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Study Facts HIV SERVICES AND TREATMENT IMPLEMENTATION IN CORRECTIONS (HIV-STIC) Guidelines and Benefits for the Correctional population and Criminal justice and HIV Care providers Criminal Justice Drug Abuse Treatment Studies

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Study Facts CJDATS HIV STIC Puerto Rico

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Table of Contents: Introduction: ............................................................................................................................................... 3 Study Objectives: ........................................................................................................................................ 3 Significance: ................................................................................................................................................ 4 Frequently Asked Questions: ...................................................................................................................... 4 Contact Information: .................................................................................................................................. 8 Appendix ..................................................................................................................................................... 8 Table 1. Inmate HIV-Care Transition: Key Players ................................................................................... 9 Table 2. Primary and Secondary Outcomes, Data Sources and Instrumentation .................................. 10 Table 3. Timing of Survey and Other Data Collection Activities ............................................................ 14

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Introduction: In previous meetings with CHSC, Department of Health, and Department of Corrections staff we have presented the need for and the design of the study sponsored by CJDATS2 involving transition to HIV care from prison to community. This topic has been chosen by the CHSC Infectious Disease Control staff as the one best responding to current services needs. This document complements presentations and documentation previously distributed. We hope it will clarify remaining doubts that have risen during follow-up meetings about the study and its value to all participating institutions.

Study Objectives: 1) Test the effectiveness of the change team approach for improving the value of HIV services among staff of correctional and community HIV organizations. Value is defined as a combination of the acceptability, perceived feasibility, and perceived costs of implementing HIV service improvements 2) Test the effectiveness of the change team approach for increasing the services penetration of HIV services for offenders infected by or at risk for HIV. Penetration, as defined in this aim, is the increase in receipt of HIV services for infected or at risk offenders 3) Test the effectiveness of the change team approach for improving the quality of HIV services delivery for offenders infected by or at risk for HIV. Potential examples of quality improvements in HIV services are reduced waiting time for HIV testing, improved ARV adherence, and reduced no-shows for services in the community.

Value Services Quality

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Significance: HIV-STIC proposes interventions that will improve our understanding of HIV services implementation, which will help to inform the development and testing of new implementation interventions to train and coach staff, increase administrative support and organizational readiness, maintain fidelity, and improve organizational culture and climate surrounding HIV services. The protocol applies a promising framework, taking advantage of the multi-site CJDATS2 cooperative agreement platform, for testing implementation intervention strategies not yet tested in criminal justice contexts that may provide specific tools for improving implementation of best practices in the field.

Frequently Asked Questions: 1) Why is this research significant? Inmates and other offenders are at high risk for HIV infection, yet a number of important gaps exist in the implementation of effective HIV services for preventing, testing for, and treating HIV across the US criminal justice system. There are substantial public health implications for improving the detection of unidentified infections, encouraging inmates to be tested or disclose their results, and facilitating access to antiretroviral (ARV) medications linked to community care after release so that uninterrupted medications are received. Studies of jail and prison populations have indicated substantial proportions of undetected infections, lack of opt-out or regular testing, and lack of testing at discharge. In addition, ongoing stigma and discrimination in correctional and community settings for offenders provide barriers for encouraging and facilitating testing, self-disclosure, and access to ARVs. Local change team process improvement approaches offer a promising model for addressing these gaps in HIV services. This project will test a change team approach to improve organizational coordination for HIV transitional care. Because it is a large multicenter study across 11 sites in the US, we will be able to use results to inform policy recommendations for US prisons and jails if applicable to the site. 2) What is the organizational change model that will be tested? HIV-STIC will compare the results of an implementation strategy using a process improvement approach to improve implementation outcomes for HIV services. In substance abuse treatment settings, team approaches to problems and providing challenging goals and participation in decision making have been shown to enhance substance abuse treatment delivery by improving staff morale and facilitating staff cohesion and goal-directed activity. Training is a common solution for implementation of new practices. Well designed training programs have been shown to build end-user acceptance of new practice. Training usually involves providing the knowledge base for a given intervention and then providing information and guidance on implementing the intervention in the organization. Specifics about how new practices should be implemented are determined by the organization to assure their contextual relvanace and appropriateness

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Specifically this study will employ a modified process improvement approach that is modeled after NIATx, but which differs in the following innovative ways:  NIATx focuses on improving clinical and business processes within a single drug abuse treatment facility. In most participating sites, the HIV study’s process improvement will cross organizational boundaries to include both correctional settings and community health and drug treatment providers. This is a novel application of this strategy. And we need to determine if it also works well in improving multi-sector processes. HIV services involve different systems (criminal justice, public health, drug treatment), funding streams, agencies, and providers both in and out of the criminal justice system.  Adapting NIATx for correctional settings provides a new mechanism for fostering organizational change and new technologies to improve implementation. NIATx focuses on the drug abuse treatment process. HIV-STIC envisions a continuum of care that includes HIV prevention, testing, and treatment over time. In parallel with NIATx, however, the key goals in HIV-STIC are improving access to HIV testing and treatment, improving continuity of HIV treatment, and the quality of these services).  NIATx is not used to implement a specific practice or intervention. Rather, the change teams may attempt to improve existing business or clinical practices. In contrast, HIVSTIC seeks to implement practices or interventions in specific areas (namely, prevention, testing, and treatment continuum). Some of these practices may already be in use in some participating sites, so the effort may also be to improve existing administrative or clinical procedures, including improvement of coordination between organizations. It is expected, however, that in some sites there will be an effort to implement new practices. 3) What is NIATx and how can this model help us improve cost efficiency? 85% of customer related problems are caused by organizational processes. To better serve customers, organizations must improve processes. NIATx (Network for the Improvement of Addiction Treatment), is a modified process improvement approach and it has been applied successfully in drug abuse treatment facilities. NIATx focuses on two key drug treatment goals: improving access to services and improving retention in treatment. NIATx uses five principles to identify problems and to introduce and test organizational changes: • understand and involve the customer • fix key, important problems • pick a powerful change leader • get ideas from outside the organization • use rapid cycle testing 4) How can we conduct the experiment with a control group if in PR the system is unified and the change team involves staff at the system level? Won’t this affect the study design by contaminating the control group? No. Although the scopes of planning the change process will ultimately affect the whole system when completed, during the study intervention phase we will only pilot interventions in the 2 institutions selected as the “experimental group”. The other 2, our control, will not be involved during this phase in any of the change processes recommended by the change team. At the end of the study year we will be able to compare the 2 groups. If the change processes adopted 5


demonstrates improvements in referrals significantly greater than those generated in our control institutions, we will have initial evidence as to its effectiveness and its potential to be adopted system wide. This phase of the study, from the organizational standpoint, can be thought of as evaluating in a sub-sample the feasibility of the changes proposed. 5) Who should be involved?  Deputy Warden  HIV Services Coordinator  Facility Medical Director  Infectious Disease Nurse  Other medical staff ( Department of Correction or contracted)  Transitional/discharge planning case manager  Community Based HIV services provider clinical director  Drug treatment provider clinical director  Educational services director  Security staff 6) What are the key roles of the DOC, CHSC, and Community Program staff in the study? a. DOC & CHS staff:  Executive Sponsor: The Executive Sponsor determines which area of the HIV Services Continuum will be the primary focus for all sites in their particular state. The Executive Sponsor will periodically monitor progress at each of the sites but will not be involved in day-to-day management of the implementation and change process.  Facility Sponsor. The Facility Sponsor, whose role is similar to that of a Chief Executive Officer (CEO) in a business organization, is instrumental in deciding which specific process improvement outcomes to target within the HIV service area designated by the Executive Sponsor; allocating resources and supporting the quality improvement effort; and in monitoring progress toward implementing the targeted changes.  Change Leader. The Change Leader guides the LCT through the quality improvement process that is intended to improve the HIV services continuum. The Change Leader will typically nominated by the Facility Sponsor. b. All involved agencies;  Local Change Team. The LCT will be composed of members of the criminal justice and community-based health agencies. The LCT will implement the change process under the direction of the Change Leader. 7) Are we going to be evaluated? No. The research objectives explore better ways to improve quality services for HIV in a correctional setting. For PR, this includes standard institutional protocols between HIV programs in the correctional agencies and HIV and drug treatment communities affecting transition to treatment from prison to community. 8) Who will have access to study results? All the data collected in this study is confidential. Your name or any kind of information will be used only for research purposes and will be safeguarded by the research team. Any publication as a result 6


of this study will present aggregated data, that is, data from all sites across the natiion that are collaborating in the study. 9) How does our participation as services providers benefit our organizations?  Training (Professional Education Approved) • HIV care and services in correctional services • Designing specific tasks and action by establishing strategies in HIV services  Organizational changes- the situation that the change process focuses on was chosen by the CHSC staff and responds to a perceived need that is sought to require attention. The project provides an opportunity to support a formal change process with other key organizations that need to come together to improve transition to HIV care in the community. The outcome of the project should therefore be of benefit to the participating organizations that share a common goal of improving coordination between HIV treatment sectors for criminal justice populations.  Infrastructure based on evidence practice. The project is able to provide ongoing consultation regarding evidence based practices and what seems to work in transitional care. Information required for strategic and services planning or reviews will be provided as required by the change team. This reliance on best evidence to plan resources can support activities of organizational significance such as accreditation processes sought by the health care providers, ongoing quality improvement, as well as in service training as required.

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Contact Information: Principal Investigator Name Carmen E. Albizu, MD Email carmen.albizu@upr.edu Department

School of Public Health – Center for Evaluation and Sociomedical Research (CIES) office A-430, 4th floor

Contacts Valerine Santiago ext. 4525 /Glorimar Caraballo ext. 4526 Telephone (787) 758-2525 Fax (787) 751-0772 Project Coordinator Name Graciela D. Vega, BA Email gra_vega@yahoo.com Mobile (787) 934-3722 Telephone (787) 758-2525 ext. 4416 Fax (787) 767-4146

Research Assistants Name Paloma M. Gonzalez López, BA

Name Edith C. López Toro, BS

Email paloma.mgl@gmail.com

Email edith.c.lopez@upr.edu

Mobile (787) 241-4352

Mobile (787) 439-5886

Telephone (787) 758-2525 ext. 4416

Telephone (787) 758-2525 ext. 4216

Fax (787) 767-4146

Fax (787) 767-4146

Name Leonell Torres- Pagán, BA

Name Ellaine Laboy

Email torres_leonell@hotmail.com

Email elaboy13@gmail.com

Mobile (787) 515-8384

Mobile (787)617-2551

Telephone (787) 758-2525 ext. 4416

Telephone (787) 758-2525 ext. 4216

Fax (787) 767-4146

Fax (787) 767-4146

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Appendix

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Table 1. Inmate HIV-Care Transition: Key Players

CommunityBased Health Services

Correctional Institution Correctional Health Services

Correctional Administration

Department of Health

Medical Unit (Medical Director/Infectous Diseases Nurse)

Pre-sentence Coordinator

Case Manager

Pre-release Program

ASSMCA

HIV Services Provider

Parole-Probation Program

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Substance Abuse Treatment Services Provider


Table 2. Primary and Secondary Outcomes, Data Sources and Instrumentation Domains Primary Outcomes Domains Value: a combination of the acceptability, perceived feasibility, and perceived relative costs of implementing HIV service improvements in relation to the Proctor Model

Data Source

Services Penetration: the increase in receipt of HIV services for infected or at risk offenders.

Participating Agency Records of Services

Aggregated information from agency records for services utilization, such as, the % of inmates tested for HIV tests at admission and to discharge, % of HIV+ inmates receiving ARV medications, % of inmates who receive discharge planning based on discharge HIV test, % of HIV+ inmates linked to communitybased HIV health care following prison release, number of prescriptions filled in the community

Quality of Services Delivery: extent to which the quality of HIV services delivery improves, related to service-level outcomes of efficiency, effectiveness, or timeliness of the services delivery.

Participating Agency Records of Services

Measures tied to process goals improvement including “reduced wait times”, “reduced no shows”, “improved access”, and “improved continuation rates.”

Secondary Outcomes Domains Stigma: Negative stereotypes, emotions or actions related to HIV or the HIV infected

Description 

Staff Survey

 

Staff Survey

 

Interagency Collaboration: extent to which agencies share responsibilities, information, and

Staff Survey

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The medical provider administration supports implementation of the HIV services continuum? Are research based practices not useful in correctional environments? The modified HIV services for people under criminal justice supervision are a fair way to handle their HIV issues?

People who have HIV/AIDS should be given treatment and care only if they stop participating in immoral or illicit activities? People with HIV/AIDS should be allowed to participate in social events? People with HIV/AIDS should be isolated from other people?

To what extent does your organization SHARE information with other organizations that provide HIV services to persons under correctional


Domains planning activities.

Data Source

Description care?

Awareness (inmate): the extent to which inmates are aware of various components of the HIV Services Continuum

Anonymous Inmate Survey

Items developed specifically for study to assess an inmate’s level of awareness of the HIV Services continuum. The following are some examples of such research questions that might be examined:     

Impact of the NIATx process: Assess the change model on the agency. Areas measured include: Staff Acceptance of the Change Process, whether there was sufficient training resources to support the changes initiated by the Change Team, and the perceived response to the changes on the part of agencies to which referrals are made.

Impact of organizational characteristics: that are likely to influence whether the implementation effort is successful.

Have you ever attended HIV education and prevention classes at this institution? Have you ever been tested for HIV while in prison or jail? Are you aware of DOC policy at this institution for providing of medications to inmates who have HIV? Are you aware of DOC policy at this institution for providing of prerelease planning services to inmates who are HIV+? Is this institution doing everything it can to stop the spread of HIV?

Assessment of Change Team Activities

designed to measure how well the Change Team functioned, both internally and in respect to the agency. The instrument measures: overall satisfaction with the functioning of the Change Team, the effectiveness of the Change Leader, the effectiveness of the Change Team group process, the self perception of the effectiveness of the Change Team group members, the effectiveness of the Change Team in completing assignments and communicating with the rest of the agency, the efficacy of the change team process, agency support for the Change Team recommendations, the supportiveness of the agency staff for the Change Team recommendations, the perceived supportiveness of agencies to which referrals are made for the Change Team recommendations

Baseline Survey of Organizational Characteristics (BSOC)

Self-report survey that includes a number of standardized scales, including scales measuring: staff needs, program needs, training needs, pressure for change, organizational resources in five domains (staff, training, equipment, internet, and supervision), multiple dimensions of organizational readiness for 11


Domains

Data Source

Description change, leadership attribute, organizational climate, interagency coordination, organizational environment of participating agencies, and characteristics (e.g., gender, experience level) of the staff . The following are some examples of such research questions that might be examined:  

Assessment of HIV Continuum training: evaluation of the quality of the HIV Continuum training, to obtain participants' assessments of the training and their intentions to use the workshop material/information.

TCU WEVAL (HIV Continuum Training Quality)

Items address adoption and implementation potential (quality and utilization, resources and skills, training, and support and commitment) as well as expected barriers to adoption and implementation. The following are some examples of such research questions that might be examined:    

Process Data: types and level of staff activities; changes in the HIV Services delivery structure; and changes in the funding, regulatory, or policy

Process Data

Are organizations that have training needs more likely to successfully implement a training intervention? Are organizations with better cross-agency collaboration more successful in implementing an HIV continuity of care intervention?

You were satisfied with the materials on procedures you learned about in this session? Your program has enough staff to implement these materials? You would attend a follow-up training session if conducted several weeks from now? Your program director (or clinical supervisor) would support and encourage the use of these materials.

These contextual data will be important for interpreting the quantitative findings and it will be important to monitor staff activities occurring at the study sites. These types of events and activities will be monitored and documented 12


Domains environments.

Data Source

Description through monthly reporting forms completed by the Facility Sponsor or Change Leader (experimental sites) or HIV study coordinator (control sites). For both the experimental and control sites, several measures of process and site activities will be collected.

Qualitative Interviews: provide critical data as to the barriers to change encountered by the Change Team and what activities were successful and unsuccessful in overcoming these barriers

Qualitative Staff Interview Guide

The semi-structured interviews will be used to collect process data on: the functioning of the Change Team, coaching activities, the interaction between the Change Team and other staff members

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Table 3. Timing of Survey and Other Data Collection Activities Instrument Prior to Training

Immediately Post Training

6 mos.

12 mos.

(March-April 2012)

(April 25 2012)

(Sept.-Oct. 2012)

(April 2013)

x

x

BSOC

x

HIV Specific Staff Survey (including):

x

Assessment of HIV Continuum training: TCU WEVAL (HIV Continuum Training Quality) Anonymous Inmate Survey

x

x

x

Qualitative Interviews

x

Assessment of Change Team Activities

x x

Process Measures

monthly

Agency Records (including): Services Penetration

x

X

Improvement in Service Delivery Processes

x

X

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HIV-STIC: Study Facts  

Guidelines and Benefits for the Correctional population and Criminal Justice and HIV Care providers

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