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Coming Soon On-Demand: Blueprints for Success Social Work and the Response to Pandemic: Innovations in HIV Care Delivery
Hello, everyone. I'd like to welcome everyone to our second blueprints for success Training Institute. Gilead is proud to partner with the Professional Social Work Association to bring this customized content that is timely and relevant for the delivery of social work. We appreciate and also want to thank collaborative solution for their great partnership. Briefly. Here's the agenda for today's program will have to 20 minute presentations and 2 30 minute workshops are first presentation will be given by Michael Tyler Ramos and is called Telehealth in HIV Care during the pandemic and beyond. That will be followed by a workshop on providing HIV care. Kobe 19 Pandemic. Our second presentation will be given by Carmen Julius and is titled Health Disparities Until Health, Alleviating or accentuating the Problem That will then be followed by a workshop on addressing mental health component of HIV. They're care through telehealth after our second workshop will come together for a panel discussion and audience Q and A where you'll have the chance to ask our faculty questions on the content of today's program. As faculty are presenting, please feel free to use the button at the bottom of your screen to submit questions. You can submit questions at any time throughout the program. We've got quite a loaded agenda with that. Our first speaker is Michael Tyler Ramos. Michael is the co founder, is the founder of CEO and MTR Therapy AH, Boutique style mental health group practice, with multiple locations in Philadelphia, Pennsylvania and New Jersey, specializing in trauma care, working with communities of color and L g B T Q Plus community. He is also an adjunct professor at the College of New Jersey, where he teaches multicultural counseling and New York University for clinical practice. He recently joined the board of directors of the Jest All Training Institute in Philadelphia. Now I'd like to turn it over to you, Mr Ramos, Thank you, Leslie, for that lovely introduction. So I'm excited to be here today and present on tele health and HIV care during the pandemic and beyond. So even before Kobe, 19 telehealth use had grown among social work practitioners. Research has shown that telehealth is an effective delivery method for many different evidence based practices that treat a range of psychiatric disorders, including anxiety, depression, suicidal ideation, eating disorders, trauma related symptoms and addictive behaviors. Clinical outcomes for both in person and telehealth modalities were seen as similar. Telehealth modalities enables social workers to engage with patients who are hard to access. These patients are not only those living in rural areas, but also those living in urban areas who can't always reach practitioners due to time constraints, work work schedules, funding for transportation or disabilities. Additionally, there are many other circumstances in which telehealth counseling could be a benefit. For example, AH person convalescing in hospital. Who needs to access mental health services or hearing impaired person who could benefit from text based technology. There is a growing awareness of child and adolescent mental health needs, but there are too few practitioners to keep up with the demand. Innovative new modes have been developed along with technology changes these advances and create new opportunities that do not simply mimic face to face visits. Some examples include providers e consulting with specialists regarding specific patients connecting a child to mental health services, be a pediatrician's office or short visits via text, which can enable a social worker to check in with a panel of several 100 patients. Frequently, the supply in response to the demand is not keeping up, but regulatory and insurance payment restrictions were barriers to growth. Next slide, please The impact of Kobe 19 on HIV care Here are some challenges The same health care challenges are also present in HIV care, with the potential for decrease frequency of monitoring and clinical appointments. Less counseling and multidisciplinary support, including mental health and substance abuse, decrease virology laboratory capacity. Rapid changes brought on by shifting to tell the health have meant retraining staff redirecting HIV staff to focus on Kobe 19 and rear orienting to new technologies, all of which takes time and brings on new challenges. Stopping group gatherings means no in person HIV educational and testing event. Some providers are moving to social media and other online activities, as well as virtual counseling sessions with at home testing to keep up services in the community. While some clinics are offering perhaps services, we are telehealth, others are suspending their services. Initiation of prep medicines requires a visit to the laugh of blood work. Although there are no national data, some primary care practices are reporting reductions in use of health care services of up to 70%. With our major cash reserves, the salaries of political staff are being frozen or reduced, and in some cases, staff are being furloughed. Moving on. Here's some good news regarding the impact of Kobe. 19. The Cares Act authorized 90 million for the Ryan White HIV AIDS program. Response to Cove in 19 and 65 million for the Housing for People With AIDS program. The federal program dedicated to housing needs for people living with HIV telehealth not only minimizes in person clinical visit, thereby helping to prevent the spread of Kobe 19 but it presents potentially innovative and effective ways to provide HIV services in the future. Telehealth for HIV prevention and management can help remove barriers to access by reducing travel time, offering MAWR convenient consultation modalities and avoiding the stigma that is often associative of accessing HIV related services. Telehealth can be more accessible to tech savvy adolescents and young adults. Moving on. Since Kobe 19 many health care practitioners are moving their services to virtue as a way to triage. The pandemic has forced primary care and specialty physicians to adopt virtual care and telehealth so patients can still receive care while social distancing and medical resource is can be re allocated to the front lines of treating Cove in 19 patients. Kaiser Permanent one of the largest providers of health care in the United States, is now reporting, on average, 65,000 telehealth encounters a day. Kaiser Permanente's video visits across the country grew from 8500 per day in April 2 45,000 per day by June 5th, 2000 and 20. Fair Helps monthly telehealth regional trackers Analysis of insurance Health claims show that claims for telehealth services increased hugely during March 2020 particularly in the Northeast, where the virus initially spiked. Around 76% of US hospitals are connecting with patients remotely using video, audio chat, email and other technologies, according to the Ariston report. Next slide, please. So here's some telehealth barriers that were removed during the cove in 19 public health emergency. Before Kobe, 19 providers will have to meet licensing requirements in the state in which there are licensed, as well as the jurisdiction where the patient is physically located. But during covert, 19 regulatory provisions for tele mental health requirements have been suspended. In some states, social workers can find out about their state on the association of Social Work boards, regulatory provisions website or a Swb. Before Kobe, 19 Medicare coverage and payment of telehealth services was provided on a limited basis on Lee during Kobe. 19 recently passed legislation has e some Medicare, Medicaid telehealth restrictions. Section 1135 allows for waivers of telehealth provider licensing regular regulations. So Medicaid, Medicare reimbursement. But waivers do not override state regulations. These waivers were and when there is no longer a declare public health emergency. Hip hop requirements for video conference platforms have been relaxed. The hip of relax ations relate to the types of platforms used for video conferencing and the need for social work. Practitioners toe enter into a business associate agreement or be a with the platform provider. The rural relaxing relates toe all hipper cover entities, even those that are not Medicare or Medicaid providers but not all public facing video conferencing platforms are allowed. Next slide, please. Okay, here's some considerations for engaging in telehealth models. Technology standards for social work practice, legal considerations, ethical considerations, payment considerations, other considerations moving on telehealth technology. Before Cove in 19 videoconferencing communications technology had to be HIPPA compliant vendors listed as HIPPA compliant, willing to enter into a B A included Skype for business up docks, VC, zoom for healthcare doxy. They're a platform and Google G Suite hangouts. Meat Now during Kobe, 19 platforms that may not fully complying with the requirements of HIPPA rules and with our be A can be used. These include Apple FaceTime, Facebook Messenger, Video Chat, Google Hangouts, Video and Skype. But social workers should enable encryption and privacy modes when using these platforms and alert clients to potential privacy risks. Using video conferencing Communication technology allows real time, two way interactive communication beyond that allowed pre covert 19 These this includes smartphones for video chat technology such as Apple, FaceTime and Skype, as well as video conferencing that was permissible pre Cove in 19. The U. S. Department of Human Health and Human Services will exercise enforcement discretion and waive penalties for most tip of violations against providers who serve patients and good faith through everyday communication technologies. During this public emergency, other technologies, such as texting services, can allow for short consoles with many patients and frequent frequent check ins using audio Onley devices for certain services, which can include psychotherapy, opioid treatment and certain telephone evaluation and management services moving on. Here are some advantages of telehealth during Colbert 19 reports from China show that mortality rates and populations with less access to health care resource is are higher than among those with better access. The Centers for Medicare and Medicaid Services issued a sweeping array of new rules and waivers of federal requirements to make sure that hospitals and other providers of health care manage surges of Kobe 19 patients. This has allowed healthcare facilities to be flexible in meeting patients needs. For example, they can transfer patients outside facilities and refer patients to other providers for essential services and served in surgeries such as cancer treatment. CMS is allowing telehealth to fulfill many face to face visit requirements for clinicians to see their patients and inpatient rehabilitation facilities such as hospice and home health, whereas prior to Kobe, 19 virtual check ins between doctors and patients could only take place if doctors had an established relationship with their patients. Now these services can be provided to new patients is well next slide, please. So studies have shown that tele health interventions can help improve outcomes for patients in addition to potentially expanding access telehealth has been shown to have important impacts on HIV treatment and prevention. Telegraph has demonstrated its ability thio. Increase access to quality healthcare, reduce patient travel to medical providers and potentially reduce health care costs. Prop telehealth programs have been shown to have sustained high rates of initiation of prop medicine and to enhance patient retention. A study conducted by the Veterans Administration show that availability of telehealth programs documented virus suppression among patients and VA clinics. The Alabama Health Study demonstrated at telehealth enhance patient engagement in the HIV care continuum. Off the 240 patients participating in the evaluation who had data at baseline six or 12 months, 76.3% were retained in care. There have also been studies investigating whether the use of telehealth may lead to enhance treatment inherent in people living with HIV. They used to telehealth and text to improve engagement in care Studies aims to assess the feasibility of using telehealth and text messaging reminders, thio increase linkage to and retention and care among youth living with HIV as well as enhanced treatment adherence. The study utilizes a three pronged approach. Engagement in HIV care mental health as substance use counseling. Moving on Here are some legal considerations as I mentioned earlier Licensing requirements follow state license sure regulations in the jurisdiction where providers are licensed and where the patient lives. But these restrictions have been temporarily suspended in some states during Kobe. 19. The the SWB Board Regulatory provisions Web page provides information on changes in each state. Informed consent. It is a pre represent in many states for clients to review and sign and tele mental informed consent form, and can be a requirement for medical insurance reimbursement. The National Association of Social Workers recommends obtaining tele mental informed consent even if it is not a requirement. Informed consent addresses many issues, including the risk associative of tele mental health. Exceptions to confidentiality, technical difficulties, Interruption of services protocol. In the event of an emergency, social workers must endeavor to continue services if they are interrupted by, for example, power outages or loss of Internet signal, such as by using landlines, privacy and confidentiality. Privacy and company company she ality rules still apply to telehealth. All the laws regarding confidentiality of protected health information and the patients right to their medical information applies to telehealth interactions. Liability coverage Social workers must ensure that their malpractice insurance carriers cover the provision of Tele Tele Mental Health Services. For example, the National Association of Social Workers Assurance Services Professional Liability Policy provides coverage tele mental health as long as it is conducted in accordance with the social workers, state regulations, state licensing board requirements and HIPPA privacy standards. Next slide please her some ethical considerations. The three seeds confidentiality, competence and cross border practice. There is risk of unauthorized individuals accessing client information through live communication and or digitally stored data. You have to choose a HIPPA compliant platform. Competence. New technology heightens the risk of people without mental health credentials offering mental health services. You have to ensure that you are properly licensed and insured to give services and are competent in using the technology. Ensure that the client is suited for remote services and assess cultural environmental economic meant to physical ability, language or other issues that may have a bearing on service delivery. It declined. Doesn't want to use elemental services. Social workers should help them identify alternative methods. You have to set expectations on services provided based on your training and expertise. Providers may not be as culturally competent when providing services to people in places they are not familiar with. It may also not be aware of environmental or illegal or legal issues moving on payment considerations under the new regular. Under the new regulations during Kobe, 19 telehealth visits are now reimbursed at the same rate as in person services. But social workers must determine in advance any telehealth guidelines that must be met for third party payers such as insurance panels, Medicare and Medicaid. CMS, Section 1135 waivers a lot of Medicare coverage and payment on a broader audio Onley telehealth basis. But these waivers did not override state regulations. Reimbursement will be offered for services provided to new or established Medicare beneficiary clients, clients who are in their own home or in any health care setting clients where services are provided using communication technology allowing real time, two way interactive communication beyond those allow before Kovar 19. Using audio Onley devices such as landlines for certain services, as I mentioned could include psychotherapy, opioid treatment and certain telephone evaluation and management services, telehealth services or reimbursed at the same rate as in person services claims can be backdated to March 6. Providers may reduce a wave cost sharing for telehealth visits during this emergency period. Except for e visits. Social workers must factor in confidentiality concerns when choosing electronic payment platforms and get consent to use them. Moving on. Here are some other considerations with elemental services Self care is a biggie. Social workers are dealing with many stressors. In this current environment, this can lead to burnout and compassion. Fatigue. Social workers are also at risk for symptoms of a carrier's trauma. As we are all navigating, the Kobe 19 Kobe, 19 is considered a collective shared trauma community trauma. The same is one can say the same for the social justice protests that are going on right now all over the country. For people of color, this is another type of trauma and in some cases can activate previous trauma. Therefore, it can start that slippery, that slippery slope into burnout and compassion fatigue. So it is important to incorporate self care practices such as adequate sleep, good nutrition, exercise, positive mindset, social support and other relax ation practices such as mindfulness or yoga. Supervision is also key in this area, Andi I use the term pacing, so pacing yourself between clients and patients as well boundary issues can is also a big sort of risk. Here. Therapists are entering clients homes and vice versa. It is important to maintain strict professional boundaries. Clients preparedness for tele mental services, technology access and privacy in the home client space confidentiality. This can be difficult to safeguard when everyone is at home for both provider and client use of sound machines outside doors and are wearing headphones so that client conversations can be heard. The space is also important. As a provider, you have to ensure that the spaces professional and distraction free and ensure that the client is not on their bed but sitting at a table of desk if possible, dress code. Both client and providers should dress as though they're meeting in the health care setting safety. In the case of new clients identified, identity should be verified with photo ID to prevent frog set up alternative communication methods should the need arise. Creating a Google voice number is a good option to avoid giving our personal telephone numbers discuss contact methods in the event of an emergency safety planning is also key here. Communication speaking more slowly and using Reiter verbalization may be needed. One cannot use hand gestures in the same way. For example, I'm laughing as I'm seeing communication here in this presentation. Next slide. Please. If here are some of the lessons learned about telehealth advantages, tell her how can access patients who live in rural areas or outside of normal health care delivery systems. I think access is really key here. It can help simplify the process of health care delivery by triaging each case and improving communication by capturing, storing and using patient data for better medical decision making. It can offer a broad range of services, including chronic disease monitoring and management, dentistry, counseling, physical and occupational therapy, home health, disaster management, consumer and professional education. It can provide a range of modalities that allow patients to engage with health care providers in a way that they prefer. These include videoconferencing, remote patient monitoring, phone calls and texting secure messaging. Next slide, please. Right. Here's some other lessons. Home based HIV testing and counseling initiatives. These studies are being conducted by the Center for Sexuality and Health Disparities by the University of Michigan Project Nexus is an online study that seeks to understand how telemedicine, how telemedicine could help improve HIV testing and reduce risk among gay and bisexual male couples. Self reported from cordoning negative couples and self reported discordant couples receive at home testing kids. They then report their results and take part and potential counseling in surveys. Project Moxie is an online study focusing on the uptake of HIV testing among transgender youth. At home testing. Kids are sent to study participant to a preferred address, the damn report, their results and take part in potential counseling in surveys. Next slide, please. So this is a study design. This is how it looks like mhm. It is important to note that transgender and gender nonconforming people experience some of the highest rates of HIV in the United States. They encounter many barriers that limit their engagement in HIV testing, prevention and care for this population with Project Nexus and home testing, kids are sent to self reported can coordinate negative couples and self reported discordant couples. The participants then report their results and participate in potential counseling services and surveys. Project moxie involves a pilot randomized controlled trial of 200 transgender youth aged 15 to 24 years. The aim of the study is to see whether the addition of counseling provided by telehealth couple home based HIV testing can lead to improvements in routine HIV testing among transgender use over a six month period. Six month follow. Uh, excuse me. Moving on. Okay, right. Another lesson is simplifies the process. A generalized approach to telehealth of prep services uptake a prep medicines remains low among those most at risk of HIV. These include young black and Latin X men who have sex with men. Recent interventions utilizing tele health are aimed at improved helping improve prep services uptake. New telehealth interventions in both private and public sector sectors offer solutions to geographical and social barriers to accessing prep services. Some established programs can serve as a model to scale of telemedicine for prep services. General schematic of telehealth programs for prep services, as I mentioned. These include video complying with the Health Insurance Portability and account of Accountability Act, or HIPPA messaging platform telephone calls, text messaging platforms, emails, laboratory testing either be at in patient visit at a local facility or mail. Deliver self test kits, prep medicines delivery, either by mail or being picked up at a local pharmacy. Although the general model of telehealth of prep services among those programs from initial environment to medication delivery, is very similar, the financial costs associated with prep medicines can vary greatly. There is a need for ongoing research to identify best practices for appointment modality, laboratory testing and medication delivery looking into cost effectiveness as well as long term outcomes for attention and inherent next slide, please. Yeah, Another lesson is that it offers a broad away of services, medical advocacy and outreach. Telemedicine, maybe use enhanced linkage to a retention and care in rural settings. One such example is the Alabama E Health Program. Medical Advocacy and Outreach launched the Alabama Health Program in 2000 and 11 patients seek care at a clinic near their residents and access of remotely located HIV specialist via telemedicine. Facilitated by an on site nurse. The telemedicine video equipment transmits real time high definition for clear virtual face to face communication whenever possible. All first appointments occur in person. The provider travels to the patient satellite site for the first in person visit and future visits a typically done remotely through telemedicine. In practice, patients could have a combination with telemedicine and in in person visits. Wrap around services are also available to patients by telling medicine. These includes social work, case management, pharmacy adherents, counseling, mental health counseling, translation services, medical advocacy and outreach. Operates a telemedicine network consisting of two full service provided locations with the third in development and 11 rural patients that are like clinics that represents M ales. Alabama Help Initiative Moving on lesson for it can provide a diverse array of interaction modality so patients can engage in a way they prefer. Okay, this is all about being very patient. Center slash Fine Center There are five basic modalities. Store and forward Elektronik transmission of health care information, including images, documents and videos to secure email communications, remote patient monitoring, transmitting health care and other patient information from the patient in one location to a health care provider in another location. Mobile health using mobile devices and APS for providing health care services and health care. Data counseling and consultations, text messaging services, live video consultations, audiovisual telecommunications technology for real time patient provided consultations face to face in patient visits in real time between provider and patient in the same room. Moving on and, in conclusion broadly adapting tele health and HIV care as a potential to increase screening and timeliness of care. Increase access to prep services. Reduce prop medicines. Delivery barriers. It can increase. Adherents. Supports medication Reminders. Allows for engagement with providers across health needs, including mental health and substance abuse. It can reduce stigma. People at risk for living with HIV will be able to speak with provided from their home or their mobile phone, potentially reducing the stigma associated with HIV or infectious disease providers. It can also remove barriers to accessing care. It can improve patient outcomes, and it can increase access to providers. Train in infectious disease. Thank you. And with that I will turn it back. Michael, thank you so much for that presentation. Our next speaker is Carmen Julius. Carmen has over 30 years of experience and health and human services, including behavioral health counseling, medical case management, community health, education, training, evaluation and research. In addition, Miss Julius has substantial experience with organizational development, strategic planning, health economics and operations management. Her expertise includes experience, extensive experience in HIV, s t. I viral hepatitis, tuberculosis, prevention and care services, teaching, training and administration. Carmen, I'd like to hand it off to you. Thank you, Leslie. Thank you for that very kind introduction and thank you all for joining me today as we discuss health disparities until health, we're going to be discussing the question of whether telehealth alleviate or accentuates the problem. So let's go ahead and get into it. And from 2014 to 2018 HIV diagnoses decreased 7% among adults and adolescents. However, annual diagnoses have increased among some groups, the highest rates of HIV diagnoses continue to occur in the South and for gay and bisexual men. HIV diagnoses decreased but trans varied by race and ethnicity for heterosexuals, HIV diagnoses declined from 2014 to 2018. But during that same period, HIV diagnoses increased among people who inject drugs. Let's keep going. Health disparities adversely affect people who have systematically encountered greater obstacles to health based on the following factors factors like race or ethnicity, sex, sexual identity, age, disability, socioeconomic status and geographic location. All of these factors affect a person's ability to achieve good help. Efforts to eliminate disparities have focused primarily on disease or illness and on health care services Moving on Let's talk about health equity. Health equality means giving everyone the same thing, whereas health equity means giving people what they need to achieve their best health. So to equalize opportunities, those with worst health and fewer resources actually need MAWR effort to improve their health. Health equity means we have toe focus on removing obstacles to health, such as poverty and discrimination, and the consequences of those things that include lack of power, lack of access to decent jobs, quality education, safe and affordable housing, safe environments and health care. Moving on uh, in 2018 about 2.8 million Americans working full time jobs were living below the poverty line. Currently, the annual poverty rate could increase. The level seen during the great recession are possibly even higher. Working age adults and Children are going to face particularly large increase in poverty rates. It's projected that poverty rates among working age adults may rise by 63% and for Children, those poverty rates could rise by 53%. Black and Latin X individuals, who will also face particularly large increases in poverty although no racial or ethnic group is likely to be spared. Rural Americans, of course, face many health inequities compared to people living in urban areas. And we know that about 47 million adults aged 18 and over live in rural areas. Let's move on and talk about Southern states now. In the early 19 eighties, the HIV epidemic was concentrated in urban areas on the East Coast and the West Coast. In recent decades, however, the epicenter has shifted to the District of Columbia and the 16 states that comprise the South. Eight of the 10 states with the highest rates of new diagnoses are in the South, and nine off 10 metropolitan areas with the highest HIV rates are in the South. Let's move forward and talk about counties with disproportionate black populations. So of 677 disproportionately black counties, 91% are concentrated in the south. The South has higher numbers of poor uninsured Adult has more numbers of poor and uninsured adults than in other regions, and not on Lee. Our rates of unemployment and lack of health insurance high in those counties, but also diabetes, heart disease and HIV. Now, these pre existing conditions play an important role in the poor. Clinical outcomes from Covic, 19 in those counties, transportation, social and health services are inadequate in rural areas, and cultural factors that fuel stigma and discrimination are are prevalent. There's also slow adoption of the latest testing, treatment and prevention services in those counties moving forward. Advances in HIV prevention and treatment tools are not equally benefiting all parts of society. New infections are highly concentrated among M S M In 2017 the South made up 52% off the new HIV diagnoses in 2018 black Americans accounted for 42% off HIV diagnoses and 13% off the population in 2017. Adult and adolescent men who have sex with men made up 70% off new diagnoses. In 2017 the percentage of transgender people who received a new HIV diagnoses was three times higher than the national average. Let's move on and talk about the intersectionality of race and sexuality. Gay, bisexual and other men who have sex with men are the populations most affected by HIV in the United States. Stigma, homophobia and discrimination put em sm off all races and risk for multiple physical and mental health problems and also can affect whether they seek or receive high quality health services, including HIV testing, treatment and other prevention services. At the end of 2018 in the United States, about 37% of men who have sex with men living with diagnosed HIV infection were white, 31% were black Americans and 25% were Hispanic. Latin X Americans. Let's keep going. We talk about young people at highest risk of HIV. 54.6% of young people who were living with HIV were unaware off their HIV infection. In 2018 92% of new HIV diagnoses were among youth. I'm sorry, 92% of new HIV diagnoses among youth occurred from male to male sexual contact, While 85% of new HIV diagnoses among young women occurred as a result of heterosexual contact. Youth are least likely to be aware that they're HIV positive, and only 9% off high school students have been tested for HIV. 46% of all sexually active high school students reported that they did not use a condom the last time they had sex and youth have the lowest rates of viral suppression. Let's move on. Eso for people living with or at risk for HIV, HIV status is just one element of a person's health. Behavioral and biomedical risk reduction services to prevent HIV and treatment for those living with HIV require engagement in care, continuing to talk about the status neutral care continuum. Sustained engagement in care is important to achieve and maintain health stigma and other social determinants can influence the HIV care continuum before an HIV diagnosis is even made. Let's move forward. So Dr Anthony Fauci, director of the National Institutes of Health, said Thio end the HIV epidemic in the United States. We must close implementation gaps to ensure that all people with HIV are diagnosed and receive the treatment and care they need to achieve and maintain viral suppression. As we move forward from that statement, can telehealth be the next disruptive innovation in HIV prevention and treatment? But when we talk about disruptive innovation, we mean we use it as a term to suggest how to mend problems and to illustrate how new technology can change an industry to make our lives better. Telehealth is considered by some to be a disruptive innovation that may change healthcare. Telehealth has shown increasing utilization, and we're currently experiencing a surge in telehealth application due to cove it 19. But questions remain around the implication off telehealth for health care in the long term. So when implemented across a broader population of people living with HIV, will certain populations benefit mawr or less from telehealth? Shoot patients with new HIV diagnoses always be seen in clinic, regardless of HIV stage. Should telehealth be offered to patients with uncontrolled HIV? And once the Covic 19 pandemic subsides, how will telehealth be used? So let's move on now. Telehealth may serve as a disruptive innovation in H. I V Healthcare. However, we still have questions on how the best use telehealth to expand access to HIV care. Some potential benefits include decreased wait times, expanded or more convenient clinic hours, stigma reduction, reduced unintended disclosure, increased access to health care providers, opportunities for HIV education and increased patient support. However, there is some potential remaining challenges, such as reimbursement policies, access to video and or broadband video for patients and providers, privacy concerns, regulations and policies in place that limit prescribing and patient and provider uptake moving forward. Currently, professionals across fields are looking for ways to work together. TOE offer the best possible services to their communities and to their patients and clients. Social workers are more crucial than ever as the pandemic creates the need for new social services, including mental health. Working together generates more ideas and innovations, and social workers must diversify their teams in order to be more effective. Covic, 19 can be a catalyst for a new model of community outreached. An interpersonal practice. Let's move forward. Telehealth, maybe an effective way to expand HIV care in rural or remote settings among younger people without significant co morbidity. Ease for people who do not access HIV care due to stigma. Hard to reach populations, such as for persons who are incarcerated. Telehealth may be used to reduce transportation barriers and improve engagement in care and medical adherence. Let's go forward to HIV counseling initiatives. The Dallas based Legacy Counseling Center and Nashville Cares showed positive results regarding tele health and HIV care during the pandemic. The urgency of Covic, 19th, spurred their social workers toe quickly adapt their HIV care model to telehealth. There was a reduction of client. No show rates toe almost zero. In some cases, insurance expansion to cover telehealth visits proved to be crucial. Training on new platforms and professional networking for adapted, adapted consent forms and other assistance was also essential. Many HIV clients have transportation problems, so telehealth can be advantageous. Many clients, even homeless persons, have smartphones, but not everyone wants to use video. The new generation of clients living with HIV are more comfortable using technology. Melissa Growth, off the Legacy Counseling Center, says, We want to continue providing this service after this crisis is over. Moving on mhm, the health Service, the Health Resources and Services Administration, recommends that HIV programs that provide or are planning to provide telehealth consult with professional organizations, regulatory bodies and private counsel to develop written telehealth policies that comply with federal, state and local requirements as well a standards of practice. Other recommendations would include network with other organizations in the field toe, identify telehealth platforms that have already been vetted, utilize local low cost technology nonprofits to help with start up and training, and secure funding for telehealth program that is sustainable in the long term. Let's move forward. Mhm telehealth may be used as a model of care to address the gaps and HIV care and prevention. Many people with HIV have limited access to HIV care and may have to travel several hours to reach an HIV care provider. Telehealth helps to bridge that gap in terms of both direct patient provider contact and training of local primary care providers. Telehealth also reduces disparities faced by people with low incomes in areas with minimal HIV care infrastructure. Let's move forward and in summary, Despite advances in HIV prevention and treatment, not everyone has equal access, race or ethnicity, gender, sexual identity, age, socioeconomic status and geographic location. Impact health equity. In order to close these gaps, we certainly need new strategies and models of care delivery that can reduce the barriers to access and adherence. Telehealth as a potential to broaden access to HIV care, particularly in a time of cove in 19 telehealth can be more affordable and can improve access to care where providers are limited. But there are limitations to hella tipped, but there are limitations to telehealth that need to be explored. Thank you so much for joining me on this discussion of health disparities and telehealth. And now give it back to you, Leslie, Thank you so much for your presentation. We're now going to close this out with the Q and A session. So again, just a quick reminder to please submit any questions using the button at the bottom of your screen, and we will go ahead and kick it off. Live with audience Q and A. All right, so first questions of both Carmen and Michael. Do you have experience starting new clients via telehealth? Do you have any recommendations about how we can build rapport with clients that we have not yet met in person? And Michael will start with you? That's a really good question. I think it's important to know a little background about me. I've been doing telehealth now for about 10 years, is a platform that I strongly believe in. I also personally believe that I think it's here to stay, and it's going to represent a significant portion of visits moving forward. I think, um, one thing is to establish Thean initial contact. I think it's you're starting to build report. So, looking at how the exchange is, whether it's B I email or phone call, I typically recommend at least a phone call so you can engage in a different way before you set up those visits. Um, what we do MTR we use a lot of were able to send a lot of documents ahead of time consent forms. So that way, when that first, let's say, clinical visit or therapy visit is we can just kind of jump into the presenting problem and sort of like what their needs are. So I think the initial contact you can utilize email. I personally recommend phone calls so you can engage the person in a different way. Really engage what their needs are kind of triaging them over the phone before you move towards them. More formal intake or first session. Michael, thank you for sharing your expertise over the last 10 years. I'm coming. Thoughts. How do you establish the report? Well, unlike Michael, we did not have 10 years of experience using telehealth, so this was a fairly new modality for us. However, what we have done with our new clients is very similar to what Michael described. We were able to kind of established a report by telephone and because we had the cove in 19 epidemic people understood that there were very special circumstances going on. So I believe that helped us a lot with many of our new clients, and we were able to kind of make sure that the client was comfortable. We had clients that didn't want to use video. We're comfortable using telephone, and so we accommodated that and those clients who were ready to take the new technology and use it with video and that kind of thing we were able to do that. We talked our clients and patients through step by step would occur during the telehealth visit. We did that by telephone prior to the first actual video call or call without video with a provider. So I think that was helpful for us, that we were transparent about what the process waas and that we ensured that the clients understood what they could expect, what they could anticipate and the challenges that they might have. Also, Simon, thank you for that perspective. I think in the breakout sessions we often heard, transparency is key and you started to talk about this of how you walked your patients and clients through what to expect in the telehealth visits. So, Michael, I want to turn it to you just to further us a little bit. Are there any other things that you did to help clients transition from seeing you in person to moving towards a telehealth visit? So, like I said, we've been doing this for a while. So it was it. And we've offered there for clients who might be traveling or might have, like high demanding jobs or in the case of severe weather, Andi, things that shut down. We've been doing telehealth. I think what we had to do differently in a dot adapt. This time around, we updated consent forms on bears. There was a lot of psycho ed now a to the front end of it, whereas before it was more like, Hey, by the way, if something comes up, we could do this remotely. Now it's more like, Okay, this is a platform that we're using. Um, do you have the technology that you have study WiFi. So, you know, there's sort of like an internal checklist that my practice manager goes through with each client to ensure that they are ready. Thio ready to transition to that service. This is more for new clients. But we also check in wolf existing clients as well just to make sure that they have everything that they need to ensure that the visit is gonna go. Aziz Ideal as possible. And Michael, thank you for sharing that again. I think this came up in the workshop sessions quite a bit meeting the client where they're at figuring out what their needs are and having that some sort of checklist to ensure that the visit is going to go smoothly. So next question coming in from the audience, Um, and Carmen will start with you. What kinds of support do you find is needed to help connect clients with all of their services that they may access when they come into your agency in person? Oh, well, I think that one of the things that is helpful for for us is pure navigation That helps with, uh, just a wide variety of things. It helps with establishing a report so that they understand that this is an organization where they can come and feel comfortable and feel safe in it and feel that they're going to get their questions answered. Our navigators have spent so much time over on the phone over the last several months again just explaining processes and allowing clients and patients to understand what they could have expect. The other piece of that is our navigators are often kind of the front man. They will contact, um uh, services outside of our agency to find out exactly what the process is to engage in services. Uh, try to find a contact person so that the client isn't making a cold call, but they actually have someone to contact. And and we ask the questions that we believe our clients would ask or we find out the information that our clients will need to know, and we pass that on to them for any other services outside of our organization. I think I answered that question. If I didn't, please let me know you absolutely Dad and Michael, anything to add? I think it's just Ah, it will entail like a It's a team effort, s so I think you need all hands on deck, um, to just make sure that it's like it can go on as smooth as possible. And I think you have to prepare for the unexpected in some cases, eso then you have to be able to adapt. I think internally for organizations, I think, providing ongoing support. Um, for your staff, I think it's critical in the rollout of sort of like moving towards this modality and supporting clients. So it's like you have to support the clients and engage clients. But I think you also have to support your staff in the process because some of this might be new for them on Bacon. Encounter some of the same technological challenges that clients may also encounter A swell. So, yes, it should be plying center and focus. But you can sort of, like leave out supporting your staff in the process and and and and and making sure they have all the tools and that maybe you have to update protocols. Um, that can factor in unexpected situations. Michael, thank you. You just summed up again. What someone had said in the breakout is Meet the client where they're at where we're capable. So before we can help them, we have to establish protocols and policies and make sure that our staff are comfortable, so moving on a little bit what have you seen in terms of ways to address the needs of clients who may not have access to some of the technology needed for telehealth? And have you seen lower tech ways? Thio Additional tech ways to meet and reach clients and Michael will start with you. So our standard policy we prefer visual or audio so we can assess for ethic and presentation because the bulk of the work that we do it's psychotherapy. Eso for us as a practice, you know, we want to see the patient, the client, so we can be able to ask for African presentation. I think when we're working with adolescents, you know a creative thing is to utilize scales, show videos, which can be which can trigger and facilitate conversations. Um, you know, But what we've seen more recently, I would say over the past two months, um, because a lot of folks are now accessing services were trying to access services we're seeing sort of like more of a diverse cool that don't they would prefer a phone call or some other means more ongoing texting. So, for for us internally, I've had toe identify, let's say, clinicians who have the bandwidth to navigate that. So that way we can, you know, assigned them appropriately. Um, which fits our model where we're assigning based on clinical fit, not availability. So I think that's key for us and because we provide mostly mental health services. But I think the key here is, um, the entry point. How are their entering? Let's say the services, how did they find out? And sort of like, Who is that initial point of contact? So when we look at sort of like the sanctuary model of, like, trauma care and basic tenets around trauma informed care, everyone plays a major role, you know? So and you gotta have some sort of like universal messaging. You know, that is consistent. So it won't. So it can reduce potential confusion for the client. Thank you, Michael. Carmen. Question for you. What do we know about the effectiveness of telehealth for addressing the needs of our clients? Can you speak to any evidence of its effectiveness? Well, I can speak to the fact that we have had a lower our reduction in our no show rate. We actually have had our clients and patients who feel even more comfortable because for many of them, they're they're in their homes, talking to us. They're not in a strange or different environment. Um, I think that it has, you know, allowed us to be more creative in serving our consumers. We have been able to utilize some different kinds of methods off engaging with our clients that are, we believe, are creative and unique to this particular situation that we're in. And there have been well received by our clients, things like, um, using hot spots for our support group. For those clients who didn't have smartphones or access to technology, we're actually able Thio provide hot spots to them. They have been able to We've been able to use things like what we call curbside service. Where consumers are able, our clients and patients are able to come to us. Those that don't have access to technology, they're able to come to us. We're able to give them some services with a set up that we have in a safe and social distance way that is very respectful and very confidential and has just really kind of stretched the imagination off our staff and, uh, you know, been able to help us meet those needs of the clients. And so, yeah, I think the success has been in our creativity and things that have worked well is that we have expanded access. So more clients and more patients are able to keep their appointments and not have to worry about transportation and those kinds of things. Herman, thank you for responding to that. And as we were discussing in the breakout rooms, we've seen a lot of agencies move quite swiftly into offering telehealth services. So, Michael, I want to turn to you. Um, you had talked about in your presentation the big ticket item of self care. So what can you all recommend as tips for providers to address their own stress with the now forced modality of service provision? So, um, I e can give you some what we do and what I typically recommend for my staff. So I frame it as pacing. Um, you know, we're hearing this term zoom fatigue, but it's really screen fatigue where in meetings after meetings, um, sessions after sessions. And then we have our phones and we're responding to blah, blah, blah, whatever. Um, you know, and if we have kids, we're dealing with all of that. So typically what I recommend internally is my clinicians should not see more than three patients back to back to back. You figure they're like 45 to 55 minutes sessions. That's three hours. They should take a break on been some cases. You know, if the client is high risk, you know they should maybe, um, take the rest of the day off and reschedule. I think self care is now more important than ever for a number of reasons. We're navigating several collective community types of trauma. Right cove. It is a shared trauma that we're all navigating experiencing. I think when we look at it from the perspective of grief and loss, we're all grieving and mourning our lives before March. And in some cases where we're grieving, let's say someone who we, we may have lost to cove it right, So So I think it's understanding to like it's important to understand the gravity of the situation and encourage supervisors and employers to be creative and maybe flexing and allowing staff to flex their time a little bit. I think that's key because we have to pace ourselves. Um, turn off notifications on your phones. You know, you don't have to be on social media. You don't have to get the most recent news blast because it can put you in an activated state and then you have to go into seeing the Klein. Other strategies is again I mentioned earlier in on and talking to my peers one of the things I do. My husband and I do like every other Friday night, we turn the living room into like a club because we like music and we like to dance. It's not ideal, but it's, you know, it's self care, you know, you have to find ways to recharge. And I think you know, whatever you do, um, you have to distinguish between wellness, which has a level of consistency. With this, the wellness is usually I go to the gym. I do this, I do that. So there's a routine that goes with it. And then there's sort of, like, triaging yourself. So I'm kind of stressed out right now. It's hard for me to focus. What can I do right now to recalibrate, you know? So I think it's finding moments of relief throughout the day, being creative with it, you know, and understanding that what's working for you now may not work tomorrow, you know, because here's the other thing we're losing like we used to commute to work. So those periods of transitions were sort of like we calibrated moment. You know, we don't have that luxury anymore, So we're sort of like transitioning from one meeting to the next meeting. If you have kids, you're dealing with that, you know? So I would maybe if you can be flexible with stuff, do that. And do not do any house chores while you're working. Separated. So that load of laundry, it can wait to the weekend because you're stressing yourself up by changing it, you know, by going from the washer dryer and then going into the next meeting, you know, and remember Thio eat, you know, and not eat in front of your computer. Take a break. And if you have the luxury off the privilege of like changing, let's say, a workstation, move it around. So that way you can be in a different like environmental stimuli. And I think that's key, you know, So like that that can provide tremendous relief. Changing your workstation for a few hours or even for a day can have a profound impact on just if you do it. You know what I'm talking about? But shut off notifications. And I think you have to be honest and real with with yourself with your loved ones and even your supervisor. So if you're feeling off, you know, denial, in my opinion, is never in season. No matter how welcoming the idea is to fit into that outfit. You know, you have to push against that because I mean what we're navigating Israel so yourself care. I think it's important. Otherwise he's going to bleed into the other areas of your life. But, Michael, I have a feeling that you are. You had a camera in my house this morning? Well, everything you told us and all these things about self care. I just jotted down so many things that I should revisit. So thank you for that. Um, Carmen, just to get a different perspective. Is there anything that you would add in terms of what you can offer for the providers in self care? Well, I think those were those were excellent suggestions that Michael just mentioned what we encourage our staff to do a schedule. Downtime. Make sure you're taking your lunch hour. Make sure you're taking a break in the morning. Ah, break in the afternoon and making sure that when you're when you have stopped work, you stopped work. That doesn't mean go back and check emails. That doesn't mean go back and check your phone messages. But make sure that you're limiting your time on your electron ICS when it comes to work. If you like video games, that's fine. But you know that constantly checking email, constantly answering that ringing phone are looking at those notifications again. Um, that's that's stressful. We also encourage our folk to be aware of how they're feeling. You know, just be aware and recognize that you know that things are different right now that, like Michael said, you have to take a break from, you know, going from one shore to the other store chore to another choice that is stressful also. And again, as as Michael said, you know, you have to be flexible with yourself as far as making sure that you are using your time off your leave time. People still have leave time. They still have time off making sure that you are making judicious, judicious use of that so that you're able to re energize your own batteries and you're able to, um, take care of others. We always say we operate from a full battery perspective that your battery has to be full so that you could take care of others. And so that's my spiel. Herman and Michael thank you for your perspectives and those friendly reminders so that we can all take care of ourselves. Um, please. As a reminder, if you guys are have questions that you'd like to ask, please use the button at the bottom of the screen. We still have some time. We did have a few questions come in that are really specific to HIV care. First one being what kind of response can a social worker offer during the pandemic for the families with HIV and AIDS and Carmen will start with you? What kind of response can a social worker offer to families during the time of the pandemic? I mean, the time of the pandemic. I think the most important thing is to understand that you can. There's some steps that you can take to stay healthy. You and your family can take to stay healthy. We want to do our regular everyday wearing masks, washing hands, limiting contact with other social distancing all those kinds of things, eliminating unnecessary travel. Um, you know those air just the very basic things that we can do to ensure that we all stay healthy. And I think, for families, the persons living with HIV. You also want to ensure that those persons remain engaged in care. But they have access to their medications. They have access to their providers and other support services, including behavior, health and mental health services. I think that's violence. Thank you. Carmen and Michael. How has the Koven 19 pandemic impacted access to HIV treatment or prevention services Among the clients that you see, I think the impact was initially felt probably within the 1st 30 to maybe 60 days as organizations, agencies and providers sort of life had to adapt, you know, in transition and maybe trained staff. Um, presently, um, it seems like at least in my area and the clients that we're working with, um, they seem to be okay on that front. We're finding, um the logjam is for, like, psychiatric evaluations, you know, things that are more like, like in that in that realm. But from the perspective of HIV care with the clients that we see, um, they've been consistently engage in their care. Thank you in question to both of you and Carmen will start with you. Do you have thoughts about which aspect of client care seemed to work best via telehealth? I am not sure. But you know, when I think about it with our case managers, they actually have been doing telehealth. They do a lot of work with clients via telephone on by text and by email, and so that is literally telehealth. Also, I think that we have not really framed that is telehealth unless there's a screen in front of you and you could see the other person. We often think that's not telehealth, but that is not true. I think that we can adapt telehealth toe almost any aspect off service provision. We're even putting together our support group. We have a group of women that were working with a program called the Red Chair Diaries that were working with women. It was originally was supposed to be in person support. But we have very easily transitioned that to telehealth. And we're really excited about that again. We've had Thio, you utilize, um, WiFi hot spots for persons who didn't have smartphones and that kind of thing. But we found that very many of the women had tablets and smartphones and that kind of thing, so we were able to transition very easily with that. The same with our housing program we've had to work with, You know, we had to purchase the software Thio sign documents online and that kind of thing and sometimes again, with patients who don't have access to technology, Uh, it might be a curbside signing of an application in order to make sure that we get the information documents that we need to assist with housing. But I think we have been able to successfully transition all of our services, um, to to telehealth the only one that I could think of that we haven't really been able to transition is our food pantry because people actually need to come in and pick up food course. And Michael, do you have thoughts about ways that the telehealth platforms that are currently being used can be improved. And along those same lines, are there additional features that you think should be integrated into the current platforms being used for telehealth? That's a really good question. Um, so this is one of my core beliefs. Any modality or intervention is only as good as the person behind it and their belief in it. That's number one second from that. I think it's also their ability to engage and build the poor with the client. So I think if we can then go to stage three. I'm all about access, right? And and I think that, you know, right now, I think that what's happening right before us, I think we're in the middle of a sort of like a realignment off how services is gonna look like moving forward and even other sectors of the economy when we look at him or at a macro level. You know, I truly believe this is here to stay. I think, um, you know, appointment reminders. I think it's key. Um, you know, But but But I think they're gonna be like, some issues that could be in the way is Ah, lot of people don't have study WiFi, you know, and a lot of people let's say that there's a lot of their sectors of the population that don't have access to. Resource is so So I think that if we can kind of, you know, I think that the movement should be there, you know, because there's so much promise an upside here. And you think that you know, organizations will have to tailor their services specific to the needs of the communities, and I think that's gonna look different within each community. And I think it's gonna look different for each discipline. But I think there are certain things that, um are let's say, transferrable, you know, appointment reminders, you know, like being able to sign documents electronically, you know, being able to share Let's say documents, um, that you don't have to sign. So, like if you assign, let's say homework and your clinician or whatever you want them to review something, you know, we can have virtual town hall meetings. That could be like rooted in psycho ad, you know, you know, and you can do surveys in some of these meetings. So So I think that technology can be our friend if is used appropriately. And if people have access, right, So, like like like the access has to come in many ways, not just access to a provider, but access to the technology and also access to WiFi and resource is that's gonna allow for this relationship toe happen and develop green. Well, Michael and Carmen, it looks like we have no further questions coming in. I wanna offer you the opportunity for any last minute closing thoughts before we we, uh, let everyone go for the rest of the evening. So, Leslie, I do want to make a point that we cannot assume that all of our clients and patients know how to use the technology, even if they have access to it, We have to train them. We have thio give them the opportunity to learn how to use the technology and learn to become comfortable with it. So that I think, is part of our responsibility also. And I think that will have a great impact on the uptake of technology for many of our clients and patients. E I agree. 110% I think to kind of like I want folks to just sort of, like, you know, take a moment and just reflect a sort of like how these last months have been what challenges you've encounter. What's your biggest challenge now? What's the biggest one of the biggest challenges you're going through right now? And whether or not um, you were experiencing this challenge before Cove it, you know? So So I think, you know, we all need to sort of, like, have a moment of self reflection on day and not underestimate what we're vulnerable towards Right now. I keep mentioning trauma because that's one of my areas of specialty. We are, ah, high risk right now and probably more than any other time in our lives. For symptoms of that carries trauma right and the expectations as providers to be on point and and like on top, I think the expectation is greater than ever because there's a lot of people that are struggling, and there are a lot of people who need services. So I think understanding that having or at least having a general understanding of the gravity of that and what that can look like as a provider, you can't underestimate what we're vulnerable towards. As provider on, Do we have to engage in really self care? We have to be very intentional about our self care so we can provide the services at the level that we're accustomed, regardless of the platform, whether we're talking to the help or at some point going back to in person, you know? So I think it really taking care of ourselves is critical now, more than ever pacing ourselves, um, plugging. I think it's also very key here. Um and just, you know, I wanna ask everyone. And when was the last time you had a moment? When was the last time you laughed so hard that, you know, because again, these air things that we are missing, these were things that were grieving and, you know, for some of us are grieving some of this, you know? So So if you haven't been able to share a laugh or you haven't been able to do something I've been wanting to do that you can do do it because it matters. It's gonna allow you to do the work and to stay sort of like on top of your game, Michael and Carmen. I want to thank you so much for your presentations this afternoon. This evening. Thank you so much for sharing your expertise during the Q and A. And throughout this entire program. All of you. Thank you for attending. And I hope you all enjoyed this session. Thank you. Thank you.
