FIELD ACTION REPORT
Assessment of a Medical Outreach Program to Improve Access to HIV Care Among Marginalized Individuals | Chinazo O. Cunningham, MD, John Paul Sanchez, MD, MPH, Daliah I. Heller, MPH, and Nancy L. Sohler, PhD, MPH
Marginalized populations are disproportionately affected by HIV, yet they have poor access to health services. Outreach programs focus on improving access, but few are evaluated. We assessed a medical outreach program targeting unstably housed, HIV-infected individuals. We extracted data from 2003–2005 to examine whether keeping medical appointments was associated with patient and program characteristics. Patients kept appointments more frequently when they were walk-in or same-day appointments (compared with future appointments; adjusted odds ratio [AOR] = 1.69; 95% confidence interval [CI] = 1.38, 2.08), when they were at a community-based organization’s drop-in center (compared with single-room occupancy hotels; AOR = 2.50; 95% CI = 1.54, 4.17), or when made by nonmedical providers (compared with medical providers; future appointments: AOR = 1.38; 95% CI = 1.05, 1.80; same-day appointments: AOR = 1.70; 95% CI = 1.03, 2.81). These findings demonstrate the importance of program-related characteristics in health services delivery to marginalized populations. (Am J Public Health. 2007;97:1758–1761. doi:10.2105/ AJPH.2006.090878)
MARGINALIZED POPULATIONS, such as racial/ethnic minorities, substance users, and the unstably housed, are disproportionately affected by HIV disease, yet they have poor access to HIV primary care services.1–8 Many outreach programs focus on improving access to care, but few have been evaluated. Improving access to HIV ambulatory care services is important for public health reasons and is specifically associated with fewer hospitalizations.9 We evaluated a medical outreach program targeting HIV-infected individuals living in single-room occupancy hotels. Specifically, we examined patient- and program-related
1758 | Field Action Report | Peer Reviewed | Cunningham et al.
factors associated with keeping medical appointments.
PROGRAM DESCRIPTION Since 1999, physicians from Montefiore Medical Center, a university teaching hospital in the Bronx, New York, have collaborated with the outreach team from CitiWide Harm Reduction, a community-based organization in the Bronx that provides harm reduction services to HIV-infected and high-risk individuals.10,11 With the outreach team, physicians deliver medical outreach, including medical triage, evaluation, and education, to single-room occupancy hotel residents. Additional outreach services include harm reduction education and supplies (e.g., condoms, bleach kits to clean syringes), syringe exchange, toilet paper, personal care and first aid kits, and occasionally food. Physicians or other outreach team members also refer residents for services, including medical care to the Health Services Program. Staffed by Montefiore medical providers (physicians, a nurse practitioner, and a physician assistant) and CitiWide nonmedical and supportive service providers (i.e., administrator, administrative assistant, and program assistants and outreach
workers), the Health Services Program offers medical services ranging from acute care to comprehensive HIV care. The Health Services Program delivers care in 1 of 3 settings: patients’ single-room occupancy hotel rooms, CitiWide’s drop-in center, or Montefiore’s community clinic. Services provided at the hotel rooms and drop-in center are similar; patient history is obtained and physical examinations, prescriptions, vaccinations, and referrals are provided. Services provided at the clinic are more extensive and also include blood tests and x-rays. Patients interested in utilizing health services can make appointments during outreach or while at CitiWide’s drop-in center. Appointments are available with any health care provider in all locations. Same-day and walk-in appointments are available at CitiWide’s drop-in center, and future appointments are available at all locations.
EVALUATION Methods We examined a total of 2666 medical appointment records with unique patient identifiers from CitiWide’s and Montefiore’s databases from 2003 to 2005. Data elements included patients’ sociodemographic information,
American Journal of Public Health | October 2007, Vol 97, No. 10
FIELD ACTION REPORT
Outreach doctor in a single-room occupancy hotel.
appointment date, appointment location (i.e., single-room occupancy hotel, CitiWide’s drop-in center, or Montefiore’s community clinic), medical provider to be seen, date the appointment was made, person making the appointment (i.e., medical provider or nonmedical provider), and whether the appointment was kept. Appointments made on the same day in which appointments occurred were defined as sameday or walk-in appointments. We used bivariate analyses (using the χ2 test) and logistic regression analyses using general estimating equations to evaluate the association between kept appointments and patient- and program-related variables. Records with any missing data elements were dropped (394 or 14.8%). Results were similar when records with partial information were retained.
Patient and Program Characteristics and Kept Appointments Among the 416 patients who made appointments, the mean age was 42.7 years; the majority were male (60.3%), Black (57.7%) or Hispanic (36.3%), and had annual incomes under $12 000 (96.2%). There were
no differences in patients’ characteristics between those who kept versus those who missed appointments. For all appointments, patients kept more same-day and walk-in appointments than they did future appointments (adjusted odds ratio [AOR] = 1.69; 95% confidence interval [CI] = 1.38, 2.08; Table 1). Patients were most likely to keep appointments at the community-based organization’s drop-in center (compared with at their single-room occupancy hotel room: AOR = 2.50; 95% CI = 1.54, 4.17; compared with at a community clinic: AOR = 1.30; 95% CI = 0.91, 1.85), and when made by nonmedical versus medical providers (future appointments: AOR=1.38; 95% CI=1.05, 1.80; same-day appointments: AOR=1.70, 95% CI=1.03, 2.81).
walk-in appointments compared with future appointments, when they were at CitiWide’s drop-in center (compared with those at other locations), or when they were made by nonmedical providers (compared with those made by medical providers). There were no differences in kept appointments by patients’ sociodemographic characteristics, although we collected limited patient-related data. In traditional medical settings, same-day appointments improve access to health care.12,13 This study shows that same-day appointments are important for improving access to care for HIVinfected marginalized individuals as well.
Patients were most likely to keep appointments made at CitiWide’s drop-in center, a place where patients experience “one-stop shopping” by addressing medical and broader structural, social, and psychological needs, than they were at other locations. CitiWide’s drop-in center provides a full range of services that address needs unique to the target population. Although the clinic has additional on-site resources (e.g., HIV nutritionist, psychiatrist), these resources may not address the population’s broader needs. However, the difference in kept appointments between the drop-in center and the clinic was not statistically significant.
DISCUSSION AND NEXT STEPS In the Health Services Program, a comprehensive collaborative program providing HIV medical services to a marginalized population, patients kept 29.3% of all appointments. Patients kept appointments more frequently when they were same-day or
October 2007, Vol 97, No. 10 | American Journal of Public Health
CitiWide’s logo.
Cunningham et al. | Peer Reviewed | Field Action Report | 1759
FIELD ACTION REPORT
0.35 (0.22, 0.56) 0.71 (0.50, 1.00) 1.0
0.40 (0.24, 0.65) 0.77 (0.54, 1.10) 1.0
care delivery is crucial for appropriate resource allocation. Our study’s findings that patients kept appointments more frequently when they were walkin or same-day appointments (compared with future appointments), when they were at a community-based organization’s drop-in center (compared with other locations), or when made by nonmedical providers (compared with medical providers), can help guide health care service delivery to marginalized populations.
214 (28.7) 1.63 (1.25, 2.14) 143 (18.1) 1.0 Same-day or walk-in appointments
1.38 (1.05, 1.80) 1.0
About the Authors
TABLE 1—Program Characteristics Associated With Appointments Kept With a Medical Outreach Program: Bronx, New York, 2003–2005 Kept Appointments
All appointments Type of appointment Same-day or walk-in Future Location of appointment SRO hotel room Community clinic CBO’s drop-in center Person making appointment Nonmedical provider Medical provider Location of appointment CBO’s drop-in center Person making appointment Nonmedical provider Medical provider
Total
No. (%)
2272
666 (29.3)
737 1535
302 362 871 746 789
OR (95% CI)
AOR (95% CI)
309 (41.9) 2.29 (1.85, 2.82) 357 (23.3) 1.0 Future appointments 32 (10.6) 80 (22.1) 245 (28.1)
737
309 (41.9)
668 69
288 (43.1) 21 (30.4)
...
1.69 (1.38, 2.08) 1.0
...
1.70 (1.04, 2.79) 1.0
1.70 (1.03, 2.81) 1.0
Note. OR = odds ratio; CI = confidence interval; AOR = adjusted odds ratio; SRO = single-room occupancy; CBO = community-based organization.
We were surprised by how few appointments were kept when made by medical providers and when made at the singleroom occupancy hotels, particularly because previous research demonstrated medical home visits increased ambulatory visits among disadvantaged individu-
als.14 Some patients may feel obligated to make appointments if made by medical providers, when they are not truly interested. Furthermore, single-room occupancy hotel residents may want to leave a negative environment, or may not perceive appointments in their rooms as true
Outreach team in a single-room occupancy hotel.
1760 | Field Action Report | Peer Reviewed | Cunningham et al.
medical appointments, and therefore do not prioritize them. Based on our findings, we modified the Health Services Program by offering more same-day appointments at CitiWide’s drop-in center and fewer at the singleroom occupancy hotels. Additionally, we are reconsidering the utility of medical providers on outreach. Most studies examining HIV health services utilization focus on patient-related factors. We examined and identified programrelated factors that were important in accessing medical services. Although patient-related factors are known to influence health services utilization, the medical community must also focus on system-related factors, such as how health care is delivered, particularly for marginalized populations. Close evaluation of health
Chinazo O. Cunningham is with the Division of General Internal Medicine and Department of Family and Social Medicine at Montefiore Medical Center/Albert Einstein College of Medicine, New York, NY. John Paul Sanchez is with the Department of Emergency Medicine at Jacobi Medical Center/Montefiore Medical Center, New York. At the time of this analysis, Daliah I. Heller was with CitiWide Harm Reduction, Inc, New York. Nancy L. Sohler is with the Sophie Davis Medical School at the City University of New York and Montefiore Medical Center, New York. Requests for reprints should be sent to Chinazo O. Cunningham, MD, Montefiore Medical Center, Division of General Internal Medicine, 111 E 210th St, Bronx, NY 10467 (e-mail:
[email protected]). This report was accepted November 5, 2006.
Contributors C. O. Cunningham cofounded the program, conceptualized the study, analyzed the data, and led the writing of the article. J. P. Sanchez led all aspects of data analysis. D. I. Heller cofounded the program and oversaw data collection. N. L. Sohler made a significant contribution to all aspects of the research, including study design, and analysis and contributed to the writing of the article. All authors helped to interpret findings and reviewed drafts of the article.
Acknowledgments This study was supported by the Centers for Disease Control and Prevention (CDC; grant U65/CCU223363-01), the Health Resources and Services Administration (grant H97 HA 00247-01), and the Center for AIDS Research (NIH grant AI-51519). C. O. Cunningham is a
American Journal of Public Health | October 2007, Vol 97, No. 10
FIELD ACTION REPORT
Robert Wood Johnson Foundation Harold Amos Medical Faculty Development Program Scholar. We acknowledge Lisa Fitzpatrick, MD, MPH, of the CDC, for her contribution to this study, and we thank Belinda Taveras and David Matthews for their work in ensuring high-quality data at CitiWide Harm Reduction.
Human Participant Protection Institutional review boards at Montefiore Medical Center and the Centers for Disease Control and Prevention approved this study.
References 1. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 2004. Vol 16. Atlanta, Ga: Centers for Disease Control and Prevention; 2005:1–46. 2. Shapiro MF, Morton SC, McCaffrey DF, et al. Variations in the care of HIVinfected adults in the United States: results from the HIV Cost and Services Utilization Study. JAMA. 1999;281: 2305–2315. 3. Robertson MJ, Clark RA, Charlebois ED, et al. HIV seroprevalence among homeless and marginally housed adults in San Francisco. Am J Public Health. 2004;94:1207–1217. 4. The HIV Research Network. Hospital and outpatient health services utilization among HIV-infected patients in care in 1999. J Acquir Immune Defic Syndr. 2002;30:21–26.
CitiWide’s drop-in center.
10. Cunningham CO, Shapiro S, Berg KM, Sacajiu G, Paccione G, Goulet JL. An evaluation of a medical outreach program targeting unstably housed HIVinfected individuals. J Health Care Poor Underserved. 2005;16:127–138. 11. Heller D, McCoy K, Cunningham C. An invisible barrier to integrating HIV primary care with harm reduction services: philosophical clashes between the harm reduction and medical models. Public Health Rep. 2004;119:32–39. 12. Mallard SD, Leakeas T, Duncan WJ, Fleenor ME, Sinsky RJ. Same-day
scheduling in a public health clinic: a pilot study. J Public Health Manag Pract. 2004;10:148–155. 13. Murray M, Bodenheimer T, Rittenhouse D, Grumbach K. Improving timely access to primary care: case studies of the advanced access model. JAMA. 2003;289:1042–1046. 14. Margolis PA, Lannon CM, Stevens R, et al. Linking clinical and public health approaches to improve access to health care for socially disadvantaged mothers and children: a feasibility study. Arch Pediatr Adolesc Med. 1996; 150:815–821.
5. Arno PS, Bonuck KA, Green J, et al. The impact of housing status on health care utilization among persons with HIV disease. J Health Care Poor Underserved. 1996;7:36–49. 6. Fleishman JA, Gebo KA, Reilly ED, et al. Hospital and outpatient health services utilization among HIV-infected adults in care 2000–2002. Med Care. 2005;43(suppl 9):40–52. 7. Smith MY, Rapkin BD, Winkel G, Springer C, Chhabra R, Feldman IS. Housing status and health care service utilization among low-income persons with HIV/AIDS. J Gen Intern Med. 2000;15:731–738. 8. Welch KJ, Morse A. Survival patterns among HIV+ individuals based on health care utilization. J Natl Med Assoc. 2001;93:214–219.
A single-room occupancy hotel.
9. Cunningham WE, Mosen DM, Hays RD, Andersen RM, Shapiro MF. Access to community-based medical services and number of hospitalizations among patients with HIV disease: are they related? J Acquir Immune Defic Syndr Hum Retrovirol. 1996;13: 327–335.
October 2007, Vol 97, No. 10 | American Journal of Public Health
Cunningham et al. | Peer Reviewed | Field Action Report | 1761
