Maurice W. Melchiono

Outreach, Mental Health, and Case Management Services: Can They Help to Retain HIV-Positive and At-Risk Youth and Young Adults in Care?

Objectives: To assess the impact of outreach, mental health, and case management services on retention in primary care of HIV+ and at-risk youth and young adult clients of the Boston HAPPENS program, a comprehensive adolescent HIV prevention and care network of agencies. Methods: Providers at 8 urban sites used standard data forms at each visit to collect background and service receipt information on at-risk clients aged 12–24 years. Data were aggregated across all visits for each client to create summary variables for the number of times each client received each type of service. The retention measure was the number of days between a clients first and last visits during the 4-year data collection period. Kaplan–Meier survival curve and Cox proportional hazards regression analyses were used to assess the association between receipt of the support services of interest and the retention measure. Results: The median retention times were 21 days for male clients (range, 0–1406, N = 512), and 26 days for female clients (range, 0–1577, N = 914). Among males, 45% were retained beyond a month, 24% beyond a year, and 10% beyond 2 years. Similar proportions of females were retained beyond a month and a year, but more females were retained beyond 2 years (15%). After adjusting for other covariates, both male and female clients had significantly longer retention times if they received ≥q2 outreach contacts, or case management at ≥q3 visits. Among males, receipt of mental health counseling at ≥q2 visits also increased retention times. Conclusions: These findings suggest that provision of outreach, mental health, and case management services can improve retention in care of at-risk youth and young adults.

Boston HAPPENS Program: A model of health care for HIV-positive, homeless, and at-risk youth

The Boston HAPPENS [Human immunodeficiency virus (HIV) Adolescent Provider and Peer Education Network for Services] Program is a project supported by Special Projects of National Significance (SPNS) Program, HIV/AIDS Bureau, Health Resources and Services Administration, which provides a network of care for homeless, at-risk, and HIV-positive youth (ages 12-24 years), involving eight agencies. The program has provided services to 1301 youth, including 46 who are HIV-positive. Boston HAPPENS provides a citywide network of culturally and developmentally appropriate adolescent-specific care, including: (a) outreach and risk-reduction counseling through professional and adult-supervised peer staff, (b) access to appropriate HIV counseling and testing support services, (c) life management counseling (mental health intake and visits as part of health care and at times of crisis), (d) health status screening and services needs assessment, (e) client-focused, comprehensive, multidisciplinary care and support, (f) follow-up and outreach to ensure continuing care, and (g) integrated care and communication among providers in the metropolitan Boston area. This innovative network of youth-specific care offers a continuum from street outreach to referral and HIV specialty care that crosses institutional barriers.

Primary care experiences and preferences of urban youth

There are few qualitative studies that assess the experiences and preferences of urban youth with regard to use of primary care. The purpose of this pilot survey was to identify positive and negative influences and underlying issues for adolescents leading to seeking and returning for primary health care. Four focus groups totaling 20 diverse adolescents ranging in age from 13 to 21 years were conducted between April 1994 and June 1994. Participants were recruited through existing peer leadership groups that meet regularly at community health centers or afterschool programs. Urban adolescents are most concerned with being respected and treated well by primary care providers. They want to be listened to, to have their problems taken seriously, and to be treated with dignity and respect. Participants expressed strong preferences regarding sex, sexual orientation, and language of providers, but not for race or ethnicity. Qualitative methods such as focus groups give a voice to youth to advocate for access to adolescent-specific health services. Further research is needed to corroborate the results of this study, to expand our understanding of existing problems, and to investigate the predictors of health care use by vulnerable youth.

Initiation of Services in the Boston HAPPENS Program: Human Immunodeficiency Virus-Positive, Homeless, and At-Risk Youth Can Access Services

This study evaluates the factors associated with initiation of services in the Boston HAPPENS Program, which is a collaborative network of care consisting of multiservice outreach agencies, community health centers and hospitals, for human immunodeficiency virus (HIV)-positive and hard to reach youth who are 12-24 years old. The program served 2116 youth who were 19.8 +/- 2.9 years old; 64% female; 45% youth of color; 16% gay/lesbian, bisexual, or undecided; and 10% homeless or runaway. At first contact with the program, 56% received outreach services; and 91% received a health intervention. Among those receiving a health intervention, 55% had HIV counseling and testing services, 49% medical care, 24% case management, and 9% mental health services. HIV-positive youth needed more contacts before a first medical visit than those who were HIV-negative or untested (p < 0.001). Different kinds of service sites reached different populations of at-risk youth. Logistic regression modeling showed that for young women, older age, lesbian-bisexual orientation, substance use, high-risk sexual behaviours, and receiving outreach services at first contact were independent predictors of initiation of services at outreach agencies; however, unprotected sex with males, and pregnancy were associated with a greater likelihood of care at hospitals or community health centers. For young men, older age, Asian/other ethnicity, and substance abuse were associated with care at outreach agencies; however, positive HIV status and unprotected sex with females were associated with care at hospitals or community health centers. Comprehensive networks of care offering a continuum of services and a variety of entry routes and types of care sites are needed to connect underserved youth to health care.

The Boston HAPPENS program: needs and use of services by HIV-positive compared to at-risk youth, including gender differences

Objective: The Boston HAPPENS (HIV Adolescent Provider and Peer Education Network for Services) Program is a linked services network of care for HIV-positive, homeless, and at risk youth in Metropolitan Boston funded by the Special Projects of National Significance Program. This report studies the needs and use of services by HIV-positive youth compared with negative and untested at-risk youth, including gender differences. Design: Providers collected information prospectively at outreach and services encounters, including demographic information, risk behaviors, and service utilization data. Results: Youth (N=1044) were 19.6±3.0 years old; 38% male; 43% youth of color; and 4% self-identified as gay/lesbian/bisexual and 11.0% as homeless and/or runaway youth. HIV-positive clients (N=26) were more likely to use a range of network related health services. HIV-positive young women were more likely to report previous pregnancy (21% vs 5%, p=0.04) or sexual contact with high risk partners such as an injection drug user (57% vs 6%, p=0.0009), an HIV-positive person (p<0.00001), or survival sex (33% vs 8%, p=0.04) than the other young women. HIV-positive young men were more likely to be youth of color (75% vs 43%, p=0.04) and self-identify as gay or bisexual (42% vs 4%, p=0.005), and to report same sex partners (80% vs 29%, p=0.03) and substance use (100% vs 26%, p=0.006) than other young men. Youth seen at an outreach site were 10 times as likely to access medical care through the program (95% CI, 6.9–14.6). Conclusions: HIV-positive youth are accessing coordinated care and there are gender differences in the needs for services. Health care policies should facilitate the development and evaluation of comprehensive, youth-specific health services for these hard to reach populations.

Health concerns of sexual minority adolescent girls.

Purpose of review The goal of this article is to provide an overview of up-to-date health information about sexual minority female youth so that healthcare practitioners can better serve their healthcare needs. Recent findings Sexual minority adolescent girls may follow diverse sexual developmental trajectories. Many in this population are quite healthy, but some may be disproportionately vulnerable to health risks, perhaps because of the stigma associated with minority sexuality in society. If sexually active, girls in this population often have sex with boys as well as girls and confront risks attendant with sex with both genders. They may demonstrate fluidity in their sexual identity as they move through adolescence. Data suggest that sexual minority adolescent girls are more likely to smoke cigarettes, drink alcohol, or use illicit drugs compared with girls who are heterosexual. They may be more likely to be victims of violence or victimization or to be depressed or suicidal. Summary Sexual minority adolescent girls may be quite resilient, but they face a range of possible adverse health risks. Healthcare practitioners should keep their health issues in mind so they can offer healthcare and counseling that is sensitive, comprehensive, and appropriate.

Evaluation of a Targeted HIV Testing Program for At-Risk Youth

With the advent of new therapies for HIV, case identification through HIV counseling and testing (CTS) has become critically important. Young women, youth of color, and disenfranchised youth are at significant risk of acquiring HIV. This study describes clients who access CTS at a program of comprehensive care for high-risk youth (aged 12 to 24 years), and assessed, using logistic regression analyses, whether youth at highest risk utilized CTS. Most of the 531 youth were female (72 percent) and nonwhite (60 percent). Sixty-eight percent received CTS. Logistic regression modeling revealed that white race and receiving care at the teaching hospital were the only independent predictors of testing. Data indicate that, despite targeted, youth-specific, developmentally appropriate and culturally sensitive outreach and intervention efforts, youth of color and high-risk youth are poorly accessing CTS. A greater understanding of the barriers to and cultural norms regarding CTS is needed.

Advanced Practice Nurse Fellowships: Creating Awareness, Creating Opportunities

Development of more nursing fellowship programs is an effective strategy to address the lack of specialty training and could advance APRNs’ clinical and research skills. those that do exist are underfunded. The fellowship model has been an effective educational venue for our physician colleagues. Medical fellowships are a time of training after residency when physicians hone their clinical and research skills within a particular area of specialization. Development of more nursing fellowship programs is an effective strategy to address the lack of specialty training and could advance APRNs’ clinical and research skills. Within the parameters of their training, certification, and state regulations, APRNs may practice in ambulatory or inpatient settings and may focus on certain subspecialty areas such as cardiology or pulmonology. However, unlike our physician counterparts, formal training for these subspecialty positions is often limited. Some APRNs may achieve high levels of specialization by first working in an area as an RN for a number of years and then continuing in that area when they transition to an APRN role. Other APRNs may come new to a patient population and learn through a specialized orientation, or learn on the job. This ‘‘on the job’’ training as an RNor APRN,while a valuable experience,

1010 A quality improvement (qi) collaborative to improve influenza immunisation rates for disease-specific paediatric populations

Background Influenza outbreaks are a major public health concern yet the majority of work to improve immunisation rates has occurred within primary care settings. Children and patients with medical complexity are particularly at risk for complications due to influenza. Emphasis on immunising all patients against the flu, including patients seen in specialty clinics, is essential to help prevent the acquisition and spread of the influenza virus. Objectives To improve flu immunisation rates for paediatric patients with chronic diseases across multiple medical divisions representing unique patient populations. Methods Over a five year period we oversaw a multi-disciplinary, nursing-focused QI collaborative including primary care and specialty clinics at a freestanding children’s hospital. The QI collaborative included monthly meetings with divisional champions, nursing leadership, pharmacy, and marketing for data review and synergistic learning. Key improvement initiatives included the development of standardised division-specific processes, implementation of a web-based dashboard for real-time data feedback, phone calls to patients and families to encourage and document flu immunizations, and a hospital-wide marketing campaign focused on patient and provider education. Five divisions followed the same disease-specific population, tracking data monthly, over the five year period. Results From the 2013 to the 2017 flu season, immunisation rates increased significantly (p=0.0270). Populations included patients with sickle cell disease (58% to 84%), inflammatory bowel disease (35% to 65%), cystic fibrosis (79% to 89%), diabetes (20% to 70%), and patients on dialysis (89% to 100%). Conclusions The creation of a multidisciplinary, nursing-focused collaborative was associated with significant improvements in influenza immunisation rates in specialty populations.