Mobilizing a Medical Home to Improve HIV Care for the Homeless in Washington, DC

Abstract

African Americans face a higher burden of HIV infection, morbidity, and mortality than other ethnic groups in the United States. As an organization that exists to serve the homeless and impoverished of Washington, DC, So Others Might Eat (SOME) works diligently to address this disparity. SOME's clients are primarily African Americans who often face obstacles to HIV care because of low socioeconomic status, mistrust of the medical establishment, and fear of being identified as HIV positive. We relate the lessons we learned at SOME's medical clinic while trying to better address the needs of our clients living with HIV/AIDS. Chief among those lessons was the need to shift from considering our patients “noncompliant” with their HIV-related care to recognizing they had needs we were not addressing.

AFRICAN AMERICANS ARE disproportionately affected at all stages of HIV infection. Though comprising only 13% of the population, non-Hispanic Blacks account for 50% of AIDS cases in the United States.¹ About 41% of US men and 64% of US women living with HIV/AIDS are African American.¹ African Americans are more likely to die from HIV/AIDS and less likely to have access to highly active antiretroviral therapy than are infected persons of other ethnic groups.^2,3

Research indicates that people infected with HIV/AIDS without accumulated financial assets have an 89% greater risk of death than do their counterparts, and those with less than a high school education have a 53% greater risk of death than do those with more education.⁴ Many of these grim predictors of HIV/AIDS survival are present in clients served by So Others Might Eat (SOME), a community-based organization that serves the homeless and impoverished of Washington, DC. SOME works to address the public health emergency that exists for poor HIV-infected African Americans. The organization faces considerable barriers despite the Healthy People 2010 call to address the disproportionate impact of HIV/AIDS among African American and Hispanic populations, because reductions in Medicare and Medicaid reimbursements for medical care and more strict Medicaid eligibility criteria make it difficult to expand care to the most needy.⁵

FACTS ABOUT SOME MEDICAL CLINIC

Staff
▪ 1 internist	▪ 1 part-time registered nurse practitioner	▪ 1 part-time laboratory technician
▪ 1 part-time ophthalmologist	▪ 6 registered nurses	▪ 3 part-time psychiatrists
▪ 2 administrative assistants	▪ 1 part-time billing specialist	▪ Several dedicated volunteers
Budget
▪ FY 2007 operating budget = $902,603	▪ FY 2007 reimbursements from health insurance programs = $160,406
Services
▪ Primary care in an outpatient setting offering history and physical exams, electrocardiogram, full laboratory capabilities including HIV testing and counseling, HIV-specific lab monitoring, general health screening and lab monitoring, ophthalmologic screening and treatment services, medication monitoring and directly observed therapy, diabetes and nutrition classes, and psychiatric care.
▪ Approximately 300 separate clients seen per month, with 600 total monthly medical visits.
▪ SOME also provides the following services: an oral health clinic, case management, residential addiction treatment and follow-up for men and women, therapy and counseling, transitional housing for single men and women and families, job training, and educational programs.

Note. SOME = So Others Might Eat.

Nearly 20% of Washington, DC, residents live below the federal poverty level.⁶ In 2005, Washington, DC, had an AIDS case rate of 128.4 per 100 000, which is 9 times the national case rate.⁷ The SOME clinic is located in the city ward with the third-highest unemployment rate,⁸ and the majority of our clients are African Americans living on incomes below 50% of the federal poverty level. In 2006 and 2007, the SOME clinic served 1039 and 1107 separate clients, respectively. Six percent of our clients are HIV positive; 90% of these HIV-positive clients have a history of substance dependence, and 60% have 1 or more Axis I mental health diagnoses according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.⁹ Most of our clients have less than a high school education and no financial assets. The socioeconomic status of our clients, combined with the legacy of medical experimentation on African Americans and their subsequent wariness of the medical establishment, present myriad challenges to meeting their needs.

PROGRAM DESCRIPTION

The impetus for changing SOME's approach to HIV care came from our clients. When staff approached them about poor attendance to appointments for HIV care outside our clinic, some clients reported they were uncomfortable receiving care at centers known for providing HIV care because their family and friends would more readily identify them as being seropositive through their associations with these centers. Other staff-observed obstacles to accessing HIV care outside our clinic included the limited number of infectious disease specialists willing to accept publicly funded insurance, client dissatisfaction with the number and inconsistency of providers at large specialty clinics, and difficulty obtaining records about our patients’ care from consulting specialists. Considering these significant challenges, we began thinking about ways to establish an infectious disease clinic at SOME so that our clients could obtain access to the regular HIV care that is shown to improve health outcomes while remaining in the comfort of their medical home.

KEY FINDINGS

• ▪ 80% of clients eligible for highly active antiretroviral treatment (HAART) received it.

• ▪ 60% of clients on HAART attained serum HIV RNA viral load levels of ≤ 400 copies/mL.

• ▪ 86% of our HIV-infected clients received a pneumococcal vaccination within the past 5 years.

• ▪ Approximately 70% of our HIV-infected clients had the recommended laboratory tests for HIV surveillance during 2007.

• ▪ Our HIV-infected clients had an average of 17 visits to our clinic during the study period; all clients averaged 10 visits per year.

Since the SOME clinic depends largely on private donations, we could not afford to hire an infectious disease specialist. However, research indicates that persons with HIV/AIDS experience better health outcomes if an infectious disease specialist or a provider with significant experience with a high HIV/AIDS caseload coordinates their treatment,¹⁰ so garnering the consultation services of HIV experts was paramount. After brainstorming, we decided to commit to educating our staff about HIV disease and treatment and to solicit donated time from an infectious disease specialist.

We collaborated with Princy Kumar, Chief of the Division of Infectious Disease at Georgetown University Hospital, to establish an HIV care clinic in our facility. This arrangement provides a volunteer HIV specialist on site 1 afternoon per month and telephone consultations when necessary; this arrangement allows our clients to be seen in their medical home on a consistent and predictable basis. To protect our patients’ privacy and allow community building between the clients who are managing a disease that often isolates them from usual support systems, only HIV/AIDS clients are seen on that day.

SOME's providers made concerted efforts to take advantage of educational opportunities that would improve knowledge of current treatment standards for adult HIV management. Our physician, nurse practitioner, registered nurses, and laboratory technician enrolled in continuing education seminars, hosted lectures given by infectious disease specialists, and attended the Albert Einstein College of Medicine conference, “HIV Management: The New York Course.” In addition, we read peer-reviewed articles and treatment guidelines that were available on the Internet.

DISCUSSION

The infectious disease clinic opened in 2006. We performed our first internal evaluation of the aggregate care provided to 55 HIV-infected clients seen between January 1, 2006, and September 19, 2007. We assessed the frequency with which clients sought care, underwent HIV-specific lab work, attained standard treatment milestones, and received preventive health services at our center; we were pleased with the results of this initial assessment.

Despite our successes, the audit indicated that there is room for improvement in our care of HIV-infected clients. First, we aim to increase our flu vaccination rates among our HIV-infected clients from 47% to 80% during our next 18-month audit period. Second, because approximately 30% of HIV-infected clients did not have any lab work done during the initial assessment period, our goal is for all our HIV-infected clients to have undergone HIV-specific lab work by the time the next audit begins. Third, we would like to maintain an average of more than 3 clinic visits per 18-month audit period for each of our HIV-infected clients. During future audits, we will also administer questionnaires to assess clients’ self-reported likelihood of attending scheduled visits within their medical home compared with previous sources of HIV care. We hope to continue creating a more comfortable home for marginalized African Americans with HIV infection.

Our center's second goal was to adopt measures that will ensure that we continue to provide high-quality, evidence-based care for our HIV clients within their medical home well into the future. This was achieved through the SOME staff's renewed commitment to its HIV clients, the clinic's important partnership with an academic center, and SOME medical staff's pursuance of HIV-related educational opportunities. Educating ourselves and enlisting the help of qualified volunteer consultants from Georgetown University Hospital have been critical to our early indicators of success.

The medical team at So Others Might Eat.