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| U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau • Special Projects of National Significance • February 2008 | |
CHAPTER 6
Proyecto Juntos Care Model: The Valley AIDS Council SPNS Project
The U.S. Mexican border es una herida (is an injury) where the Third World grates against the first and bleeds. And before a scab forms it hemorrhages again, the lifeblood of two worlds merging to form a third country—a border country.
(Anzaldua, 1999, p. 25)
This chapter presents the “Proyecto Juntos” care model that guided the project activities of the Valley AIDS Council (VAC) during the Health Resources and Services Administration (HRSA) HIV/AIDS Bureau (HAB) Special Projects of National Significance (SPNS) U.S.–Mexico Border Health Initiative from 2000 to 2005. The English translation for the Spanish title Proyecto Juntos is “joint project” or “together project.” It is a metaphor for the primary goal of the model: to form partnerships with AIDS service organizations and health care providers in an expanded service area. VAC envisioned that community health partnerships would lead to increased health care access for people living with HIV/AIDS (PLWHA) in 12 South Texas counties. This chapter describes the population demographics of the expanded service area and provides a brief history of VAC leading to the SPNS initiative. The model components, the process of implementation, and the results are described in the context of the project’s three goals.
The Texas border extends for 1,254 miles on a path from El Paso–Ciudad Juarez to Brownsville–Matamoros. Border residents fare poorly compared with nonborder Texas residents. State health and income statistics indicate border residents have a significantly higher rate of poverty, HIV infection, and disease (AIDS Education Training Centers National Resource Center [AETC/NRC], 2006). Struggles of daily survival consume people’s energy, and preventative health measures are viewed as an unaffordable luxury. Eighty-six percent of the South Texas border population is of Hispanic, primarily Mexican, origin, and more than half lack health insurance (Texas Department of State Health Services, 2003). The 32 counties that make up the Texas Border County Area (BCA) are federally recognized for funding allocations and programs because of the area’s impoverished population.
In individual border counties, the proportion of the population that is Hispanic ranges from 55 percent to 85 percent, compared with 28 percent in the 222 nonborder Texas counties (Texas Department of State Health Services, 2003). Health care and social service organizations face considerable challenges in meeting basic care needs for this large population. Caring for the chronic needs of PLWHA further stresses this already resource-constrained environment.
Agency History
In 1987, county health administrators from Cameron and Hidalgo counties and two leaders representing Planned Parenthood agencies in both counties met with representatives from the Texas Department of Health in response to the reported growing incidence of HIV/AIDS on both coasts of the United States. They assumed that the disease would eventually reach the Rio Grande Valley in South Texas. Those visionary community leaders sought to alert the health care community leaders to educate personnel and secure funding for an expected onslaught of HIV/AIDS patients.
That meeting led to the founding of VAC, a nonprofit organization. Early in 1988, VAC secured one HIV/AIDS community health educator position funded by the Texas Department of Health. A grant from the Texas Tech University Health Science Center the following year (1989) funded a research position to conduct an epidemiologic study. Partly as a result of that study, in 1993 VAC was awarded one of two national grants under Part C of the Ryan White HIV/AIDS Program. By 1990, the agency had grown to a staff of six: an executive director; an education and outreach director; two education and outreach staff; an office manager; and one case manager, with a caseload of 11 clients living with HIV/AIDS.
The Federal grant enabled the agency to hire a physician to manage an HIV/AIDS specialty clinic in Harlingen, Texas (Cameron County) to care for the increasing number of PLWHA identified by the VAC outreach staff and local health care agencies. Having a full-time physician with HIV/AIDS support staff reduced the waiting period for PLWHA seeking medical care from 2 months to less than 2 weeks.
The early VAC service goal was to provide a seamless continuum of care with support services through a “one-stop” delivery system at the Harlingen clinic. In 1994, outreach education and case management services were initiated in satellite offices in Brownsville (Cameron County) and in McAllen (Hidalgo County) in 1995. From 2000 to 2005, VAC was one of five organizations awarded funds under the SPNS U.S.–Mexico Border Health Initiative. During this period, the agency’s service area expanded to include nine additional South Texas counties, including four in the Del Rio area. The agency’s service counties are part of the 32 federally designated border special needs counties.
The 12 service area counties were Cameron, Dimmit, Edwards, Jim Hogg,
Hidalgo, Kinney, Maverick, Starr, Val Verde, Webb, Willacy, and Zapata.
A once-weekly medical clinic serving PLWHA was opened at the Brownsville
site in 2001. The VAC continues to be the main provider of medical care,
case management, and other support services for PLWHA in the 12-county
VAC service area.
VAC MISSION STATEMENT The Valley AIDS Council by utilizing a multi-facility system will continue to provide and expand capacity of HIV services in South Texas. These services will be provided to individuals infected with or affected by HIV/AIDS and related co-morbidities. Valley AIDS Council will accomplish this by providing medical care, medical training, research, social services, education, prevention and outreach. Valley AIDS Council is committed to achieving this by employing and empowering professionally competent staff who desire success for the clients, the agency and themselves. November 24, 2003 |
VAC is also a Local Performance Site (LPS) for the Texas–Oklahoma AIDS Education Training Center (TOAETC). The South Texas Rio Grande Valley, which is part of the VAC service area, has the highest concentration of Hispanics in the State (86 percent; AETC/NRC, 2006). The VAC staff reflect the Hispanic population in the border region: Most staff members are fluent Spanish–English speakers and bicultural. The agency administration is committed to having staff acquire knowledge of cultural norms that may influence prevention efforts or client acceptance of HIV/AIDS primary health care.
The Proyecto Juntos SPNS model involved creation of a health care network linking AIDS service organizations with community health centers (CHCs) in the target areas. During the SPNS project, VAC created partnerships with three CHCs and three area hospitals: a general hospital in Harlingen, a private hospital in Brownsville, and a hospital in Eagle Pass.
In March 2003, VAC responded to a request by the HRSA regional office to start an HIV/AIDS clinic in Corpus Christi (Nueces County) to serve the Coastal Bend Health Service Delivery Area. The new HIV/AIDS clinic replicates the Harlingen medical care treatment model.
Since its founding, VAC has earned a reputation as a local, national, and international leader for its successful HIV/AIDS education and medical care programs, which include an array of support services. VAC support services include pharmacy medications, oral health care, case management, transportation, a food pantry, housing, pastoral care, and substance abuse counseling and prevention education.
Target Population and HIV/AIDS
In 2003, a total of 233 cases of HIV (not AIDS) were reported for the 32 counties in the border region, an increase of 16 percent over the 187 cases reported in 2002 (Texas Department of State Health Services, 2003). The 32 border counties reported 220 AIDS cases in 2003, a rate of 11.9 cases per 100,000 population (Texas Department of State Health Services, 2003). AIDS cases in border counties located contiguous to the Mexican border were 6 percent of the total number of cases for the State in 2003 (AETC/NRC, 2006, p. 4).
The goals of Proyecto Juntos were (1) to increase access to HIV/AIDS primary health care for PLWHA along the South Texas–Mexico border; (2) to increase the capacity of primary health care systems to meet the health care needs of poor, underserved PLWHA along the border; and (3) to create a health care network linking AIDS service organizations with CHCs in the target area. In 2001, VAC, historically the sole provider of indigent HIV/AIDS care in the target region, partnered with Brownsville CHC, Pharr/McAllen’s Nuestra Clinica del Valle (Our Lady of the Valley), and the United Medical Center in Eagle Pass to provide HIV/AIDS medical care. The VAC partnership included an agreement between VAC and the medical centers that together (juntos), they would care for PLWHA during the interim period while physicians and nurses at the medical centers were learning about HIV/AIDS and developing their knowledge and skills for treating patients with HIV/AIDS.
A key component of the VAC Proyecto Juntos model included making available to institutional partners (i.e., CHCs) the expertise of a rotating HIV/AIDS primary health care team, which consisted of a nurse, a physician, and a case manager. The team made quarterly visits to health care centers to provide didactic instruction about HIV and mentored physicians, nurses, and case managers who wanted to learn about HIV/AIDS.
Sinclair & Cantu (2006) referred to the physician training component as “continuous mentored patient care” (p. 77), whereby the attending physician at the CHC is supported by a more experienced physician located at an institution hundreds of miles away. During quarterly visits, the Proyecto Junto HIV-specialist physician sees the patient jointly with the attending CHC physician. The team of physicians and nurses providing mentoring were continuously available for consultation between quarterly site visits by telephone or e-mail.
The physician-mentoring program was a collaboration among VAC, the three CHCs, and the TOAETC. In Year 3, the primary mentoring role for South Texas CHC physicians was turned over to the VAC physician with backup from the senior TOAETC physician. The VAC physician had been a trainee during the first 2 years of the mentoring program (Sinclair & Cantu, 2006, p. 77).
Patients were given a choice of receiving care at their local area CHC or at the VAC clinic. Some patients said that the VAC was known throughout the lower Rio Grande Valley as “the best place to go for HIV” (Sinclair & Cantu, 2006, p. 82). Some patients opted to be seen outside their CHC communities because of privacy concerns. Staff of each health care center coordinated health care referrals across partner agencies so that patients could access other medical personnel or VAC case managers.
Media and Marketing
In addition to direct patient care services, VAC engaged in a media campaign to educate at-risk Hispanic women of limited English proficiency, between ages 13 and 45, about HIV. The goal was to educate them about risk behaviors and signs of HIV disease to motivate them to seek HIV counseling and testing.
The campaign was conducted over 6 months using advertisements on local Spanish-language television and radio stations. The television ads aired mornings and afternoons during telenovelas (Mexican soap operas). Well-known local media personalities were featured in the HIV information ads. In addition to the electronic media, Spanish and English brochures and posters were produced and distributed in neighborhood churches, grocery stores, laundromats, and beauty salons.
The Spanish-language television ads generated more than 400 calls from people seeking HIV information that led to HIV testing and counseling. Testing identified 15 at-risk women, 10 of whom tested positive for HIV. Most women with a positive test had no knowledge they were at risk.
Evaluation and Dissemination
The evaluation component was conducted by a research team from the University
of Texas Health Science Center at San Antonio (UTHSC) Department of Pediatrics.
The Centers for Disease Control and Prevention’s (CDC’s)
Framework for Evaluating Public Health Programs (CDC, 1999) was used
to guide the work of planning outcomes and evaluation. Community AIDS
organization leaders were involved in conceptualization, planning, and
implementation of the care model. During the SPNS application phase,
the evaluation team used epidemiologic data to help local community leaders
become knowledgeable about the prevalence of HIV in their respective
communities. Both quantitative and qualitative measures were used in
the process of conducting local site studies and to evaluate outcomes
at the end of the project (see Figure 6.1). As a partner in the SPNS
initiative, VAC staff collected both qualitative and quantitative data
to evaluate collective SPNS
outcomes.
VAC SPNS Border Project Logic Model
VAC’s Proyecto Juntos used the United Way of America’s (1996)
logic model to create a graphic blueprint that identified key project
elements and how they would (ideally) work under certain conditions to
resolve problems. VAC staff found this approach useful in planning desired
outcomes for the service model. As indicated in Chapter 1, the logic
model was introduced in the initial collective SPNS meeting. The UTHSC
evaluation team worked closely with the VAC staff to identify service
components and outcome measures appropriate for evaluating planned outcomes.
As shown in Figure 6.1, the outcomes were identified in three stages:
immediate, intermediate, and long-term.
| Inputs | Activities | Outputs | System and Client-Level Outcomes* | ||
|---|---|---|---|---|---|
| Initial | Intermediate | Long-Term | |||
| AIDS Education and Training Center (AETC), HIV system specialists | Training and educating providers | Number of providers trained (physicians and nurse care coordinators) | Increased provider understanding of HIV care | Increased primary care system capacity to provide “quality” HIV care (i.e., standard of care) | System with sufficient capacity to provide HIV primary care |
| Trained health care providers (physicians and nurse care coordinators) | HIV health care and patient education | HIV primary health care encounters (~48 new patients yearly) | Connection to local skilled HIV primary health care | Reduced barriers to HIV care (i.e., transportation, geography) | Maintained or improved quality of life (i.e., health and well-being of clients) |
| Case managers | Population education about location of new HIV primary care sites by case manager, care coordinator, and outreach staff | Number of PLWHA entering HIV primary care for the first time | Clients will understand the continuum of HIV health and social services available to them | Increased use of local HIV primary health care and case management services by informed PLWHA | Maintained or improved quality of life (i.e., health and well-being of clients) |
| 2001 | 2002 | 2003 | 2004 | Total | |
|---|---|---|---|---|---|
| Intakes |
131 |
113 |
117 |
81 |
442 |
| Refusals |
19 |
29 |
24 |
34 |
106 |
| % Refusals |
14.50 |
25.66 |
20.51 |
41.97 |
23.98 |
Findings
Again, the Proyecto Juntos goals were to (1) increase access to HIV/AIDS primary health care for PLWHA along the South Texas–Mexico border; (2) increase the capacity of primary health care systems to meet the health care needs of poor, underserved PLWHA along the border; and (3) create a health care network linking AIDS service organizations with community primary care health centers in the target area.
Table 6.1 presents outcomes related to the outcome goal of increasing access to care, as reflected in the number of participants in Proyecto Juntos over a 4-year period. A total of 442 patients participated in the project (see Table 6.1). For various reasons, primarily time demands, 106 project candidates (24 percent, categorized as “refusals”) over the 4-year period declined enrollment. The SPNS participants represent a fraction of the more than 700 patients served by the VAC and its partner clinic sites.
The increased patient caseloads over time reported by Cantu, Sinclair, and Duggan (2004) in the four service locations indicate that the goal of increasing service capacity for HIV/AIDS patients was achieved. The Harlingen site had 514 patients; Pharr/McAllen, 26; Brownsville, 66; and Eagle Pass, 20. The total exceeds 1,000 if the Coastal Bend area is included.
The second goal, to increase capacity of primary care facilities in the service area, was achieved through the training for physicians and allied health care personnel. This unique component contributed to the increased capacity of the CHCs. As indicated earlier, the training began with didactic instruction the first year and was continued in subsequent years with quarterly onsite mentoring visits and on-call consultations, which totaled 75 during Years 1 through 3 and 23 additional consultations between 2003 and 2004. A total of five physicians were trained during the 4 years.
The HIV specialty onsite physician training program was successful because it addressed time constraints of physicians with heavy patient loads and provided onsite the needed HIV/AIDS knowledge and skills to care for PLWHA. Providing ongoing HIV/AIDS education in remote areas with high health care personnel turnover remains a challenge (Cantu, Sinclair, & Duggan, 2004).
The third goal, to create a health care network linking AIDS service organizations with CHCs in the target area, was met through the agency’s development of partnerships with those CHCs during the SPNS project. The social marketing campaign targeted to Spanish-speaking women produced more than 400 HIV phone inquiries. A total of 78 callers accepted an HIV test, which resulted in 15 at-risk women being referred for counseling and 10 additional women testing HIV positive.
Summary and Conclusion
In summary, the success of the VAC may be measured by its client caseload,
which started with 11 PLWHA in 1989 and grew to almost 1,000 patients
in 2005 (713 in the Brownsville Health Services Delivery Area [HSDA]
and 225 in the Corpus Christi Coastal Bend HSDA). The VAC was able to
extend care for HIV/AIDS patients by forming partnerships with regional
CHCs and hospitals in the 12-county service area. The agency’s
international visibility came about because of its leadership as the
primary organizer of an annual U.S.–Mexico Border Health Summit
on HIV/AIDS held in South Padre Island, Texas. In October 2007 the agency
will hold its 15th
annual conference.
The VAC achieved the SPNS project goals. The agency can be said to have become a victim of its own success. The expanded service area increased expectations and resulted in a higher patient load. When clients were given a choice of seeing an internal medicine physician in a CHC instead of an HIV/AIDS specialist in a clinic known for its primary care for PLWHA, most patients opted to receive care at VAC. All SPNS patients treated at CHCs eventually became VAC patients.
The patients’ preference for a specialist physician at VAC instead of a nonspecialist physician at a CHC seems clear. Other factors that might have contributed to patients’ choice of the VAC clinic are the stigma associated with HIV/AIDS and the shame associated with the route of exposure. The therapeutic group outcome of being among others who share a common life experience tends to normalize participants’ personal feelings about the disease and may explain the attraction of PLWHA to being among patients who are living with the same disease. Moreno (1994), describing his work with groups of patients with eating disorders, wrote, “With rare exceptions, patients express great relief at discovering that they are not alone, that others share the same dilemmas and life experiences” (p. 417). Of course, many patients are concerned about confidentiality and may have chosen VAC because of the fear of running into someone they know at their neighborhood CHC.
CHC administrators learned that HIV/AIDS patients have multiple medical needs and require more physician treatment time. The budget constraints became a disincentive for increasing the number of HIV/AIDS patients seen at CHCs. The Ryan White HIV/AIDS Treatment Moderniza-tion Act of 2006, which funds HIV/AIDS care, and the Bureau of Primary Health Care, which funds CHCs, use different formulas for patient care reimbursement; for the CHCs, billing requirements that added to administration costs became an additional disincentive to treating PLWHA.
Results from the project continue to be disseminated via local, regional, national, and international forums as well as in scholarly publications. The VAC Web site (www.valleyaids.org/) remains a source for further information and lists achievements by subject, date, and author. The Web site describes the VAC mission and lists current HIV/AIDS projects, services, and staff.
References
AIDS Education and Training Centers, National Resource Center. (2006). Overview of HIV/AIDS in the Texas–Mexico border region. Retrieved July 9, 2006, from www.aetcborderhealth.org/aidsetc?page=rep-umtx-bg
Anzaldua, G. (1999). Borderlands/La Frontera: The new mestiza (2nd ed., p. 25). San Francisco: Aunt Lute Books.
Cantu, Y., Sinclair, G. I., & Duggan, S. N. (2004, August 23–26). Training physicians to provide HIV medical care along the Texas–Mexico border. Paper presented at the Ryan White CARE Act 2004 Grantee Conference, Washington, DC.
Centers for Disease Control and Prevention. (1999). Framework for program evaluation in public health. Retrieved July 12, 2007, from www.cdc.gov/mmwr/preview/mmwrhtml/rr4811a1.htm
Moreno, J. (1994). Group treatment for eating disorders. In A. Fuhriman & G. M. Burlingame (Eds.), Handbook of group psychotherapy: An empirical and clinical synthesis (pp. 416–457). Provo, UT: Brigham Young University Press.
Ryan White HIV/AIDS Treatment Modernization Act of 2006, Pub. L. 109–415.
Sinclair, G. I., & Cantu, Y. (2006). A training program designed to increase capacity of community health centers along the United States–Mexico border to treat HIV infection. Journal of HIV/AIDS and Social Services: Research, Practice and Policy, 5(2), 73–88.
Texas Department of State Health Services, HIV/STD Epidemiology and Surveillance Branch. (2003). 2003 Texas HIV/AIDS border report: The 32 Texas–Mexico border counties. Retrieved October 19, 2006, from www.dshs.state.tx.us/hivstd/stats/pdf/2003_Border_Report.pdf
United Way of America. (1996). Measuring program outcomes: A practical approach. Arlington, VA: United Way of America. Retrieved July 2007 from www.unitedway.org/outcomes/