toHIVhealthcareservices.UnderstandingtheneedsofPLWHIVsandlinking
themwithservicesareessentialtopromotingincreasedsurvivalandahigh
levelofwellness.ThevaryingneedsofPLWHIVsreceivingcareindifferent
settings (e.g., home care, hospital, outpatient clinics, long-term care) have
been compared.20 The independent effects of demographics and socioeco-
nomic variables on unmet needs for HIV-related services have been exam-
ined.21 Solomon and colleagues reported on the use of health services in a
cohortofintravenousdruguserswithknownHIV-1serostatus.22Caseman-
agementmodelshavebeenusedtolinkPLWHIVswithhealthcareandsocial
services.23-29SpecialprogramshavebeenestablishedtolinkcertainAIDSpop-
ulationswithservices.Forexample,theWell-BeingInstituteinDetroit,Michi-
gan, seeks out multiple-diagnosed women living with HIV/AIDS,
“hyperlinking”themintocare.30ThefocusoftheseprogramshasbeenHIV-
seropositive persons.
Seronegative individuals who may have emergent health care and/or
socialneedsdonotroutinelyreceivereferralsfromHIVcounselors.Krauss
andcolleaguesemphasizedtheimportanceofmeetingtheneedsofanyindi-
vidualwhorequiresservices.31Theclient’sprimaryneeds(i.e.,housing,food,
drugtreatment,etc.)shouldbeaddressedfirst.Anextensivereferralnetwork
for services can ensure that the client’s needs are met.
Twoteamsofinvestigatorsdidreportonprovidingservicestopersonspar-
ticipatinginmethadonetreatmentprograms.Selwynetal.describedonsite
health care services provided to seronegative and seropositive individuals
whowereinamethadonetreatmentprogram.32Theinvestigatorsconcluded
thathighratesofacceptanceandcompliancewithchronicmedicalregimens
forPLWHIVsandseronegativeindividualsarepossibleamongintravenous
drug users in a methadone maintenance program. In a 1993 report, Selwyn
andcolleaguesnotedthatonsiteprimarymedicalcareserviceswerereadily
andfrequentlyusedbyPLWHIVsandseronegativepersonsinamethadone
Patsdaughter et al. 383
BOX 1
CASE STUDY
Larryisa45-year-oldAfricanAmericanwithseverecardiomyopathyfromyearsofal-
coholandIVdrugabusewhobecameknowntothestaffofamobileHIVcounselingand
testingunit(MU)inatherapeuticresidentialcommunity.Larrytestedandwasinformed
thathewasHIVpositive.Larrythoughthecould“livewithHIVforyears”andwasmore
immediatelyconcernedabouthisheartdisease.Hisinitialconcernsincludedaccessing
homeoxygenandahospitalbedaswellasnutritionalsupplementsandtaxivouchersfor
transportation to his cardiology appointments. Referrals to meet these needs were ar-
rangedbyMUstaff.However,LarryrefusedreferraltoHIVspecialtyservicessincethey
wereavailableintheagencywherehiscardiologistpracticed.Hesaid,“Myheartdoctor
canhelpmewiththatproblem.Shedoeseverythingelse.”Duringthenextencounterwith
Larry3weekslater,theMUnurselearnedthathewasprescribedmanycardiacmedica-
tionsaswellassuboptimalantiretroviraltherapywithwhichhewasnonadherent.Arefer-
ralwasmadeforHIVspecializedhomecaretoassisthimwithmedicationadherenceand
foradvocacywiththecardiologistforappropriateHIVmanagement.Almost4months
later,LarryagaincontactedtheMUnursetoinformherthathiscardiologisthadmoved
andthathewouldnowconsiderreferraltoHIVservices.Thus,acircleofcarebeganwith
counseling and testing in the mobile unit.
maintenanceprogram.33PersonswhowereHIV-seropositive(n=212)made
morefrequentvisitsthanthosewhowereseronegative(n=264)(meanannual
visits 8.6 versus 4.1, p < 0.001). In this situation, primary care services were
provided onsite to persons receiving treatment for intravenous substance
abuse.Theavailabilitytoanduseoftheseservicesbypatientsoncetheycom-
pleted the methadone maintenance program were unclear. Dennis,
Karuntozos,andRachalalsoreportedsuccessinlinkingmethadoneclientsto
community resources through case management.34 Seropositive and
seronegativeindividualswerelinkedtoservicestomeetsocialandpsycho-
logicalneeds(e.g.,vocationalassessments,jobpreparation,supportservices,
etc.).Referralsformedicalserviceswerementionedbutnothighlighted.The
investigatorsconcludedthatsupportservicestoaddresslogisticalproblems
suchasemployment,transportation,childcare,andmedicalcareshouldbe
available to methadone clients in treatment programs.
Inbothofthesituationsdescribedabove,referralserviceswereprovided
by health care providers involved in methadone maintenance, limiting the
availability of services to those in drug treatment programs. In these pro-
grams,theclientself-referredandidentifiedhisorherneeds.Theuseofindi-
vidualclientassessmenttoinitiateclientreferralswasnotaddressed.Finally,
onlytheclientwasreferredforservices.Frequently,thewell-beingoftheclient
is intimately linked to the welfare of family members, but family referrals
were not addressed. HIV education, counseling, and testing programs that
serve disenfranchised populations and link seropositive and seronegative
individualsandfamilieswithcomprehensivehealthcareandsocialservices
can make a difference in the well-being of participants.
384 Circle of Care
The East Boston Neighborhood Health Center
TheEastBostonNeighborhoodHealthCenter(EBNHC),thefourthlargest
healthcenterintheNortheast,servesaworking-classcommunityofdiverse
ethnicorigins.EBNHCisseparatedfromBostonanditsmajormedicalcenters
byaharborandtunnel,whichactasbothphysicalandpsychologicalbarriers
forinhabitantsofthisneighborhood.Thesebarrierswereoneofthereasons
forestablishingcommunity-basedHIVservicesin1989.Currently,HIVSer-
vicesdeliverscounselingandtestingthroughfourprograms:(1)aconfiden-
tialwalk-inprogramforexistinghealthcenterclients,(2)ananonymoustest
site(ATS)servinginner-cityresidentsinthehealthcentercatchmentarea,(3)a
mobileunit(MU)servingsevensiteswithclientswithhigh-riskbehaviorsfor
HIV/AIDS,and(4)ahealthscreeningclinicfornewimmigrants.Asshownin
Table 1, these programs have been very successful in providing counseling
andtestingservicestoinhabitantsofeastBostonandsurroundingcommuni-
ties. Counseling and testing data for two time periods are presented: time
period 1 was from October 1, 1996, through September 30, 1997, and time
period 2 was from October 1, 1997, to September 30, 1998.
AsshowninTable1,atotalof970personswerecounseledintimeperiod1,
and967electedtobetestedinallfourprograms.Nineteen(1.96percent)tested
HIVpositive,comparabletothestateofMassachusetts’soverallaverageof2
percent.35Intimeperiod2,atotalof714personselectedtobetested,and12
testedpositive(1.68percent).Decreasedcounselingandtestingfiguresintime
period 2 may reflect, in part, (1) changes in health center staffing, which
diminishedreferralstotheConfidentialProgramforhealthcenterclients,and
(2) reduction in service delivery at the Immigration Clinic, with referral of
immigrantstoaprivate,for-profitclinicforexpeditedresults.Theprogram
withthehighestnumberscounseledandtestedduringbothtimeperiodswas
theATS.Duringtimeperiod1,theprogramwiththehighestseroprevalence
wastheMU;however,thisfiguredecreasedduringtimeperiod2duetorepeat
admissionstoprogramssites(i.e.,outpatientsubstanceabuseandmethadone
maintenance). Finally, the majority of referrals came from the MU.
SincetheATSandtheMUserveindividualswhoaregenerallynotengaged
inprimarycareservices,thispaperwillfocusonthereferralsmadethrough
them.TheATSisananonymous,free,walk-inclinicheldfortwo3-houreve-
ningsessionsaweek.ThesevensitesservedbytheMUincludetwodistrict
courts,twomethadonemaintenanceclinics,andoneresidentialandtwoout-
patientsubstanceabusetreatmentprograms.Inthecourtsystem,sexworkers
and their clients, first-time perpetrators of domestic violence, and drug-
relatedoffendersaremandatedtoattendHIVeducation,counseling,andtest-
ing sessions.
TheobjectivesoftheATSandtheMUaretoprovide(1)riskreductionand
behavior change strategies through individual sessions or group format,
(2)anonymousandconfidentialHIVcounselingandtestingusingguidelines
from the Massachusetts Department of Public Health HIV/AIDS Bureau,36
Patsdaughter et al. 385
TABLE 1
NUMBERS OF INDIVIDUALS COUNSELED, TESTED, AND
IDENTIFIED AS HIV POSITIVE IN EAST BOSTON
NEIGHBORHOOD HEALTH CENTER’S FOUR
PROGRAMS DURING TWO TIME PERIODS
TIME PERIOD 1: OCTOBER 1, 1996, THROUGH SEPTEMBER 30, 1997
COUNSELED TESTED POSITIVE PERCENTAGE
Confidential program 198 195 3 1.54
Anonymous program 504 504 7 1.39
Mobile unit 106 106 6 5.66
Immigration clinic 162 162 3 1.85
Total 970 967 19 1.96
TIME PERIOD 2: OCTOBER 1, 1997, THROUGH SEPTEMBER 30, 1998
COUNSELED TESTED POSITIVE PERCENTAGE
Confidential program 79 78 4 5.13
Anonymous program 493 477 3 0.63
Mobile unit 132 131 3 2.29
Immigration clinic 28 28 2 7.14
Total 732 714 12 1.68
and(3)linkstoawiderangeofhealthandsocialservices,includingcompre-
hensiveHIVservices,primarycare,specialtymedicalcare(e.g.,dermatology,
gynecology,ophthalmology,pulmonaryclinic),mentalhealthservices,dental
services, substance abuse treatment, health insurance enrollment, and
transportation.
TheATSandtheMUarestaffedbyadirector,coordinator,threecounselors,
andvolunteersandserveasclinicaltraininglocationsformedicalandnursing
students.IntheATSprogram,individualsself-referforone-on-oneHIVrisk
assessment, counseling, and testing. An average counseling session lasts
approximately30minutes.StaffpresenttheHIVeducation,counseling,and
testingprogramonaregularlyscheduledbasisateachoftheMUsevensites.
TheMUprogramusesagroupmodelthatincludesa11 houreducationalses-
2
sion. Following the educational presentation, individuals opting to test
receive a 30-minute one-on-one counseling and testing session. Two weeks
followingthepresentation,staffmembersreturntothesitetoinformpartici-
pantsoftheirHIVstatus.Adescriptionofprogramdevelopment,thegeneral
model,andsite-specificmodificationshavebeenpublishedpreviously.3ATS
andMUstaffconductindividualizedintakeassessmentsforbothseropositive
and seronegative clients requesting assistance. Referrals are made to
386 Circle of Care
appropriateprimarycareandsocialservicesbothattheparenthealthcenter
andthroughoutthemetropolitanarea.Staffalsolinkfamilymembersand/or
membersofparticipants’socialnetworkswithservicesasneeded.Thus,acir-
cle of care is created that extends beyond HIV counseling and testing.
Health and social service referrals for seropositive individuals are pre-
sentedinTable2.Duringtimeperiod1,all19seropositiveindividualswere
referredtoHIVservices,withallbutone(94.7percent)keepingtheirinitial
primarycareappointment.Inaddition,33referralsweremadeforspecialty
medicalcare,15formentalhealthservices,7fordentalservices,6forhealth
insurance,and3forsubstanceabusetreatment,foratotalof83referrals;the
healthcentertrackingsystemindicatedfollow-throughfor80(96.34percent)
of the initial appointments.
Duringtimeperiod2,all12seropositiveindividualswerereferredtoHIV
services, with all but one (91.7 percent) keeping their initial primary care
appointment. Fifteen referrals were made for specialty medical care, 6 for
mentalhealthservices,7fordentalservices,7forhealthinsurance,and1for
substanceabusetreatment,foratotalof48referralswitha97.9percentfollow-
throughrate.Noreferralsweremadetourgentcareforseropositiveindividu-
alsatthetimeofintake;rather,theclientswereinitiallyseenbyHIVservices.
Referrals were also made for other services for seropositive individuals,
includingbutnotlimitedtonutritionalservices,homecare,HIV-specificedu-
cation, needle exchange programs, and transportation services; however,
therewasnosystemavailablefortrackingreferralstoagenciesandservices
outside of the health center.
ReferralsforseronegativeindividualsarealsopresentedinTable2.Refer-
ralsweremadeforatotalof48individualsbetweenOctober1,1996,andSep-
tember30,1997.Ofthesereferrals,18wereforprimarycare,49forspecialty
medicalcare,25formentalhealthservices,4fordentalservices,6forhealth
insurance,and1forsubstanceabuse,foratotalof103referrals.Noadditional
referralsforsubstanceabusetreatmentweremadebecausemanyparticipants
were from MU sites where clients were already receiving substance abuse
care.Allhealthcarereferralsweremadeatthetimeofintakeforseronegative
patients.Mostofthesepatientshadacuteorpressingmedicalconcernsattheir
first encounter with MU staff.
Duringtimeperiod2,referralsweremadefor71seronegativeindividuals.
Fifty-sixreferralswereforprimarycare,37forspecialtymedicalcare,24for
mental health services, 8 for dental services, 12 for health insurance, 13 for
urgentcare,and1forsubstanceabusetreatment,foratotalof151referrals.It
might be postulated that different trends in time periods 1 and 2 could be
explained, in part, by the fact that the program became more firmly
entrenchedinthecommunityandwasseeingincreasingnumbersofhomeless
anduninsuredpersons.Sinceseronegativeindividualswerenotadmittedto
HIVservicesattheparenthealthcenter,itwasnotethicallyorlogisticallypos-
sibletotrackfollow-throughforeitherinitialappointmentsorrepeatvisits.