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| Reports
& Studies: |
2002
SPNS Report to CARE Act Grantees on Thirteen SPNS Initiatives |
| Print the Complete Report (pdf 324KB). | |
| TABLE OF CONTENTS | |
| Preface | |
| Overview | |
| DIRECTLY-FUNDED SPNS INITIATIVES - Centers and Affiliated Sites | |
|
Adherence Initiative |
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| DIRECTLY-FUNDED SPNS INITIATIVES - Centers Only | |
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Collaborative
on Improving Quality of Care |
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| SPNS COLLABORATIONS | |
| Corrections
Initiative Corrections Demonstration Projects HIV Treatment Error Reduction Project (CLIPS) Intervention for Seropositive IDUs: Research and Evaluation (INSPIRE) Treatment Adherence Health Outcomes and Cost Study Cost Study Intervention Sites |
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| PREFACE | |
| The
purpose of this report is to provide Ryan White CARE Act grantees
with preliminary findings from the SPNS initiatives and their multi-site
evaluations. Each of the initiatives in the report addresses a critical
issue identified as an obstacle to providing care to people with HIV/AIDS
in the U.S. The report describes models that have been developed to
overcome these obstacles and provides up-to-date preliminary findings
and lessons learned as the innovative models of care are evaluated.
The report also includes updated contact information so that agencies
can obtain more detailed information from the demonstration projects
themselves or from the evaluation centers for each initiative. Thus,
HIV program planners can obtain technical assistance now, as they
make critical implementation decisions, rather than waiting until
an initiative has formally completed its three- to five-year evaluation
process.
We trust this report will enhance HIV/AIDS programs today, arming them with the best information available about overcoming barriers to providing services to hard-to-reach individuals, even though the SPNS initiatives are still in progress. Developing relationships between providers with experience and those just starting out ensures that what is being learned today can be shared today. SPNS grantees and their Federal partners are developing innovative models to meet the changing needs of people living with HIV/AIDS. We encourage providers not only to read this document but to talk with the initiatives' grantees and project officers. Refer to the HRSA/HAB web site for more information on SPNS initiatives. The SPNS program exists to ensure better care for people living with HIV/AIDS. This series is part of the continuing dialogue between SPNS grantees and care providers to share the lessons learned through the SPNS program. May the result be high-quality care for all people living with HIV/AIDS. Sincerely,
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| OVERVIEW | |
| THE
SPNS MANDATE
The purpose
of the Special Projects of National Significance (SPNS) program
is to advance knowledge and skills in the delivery of health and
social services to people with HIV infection who are disadvantaged
financially and medically underserved. The SPNS program, which is
administered by the Health Resources and Services Administration
(HRSA) HIV/AIDS Bureau (HAB), is part of the Ryan White Comprehensive
AIDS Resources Emergency Act, also known as the CARE Act. The program's
goals are to:
HAB has identified four factors that will impact HIV/AIDS care over the next decade. These factors form the basis for SPNS priorities:
HOW THE INITIATIVES WORK Recognizing the creativity and innovation within existing CARE Act programs, many of the new SPNS initiatives focus on evaluating existing programs as well as on developing new models of care. The initiatives usually describe the components of the innovative model and then evaluate its effectiveness, efficiency and replicability. An important corollary is an examination of the contextual issues that contribute to the success or failure of an intervention in a particular setting or with a particular population. For example, the Border Initiative not only takes into consideration but explores the socio-political and economic context of services to at-risk persons along the border. The structure of most of the multi-site initiatives is designed to collect data and evaluate interventions across sites. The projects are grouped by type of intervention or topic (e.g., adherence, corrections) with the guidance of an evaluation center that facilitates cross-site evaluation. Each grantee is required to participate in development of the evaluation plan for the overall initiative and to collect uniform data that can be analyzed and compared across programs. The SPNS initiatives have demonstrated that collaboration for multi-site evaluation of care programs is possible and rewarding, and that it requires time and effort on the part of all stakeholders: the evaluation centers, HRSA/SPNS, and the projects. The evaluation center coordinates evaluation activities of the initiative's grantees through a systematic process:
Each evaluation center also coordinates the dissemination of findings, and provides technical assistance to grantees in reporting their own findings. In doing so, the evaluation center also addresses the issues that arise when multiple entities collaborate in an evaluation effort, such as:
The evaluation center for each initiative is also responsible for the assessment of the policy implications of study findings and the production of a report that provides policy recommendations. The mechanism for establishing a collaboration partnership for each initiative is the convening of one or more meetings of the evaluation center and the grantees. This enabled all parties to meet and become familiar with each others' projects, begin establishment of a shared group identity and mission, and begin a dialogue about the multi-site evaluation effort. Continuation of the dialogue usually occurred through emails and regularly scheduled telephone conference calls as well as a second multi-site meeting. By the end of the first year, most initiatives have achieved consensus about their evaluation methodologies and finalized their multi-site evaluation plans. Numerous challenges have been faced and lessons learned, some of which will be discussed under individual initiatives. Several of the SPNS initiatives draw upon expertise of Federal agencies outside HRSA, through active collaboration with the Centers for Disease Control and Prevention, Agency for Healthcare Research and Quality, and Substance Abuse and Mental Health Services Administration. SPNS has contributed funding as well as its unique perspective to research efforts within each of these agencies, expanding the research focus to the challenging issues of providing health care to marginalized or hard-to-reach groups of people living with HIV/AIDS. Some of the collaborative projects have structures that differ from the typical SPNS initiatives. Some are cooperative agreements in which the lead funding agency serves the function of the SPNS evaluation center. Others are more like grants to researchers to conduct research projects that they designed. The projects described in this report demonstrate a wide range of mechanisms being used to develop and evaluate creative programming to meet the needs of marginalized people living with HIV/AIDS. |
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| DIRECTLY-FUNDED SPNS INITIATIVES - Centers and Affiliated Sites | |
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Adherence Initiative: In order for the highly active antiretroviral therapies (HAART) to be effective, strict adherence to the regimens is essential. However, adherence to the complex regimens is challenging, particularly for people with HIV who experience other difficulties such as substance use and homelessness in their lives. Many CARE Act-funded grantees and their contractors are funding innovative programs to increase adherence to HIV therapies. The objective of the Adherence Initiative is to evaluate existing interventions that have been designed to increase adherence to HAART among underserved populations such as women, adolescents, the homeless, substance users, and in minority and ethnic population groups. Twelve programs that span a range of target populations, adherence interventions, and client service settings have been provided the funding to evaluate their adherence support interventions. The Center for Adherence Support Evaluation (CASE) Project supports them in evaluating what kind of adherence support works best for whom, at what cost. CASE will also facilitate the development of a national consensus about what the best practices are to support adherence, and will broadly disseminate the findings. Read
more... American Indians and Alaska Natives Initiative: The American Indian/Alaska Native (AI/AN) Initiative is designed to integrate substance abuse and mental health services with HIV care for American Indian and Alaska Native communities. Six demonstration projects and a technical assistance center comprise this five-year initiative, which begins in October 2002 and ends in September 2007. Since AI/AN agencies operate under a Federal policy that promotes self determination for American Indian and Alaska Native peoples, the technical assistance center will respect the interest of AI/AN projects to develop culturally appropriate solutions to community, tribal, and village issues and will encourage solutions to come from the local level. The role of the center is to provide technical assistance to the six HIV/AIDS care demonstration projects for their local evaluation efforts, to assess local evaluation capabilities, and to disseminate the findings of the initiative. Read
more... Information Technology Initiative: The Information Technology Initiative (Evaluating the Impact of Information Technology on Optimizing Quality of HIV Care) will evaluate the impact of information technology (IT) on improving the delivery and quality of care for underserved people living with HIV. The three-year initiative, which begins in October 2002 and is expected to continue through September 2005, is a collaborative effort of the HRSA HIV/AIDS Bureau (HAB) and the Agency for Healthcare Research Quality (AHRQ). Both the Special Projects of National Significance (SPNS) and the AIDS Education and Training Centers (AETC) of HAB are involved in the initiative. Outreach Initiative: Identifying effective models of outreach to underserved HIV positive people not in care is a critical element in responding to the changing AIDS epidemic. Recent advances in the treatment of HIV/AIDS have slowed both AIDS death rates and the progression of disease for many individuals. However, certain vulnerable and marginalized groups of people, including people of color, women, substance users, the homeless, youth, men who have sex with men, and people who are incarcerated, are not benefiting as much from these advances. Populations with the highest HIV infection rates have a correspondingly greater need for treatment, yet behavioral and delivery system factors such as cultural and linguistic biases, racial and gender discrimination, and lack of insurance have a profound influence on access to medical care. The SPNS Outreach and Intervention Initiative characterizes and evaluates outreach strategies intended to bring underserved people living with HIV into comprehensive continual care. The evaluation and technical assistance center for the initiative is the Center for Outreach and Evaluation (CORE), part of the Health and Disabilities Working Group at the Boston University School of Public Health. Seventeen HIV service programs have been selected to evaluate and refine their outreach activities directed toward people with HIV facing persistent barriers to enter and remain in care. Read
more... Palliative Care Initiative: Although death rates from HIV/AIDS have fallen in recent years, nearly 20,000 people die from AIDS each year in the United States. SPNS is supporting innovative service models targeted to people with HIV/AIDS who are homeless, uninsured, substance users, and/or mentally ill, and individuals in or about to be released from correctional facilities. Five demonstration projects test different models of end-of-life care and palliation service delivery to various medically underserved and hard-to-reach populations with HIV/AIDS. The evaluation and technical support center provides evaluation oversight and exchange of information and expertise among the projects as well as dissemination of information to the broader service, research and funding communities, to foster replication and adaptation of viable service models for the targeted populations. Read
more... Prevention with Positives Initiative: The Initiative on Prevention with HIV Infected Persons Seen in Primary Care Settings (the Prevention with Positives Initiative) will evaluate the effectiveness of a behavioral prevention intervention program for HIV positive clients in clinical care. The five-year initiative begins in October 2002. An Evaluation and Support Center will be funded to work with SPNS to refine a proposed multi-site evaluation design for behavioral interventions with HIV positive people. In Years 2-5 of the initiative (beginning October 2003), four to five providers currently funded under Titles I-IV of the CARE Act will be funded as demonstration sites. US/Mexico Border Health Initiative: The U.S.-Mexico border region is over 2,000 miles long, and contains some of the poorest counties in the United States. Identifying and linking people with HIV to needed health services is challenging in this context of multiple socio-economic and health systems problems. Five projects, two in Texas and one each in Arizona, New Mexico and California, were funded in FY 2000 to identify people with HIV and to develop services linking them with appropriate HIV care. El Centro de Evaluacion: HIV/AIDS Evaluation and Technical Assistance Center assists each of the projects to describe its model and to evaluate its effectiveness in linking persons to care, to conduct a multi-site evaluation, and to disseminate the findings so that successful models can be replicated. |
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| DIRECTLY-FUNDED SPNS INITIATIVES - Centers Only | |
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Collaborative on Improving Quality of Care: The Institute for Healthcare Improvement (IHI) is working with HAB to improve the quality of care provided by CARE Act grantees through development and implementation of the Breakthrough Learning Series Collaborative on Improving Care for People Infected with HIV. This process teaches and applies methods for organizational change to improvement of clinical care. Participants participate in a series of learning sessions after which they engage in making and tracking changes in clinical care in their healthcare settings. A first round of Title III and IV grantees has applied the Breakthrough process to HIV care in their institutions, Based on their positive experience, the model has been revised and is being made available to a second round of grantees. Innovative Programs for Substance Users: Since the onset of the HIV/AIDS epidemic, a large proportion of people with HIV have become infected either through injection drug use or sexual activity with drug users. For them and for the people who provide their care, the epidemics of HIV and substance use are intertwined; neither epidemic can be addressed without addressing the other. The Health and Disabilities Working Group at Boston University has conducted a series of activities to identify performance standards and innovative and successful practices in serving individuals with HIV and substance abuse disorders. Based on these findings, a training program is being developed to disseminate innovative practices, engage CARE Act grantees and providers in hands-on discussions about overcoming barriers in serving substance users living with HIV, and provide evaluation and training and support to community-based providers. |
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| SPNS COLLABORATIONS | |
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Corrections Initiative: The goal of the Corrections Initiative is to improve access to HIV care and prevention services both inside and outside corrections institutions, and to develop model programs that assure continuity of care for incarcerated persons with HIV upon their release from jail or prison. The Initiative is a collaboration between The Centers for Disease Control and Prevention (CDC) and HRSA that funds seven demonstration projects (State health departments or their bona fide agents) as well as the Evaluation and Program Support Center (EPSC) to assist with program implementation and evaluation. In each State, the health department and department of corrections work collaboratively with one or more community-based organizations to provide services. Projects provide a variety of service interventions, such as primary care, prevention, psychosocial support, and referral systems that link correctional and community settings. They target a range of different populations in different settings, such as youth in juvenile detention centers, women in State prisons, and drug-using inmates in city jails. Read
more... HIV Treatment Error Reduction Project (CLIPS): The study entitled HIV Treatment Error Reduction using a Genotype Database is a collaborative project of the Special Projects of National Significance (SPNS) at Health Resources and Services Administration and the Agency for Health Research and Quality (AHRQ). It is one project in AHRQ's Clinical Informatics for Patient Safety (CLIPS) Initiative. The goal of the study is to optimize patient safety by decreasing medical errors in the prescribing of antiretroviral drugs. Previously-ordered HIV genotypic resistance test results will be integrated with corresponding patient medication data into an electronic medical record system, where a computerized clinical decision support system will alert the patients' physicians of potential inappropriate choices of antiretroviral drugs. Intervention for Seropositive IDUs, Research and Evaluation (INSPIRE): The HRSA HIV/AIDS Bureau (HAB) is collaborating with the Centers for Disease Control and Prevention (CDC) to conduct a randomized controlled trial of a peer-based intervention to reduce behaviors that put people at risk for HIV and to enhance utilization of medical care and adherence to HAART. The target population is HIV positive people who are still using drugs and/or practicing unsafe sex. During the first three years of the initiative, the partners worked closely in the development of the theoretical framework, the intervention to be tested, the study protocol, and the evaluation instruments. As the initiative enters its fourth year, baseline data have been collected on nearly half of the subjects and the programs are continuing to collect data and conduct the intervention. When baseline data have been collected on 1,500 subjects, the data analysis will begin. The intervention is based on a combination of peer-mentoring and cognitive-behavioral models of behavior change. Treatment Adherence Health Outcomes and Cost Study: The HIV/AIDS Treatment Adherence Health Outcomes and Cost Study (Cost Study) is a cooperative agreement to study the provision of integrated mental health, substance abuse and HIV/AIDS primary care services care to HIV positive people with mental health and substance use problems. The study is a collaboration of six U.S. Department of Health and Human Services components: The Center for Mental Health Services (CMHS), which has lead administrative responsibility, and the Center for Substance Abuse Treatment (CSAT), both of which are parts of the Substance Abuse and Mental Health Services Administration (SAMHSA); the HIV/AIDS Bureau (HAB) of the Health Resources and Services Administration (HRSA); and the National Institute of Mental Health (NIMH), the National Institute on Drug Abuse (NIDA), and the National Institute on Alcohol Abuse and Alcoholism (NIAAA), all of which are parts of the National Institutes of Health (NIH). The HIV/AIDS Cost Study will yield valuable, practice- and policy-relevant new knowledge about caring for HIV positive persons with co-occurring mental health and substance use disorders. |
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