Unstable Housing, Substance Use Disorder, and Serious Mental Illness among People with HIV 16791

– Hello everyone And thank you for joining us for the 2020 National Ryan White conference on HIV care and treatment My name is Nicole Chavis and I am a public health analyst in HRSA’s, HIV AIDS Bureau Today, we are discussing a topic that is very important for people with HIV We are very enthusiastic about this presentation and the important information we are about to share with you all regarding unstable housing, substance abuse, and serious mental illness among people with HIV As many of you may know or have experienced, data indicates that people with HIV who are not virally suppressed are sometimes also impacted by co-occurring challenges, which may include substance use disorder, mental illness, unstable housing, homelessness, or a combination of these The Ryan White program has demonstrated continuous dedication and success in providing services that meet the needs of people with HIV and to help them achieve viral suppression, thus reducing HIV transmission, and helping us to end the HIV epidemic in the United States For this presentation today, I’m joined by multiple amazing speakers One of the first voices that you’ll hear from is miss Jasmine Augustino She is a public health analyst in HIV AIDS Bureau, Jasmine and I both serve on the HIV AIDS, Bureau’s housing and homelessness work group Jasmine has served as a behavioral health scientist at the Center for Disease Control and Prevention and the office of Safety Security and Asset Management, providing mental health support and psychosocial assessment during public health emergencies and infectious disease outbreaks She has also provided psychotherapy to homeless HIV positive persons and community based settings Jasmine currently provides programmatic legislative and fiscal monitoring and oversight to Ryan White HIV/AIDS Program funded recipients We’ll also be hearing from Dr. Serena Rajabiun, who is a assistant professor in the Department of Public Health in the Zuckerberg College of Health Sciences at the university of Massachusetts Lowell She is currently the Principal Investigator for the HRAS’s spins initiatives, improving HIV health outcomes for supportive housing and employment services and dissemination of evidence informed intervention, dissemination and evaluation center We also have Ms. Lisa McKeithan Lisa is a healthcare consultant, improving infectious disease care through policy education and evidence based practice, drawing on her clinical research and policy expertise in clinical quality management and public health She currently serves as the director of the positive life infectious disease clinic at a federally qualified health center, providing strategic management and ongoing programmatic excellence, rigor program evaluation, and continuous fiscal monitoring and administration of the Ryan White program and the BC and D parts of our program Later we’ll also hear from miss Kate Bennett, who is the CEO of the Cincinnati health network since 2003, with oversight of all health services programs, including health care for homeless and local Ryan White part C program, a combined total of 10 contracted partner programs and serving approximately 12,500 patients She has dedicated the last 50 years of her life to advocating for equal housing rights, and quality medical care for underserved populations We also have with us, Ms. Susan McElroy, who is a Behavioral Healthcare Manager and the Infectious Disease Clinic at the University of Cincinnati Medical Center, Ms. McElroy, has over 15 years of experience in treating trauma related disorders as a certified provider and multiple evidence based treatment protocols she specializes in cognitive and Dialectal Behavioral Therapies Susan worked with her IDC team to implement a collaborative care model within the clinic to deliver gold standard of care to patients with mental illness and substance use disorders And last, but certainly not least We also have Ms. Carolyn Yorio who is working at Cincinnati’s AIDS service organization as a medical case manager and she started there in 2013

She moved to Caracole’s Housing Department in 2019 as the Associate Director of Housing Carecoles Housing Department serves 250 households every year with a range of short term services and permanent supportive housing options And just as an additional note, HRSA is on four social media platforms, so, please feel free to join any of those, to learn more about HRSA and the Ryan White program So, this slide is just for our disclosures Neither I nor any of the other presenters have any relevant financial or nonfinancial interests to disclose in addition, I did want to mention that this is a continuing education activity presentation and is managed and credited by AffinityCE in cooperation with HRSA and LRG So for this presentation, we hope to provide information on how to improve Ryan White part A through F recipient’s understanding of how unstable housing substance use disorder and severe or serious mental illness, affects HIV health outcomes We’d also like to highlight innovative strategies to improve viral suppression rates and clients experience a combination of HIV, unstable housing, substance use disorder and serious mental illness And I’ll just say SUD first, substance use disorder and SMI for serious mental illness moving forward And we’d also like to highlight which portfolio of services can work to improve HIV health outcomes, in clients experiencing unstable housing along with SUD and SMI So now I’d like to turn it over to my colleague, Jasmine Augustino to discuss more about HRSA, HRSA’s Ryan White program, and an overview of our data from the Ryan White HIV AIDS client level services report to lay the foundation for our discussion today Jasmine, – Thank you, Nicole Good afternoon, everyone Health resources and services administration overview, HRSA supports more than 90 programs that provide healthcare to people who are geographically isolated, economically, or medically vulnerable through grants and cooperative agreements to more than 3000 awardees, including community and faith based organizations, colleges and universities, hospitals, state, local and tribal governments and private entities Every year HRSA program serve tens of millions of people, including people with HIV and AIDS, pregnant women, mothers, and their families, and those otherwise unable to access quality health care Next slide please HRSA’s HIV and AIDS Bureau vision is optimal HIV and AIDS care and treatment for all Our mission is to provide leadership and resources to assure access to and retention in high quality integrated care and treatment services for vulnerable people with HIV and AIDS and their families Next slide, please HRAS’s Ryan White HIV and AIDS program The Ryan White HIV and AIDS program provides a comprehensive system of HIV prevention medical care, medications and essential support services for low income people with HIV More than half of people with diagnosed HIV in the United States, which is approximately 519,000 people receive care through the Ryan White HIV and AIDS program Our program funds grants to States, cities, counties, and local community based organizations Recipients determine service delivery and funding priorities based on local needs and planning processes Our program is a payer of last resort, statutory provision This means that Ryan White HIV and AIDS program funds may not be used for services, if another state or federal payer is available 87.1% of Ryan White HIV and AIDS program clients, were virally suppressed in 2018 exceeding the national average of 62.7% Next slide, please We are excited to present a thoughtful and rich presentation today As Nicole mentioned, I am Jasmine Augustino, a public health analyst and homeless and housing work group member I will provide an overview of unstable housing,

substance use and serious mental illness in the Ryan White HIV and AIDS program The Ryan White HIV and AIDS program response will be delivered by Nicole Chavis also a public health analyst and homeless and housing work group member And engaging examination of the issues and solutions to address clients at this intersection will be presented by Dr. Serena Rajabiun from the university of Massachusetts And finally, we are fortunate to have two recipients discuss their successful programmatic models We will have Lisa McKeithan from CommonWell Health, as well as Kate Bennett in collaboration with Susan McElroy, and Carolyn Yorio from Cincinnati Health Network As Nicole mentioned, in the Ryan White HIV and AIDS program, our service categories were designed to be flexible so that our recipients can tailor their programs to meet the needs of emerging or special populations in their communities So I’d like to just reiterate that we are very happy to have guest speakers today, that have utilized these models and can discuss how they have customized their portfolio of services to retain clients and encourage virologic suppression Next slide, please Overview of Unstable Housing, Substance use, and Serious Mental Illness and the Ryan White HIV and AIDS program Next slide, please Why are housing concerns important to Ryan White HIV and AIDS program? This is a recurrent slide integrated into other homeless and housing work group presentations because we believe it is salient to substantiate why the HIV and AIDS Bureau dedicates time and resources to address the intersection of HIV care, treatment and housing While the Ryan White HIV and AIDS program is not a direct housing provider We collaborate with health agencies and communities to strategize and assess what the role of the Ryan White HIV and AIDS program should be in addressing the housing needs of persons with HIV Unstable housing is a particular social determinant of health of interest to the Ryan White HIV and AIDS program because we recognize how far reaching the impacts are People who are unstably housed are more likely to contract HIV and more likely to have poor treatment outcomes Given this, our concerted efforts to address housing are critical to actualizing our mission The increased vulnerability to coexisting health problems associated with housing are well documented and here are some important findings So there is a large and increasing body of research that indicates that stable housing has a direct and powerful influence on HIV incidents, HIV health outcomes, and on health disparities In fact, and this is profound Housing is a more significant predictor of healthcare access and HIV outcomes than individual characteristics, behavioral health issues, and access to other services And finally, we recognize that prioritizing housing provision and assistance is a proven and cost effective intervention that can improve HIV healthcare outcomes In the following slides, I will draw from the Ryan White HIV and AIDS program’s service report data also known as the RSR that many of you collect to tell the story of unstable housing among our Ryan White HIV and AIDS program clients I will use this information to convey the compelling impact of unstable housing on HIV health outcomes Then, I will briefly review how HAB supports recipients address the needs of clients experiencing unstable housing Next slide, please The following Pie chart shows the 2018 percentage distribution of stable, temporary and unstable housing among all Ryan White HIV and AIDS program clients This data was collected from clients in the United States, Guam, Puerto Rico, and the U.S Virgin Islands In 2018, of the 501 478 clients

with reported housing status, 7.7% had temporary housing represented by the light green They also reported 5.3% unstable housing represented by the yellow It is important to note that these findings have remained somewhat stable since 2018 There have been very small changes We remain at approximately 5% unstable housed among our clients and the 7.7% temporary housing figure has decreased only slightly Next slide, please Here wee present housing status data from a sample of Ryan White HIV and AIDS program clients 13 years of age and older with HIV infection attributed to injection drug use We observe a significant shift in the percentage of clients who self-reported a temporary and unstable housing status In 2018, among 29,479 clients served by the Ryan White HIV and AIDS program, with HIV attributed to injection drug use And with a report at housing status, 10.8% had temporary housing shown in the figure in the light green and 9.9% had unstable housing represented by the yellow Compared to the last slide in which we presented the overall Ryan White HIV and AIDS program, client population, a higher percentage of clients who reported drug use as their transmission category were temporarily housed Similarly, among this sub-population a higher percentage of clients were unstably housed as compared to the general Ryan White HIV and AIDS program, client population It is important to know that our data contains limitations There currently is no mechanism to capture substance use disorder diagnosis in our data But we do have self reported information from clients who identify injection drug use as their mode of transmission With that said, this data may not reflect current behavior It does not include male to male sexual contact and injection drug use nor is it inclusive of sexual contact and injection drug use among transgender clients Next slide, please This bar graph demonstrates viral suppression among clients with HIV infection attributed to injection drug use We collected this data from clients age 13 years and older in the U.S., Guam, Puerto Rico and the U.S. Virgin Islands In 2018, for clients with HIV infection attributed to injection drug use viral suppression was 86.4%, which is quite consistent with the national Ryan White HIV and AIDS program average of 87.1% This is indicated on the figure by the dashed green line Each five year age group from 20 years of age to 44 years of age had lower percentages of viral suppression They range from 68.9% to 79.1% Those were lower compared to clients with IDU transmission risk overall, which was 86.4% Additionally, lower percentages of viral suppression, were among those with no healthcare coverage shown on the figure at 77.8% And those with a temporary housing status, which was 79.4% And finally, those with unstable housing had a viral suppression of 71.8% These findings are important as they demonstrate the impact on health outcomes, HIV positive clients with substance use behavior and unstable housing had viral suppression rates that are significantly below the national average and significantly below other groups who also identified as having injection drug use behavior, one limitation

in Ryan White HIV and AIDS program service report data, related to this presentation, is that there is no mechanism to capture people with a mental health diagnosis Data represents clients who reported injection drug use as their transmission risk category, but data may not reflect current behavior Data also does not include male to male sexual contact and injection drug use nor does it include sexual contact and injection drug use among transgender clients In this figure, N represents the total number of clients in this specific subpopulation We operationalize viral suppression as one or more outpatient ambulatory health service visit during the calendar year and one or more viral load reported within the last viral load result of less than 200 copies of HIV per milliliter of blood Next slide, please Focusing on the research Much attention has been drawn to the vital influence of unstable housing, substance use and mental illness on HIV treatment I will present a sample of compelling research findings from a literature review that highlights the impact of mental illness and depression on HIV outcomes across the HIV care continuum and on unstable housing Our aim is to present evidence based findings that examined how mental illness and substance use leads to an increased risk of homelessness or unstable housing and how the combination of unstable housing, substance use and mental illness increases an individual’s risk of poor HIV outcomes across the HIV care continuum The first study presented was published in “The American Journal of Public Health” in 2004, by M.B. Blank et al It asserts that HIV prevalence for individuals receiving mental health services was nearly four times as high as in the general population The second study presented was published in the “Journal of American Medical Association Psychiatry” in 2018, from B.W. Pence et al It purports that the greater chronicity of depression increased the likelihood of failure at multiple points along the care continuum of HIV Even modest increases in the proportion of time spent with depression led to clinically meaningful increases in negative outcomes Lastly, we present this quote that aims to explain the research findings published by an AngelaI Dalla et al in the American Journal of Public Health in 2006 Her team conducted a systematic review of housing status, medical care and health outcomes among people with HIV The investigation contends that likewise, mental illness and substance abuse are known predictors of both homelessness and unstable housing and health outcomes Thank you very much The next speaker is Nicole Chavis She will present, the Ryan White HIV/AIDS Program response – Awesome, thank you so much, Jasmine So, as Jasmine mentioned in her overview of the Ryan White Program clients and the various peer reviewed literature, it is well established that, stable housing is a critical component in ensuring long-term positive health outcomes, especially for people with HIV This slide lists two service categories that can be used directly to provide housing to people with HIV and those with unstable housing, substance use disorder and mental illness The Ryan White Program, it’s recipients are funded to provide a range of services to support the HIV related needs of eligible individuals to gain or maintain access to medical care, including prevention of homelessness HRSA, HAB’s policy clarification notice, or commonly known as PCN 16-02 details,

the allowable uses of the Ryan White Program funds to provide services to both people with HIV and in some instances, people who are affected by HIV These services are listed in PCN 16-02 on the slide and include housing services and emergency financial assistance or EFA In the context of housing EFA is used for primarily clients that only need one or two months of assistance to address their housing needs While EFA is designed to support a client through a unique emergency situation, allowable services under EFA can include housing and utility payments, but also can include other services not covered under the jurisdictions, Ryan White Programs, such as food, transportation and medications not covered under the ADAP or the AIDS Drug Assistance Program or clients’ insurance The primary difference between these two categories is that the housing support category is designed to link clients to the housing network, including housing case managers, in order to promote long-term stability Recipients who use the housing assistance to address the more prolonged need that clients may present, with to transition to a more permanent housing situation It is worth noting here as well, that these services work best when the client at risk is supported with other services, according to their service plan So next I’ll talk a little about program implementation and then the behavioral health services So PCN 16-02 also permits behavioral health services as listed on this slide Is important to note that both mental health services and substance abuse, outpatient care services are considered core medical services and would count towards the Ryan White legislative mandate that 75% of the funds go towards core medical services The services listed on this slide, allow recipients to fund an array of services in each category For example, under the substance abuse, outpatient care providers may use Ryan White funds to pay for treatment of substance use disorder, including pretreatment or recovery readiness programs, harm reduction, such as syringe service programs for injection drug users, behavioral health counseling associated with substance use disorder, outpatient drug-free treatment and counseling Medication assisted therapy or neuropsychiatric pharmaceuticals and relapse prevention In addition, there is medical health services such as outpatient, psychological and psychiatric screening, assessment diagnosis treatment and counseling services offered to clients with HIV And lastly, for substance abuse services that are also residential, where treatment of drug or alcohol use disorders and a residential setting to include screening assessment diagnosis and treatment of substance use disorder For more information on these types of services offered through the Ryan White Program, please review PCN 16-02 and the link is provided here, or you can also contact your project officer, as they have additional valuable resources for additional questions And lastly, a part of the Ryan White Program are our ancillary services These core medical and support services are used to implement programs to address homelessness and should include either directly funded or leveraged support services to address trauma, substance use, mental illness, health literacy, special health needs or others Some relevant service categories or activities, may include medical or non-medical case management And in the case of non-medical case management, that focus on accessing services such as employment and education centers and permanent housing, mental health services, peer navigators, support groups, or specialized medical care Utilizing a whole person approach to address the complexities of HIV, substance use disorder or serious mental illness in unstable housing are essential to assuring Ryan White clients receive the care and treatment they need to improve their HIV health outcomes And lastly, I’d just like to address and discuss a little bit about the Special Projects of National Significance

or our SPNS Program within the Ryan White Program The SPNS Program supports the development of innovative models of HIV care and treatment in order to quickly respond to emerging needs of clients served by the Ryan White Program The SPNS Program advances knowledge and skills and delivery of health care and support services to underserved populations living with HIV Through its demonstration projects, SPNS evaluation designs, implementation, utilization, costs, and health related outcomes of treatment models, while promoting the dissemination and replication of successful interventions Over the last several years, the SPNS project evaluated several models that examine services that prioritize multiple diagnosed people with HIV experiencing unstable housing or homelessness This slide includes some examples and links where you can find more information about SPNS and information about specific HIV innovative practices These programs help keep clients in care and work to make sure that they stay as virally suppressed as possible The recipients of the SPNS grant will share more about the successes and barriers they’ve had and how they’re continuing to implement these projects for this population I’ll now turn it over to our first speaker, Dr. Serena Rajabiun at the University of Massachusetts to discuss lessons learned from one of HRSA, SPNS Initiative – Thanks, Nicole Hello everyone It’s a pleasure to be part of this distinguished panel here today And I am very happy to present and share with you some of the lessons learned from the HRSA, SPNS initiative, building a medical home for healthily multiple diagnosed HIV positive homeless populations I served as the Principal Investigator for this five year initiative And I’m also pleased to have my colleague who was part of this initiative, Lisa McKeithan, who will be sharing from a sights perspective, lessons learned from this program And if you can go ahead to the next slide Thanks, so the Building a Medical Home initiative, this is a five year initiative As Nicole mentioned, it was funded from 2012 to 2017 The main goals included, to increase engagement and retention in HIV primary care, improved viral suppression rates and obtain stable housing for eligible participants The initiative funded nine demonstration sites across the United States, three were City or County health departments, two federally qualified HARSA health centers Two were Ryan White comprehensive HIV care organizations And two were outpatient clinics that were associated with university hospital settings and you can see where they were located geographically in this map Eight of the sites were urban areas and one was a rural setting Next slide So, in terms of the intervention models the demonstration sites implemented to address homelessness, mental health and substance use issues All of the models used a patient centered medical home framework, that is they were designed to deliver comprehensive, coordinated, accessible and improve the quality of HIV care And they did this through several common strategies The first one, was at each of the sites they strive to obtain integrated behavioral health and HIV primary care and treatment And they did this in different ways Some already had onsite what we call internal services behavioral health services at their clinics or organizations And this could be through having a psychiatrist come on staff, or a behavioral health nurse practitioner Somebody who could actually prescribe and do treatment for substance use or mental health Another strategy they use to integrate behavioral health care was maybe form external partnerships with agencies So we had some sites that also worked out at memorandum of understanding with substance use treatment provider or the mental health providers Another common element across all nine sites was the use of what was called a network navigator You all may know this term, for positions in your own agencies as care coordinators,

peer navigators, service linkage workers, community health workers What they were not were medical case managers, that was a different position So, the network navigator was critical ’cause this was really the person who complemented and work closely with medical case managers, but they were more in charge of working with the client to obtain the needed services, especially housing, mental health and substance use treatment, make sure that they attended those appointments and then also their HIV primary care appointments And also get their medications, so that they could achieve viral suppression And that was unique, despite the different names that each organization called their staff members The common piece was that they were a network navigator Another critical piece that these network navigators did, was what we call the system level coordination So, it wasn’t only working internally and making sure people, the participants and clients attended their appointments, but that they were working across partnerships with housing, health care, behavioral health care and really making a seamless system of care for the client So, instead of a client having to go to each individual service by themselves, they try to reduce those barriers, to accessing those services and smooth out the coordination across different agencies In addition, network navigators also played a critical role in working with housing providers, such as hop wall, local landlords to help clients who were unstably housed, find more stable housing And finally, another important piece of the interventions was in some cases, particularly in rural areas, was reuniting clients with their families or other support systems, which are critical for maintaining support both in housing, but also in terms of behavioral health and HIV primary care Next slide, please So, a little bit about the population that we reached as Nicole and Jasmine so eloquently discussed We really focused on the population who was most vulnerable to falling out of care and not achieving viral suppression So our population were adults, persons living with HIV who were 18 years or older and they were experiencing homelessness or unstable housing And the definition that we use for unstable housing, was from HUD, which describes this unstable housing as being, they were either literally homeless, that is living on the streets in their car or in a shelter or other public place They could be unstably had almost, maybe they did not have a lease They did not own a rent an apartment For at least 60 days, they may have been moving from place to place They may be what we call couch-surfers or doubling up, staying with family, friends it wasn’t a stable environment, or they could be in a stable place, but actually in the process experiencing domestic violence and in trying to find a more stable, safe environment And in addition to experiencing homelessness or unstable housing, they also had one or more co-occurring mental health and/or substance use disorders Next slide, please So I’m gonna just share with you some of the characteristics and issues that our clients in this SPNS initiative faced During the initiative, we served over 1300 clients, majority were male We had a small transgender population, majority were from racial, ethnic minority communities, mainly African American or Hispanic And the average years of experiencing homelessness, this is at baseline was, just over six years So these were people who had been experiencing homelessness or unstable housing situation for quite a long period of time Next slide, please In addition to the unstable housing characteristics, there are many other issues that our clients had faced at the time of enrollment into the intervention 80% vast majority had an incarceration history, with about, probably about 40% that were recently incarcerated

in the last 12 months from these at the time of baseline 3/4 had a diagnosed mental health condition, 40% had experienced some sort of trauma that is either sexual assault or physical injury 3/4 had a moderate risk of an illicit substance use and 24% actually had a high risk or what we would call a dependence issue on illicit substance use And this was mainly drugs, particularly around Opioid use, cocaine use, methamphetamines So these were illicit drugs Majority, almost 2/3 were food insecure in the last 30 days 1/3 had been out of care and had not seen an HIV primary care provider in at least six months And over 50% over half of our population, talked about experiencing some sort of HIV stigma and discrimination So it was a very marginalized and vulnerable population at the time we started our intervention Next slide, please In this slide here, this graph shows you the variation and the types of housing status, physical housing status, our clients were at baseline So, a little over a 1/3 were either doubling up or staying with friends or family, did have their own own place to stay at the time of enrollment About 25% were literally homeless That is that they were either in a street or in a public place, were living out in their car or have been in some sort of emergency shelter environment Another 20% or so, were in a more temporary situation, what we call transitional housing or maybe in residential treatment for anywhere between six or to 24 months, but that was seen as temporary that they would eventually be need to find a more permanent place to live Had about 10% who were in an institution, such as, assisted living or rehabilitation needing some sort of medical treatment And a very small percentage about 5% were in a stable situation with case management support but were at risk of losing that housing, maybe due to facts that they couldn’t pay their rent or behind on utilities So it was a very precarious housing situation And I showed you this slide because it’s not so easy There’s a lot of variation in our clients in terms of what their physical housing status looks like And even if there is a physical place, it’s still for other reasons may not be “stable” Next slide, please And so this slide shows the diagnoses in terms of mental health and substance use at baseline So, as I mentioned about three quarters 76% at baseline had a mental health disorder or diagnoses, almost half were suffering from depression, 41% had both co-occurring substance use or mental health disorder and that could include either alcohol, marijuana or some illicit drug use 20% actually more than that probably about The other 40% or so had some sort of serious mental health issue, 20% had bipolar, 15% were diagnosed with severe anxiety, 9% with schizophrenia, 6% with PTSD So, again a very vulnerable population, particularly for falling out of care or staying adherent to treatment due to these mental health and substance use disorders And also important to note is that at the time of baseline while three quarters had some sort of diagnosis, only about 40% were actually on a prescribed medication treatment and we got this from charts So a much smaller percentage were actually in treatment for a mental health or substance use disorder Next slide, please So, I’m gonna just share now briefly some of the outcomes or impacts of our intervention models from the SPNS Initiative You’ll see here, this graph shows you the percentage of people who at the time were referred into a mental health or substance use treatment when they came into the program,

so about 40% had an internal mental health referral and about 15 were referred externally, 17% were referred for substance use treatment and 13% for external substance use treatment And then the orange bars show you how many as a result of the intervention actually made it and had a visit to that mental health treatment or substance use treatment And you can see about three quarters once they were referred with the support of the intervention actually made it to that first visit or into treatment Next slide, please Another important impact and what was designed of our program and with our population was that there were multiple service needs, not just housing, substance use and mental health treatment but other issues such as transportation, food, which all go along with the unstable housing situation And this graph shows you the impact of the intervention over time from baseline to 12 months on reduction in unmet needs And I just call your attention particularly to the housing one where at baseline, 55% actually reported having an unmet need for housing That is all majority of our clients had a need but some weren’t successful prior to coming to the SPNS intervention and getting that need for housing met So, some were some weren’t So we had about 55% who had the unmet need for housing and by 12 months that had gone down to 41% And another critical piece is looking at substance use and mental health treatment about 13% reported that they had an unmet need for substance use treatment and that went down to 11% at 12 months And for mental health, 21% report and unmet need and that went down to 15% post 12 months Next slide, please In terms of the HIV health outcomes this graph here shows you the impact of getting other unmet needs, getting housing address, substance use and mental health and the subsequent impact on viral suppression So, we had at baseline about 49, about half actually were virally suppressed at baseline and that increased up to 70% at 12 months So, it’s much lower than the 87% that Jasmine reported for overall Ryan White clients but actually as a result of the interventions, we did see an improvement with this vulnerable population, so going up as high as 70% Next slide And then in terms of other Care Continuum Outcomes in looking at our population and this is the population we took a subset of looking at those who were unstably housed either newly diagnosed or had been out of care and what happened to them, we followed them through the care continuum So, in this sub sample of 334 84% were successfully linked to care among those who were linked, 74% were retained in care 90% actually got prescribed antiretroviral treatment and 71% reached viral suppression So, we are seeing some positive outcomes of the SPNS Initiative And then in terms of housing status we also saw a change in terms of people who reported being unstably housed at baseline, that was as high as 84% a decrease down to 30% at post 12 months And those who were stably housed where we had a very small percentage who reported some sort of stable housing that actually increased up to 34% after 12 months Next slide, please And so I just want to share with you some Next slide, please Thanks So, looking at this data and talking with the sites, we have some key messages for replication First of all, for those of you who are interested in designing programs that can reach people with HIV who have unstable housing and suffering from these co-occurring mental health and substance use disorders, one of the critical pieces we found

is really creating this mobile team based care and I emphasize mobile in this part, having the network navigator who somebody who could actually leave the clinic, go out into the community, go out into the field and work directly with the client and accompany them to various appointments to meet housing providers, to meet behavioral healthcare providers, to meet employment specialists, this is really critical If the people don’t expecting a client now and then has many challenges to come to you and navigate this fragmented service system is quite challenging I think And so having a member of your team who has that flexibility that doesn’t have to be in clinic and take the time to go out there and accompany clients is really critical A second key point for replication is having open access to integrated services, and what I mean by that is having on in your clinics, if you have integrated care, having open walk in appointments available, not just for HIV primary care but for substance use, mental health counseling or even to meet with a housing case manager, this is really critical because people are experiencing unstable housing and these co-occurring issues, they’re dependent on getting to your services and dependent on transportation and bus schedules and they might not be able to make an appointment on time So, having some flexibility and open access to have people ready who can meet the client and address their issues directly when they do show up is critical We also found having frequent team huddles and communication between healthcare providers, physicians, nurse practitioners, PAs, as well as our network navigators, as well as case managers, having the team meet at least once a week might be before clinic, when you’re expecting to see the client but having them each share their opinion and view of what’s happening with the client, what services they’re working on is really critical And then each member of the team knows what the other one is working on Conducting acuity assessments and integrated care plans are really critical, our network navigators were able to do this and work with medical case managers on this to get a detailed assessment about what is the severity of need for clients? What are their priorities? What do we need to work on? And what do we need to do in terms of housing, in terms of health care, behavioral health? What are the steps that need to be taken? And to revisit those care plans quite regularly, every three months to show the client where they’re making progress and empower them to take action on their care plans as well, and be there to support them And then finally, creating trauma informed and welcoming culture that really understands the needs of people living with HIV, who are experiencing homelessness and co-occurring mental health and substance use disorders We had a few several sites who went through trauma informed care supervision training and this was really critical to set up a welcoming environment where the client felt safe to come in And this is not just about the healthcare team it has to do with the front desk staff, It has to do with your security guards, really everyone understand what it means to provide trauma informed care and services in a welcoming environment for this population Next slide, please And so, I just wanted to share with you a couple of resources that were produced by our own initiative So there’s implementation manuals and videos from each one of the demonstration sites, as well as this multi site manual that you’ll see here on the slides And then we’ve also produced through the “American Journal of Public Health” we published a series of studies about our population and the impacts of the intervention, so that to advance the evidence on models that will address the needs and help achieve this population viral suppression Next slide, please So this is my contact information I’m happy to talk with you about any of the results of our studies or connect you with resources, if you have further questions And with that, I’d like to turn it over to my colleague, Lisa McKeithan who will talk about her program at CommWell Health Lisa – Thank you Serena I would also like to thank Jasmine and Nicole for inviting me to be a part of this panel, and on behalf of CommWell Health, we were truly grateful to be a part

of the SPNS Initiative, led by most amazing principal investigator ever Serena, It was truly a joy to work with you and your team and everyone at HRSA and in particular the other sites across the country So again, my name is Lisa McKeithan and from 2012 to 2017 CommWell Health implemented the NC reach program Next slide, please At the start of this initiative we weren’t aware of the homeless population beyond the seasonal migrant farm workers but our whole perception seemed to change when we discovered the hidden homeless right here in our community and in our patient population, we were grateful that we had network navigators who use motivational interviewing as well as strength based counseling approaches and shared experiences to offer support and ensure that our patients receive the treatment as well as the services they needed, which helped them and to link them into mental health, substance abuse treatment, and HIV AIDS primary care services The network navigators were able to provide that, the tailored services to address the individual barriers to housing for our participants And this essential program element was having network navigators who coordinate behavioral health services while integrating housing and health services through a comprehensive care coordination team Additionally, this work was important in helping our participants overcome stigma and connecting them with the resources that stabilize their lives outside of the clinic walls We were about building those partnerships and those systems of care with other community resources like local landlords, the Salvation Army, we connected with the local DDS so that we could have a more streamlined process and approach when helping our patients, our main focus as Serena noted, was all about community engagement Next slide, please And it was an innovative and invention for improving primary health care and supportive service delivery as well as patient outcomes As you can see, we had a total of 80 participants in our study, the viral suppression rate at the end of the study was 83% 74% of our participants were transitioned back to the standard of care, so they graduated from our program We only had 3% that were lost to care And at the end of the study about 70% were stable housed by the end of the initiative which showed us a direct correlation between stable housing and the virus suppression rate It’s because of HRSA and the SPNS Initiative that we were able to address the gaps that we saw in housing as well as care Next slide, please, Not only do the network navigators utilize motivational interviewing strategies to help clients to reframe experiences and follow up on appointments, but they spent most of their time outside of the office They were intentional building those systems of care with community agencies As Serena noted, we were a mobile team based care and by providing focus advocacy with housing providers on behalf of the participants, educating housing providers regarding housing first principles, enabling participants to receive permanent housing, as well as helping participants address internal stigma and reframe their approach when promoting stability and decrease acuity level Next slide, please Because of the network navigators, we were able to change our agency’s approach to serving these individuals with who were experiencing homelessness or unstable housing, impacted by substance abuse and substance use and serious mental illness by strengthening our interdepartmental communications and continuing to foster and promote relationships with community resources Next slide, please As well as we support retention and care by identifying the hidden homeless, by client tracking and outreach, by finding those with fallen out of care, connecting with individuals who are recently incarcerated, accompanying our participants to their medical appointments, assisting with and providing transportation appointment reminders, bridging communication with providers

and providing emotional support as well as helping our patients navigate the systems and coordination of care Next slide, please However, despite the systems of care that we built with our community resources, unfortunately there still continues to be some individual in some system challenges that we experience concerning like stigma regarding the mental health and HIV services and right now unemployment particularly now doing to COVID, trauma, lack of permanent and affordable and safe housing, a lack of availability of behavioral health care Actually in our County we only have one psychiatrist who was actually held here at ConmWell Health and the fragmented system, poor coordination Next slide, please However, the biggest lessons learned were the importance of community engagement of being outside of the walls of the clinic and inter departmental communications, having those frequent team huddles and establishing those relationships with non traditional landlords During this initiative, we actually hosted quarterly community housing correlation This was a meeting provided here at CommWell Health and it was a critical opportunity to increase transparency amongst agencies in our community but also gave the opportunity for all of us to seat, dine and to just share information and to discuss long term solutions It was all about the patients and having a shared goal to help our patients access the services and programs that they needed to improve health outcomes, as well as their wellbeing Next slide, please Here’s my contact information, if you have any questions or concerns, please reach out to me And now I would like to hand it over to Kate Bennett Thank you – Hi Thank you that was very interesting I just wanted to take a minute if I could and introduce you to the Centenary Health Network We were established in 1986 and we become a system of partner organizations that was necessary to create that seamless continuum of care that we’ve all talked about, particularly for the underserved populations of the healthcare for the homeless program in a Ryan White Pep C program As in FQHC, CHN is funded exclusively to meet the complex healthcare needs of people experiencing homelessness We do provide an array of primary medical, mental health, substance use services along with oral health care, respite care, intensive collaborative case management and all the other supportive social services that are necessary to approximately 1100 patients or more experiencing homelessness annually and the greatest Cincinnati Northern Kentucky Area Our Ryan White Program includes; Linkage to care, Comprehensive HIV Primary Care, Behavioral Health services, including Substance Use Counseling and Referral Medical Care Management and other supportive services to over 2300 individuals living with HIV in 15 counties, both urban and rural of the Tri-State area of Ohio, Kentucky and Indiana CHN also works really closely with Caracol which is the local Ryan White Part D provider Caracol offers medical case management and operates a variety of housing programs a newly developed Needle Exchange Program and a broad based HIV Prevention Education Program In fact, recently to meet the changing needs of individuals living with HIV, the health network opened a small primary care clinic

right inside one of Caracol’s case management locations We all know that the face of HIV virus has changed in the last several years, the recent Opioid Epidemic has really impacted the homeless population significantly increasing the numbers of people who are at risk for acquiring HIV And when diagnosed with HIV, like has been brought up repeatedly in this presentation, anyone experiencing homelessness, not only has a life changing condition now but they also have to deal with the stress of finding stable housing and all the resources that are necessary from just basic survival Early diagnosis and the delivery of integrated care treatment and supportive services are crucial, for this growing population I would like to introduce you to Susie McElroy, so she can address these pillar and also discuss the need for the continuity of care for patients we serve as well as for the organizations we collaborate with Susie – Thank you, Kate Next slide, please And maybe next slide too, please Okay, I’m gonna speak to today about some portfolio of services that we are offering in terms of mental health and substance use disorders And then I will turn it over to my colleague Carolyn Yorio who is to discuss homelessness aspects of our program So in our clinic, we have implemented a couple of services that I wanna to take a deep dive with you today on The first one and perhaps the most that I’m the most involved in is the collaborative care model, we have integrated behavioral health care into our primary care specialty clinic to treat HIV with our patients We implemented this particular model because research has shown that it improves patient outcomes, it saves money and it reduces the stigma related to mental health Our primary care providers collaborate with behavioral healthcare providers to effectively share patients treatment plans And in this population based model of care, that initial patient centered team helps get both the physical and the mental health care at one location which we know that our patients are very comfortable with and it reduces the amount of duplicate assessments that can be very irritating to our clientele Increased patient engagement often times results in better health care experience and improved patient outcomes The next part of this particular implementation of collaborative care is creating a group of patients that get tracked in a registry to ensure that no one falls through the cracks This registry helps us track and reach out to patients who are not improving and mental health specialists can focus on reaching out to those patients and have ongoing treatment and ongoing dialogue, not just ad hoc advice Next and another important part of the collaborative care model is to have measurement based treatment to target Each patient’s treatment plan is clearly outlined to articulate their goals because this is a patient centered approach, but it also incorporates clinical outcomes that routinely get measured by evidence-based tools Evidence-based self-reports such as a PHQ 9, GAD 7, these are all standardized self report measures that help measure a patient’s progress And if they’re not showing improvement as indicated by these measurements, then the treatment team comes together and talks about other ways to help the patient Another prong of this approach is providing evidence based care So patients are offered treatments that have credible research evidence to support their efficacy in treating the target condition

such as depression, cognitive behavioral therapies, anxiety and panic treatments that are good standard or evidence-based in terms of their results and helping our patient A large percentage of our population as we’ve already talked to you today by many presenters have experienced trauma and providing evidence-based trauma focused treatments has been something that our clinic has had great success with So, using these evidence based care treatments protocols has been very effective And lastly accountable care is the final prong of this approach And providers are accountable and often times work together to provide good standard treatment for our patients and meeting their needs So, in addition to administering the court, establishing and administrating collaborative care in our clinic, we also have implemented trauma informed care So, in this particular other people have spoken about this today but trauma informed care is really important to help increase all staff’s awareness of the impact trauma can have in the communities that we serve A trauma informed approach is not a singular technique, however, or checklist but it requires constant attention, awareness and sensitivity and possibly a cultural change in the organization It requires ongoing review, organizational development changes and practice improvement constantly and we do that in our clinics, we are in the midst of rolling this out We are in the phase of really looking at how we address providers and its staff self care, because that’s an important component in having a trauma informed approach within our clinic is really being able to provide self care and self care techniques to our staff, to help them to deliver the best care to our patients because if staff isn’t feeling good, it’s gonna be reflected to patients So, some of the key challenges and lessons we’ve learned in implementing these two different programs I’ll speak to, in the lessons and the challenges that we learned with implementing Collaborative Care, first and foremost it takes time to educate staff and get staff on board with integrating this model It requires primary care to have a shift in terms of thinking about and putting on their radar mental health administering mental health self report measures in their meetings, making the referral and then collaborating with mental health providers, psychiatrist for medication management as well as recommendations, being able and willing to prescribe some medications that they might be uncomfortable with and also training some of the clinicians to provide medical assistance therapy for addiction Secondly, another big learn that we had was being able to hire highly skilled psychologists and social workers that can complete psychological assessments as well as provide evidence based treatments The social work or the psychologists that are working the clinics and this model has to be pretty highly trained to be able to provide that level of service to diagnose and to treat And in terms of trauma-informed care, key learnings that we have found so far, is that this requires an organizational buy-in from upper level management to support the philosophy of trauma-informed care It’s not easy to create an environment and an awareness of understanding the impact trauma has in the communities we serve And on sometimes the staff that we hire, if upper level management isn’t aware, it doesn’t have the buy-in to create the safe place within awareness of the role trauma plays in both our patients and staff’s lives And it with that being said, I will turn it over to my colleague, Carolyn Yorio, who is the Director of Housing for Caracole Thank you

– Thank you, Suzie Hi everyone Thank you for your attention I promise we’re in the home stretch You’ve gotten a good picture of the problem nationwide that we’re addressing today, but I’d like to give you an example of the powerful work that we’re doing at Caracole Of Caracole’s 883 clients who are stably housed, 91% of that group has been able to achieve viral load suppression, but of the 67, who most recently reported that they were homeless or between stable housing, only 79% of that group are virally suppressed People can’t address their health needs without a place to rest, to eat and to care for themselves They have to have the mental space and consistency of a home to proactively manage HIV through medication and care Housing makes viral load suppression possible Next slide, please Caracole practices housing first, both in scattered site and site-based permanent housing This means that we prioritize, people experiencing homelessness with multiple barriers to stability On top of the systemic barriers to housing, our clients often are also dealing with mental health diagnoses, substance use legal issues, lower or no income and cognitive or developmental disabilities, as I’m sure of the many of the people that you serve These layers of challenges can contribute to multiple evictions, setbacks for our clients on their progress to their own goals and frustration and burnout for our staff It is hard but worthy work We work really hard to help clients maintain housing and avoid evictions, but evictions do occur And when that happens, we rehouse people and try to address the underlying factors that led to eviction We use a client-centered approach to make permanent housing possible And the three models that I’m gonna talk about today are harm reduction, motivational interviewing and trauma-informed care To start, motivational interviewing is a commitment to supporting the client as their own expert We help people explore the pros and cons of their current situation and what might be ahead of them We roll with resistance when change is hard and we foster self-propelled change, so that the client is their own driver More likely to identify change that works for them and that they can stick to One project that we are just starting, is making our housing plans more collaborative So each client has both a housing specialist and a case manager to address their housing and medical needs And our new housing plans will be written by the client and both staff people in a motivational interviewing format I wanna give a shout out to our viral load suppression for HIV team, which does innovative, high level of engagement work for leading this change in our housing plans The next model I wanna talk about is harm reduction So if you are not familiar with harm reduction, I urge you to go to the Harm Reduction Coalition Website for more information The harm reduction, is the idea that we could help people use drugs more safely, use less and/or discontinue use as they’re able So, harm reduction can include really practical resources, such as access to clean syringes, Narcan, rubber stem tips for crack pipes But it also includes a really personalized approach to creative problem solving, so that the client can identify what will work for them This fits perfectly with motivational interviewing So for instance, if someone had previously overdosed while they were alone, can we identify a person that they would feel safe using around, so that that’s less likely to happen the next time Harm reduction can be applied more broadly in housing, for instance, your landlord called and said that you were drinking on the front stoop and he has a problem with that Is there a place around back that you could use, where you’ll draw less attention from your landlord, neighbors and police and still recognize the situation that the client’s in and that abstinence is not likely possible for them, at this moment in time? So finally, I’ll continue our discussion of trauma-informed care that Suzie and others have started We know that all of our clients have experienced trauma It is likely that our staff has experienced various traumas and so have the landlords and other community partners that we work with With trauma in the background or the foreground for each client, we know that also on the systemic front, there isn’t enough housing available The relevant systems are too slow and the communities available financial assistance is just not enough to meet everybody’s needs That makes homelessness and housing services, a pressure cooker We have to recognize that there is trauma for each one of us and every client that we serve and engage in services with grace and hope for healing So, if you wanna take a look back on these three models that I’ve talked about, Motivational Interviewing, Harm Reduction and Trauma-Informed Care, consider what you’re already using in your practice, or what might be useful for you to implement And I want you to apply those models

to an investment in relationships I’m gonna talk about four relationships that are really key First of course, that’s building trust with clients through regular contact, becoming a trusted resource who does not force change, but is available and ready when the client is ready Of course, we also need to have collaborative relationships with our providers and be able to facilitate a trusted, warm handoff with follow-up So no matter who that provider is in the community, do you know somebody there? Can you help the client schedule intake and maybe go to intake with them? Can you follow up to make sure that they engaged in the services and that they’re working for them, or try to find an alternative if that first attempt didn’t work? Of course, we also need to network with our landlords We have to help them understand the barriers and challenges facing our population and encourage them to give second or even 15th chances to our clients And we would be nowhere without our program team So, between team members, we share resources, sympathy, and encouragement and we provide respite through case coverage and mutual support In conclusion, I wanna think about how can you improve your services this month or this year? And I would say that, that is investment in your direct service staff, even more so during COVID when we are all feeling stretched, thin and burdened, your direct service staff is going to be key So, today have case loads that allow for quick response times and individual relationships? Do they have the education skills and tools they need to do their job well? And do they have access to supports within and outside your organization to process the hardships they see and experience on the job? The most critical point of this work is direct service If they don’t have what they need, they will not be able to help clients get and stay in HIV or mental health care, substance use treatment, or housing Thank you so much for your interest And I’ll turn us back to Nicole to conclude our session – Great, thank you so much, everyone for your presentations We are now at the question and answer portion of our presentation, but I did just want to just completely say thank you for all that you have provided, all that you have done to serve these population of people with HIV and also with co-occurring substance use disorder, unstable housing and serious mental illness This presentation has been extremely enlightening and provided important details and resources, that we hope everyone can utilize and leverage to make sure that, the clients that you serve are receiving the care and their needs are being met sufficiently So, for the question and answer portion, both either myself or Jasmine Augustino will be assisting in the moderation