On the Frontlines of Communities in the U.S. (FOCUS)
Roots Alliance practices serve traditionally “hard to reach” populations including a large number of low-income African American patients, those re-entering society from prison, and those with substance abuse histories. The HealthSTATS project presents a powerful opportunity to routinize screenings in this high-risk population, establish an accurate baseline, increase the number of patients who are diagnosed early, and provide succinct and comprehensive follow-up care for patients who test positive. Of the Alliance practices, ten have been selected to participate. The HealthSTATS program proposes to expand current testing practice by offering HIV/Hepatitis C testing with routine blood work to all patients 13+ annually regardless of risk factors. Not only is there buy-in from each of the physician leaders at the individual practices, but there is also a strong commitment from Roots Clinic’s entire leadership staff to ensure that HealthSTATS is successful and sustainable across similar clinical sites and beyond. To maintain the highest efficacy of new protocols and accuracy in data, the HealthSTATS program includes a strong professional education component including regular on-site in-services for each clinic and quarterly symposia as well as oversight by a CQI subcommittee. In addition to disseminating our findings to all members of our Alliance, we plan to publish a comprehensive report, including recommendations and best practices, to be widely distributed via our existing relationships with Alameda County Public Health Department and Alameda County Social Services Agency and will seek other opportunities to present this material such as national, regional and local conferences and symposia.
Core Whole Health Area:
Program: HealthSTATS
Themes, Keywords & Tags: Reentry, HIV, Hepatitis C
On the Frontlines of Communities in the U.S. (FOCUS)
The HealthSTATS program proposes to expand current testing practice by offering HIV/Hepatitis -C testing with routine blood work to all patients 13+ annually regardless of risk factors. Testing practices will be implemented seamlessly since each practice is physician-led and each has made an agreement through their membership in the Alliance to implement the HealthSTATS program. Of the Alliance practices that will participate in HealthSTATS, HIV screening practices currently vary somewhat; generally, testing is done when a patient admits to high risk behavior or requests screening for sexually transmitted infections. Routine Hepatitis screening is generally not done; testing is typically performed when a patient displays abnormal liver function tests or has engaged in high-risk behavior.
The Project Director and Project Liaison will implement, monitor, and maintain routine testing practices in all participating clinics through a comprehensive program design customized to each practice. In addition to routinizing testing in each of the participating clinics, our primary goals include: developing tools for patient and staff education and awareness, reducing the number of undiagnosed patients, and providing succinct follow-up care for HIV and Hepatitis C-positive patients. Program design will also include a strong educational component for physicians and their lead staff, as they are the primary influencers of behavior among their loyal patient populations.
Core Whole Health Area:
Program: HealthSTATS
Themes, Keywords & Tags: HIV, Hepatitis C
On the Frontlines of Communities in the U.S. (FOCUS)
Roots Alliance practices serve patients who can be classified as “at-risk” for HIV/Hep-C and thus are well-acquainted with the “at-risk” model of offering tests to a select group. During practice recruitment for this study, Alliance physicians came to understand that this method leads to inconsistencies in testing behavior and missed opportunities for screening, early diagnosis and treatment. As such, each of the physicians has expressed a desire to uphold the most up-to-date recommendations by performing routine HIV/Hep C screening, thereby preventing the spread of these infections while simultaneously de-stigmatizing testing.
In addition, a critical component of Roots Alliance is to engage in research initiatives and evaluations that shape best practices, improve service delivery models, and inform systems change to improve the health status of underserved communities. The HealthSTATS project presents a powerful opportunity to routinize screenings in this high-risk population, and establish an accurate baseline. Alliance physicians are committed to discovering and treating health issues that affect their population and look forward to the opportunity to be at the forefront of this work. Not only is there buy-in from each of the physician leaders at the individual practices, but there is a strong commitment from Roots Clinic’s entire leadership staff (CEO, Noha Aboelata, MD; CMO, Chris Alexander, MD; COO, Aquil Naji; Director of Policy and Planning, Daniel Muhammad), to ensure that HealthSTATS is successful and can inform broader policy change and routinization of screening across similar clinical sites and beyond.
Core Whole Health Area:
Program: HealthSTATS
Themes, Keywords & Tags: HIV, Hepatitis C
On the Frontlines of Communities in the U.S. (FOCUS)
The HealthSTATS program proposes to expand current testing procedure by integrating HIV/Hepatitis C testing with routine blood work, making such testing routine in each clinic. Within the new testing model, physicians will include annual HIV/Hep C tests for all eligible patients age 13+ regardless of risk factors. Tests will be offered as part of the standard baseline labs. Additionally, HealthStats will institute comprehensive, universal, opt-out testing at all ten clinics. EHR will prompt physicians with a reminder or “tickler form” for those who do not have an EHR. For patients who opt out, testing would continue to be offered at each subsequent visit, presenting additional opportunities for education on the importance of routine testing. Patients will be tested using ELISA or Western Blot technology; blood is drawn at the clinic for most sites, although some will be sent to an off-site laboratory. Three of the Alliance practices have requested to have rapid testing technology on hand only for those patients for whom a routine blood draw may not be indicated, but plan to use ELISA or Western Blot in the majority of cases. Patients who don’t opt out of testing will return for a follow-up visit with the physician to receive results; the physician will deliver both positive and negative results. If the patient tests positive, after meeting with the physician, the patient will meet immediately with the Patient Liaison who will manage the referral to the HIV clinic, assist in linking patient to counseling services, and be available for immediate support during the crisis period after diagnosis is given. Among the ten participating clinics, HIV screening practices currently vary somewhat, but by and large, testing is being done when a patient admits to high risk behavior or requests screening for sexually transmitted infections. Routine hepatitis screening is generally not done; testing is typically performed when a patient displays abnormal liver function tests or has engaged in high-risk behavior. Thus, the HealthSTATs program will represent a change to the current workflow only in that there will be EHR or tickler prompts, and testing will become routine as opposed to risk-based.
Core Whole Health Area:
Program: HealthSTATS
Themes, Keywords & Tags: HIV, Hepatitis C
On the Frontlines of Communities in the U.S. (FOCUS)
Roots Alliance providers are invested in upholding the 4 Pillars of HIV FOCUS; our commitment to institutional change includes a willingness to further educate ourselves and each other on best practices regarding routine testing. HealthSTATS will provide an initial orientation for physicians and staff whose jobs will be affected by the revised workflows; this training will be coordinated by the Program Director who will present on new protocols, introduce literature for waiting and examination rooms, and instruct on the details of the revised workflow. After the initial orientation, participants will meet collectively on a quarterly basis (months 4,7,10) for symposia to include updates on programmatic functioning and troubleshooting, as well as clinical updates from Roots’ HIV and Hepatitis specialists. Importantly, Myra Ozaeta will attend these meetings commencing on month 4, at which point data will have been collected from all participating practices. Our physicians and staff will also receive direct, ongoing education and support through in-services offered on-site by the Program Director during monthly check-ins with physicians and support staff. The Program Director will also gather anecdotal evidence from in-person and online questionnaires through which additional educational materials will be developed and disseminated on an as-needed basis.
Core Whole Health Area:
Program: HealthSTATS
Themes, Keywords & Tags: HIV, Hepatitis C, Training
On the Frontlines of Communities in the U.S. (FOCUS)
Data collection will occur at each practice site per HealthSTATS customized workflow, to be delineated during the planning phase. The Project Liaison will be responsible for gathering and inputting the data into the Roots database on-site at each practice on a monthly basis. In practices that have an EHR with a full laboratory interface, lab results will be easily exported from the EHR and uploaded into the Roots HealthSTATS database. This will occur on a monthly basis, as coordinated between the Project Liaison and lead staff person appointed by the physician at each site. For those practices still in a paper environment, “tickler forms” will be placed in a designated location along with the lab results when available. The Project Liaison will gather this information on a monthly basis, entering it manually, directly into Roots’ database. For those who have an EHR that may not be fully integrated, a hybrid model will be utilized, including some data export and some manual entry. The exact method of coordinating with the staff and gathering the data will be customized to each setting so as to minimize disruption to the practices and maximize the use of technology.
Core Whole Health Area:
Program: HealthSTATS
Themes, Keywords & Tags: HIV, Hepatitis C, Data
On the Frontlines of Communities in the U.S. (FOCUS)
Roots Clinic leadership provides research and advocacy, are thought leaders in the area of health disparities in communities of color and has built a strong network of physicians, policymakers, academic and research partners to support its ability to translate research into practice and policy change in accordance with our overarching goals. In addition to disseminating our findings to our provider Alliance, including those not directly involved in this study, we plan to publish our findings in a comprehensive report, including recommendations and best practices. This publication will also be widely distributed via our existing relationships with Alameda County Public Health Department and Alameda County Social Services Agency, and we will seek other opportunities to present this material such as national, regional and local conferences and symposia. In addition, Roots will disseminate a press release as well as opinion/editorial pieces as appropriate to the findings of the study.
Core Whole Health Area:
Program: HealthSTATS
Themes, Keywords & Tags: HIV, Hepatitis C, Research, Advocacy
Hepatitis C Screening and Treatment
Roots’ patients are not resistant and do not tend to opt-out of testing or treatment recommendations because of the trust that grows between providers and patients, where each person is encouraged to play an active role in their own care. We implemented routinized Hepatitis C and HIV testing through our campaign called “HealthStats: Know Your Stats” in 2014, to institutionalize the concept that “knowledge is power” and that every individual, regardless of existing beliefs about or access to the medical care system, has the “right to know” his/her health status. This approach to patient engagement through self-empowerment has resonated with hard-to-reach populations, because many individuals recognize that they don’t know their health status and respond positively to the element of choice our approach offers them. This message is consistent throughout our organization, but often begins with interactions between the potential patient and a member of our team of outreach workers. Roots outreach workers, including Roots Health Navigators, come from the communities we serve and represent the population we are attempting to reach. Meeting people “on the ground-level” with a deep understanding of the barriers they face enables meaningful connections with clients that ultimately facilitate their development of skills in self-advocacy and self-care.
Core Whole Health Area:
Program: HealthSTATS
Themes, Keywords & Tags: HIV, Hepatitis C, Treatment
Hepatitis C Screening and Treatment
Our target population matches the target group for the RFP; 87% of Roots’ adult patients are on Medi-Cal and 82% are African-American. While clients come to Roots from all over Oakland and surrounding areas, ~30% come from West Oakland, and ~60% from East Oakland. Roots connects with vulnerable communities through three additional sites: our workforce site on 41st and Broadway; our Pediatric Clinic located in the lower Fruitvale neighborhood, and our recently acquired client empowerment site (computer skills, barrier removal, etc.) in Union City. Roots’ facility square footage has quadrupled in the past two years, deepening our service capacity and reach into the communities targeted for this RFP.
Core Whole Health Area:
Program: HealthSTATS
Themes, Keywords & Tags: HIV, Hepatitis C, Target Population, Demographics
Hepatitis C Screening and Treatment
Roots programs and services have resulted in expertise that positions us well to expand our capacity in treating HCV. We have implemented culturally-congruent, trauma-aware methods of service delivery to effectively engage and treat the many individuals who have been marginalized by – or have negative perceptions of – healthcare institutions. Early on, we launched our care and case management model to serve the reentry population being released to Oakland from San Quentin through our “Healthy Measures Initiative.” Subsequently, with support from Alameda County Health Care Services Agency, we expanded this initiative to facilitate successful community reentry for increased numbers of individuals being released from Santa Rita Jail, via short-term transition and overall stabilization in our primary care medical home. To build trust and peer support, we established peer-led case management through Roots Health Navigators (RHNs), who are formerly incarcerated, primarily African American men who are Certified Community Health Workers. RHNs are assigned a panel of reentry clients with whom they form long-term relationships as they enroll them into public benefits, assist with barrier removal/ navigation of bureaucratic processes, secure housing, attend appointments, establish healthcare as needed, and link to resources. In the past year, RHNs provided navigation and case management services to 310 individuals in 764 face-to-face visits, along with ongoing contact through phone calls, texts, written letters, etc.; completed 284 Medi-Cal enrollments; 81 CalFresh applications; and facilitated 648 primary care visits with Roots physicians. This May, Roots added a RHN to the mobile clinic team, and we are moving towards a model for RHNs in which each takes a lead in a specific chronic illness, such as diabetes and Hepatitis C; or population, such as homeless or reentry. Our well-tested case management model has built trust between patients, their RHN and clinicians, resulting in greater patient compliance. We see a strong potential for the peer-led case management methodology to break through patient barriers in maintaining and completing treatment regimens such as HCV treatment.
Core Whole Health Area:
Program: HealthSTATS
Themes, Keywords & Tags: HIV, Hepatitis C, Cultural Competency, Partnerships
Hepatitis C Screening and Treatment
Roots utilizes a mobile clinic to expand our reach, especially among the homeless, through OaklandSTOMP (Oakland Street Team Outreach Medical Program), supported by AC Department of Public Health. Last year we brought clinical services to 279 homeless Oakland residents via 512 visits, providing them with a secure bridge to a medical home they will utilize. We have gained significant expertise through this effort, and client numbers remain strong as we continue with 20+ hours of street medicine per week. A weekly walk-in clinic at Roots has also been added to facilitate linkage and establishment of a primary care medical home (in-clinic visits are not counted in the numbers above). Clinical exams and lab work can be done directly in the mobile clinic, bypassing the need to be physically present to a clinic and providing direct access to care at the time and place of need. In addition to serving unsheltered encampments, we also regularly provide clinical services at needle exchange sites, which attract both sheltered and unsheltered individuals, and allow for continuity in visits given the predictability of clientele.
Core Whole Health Area:
Program: HealthSTATS, STOMP
Themes, Keywords & Tags: HIV, Hepatitis C, STOMP
Hepatitis C Screening and Treatment
Knowledge of HCV risk factors and procedures for screening, anti-HCV testing, treatment, counseling and reporting. There is a compelling need to improve rates of HCV testing, continuity of care, and adherence to treatment. For the over two years Roots has been routinely testing all adult patients, we have seen a positivity rate of ~14%. Therefore, while our clinical staff is well-versed in the risk factors and age cohort for HCV, because we serve a high-risk population and have already identified a high rate of HCV among our patients, we routinely screen all adult patients for HCV irrespective of perceived risk. We believe that the greatest challenges to eradication of Hepatitis C in our community are that many individuals go untested and/or untreated, potentially transmitting the infection to others. Prior to care through Roots, many of our patients had no medical coverage since childhood, some only received care on an emergency basis, others only in correctional facilities; some were/are homeless or without stable housing. A general mistrust of institutions is a common theme especially prevalent among our African American patients, and more so among the formerly incarcerated or institutionalized. For this population, personal safety is often understandably equated with “avoidance of the system,” including enrollment for health coverage and use of medical facilities. Through Roots’ commitment to building trusting relationships and patient empowerment, our patients don’t opt out of testing and generally adhere to treatment. And through the use of peer-based counseling facilitated by Roots Health Navigators, patients grow in knowledge and self- advocacy – especially critical for compliance when treatment occurs over a significant time period.
Core Whole Health Area:
Program: HealthSTATS
Themes, Keywords & Tags: HIV, Hepatitis C, Treatment
Hepatitis C Screening and Treatment
Roots proposes a comprehensive service delivery plan that builds capacity to respond to unmet needs for individuals at high risk of or testing positive for HCV. Clinical care will take place at our main clinic at 99th and International, enhanced by services through our mobile clinic which travels to homeless encampments and needle exchanges throughout Oakland year-round. Medical treatment will be integrated into regular clinic workflows at our main site and on the mobile clinic when needed. We anticipate a cyclical service process that will include outreach/inreach, education, screening and testing; and for those who test positive, we will incorporate reporting, counseling, workup, treatment and post-treatment/care plan, and referral to services as needed.
Phase 1: Outreach/Inreach and Education. Because Roots is already routinely testing our patients, we are well-positioned to ramp up our outreach, “inreach” and staff education/training immediately beginning January 1, 2017. We will re-launch our “HealthSTATS: Know your Stats” education campaign to bring attention to the importance of screening and testing. Posters and flyers will be posted and circulated at our clinical and workforce sites, and via our mobile clinic (at homeless encampments and needle exchanges in East Oakland, West Oakland and Downtown Oakland), and we will add the campaign to our client encounters at Santa Rita Jail (occurring 30 days prior to release). Numerous referral relationships have been developed with transitional housing and other sites that serve and identify recently released individuals with chronic medical conditions, and we will also outreach via those organizations, enabling comprehensive outreach to the highest-risk populations in Alameda County. (Meets RFP criteria 1)
Phase 2: Screening, Testing, and Assignment to Roots Health Navigator Testing. HealthStats, described above, implements comprehensive, universal education and opt-out testing, irrespective of perceived risk. We will test a minimum of 75% of patients in the birth cohort with whom we have a clinical encounter. Care team members (medical provider, medical assistant, phlebotomist, patient care coordinator) play a role in ensuring that testing is performed. The patient care coordinator reviews patient records prior to clinical appointments to determine whether the patient has received testing, and flags the record accordingly. Laboratory tests are ordered by the provider as part of “routine” bloodwork, the medical assistant and/or phlebotomist ensures that the test was ordered, and in the event that it was missed, consults with the provider to add the test as indicated. Roots conducts blood draws at both our 99th and our mobile clinic locations for HCV Antibody, which reflexes to Quantitative RNA if positive. For patients who do opt out, testing is offered at each subsequent visit, presenting additional opportunities for education on the importance of routine testing.
Assignment to Roots Health Navigator. Mirroring our successful linkage to care model for HIV whereby, upon the receipt of a positive diagnosis, our Patient Care Coordinator or medical provider will notify the Roots Health Navigator (RHN) and advise him of the follow up appointment time when the diagnosis will be delivered. The provider may choose to work with the RHN for support at the disclosure session. Immediately after the physician’s counseling, there is a “warm handoff” to the RHN, who begins by establishing rapport and building trust with the patient. The patient is closely monitored – especially within the first 48 hours following a positive diagnosis – including telephone follow-ups, home visits and family conferences as needed. This crucial time is used to assess the patient’s ability to cope with their diagnosis, the presence and strength of a support network, and other factors that may affect the likelihood of follow-up such as housing instability, food insecurity or substance abuse. This is also the ideal time to connect with the patient because, based on our experience, this critical time is often when the patient is most open to confront and attend to their situation. The RHN ensures completion and receipt of laboratory, radiology and/or specialty referrals as indicated.
Phase 3: Treatment Approach and Referral. Roots is enthusiastic about the opportunity to increase our capacity to treat Hepatitis C within our primary care medical home. We will aim to evaluate all patients testing positive for HCV for medical necessity for treatment, and treat at least 75% of those who screen positive for cirrhosis/fibrosis. We will provide training for our physicians regarding Hepatitis C treatment, through external trainings/conferences/continuing medical education opportunities. We anticipate identification of ~25 individuals who are positive for HCV, and as necessary, will triage treatment to prioritize those born in the 1945-65 group and with more advanced liver staging. We will also introduce our recently developed curriculum through for an educational program for Hepatitis C positive patients in the community, and hold at least four group visits/classes, ensuring patients awaiting treatment are well informed, and the risk of spread is reduced. Our RHN, who is also a certified health coach, will implement the health coaching model, building trusting relationships with patients, promoting understanding of and personal responsibility for their health issues, including adherence to recommended treatment, resulting in improved care for the whole person.
Phase 4: Post-treatment/care. A care and post-treatment plan will be co-created between patient and RHN, to include provider post-treatment recommendations. Patients will be monitored to ensure a sustained viral response for a period to be determined by the physician, but no less than 12 weeks (i.e., SVR12). Referrals for additional services that reduce risk of HCV re-infection, including alcohol/substance abuse programs, housing, mental health and needle exchange programs, will be made by RHN. Other aspects of barrier removal and overall stabilization will continue to be addressed with the RHN until overall stabilization is achieved and the patient “graduates” from the RHN’s active caseload to monitoring status (monthly phone calls, face-to-face visits as needed.
Core Whole Health Area: Navigation
Program: HealthSTATS
Themes, Keywords & Tags: HIV, Hepatitis C, Treatment, Navigation, Care
Hepatitis C Screening and Treatment
Occurring concurrently with all phases, Roots care team (clinical staff including RHN) will ensure that all patient electronic records are updated for each HCV patient screened, tested, treated and case managed, and that relevant information is gathered for quarterly reporting over the grant duration. Data collected will include: percentage of patients born 1945-65 whose medical home is Roots with an HCV Ab test in system; percentage of patients with chronic hepatitis C who have received lab-based staging tests; percentage of patients with chronic hepatitis C who have received prescriptions for hepatitis C treatment; percentage of patients who have initiated HCV treatment that complete the prescribed course of treatment; percentage of patients with chronic hepatitis C who have received prescriptions for hepatitis C treatment and have achieved a sustained viral response (undetectable HCV for at least 12 weeks). The patient care coordinator will also assess patients’ insurance eligibility in order to ensure the reimbursement of services. In addition, reporting HCV cases will be made via the Confidential Morbidity Report.
Core Whole Health Area: Care
Program: HealthSTATS
Themes, Keywords & Tags: HIV, Hepatitis C, Treatment, Testing
Hepatitis C Screening and Treatment
The importance of cultural competence in identification and treatment of HCV. Since our inception, Roots has developed best practices and significant expertise in the engagement of hard-to-reach populations. Inspired and informed by the findings of patient and physician “focus groups,” which identify the qualities of a “culturally competent physician” and methods to engage newly diagnosed patients in care, Roots has generated innovative strategies using our insight into the issues and barriers our patients face; our wisdom about how best to serve priority populations; and our knowledge of effective, culturally and situationally sensitive approaches to educating our patients about the importance of meaningful engagement in the medical care system and the uptake of public benefits programs.
Roots also employs the strategy of “cultural congruency” by hiring Health Navigators and outreach workers from our priority populations who share race, ethnicity and experiences with those our campaigns target. Importantly, Roots provides training to all existing and incoming staff members in order to ensure a comprehensive understanding of “real” cultural competency, which is not achieved merely by sharing a race, language, ethnicity or gender with someone. Roots emphasizes that cultural competency requires an awareness and understanding of different cultural experiences, histories, thoughts, values, interests, practices, and fears. True cultural competence must include the development of sufficient skills to allow one to interact comfortably with other groups while respecting and understanding the real differences that exist. As described previously, for our population, forming a trusting relationship between patient and provider is often a requirement for even screening and testing to occur; this relationship becomes even more critical when a patient’s doubts, fears, and personal situations may otherwise present barriers to receiving the treatment they deserve.
Core Whole Health Area:
Program: HealthSTATS
Themes, Keywords & Tags: HIV, Hepatitis C, Cultural Competency
Hepatitis C Screening and Treatment
Data collection to support RFP indicators. Roots prioritizes rigorous community-led research and evaluation; as such, we maintain the technology and staff support needed to collect and analyze data internally as well as for outside partners and funders. Program evaluation provides data-driven feedback on program implementation to continually improve the quality of education, services, and training. Through its community research department, Roots has considerable expertise in data collection (including field data collection), data entry and analysis, Electronic Health Records (EHR) abstraction, as well as data packaging and upload to various partners and funders. We also are accustomed to tracking data using systems provided to us by partners and funders, and to compiling client-level as well as aggregate data as required. For our own research and tracking purposes, we also develop customized databases when needed. In order to report on the outcomes as expected for this project, the majority of data will be abstracted from our electronic health record. This includes results of screening, laboratory test ordering and results, all clinical and RHN visits, referrals, and post-treatment surveillance. Case management notes, prescription and radiology orders and refills, and psychology encounter summaries are also entered into the shared medical record, enabling not only improved coordination of care, but data collection and analysis as well.
Core Whole Health Area:
Program: HealthSTATS
Themes, Keywords & Tags: HIV, Hepatitis C, Data, Evaluation
Hepatitis C Screening and Treatment
Root’s Quality Assurance and Improvement (QA/QI) Program is summarized in its policy that was approved by its Board in February 2012. Objectives of Roots’ QA/QI Committee and each of its subcommittees are designed to ensure that the provision of services is consistent with and sets a high benchmark for the standard of care in the community. Quality review activities include ongoing analyses of operational efficiency, policies, patient satisfaction, and data collection and interpretation. Roots’ Patient Experience Subcommittee is responsible for ensuring that satisfaction surveys are properly distributed and collected for the overall organization as well as specific programs such as the program proposed herein. This subcommittee reviews all patient satisfaction surveys to inform continuous quality improvement, and acts upon any issues that arise.
Roots’ Director of Research and Compliance is co-chair of the Data Quality Subcommittee of the QA/QI committee, and is responsible for ensuring data quality and accuracy across all Roots research and evaluation programs and projects. Internal data audits are performed by the Director of Research and Compliance on at least a quarterly basis and results are reported to the Data Quality Subcommittee. For newly-implemented programs, internal audits typically occur on at least a monthly basis until a determination is made that quarterly audits are appropriate. Any issues in data accuracy or quality are addressed immediately to ensure the integrity of the research or evaluation effort. Challenges in field data collection are addressed in team meetings in order to develop and implement strategies to overcome them. Roots internal systems or database-related issues are addressed in real-time and then taken to the Data Quality Subcommittee for discussion and action.
Our data collection will include percentage of Roots patients born 1945-65 who have ever had an HCV Ab test in their record; percentage of patients with chronic hepatitis C who have received lab-based staging tests; percentage of patients with chronic hepatitis C who have received prescriptions for hepatitis C treatment; percentage of patients who initiated HCV treatment that have completed the prescribed course of treatment; and percentage of patients with chronic hepatitis C who have received prescriptions for hepatitis C treatment and have achieved SVR12.
Core Whole Health Area:
Program: HealthSTATS
Themes, Keywords & Tags: HIV, Hepatitis C, Data, Evaluation, Research, Quality Assurance
Alameda County Office of AIDS Administration Program Description
Roots Community Health Center will coordinate expanded, “routinized” HIV screening at its main site in East Oakland; Roots Pediatrics, Oakland CA; and at an affiliate site in North Oakland, Watson Wellness Center. The proposed HIV testing expansion into Roots Community Health Center will be overseen by Lavetta Cross, MPA, who has served as Roots’ Director of Community Research and Compliance since October 2013. Ms. Cross brings over ten years of experience working in the field of research and compliance. This program will be sustained in the following ways:
- Proposed testing plan is consistent with overall goals and mission of Roots as it represents a needed service to our high-risk population.
- Once implemented, providers will have the tools, reminders, reinforcements to continue the practice (customized lab forms, ticklers, flags, etc.).
- Third-party billing will result in compensation for point of care testing, covering the cost of testing supplies and collection time, making the proposed testing sustainable going forward.
Core Whole Health Area:
Program:
Themes, Keywords & Tags: HIV, AIDS
Getting to Zero
Roots Community Health Center South Bay will develop infrastructure that will enable and begin initiate administration of pre-exposure prophylaxis (PrEP), post-exposure prophylaxis (PeP), and universal, comprehensive sexually transmitted disease (STD) screening and testing for individuals who are of African descent and are at risk of HIV/AIDS infection. Roots physicians and outreach staff will provide supportive services that include identification, management and follow-up with individuals who are at risk for exposure to HIV and/or STDs to ensure timely administration and management of PrEP, PeP and STD medications.
ref. Getting to Zero_FINAL draft, March 2017
Core Whole Health Area:
Program: Getting to Zero
Themes, Keywords & Tags: South Bay, PrEP, HIV/AIDS, STD
Getting to Zero
The Project Director will coordinate training for staff who will be directly involved in outreach, treatment and follow-up for individuals identified as high risk for HIV infection. Staff involved include a physician, licensed clinical social worker, project director and outreach workers/Health Navigators. Staff will participate in no/low cost webinars, online courses, workshops and conferences on topics such as HIV/AIDS pathology, STD 101, effective counseling methods, PrEP/PeP and other HIV Prevention Strategies, etc.
Once the Getting to Zero Project infrastructure is in place, Roots Health Navigators will target individuals who are at risk for HIV and/or STD infection. Our Navigators know the community and will go to where our focus population lives, works and socializes. Roots Health Navigators are Certified Community Health Workers who are supported and formally supervised by a licensed medical professional. Navigators form intense, long-term trusting relationships with their clients/patients that enable them to influence and empower their clients to make life changing positive decisions. Our trained Navigators will assist engage clients by:
- assisting them to remove barriers that limit healthy choices,
- ensuring clients they are well informed about HIV and STD prevention, transmission, and testing,
- helping clients them to identify specific behaviors that put them at risk for acquiring and/or transmitting HIV and STD, and
- empowering them to commit to steps that reduce their risk
ref. Getting to Zero_FINAL draft, March 2017
Core Whole Health Area: Navigation
Program: Getting to Zero
Themes, Keywords & Tags: South Bay, PrEP, HIV/AIDS, STD
Getting to Zero
The Public Health Department’s 2014 African & African Ancestry Health Assessment states that “while rates of newly reported HIV infections among African/African Ancestry community members have declined from 70.8 per 100,000 people in 2006 to 27.5 per 100,000 people in 2012, African community members are disproportionately affected by the HIV/AIDS epidemic and have a higher rate of new HIV infection (27.5 per 100,000 people) compared with 12.6 for Latinos and 6.4 for Whites.” It further states that “despite representing only 3% of the county population, African/African Ancestry community members comprised 12% of the HIV/AIDS case load in the county in 2012…these findings have implications for how HIV prevention and treatment related resources should be allocated and suggest a need for a greater focus on this community.” With regard to STDs, data reveals communities of African descent suffer disproportionately to other ethnic groups. For example, the Syphilis rate for African descent communities is 19.1 per 100,000 compared with 3.5 for Whites; and in the case of Gonorrhea the rate for Africans is 40.3 per 100,000 while for the White communityWhites the rate is 5.1 per 100,000.
ref. Getting to Zero_FINAL draft, March 2017
Core Whole Health Area: Navigation
Program: Getting to Zero
Themes, Keywords & Tags: South Bay, PrEP, HIV/AIDS, STD, Demographics
Workshop for Psychosocial Support Services
General Application
Core Whole Health Area:
Program:
Themes, Keywords & Tags: Santa Clara, Partnerships, HIV/AIDS
Workshop for Psychosocial Support Services
For decades, residents of the inner neighborhoods of Oakland have encountered many challenges, including a high crime rate, gangs, and military base closings. Additionally, Oakland’s population experiences great health disparities. These include a high mortality rate for diabetes (age-adjusted rate of 38.4 deaths per 100,000 population compared to California as a whole at 23.6); cerebrovascular disease (age-adjusted rate of 47.4 per 100,000 compared to California at 40.2); cancer (206.2 per 100,000 compared to California at 172.0); and births to teenage mothers aged 15 to 19 (10.1% of all births compared to 8.5% for California). An additional health issue is the percentage of children (19–35 months) who have not received the recommended immunizations (41.6% compared to the national benchmark of 34.6%). The rate of Hepatitis C in the service area is another health disparity that has not been adequately tracked but is reaching epidemic proportions. Roots Alliance, a collaborative of healthcare providers of which Roots Community Health Center is the founding and managing member, has implemented a program called HealthSTATS in five of its practices to evaluate the effectiveness of routine Hepatitis C testing in the primary care setting. HealthSTATS data show approximately 18% of patients in these predominantly low-income African-American practices are testing positive for Hepatitis C in routine screening, which would indicate a rate much higher than the 114.7 per 100,000 population reported for Alameda County in 2011 (the most recent statistics available from the California Department of Public Health). HIV/AIDS is an ever-prevalent health disparity as well. The California Department of Public Health reports 1,899 total cases of HIV in Alameda County as of June 30, 2014 (1,824 living and 75 deceased), including 8,607 cases of AIDS (3,901 living and 4,706 deceased). Prevalence of HIV in the service area is more than two times higher than the national median benchmark (0.48% compared with 0.2%). Although the racial/ethnic breakdown for Alameda County is not available, in California as a whole, 17.8% of the total HIV/AIDS cases are African Americans, yet African Americans are only 5.6% of the State population. Many of these health disparities could be ameliorated with greater access to culturally appropriate healthcare.
ref. ROOTS TCWF Request Narrative DRAFT 031915 (1), March 2015
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Themes, Keywords & Tags: HIV/AIDS, Hepatitis C, Health Issues
Tobacco Control Policy Leadership Institute
In response to concerns regarding the unknown prevalence of Hepatitis C virus (HCV) among low-income African Americans in Oakland and Richmond, CA, Roots led an effort to conduct a needs assessment/study and “routinize” Hepatitis C screening at four independent Safety Net primary care practices. Roots led implementation across all collaborative sites, and served as the “hub” organization where data collection, data analysis, coordination of research, and data reporting occurred. The study revealed that the HCV prevalence rate across the sites (14%) is 10 times higher than the estimated average nationwide (1.4%). In addition, 40% of individuals testing positive were outside of the birth cohort for whom screening is recommended, compared to 25% nationwide. Roots is now coordinating efforts to disseminate this information among additional community and collaborative partners, including policy makers. Our goal is to raise public awareness and shape recommended testing guidelines, demonstrating the power of collaboration among community-rooted providers, led by a “hub” organization, to offer a promising approach involving community-based health providers that conduct public health research and inform future environmental and policy change efforts.
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Themes, Keywords & Tags: Hepatitis C