WELCOME TO THE SECOND DAY OF -- THEY TOOK AWAY MY SLIDES -- STRENGTHENING THE IMPACT OF COMMUNITY HEALTH WORKERS ON HIV CARE AND VIRAL SUPPRESSION. TODAY WE'RE REALLY FOCUSING ON IMPLEMENTATION SCIENCE BECAUSE IT'S GOING TO BE SUPER-IMPORTANT TO REALLY UNDERSTANDING HOW WE REACH A LOT OF PEOPLE WITH COMMUNITY HEALTH WORKER SUPPORT, SO I'M NOT GOING TO SAY MUCH, JUST LET'S GET GOING, WE HAVE OUR MODERATORS FOR THIS PANEL, MARY GLENSHAW AND LISA HIRSHORN, I WILL LET YOU GUYS TAKE IT FROM THERE. >> GOOD MORNING, EVERYBODY H CAN YOU HEAR ME OKAY? SO I KNOW WE'RE KIND OF TRICKLING IN, SO YOU GUYS P ARE THE EARLYBIRDS. WE WANTED TO TAKE A QUICK SHOW OF HANDS, WHO IS KEEN TO SKIP THE BREAK OR STAND UP AND STRETCH? AND END A LITTLE BIT EARLY? OKAY. EARLIER? OH H YOU CAN GO TO THE BATHROOM, YES. YES. [LAUGHTER] NO HALL PASS NEEDED. >> SO AS FOLKS ARE COMING IN I THINK WE'LL JUST INTRODUCE OURSELVES, THIS IS MEANT TO BE THE IMPLEMENTATION SCIENCE SESSION, THERE'S SIX PRESENTATION SESSIONS, A LITTLE LONGER THAN THE OTHER ONES, SO WE'LL MIX IT UP WITH SOME STRETCH AND FEEL FREE TO STAND UP IF YOU WANT TO GO AHEAD AND WALK AROUND. THIS IS REALLY BRINGING IT ALL HOME, WHAT DID WE HEAR YESTERDAY , WHAT DOES IT ALL MEAN , WHAT ARE WE DOING WITH TAKING IT TO SCALE?D HOW ARE WE- MY NAME IS MARY GLENSHAW, LIAISON AT THE OFFICE OF AIDS RESEARCH, AS OF YESTERDAY, THAT'S MY NEW JOB. >> AND I'M LISA HIRSCHHORN, PROFESSOR AT NORTHWESTERN UNIVERSITY AND AT LAST MILE HEALTH A NONPROFIT IN LIBERIA, I STARTED MY CAREER IN RYAN WHITE PART C AND THEN A AND B AT DEM MECHANIC COMMUNITY HEALTH CENTER , IT'S REALLY FANTASTIC TO BE HERE TO ACTUALLY BE TALKING ABOUT ENDING THE HIV EPIDEMIC, SOMETHING THAT I NEVER THOUGHT I WOULD ACTUALLY LIVE TO SEE, IT'S REALLY GREAT TO BE HERE AND AGAIN THE IDEA OF HOW CAN IMPLEMENTATION SCIENCE HELP WHETHER YOU'RE AN IMPLEMENTER, POLICYMAKER, POLITICIAN OR CONSUMER. >> AND I JUST WANTED TO -- LISA WILL BE OUR FIRST PRESENTER TODAY, BUT I JUST WANTED TO SHARE A LITTLE BIT OF SORT OF REALITY. I'M COMING FROM SIX YEARS IN SOUTH AFRICA WHERE I WORKED ON THE POP ART TRIAL AND WE TOOK THIS AMAZING COMMUNITY HEALTH WORKER INTERVENTION, THE CHIPS WORKERS AND TRIED TO TAKE IT TO SCALE NATIONALLY, AND WE'RE STILL WORKING ON IT, BUT IT'S TAKING A REALLY LONG TIME AND FOR A LOT OF VERY, VERY PRACTICAL REASONS, LIKE SALARY, LIKE CREDENTIAL SAYS, YOU KNOW H LIKE SCOPE OF PRACTICE, TRANSPORTATION, YOU KNOW, ALL THE BASICS, WE HAVE AN APP TO TRACK AND DO M & E BUT TAKING SOMETHING FROM A CLINICAL TRIAL SETTING AND BLOWING IT UP TO SCALE IS A HUGE, HUGE CHALLENGE. WE HAVE A POLICY, YOU KNOW, WE HAVE STANDARDS, AND IT'S TAKEN A WHILE TO GET IT INTO PLACE, BUT WE HAVE 30,000 COMMUNITY HEALTH WORKERS IN SOUTH AFRICA AND IT IS A HUGE, HUGE CHALLENGE. SO I'M VERY HUMBLED BY YOUR WORK , I'M IN AWE AND INSPIRED AND I HOPE IT CAN CONTINUE. WE HAVE A PACKED AGENDA, SO I THINK WITHOUT FURTHER ADO, LISA CAN TAKE IT AWAY. >> GREAT. SO GOOD MORNING, EVERYBODY. >> GOOD MORNING. >> BEFORE I GET STARTED, ONE SLIGHT CAVEAT, WHICH IS IF YOU GET ABOUT FIVE IMPLEMENTATION SCIENTISTS IN A ROOM AND YOU ASK FOR DEFINITIONS, YOU'LL PROBABLY GET ABOUT SIX DIFFERENT DEFINITIONS, SO YOU MAY FIND THAT I USE DIFFERENT TERMINOLOGY , AND WE CAN GET SOME IN GERMAN AS WELL, YOU MAY FIND I USE DIFFERENT TERMINOLOGY, BUT THIS IS ABOUT THE CONCEPTS, NOT ABOUT THE TERMINOLOGY. , AND HOW THIS CAN BE A VERY IMPORTANT TOOL TO TAKE ALL THE INCREDIBLE WORK THAT YOU'RE DOING AND FIGURE OUT HOW DO WE ACTUALLY TEACH OTHER PEOPLE, HOW DO WE BRING IT TO SCALE, HOW DO WE IMPROVE WHAT'S HAPPENING BOTH ON THE GROUND AS WELL AS INFLUENCING POLICY. THE CHALLENGE AS WE ALL KNOW IS THAT THERE'S A ARE WEALTH BASED ENTER VEPTIONZ, A NUMBER OF STRATEGIES MANY OF WHICH WE HEARD ABOUT YESTERDAY, MANY ARE NOT IMPLEMENTED AT ALL, EVIDENCE-BASED INTERVENTIONS THAT NEVER GO ANYWHERE, NOT IMPLY MERNLTED WITH QUALITY, NOT AS EFFECTIVE, NOT DISTRIBUTED EQUITY BLIRKS REACH WEALTHIER OR EASIER TO REACH AND NOT TO SCALE EFFECTIVELY, THAT IS I THINK THE AREA THAT'S IMPORTANT. THIS IS A LITTLE BIT OUTDATED SO -- [PHONE RINGING] OH, I'M SORRY. I CAN'T FIGURE OUT HOW TO TURN OFF MY PHONE. SO THIS IS REALLY I THINK A REALLY GREAT EXAMPLE, IT'S SOMETHING WE'VE ALL BEEN FOCUSING ON WHICH IS THE HIV CARE CONTINUUM, SO WE HAVE NON, WE HAVE KNOWN, I STARTED DOING HIV WORK IN 195 SO FOR ME 196 WAS A SEMINAL EVENT WHEN WE HAD EFFECTIVE THERAPY SO WE'VE KNOWN FOR MANY YEARS WHAT IT MEANS FOR PEOPLE TO START FREE, STAY FREE AND STAY AIDS FREE, THE THREE COMPONENTS OF THE UNICEF STRATEGY RIGHT NOW AND YET WE'RE NOT ABLE TO DO THAT. SO HOW DO WE BRIDGE THE GAP? THAT'S WHAT WE'LL BE TALKING ABOUT AND LEARNING ABOUT AND THE GAP IS NOT JUST THE TWHAWN WE TEND TO TALK ABOUT -- THAT WE TEND TO TALK ABOUT,S WHICH THE KNOWLEDGE INTO IMPLEMENTATION, BUT IT'S ALSO THE KNOWLEDGE AND EVIDENCE INTO POLICY BECAUSE WITHOUT POLICY WE'RE NOT GOING TO ACTUALLY GET COMMUNITY HEALTH WORKERS THAT ARE PROPERLY REIMBURSED, THAT HAVE STANDARDS, THAT HAVE CERTIFICATION, EVEN WHEN WE HAVE POLICY HOW DO WE GET POLICY ACTUALLY INTO PRACTICE AND THEN THE AREA WHERE I PROBABLY STARTED MOST OF MY WORK AND HAVE COME BACK TO WHICH IS THE DO QUALITY GAP K EVEN WHEN WE GET IT INTO PRACTICE, HOW DO WE MAKE SURE IT IS BEING DONE WITH QUALITY? SO THE IDEA IS THAT WE'VE DONE A LOT OF THIS WORK, WE'VE USMSED RANDOMIZED CONTROLLED TRIALS, WE'VE EUFERLSED OTHER TYPES OF IDEAS AND THE -- USED OTHER TYPES OF IDEAS AND THE IDEA IS WITH HEALTH SYSTEMS WE'RE TALKING ABOUT COMPLEX HEALTH INTERVENTIONS AND REALLY NEED THIS GENERATION OF RESEARCH TO IMPROVE HELP IMPROVE QUALITY H IT SHOULD BE RIGOR, RESEARCH IN SCIENCE IS CREATING GENERALIZEABLE KNOWLEDGE BUT IT SHOULD BE WHETHER THINGS ARE BEING DONE AS PLANNED AND ARE THEY WORKING OR NOT AND WHY NOT. WE GENERAL. >> >> Jeanette: LY USE FRAMEWORKS TO IDENTIFY THE WAY WE STUDY, DESIGNED TO IDENTIFY WEAKNESS MS IN THE SYSTEMS OR IMPLEMENTATION, RECOGNIZES THE NEED TO ADAPT TO LOCAL REALITIES , I WAS TALKING A LOT TO THE WE ARE FAMILY FOLKS ABOUT WHAT WOULD IT TAKE TO TAKE THE CORE OF WHAT THEY DO AND THEN IMPLEMENT IT OTHER PLACES SO WHAT NEEDS TO BE ADAPTED, IT EXPANDS THE METHODOLOGIES WE'VE TRADITIONALLY VIEWED AS GOLD STANDARD TO INCLUDE QUASI EXPERIMENTAL MIXED METHODS AND CRITICALLY IMPORTANT AND WE HEARD THIS AGAIN AND AGAIN YESTERDAY IS THE NEED TO ENGAGE KEY STAKEHOLDERS BOTH BEFORE, DURING AND AFTER, AND I'LL ARGUE THAT'S NOT JUST ACTUALLY HAVING THEM AS PARTICIPANTS OR AS EXPERT ADVISORS BUT ACTUALLY BUILDING THEIR OWN CAPACITY TO BECOME FIRST AND FOREMOST CONSUMERS OF THE INFORMATION AND CONSUMERS OF THE RESEARCH BUT THEN ALSO PRODUCERS OF THE RESEARCH ALONG WITH PEOPLE WHO DO THAT FOR THEIR LIVING. THE PROBLEM IF YOU LOOK AROUND AND PEOPLE HAVE SEEN THIS BEFORE THE TRADITIONAL PIPELINE, WE HAVE TO KNOW COULD A PROGRAM WORK, COULD SOMETHING WORK, SO WE LOOK AT EFFICACY STUDIES. IF WE ACTUALLY TREAT PEOPLE AND ACTUALLY GET THEM UNDETECTABLE, DOES U EQUAL U IS THAT ACTUALLY TRUE? THE ANSWER FOR THAT WAS YES. EFFECTIVENESS YOU GO INTO, IF WE TRY THIS IN PLACES THAT ARE NOT IN A RANDOMIZED CONTROLLED TRIAL , CAN WE MAKE IT WORK? DOES A PROGRAM WORK? ONCE YOU'RE PAST THAT AND OUT. RESEARCH SETTING, HOW DO WE MAKE THAT PROGRAM WORK? THAT'S A LOT OF IMPLEMENTATION& PRACTICE, WHAT ARE THE DIFFERENT STRATEGIES YOU NEED FOR U EQUALS U WHETHER YOU'RE BASED IN CHICAGO WHERE I AM SOUTH AFER SOUTH AFRICA WHERE MARY USED TO WORK OR YOUR LIBERIA ARE THE COMMUNITY HEALTH WORKERS I'M WORKING WITH ARE STILL THERE. WE NEED TO THINK ABOUT THIS DIFFERENTLY AS OPPOSED TO HERE IS AN INTERVENTION LET'S PUT IT INTO PLACE. I'LL TALK ABOUT THIS MORE ABOUT THE FOUR PHASES OFTEN DONE AND OFTEN IGNORED ABOUT EXPLORATION, PREPARATION, WHICH IS ALL THE THINGS YOU DO OF STAKEHOLDER ENGAGEMENT, ADAPTATION, UNDERSTANDING REALITIES ON THE GROUND, WE HEARD ABOUT FORMATIVE REFN FOR 18 MONTHS WHICH IS SOMETIMES REALLY WHAT IS NEEDED BEFORE WE GET TO IMPLEMENTATION AND THENT LAST PHASE OFTEN IGNORED IN RESEARCH WHICH IS REALLY SUSTAINABILITY WHICH IS IF WE MAKE A DIFFERENCE, HOW DO WE ACTUALLY MAKE IT STICK? AGAIN THE KEY THING IS STAKEHOLDER ENGAGEMENT, ADAPTATION TO REFLECT THE CONTEXT BUT ALSO MAINTAINING THE CORE ELEMENTS, DO TOO MUCH ADD APPEAR TAIRKS IT'S A DIFFERENT INTERVENTION. SO WHAT KIND OF TERMINOLOGY, THERE ARE THREE THINGS I'VE FOUND TO BE PARTICULARLY HELPFUL , SO IMPLEMENTATION PRACTICE IS WHAT PEOPLE DO EVERY DAY WHEN THEY'RE TRYING TO GET SOMETHING IN PLACE AND WORKING, SO USE OF STRATEGIES TO ADOPT AND INTEGRATE EVIDENCE-BASED HEALTH INTERVENTIONS AND CHANGE PRACTICE PATTERNS WITHIN AND ACROSS SPECIFIC SYSTEMS AND THAT OFTEN CAN CREATE LOCAL KNOWLEDGE , THAT'S WHERE QUALITY IMPROVEMENT FOR EXAMPLE COMES IN LIMITATION RESEARCH EVALUATE THE USE OF THESE STRATEGIES TO INTEGRATE INTERVENTIONS INTO THE REAL SETTING TORQUES IMPROVE PATIENT OUTCOMES, SO IT CAN ALSO CREATE LOCAL KNOWLEDGE BUT IT'S DESIGNED TO CREATE GENERALIZEABLE KNOWLEDGE AND THEN IMPLEMENTATION SCIENCE, THIS IS IN THE DEFINITIONS FROM NIH AND FROM THE BROWN IS THE STUDY OF THE METHODS TO PROMOTE THE INTEGRATION OF RESEARCH FINDINGS SO IF YOU'RE GOING ON DESIGN A QUASI DESIGN, WHAT ARE SOME OF THE FRAMEWORKS WE MIGHT BE USING, THE METHODOLOGIES? WE ACTUALLY MEASURE BEYOND EFFECTIVENESS SO WE'RE NOT JUST INTERESTED IN DOES IT WORK OR DOESN'T WORK AND THIS IS AN EXAMPLE OF A NUMBER OF DIFFERENT IMPLEMENTATION OUTCOMES SUCH AS ACCEPTABILITY OR FEASIBILITY OR FIDELITY THAT ARE CRITICAL TO UNDERSTAND AND THINK ABOUT HOW WE MEASURE THEM AS WE'RE MOVING FORWARD. WE ALSO NEED TO GO AGAIN BEYOND THE EFFICACY AND EFFECTIVENESS SO THIS IS FOR EXAMPLE ONE OF THE FRAMEWORKS I TEND TO USE A LOT CALMED REAIM WHICH ASKS SUCH QUESTIONS AS DID I REACH THE TARGETED POPULATION? SO IF I SAY I WAS GOING TO REACH 100 AND I REACHED 100, WERE THECH THE RIGHT 100 -- WERE THECH THE RIGHT 100? WHO WHO WERE THE PEOPLE I ACTUALLY MISSED? WAS IT EFFECTIVE? DID THE ORGANIZATION ADOPT IT? IF I AND THE RESEARCH STUDY GO AWAY, WILL IT CONTINUE TO STICK THERE? HOW WELL IT WAS IMPLEMENTED AND VERY IMPORTANTLY HOW IT'S MAINTAINED. THERE'S A NUMBER OF REALLY SORT OF IMPORTANT AREAS IN WHICH THIS IS ACTUALLY BEING DONE, THIS IS ONE OF USING THE REAIM FRAMEWORK TO EVALUATE THE INTEGRATION OF CASE MANAGEMENT IN KEN YARKS ONE THAT'S ALREADY BEEN DONE AND ADOPTED FOR COMMUNITY HEALTH WORKERS. WE'VE HEARD A LOT OF THIS, SO YESTERDAY WE HEARD THE TRANS NATIONAL THEORY AND IMPLICATIONS FOR INCREASING HIV CARE CONTINUUM, WE HEARD ABOUT MEASURING ACCEPTABILITY, EFFECTIVENESS, FIDELITY AND REACH, FOR THE M-HEALTH WE HEARD ABOUT MEASURING ACCEPTABILITY, ADOPTION AND FEASIBILITY SO THERE'S EXPERTISE IN THIS ROOM IN TERMS OF FIGURING OUT HOW DO WE ACTUALLY DO THIS AND THEN HOW DO WE TAKE THIS KNOWLEDGE AND MOVE IT FORWARD. WE LEARNED ABOUT VALUING THE FORMATIVE PHASE SO AGAIN THE EXPLORATION AND PREPARATION FROM AARON'S AS WELL AS IMPLEMENTATION SO WE ARE FAMILY WAS A GREAT EXAMPLE OF THAT, EXPLORATION OF WHAT ARE THE GAPS , WHAT ARE THE EXISTING RESOURCES AND CONNECTIONS, WHO DO WE NEED TO ENGAGE AND PARTNER WITH, AND PREPARATION, REALLY LEARNED A LOT FROM TALKING TO THE TEAM ABOUT ENGAGING THOUGHT LEADERS WITH THE HOUSE MOTHERS AND FATHERS AND GAY PARENTS, CREATING THE CONNECTIONS, UNDERSTANDING WHAT NEEDS TO BE ADAPT AND HAD WHAT ARE THE CONTEXTUAL FACTORS. NOW, ONCE WE ACTUALLY DECIDE TO DO T THE NEXT THING IS YOU HAVE TO FIGURE OUT WHAT ARE THE STRATEGIES YOU'RE ACTUALLY GOING TO DO? IT'S VERY IMPORTANT TO ACTUALLY ARTICULATE AND SPECIFY THAT IN THE SAME RIGOR THAT WE DO IN TERMS OF IDENTIFYING WHAT OUR OUTCOMES R YOU NEED TO BE ABLE TO NAME IT, TO DEFINE IT AND TO SPECIFY IT AND THERE'S SOME VERY GOOD GUIDANCE FROM NOLA PROCTOR IN TERMS OF SOME OF THE DIFFERENT AREAS YOU NEED TO THINK ABOUT SO IN THE SAME WAY WE PAY ATTENTION TO INTERVENTION , PAYING ATTENTION TO OUR STRATEGIES, OTHERWISE YOU'LL NEVER KNOW WHAT WORKED. THIS IS ONE EXAMPLE OF LOOKING AT CLINICAL SUPERVISION LSZ FOR COMMUNITY HEALTH WORKERS SUPERVISORS SO YOU NEED TO HAVE THEM WHO ARE KNOWLEDGEABLE IN SUPERVISION, THEY'RE SUPPOSED TO PROVIDE SUPERVISION IN THE FIELD AND VIA PHONE, WHO ARE THE TARGETS OF ACTION, THIS WAS FOR NEWY TRAINED AND EXISTING COMMUNITY HEALTH WORKERS, WHEN ARE THEY SUPPOSED TO DO IT, HOW OFTEN ARE THEY SUPPOSED TO DO IT , SO YOU'RE BEGINNING TO SEE HOW YOU MIGHT MEASURE FIDELITY, FOR EXAMPLE, WHAT ARE IMPLEMENTATION OUTCOMES AND FINALLY WHY ARE YOU ACTUALLY DOING THIS, WHAT'S THE JUSTIFICATION, WHAT'S THE EVIDENCE BEHIND YOUR CHOICE OF THIS STRATEGY? NOW, ONE OF THE OTHER THINGS THAT'S IMPORTANT IS NOW WE'VE TALKED ABOUT SORT OF WHAT DO WE WANT TO KNOW IN TERMS OF THE INTERVENTION, WHAT ARE THE STRATEGIES, IMPLEMENTATION STRATEGIES, BUT VERY IMPORTANTLY THE RECOGNITION IS AS OPPOSED TO SOME TRADITIONAL RESEARCH WHERE YOU TRY TO CONTROL FOR OR MAKE IT GO AWAY OR STATISTICALLY ADJUST FOR CONTEXTUAL FACTORS, IMPLEMENTATION RESEARCH, YOU EVER TO EMBRACE THEM OF THE VARIABILITY IS PROBABLY ONE OF THE MOST IMPORTANT FACTORS WE SHOULD BE ABLE TO EXPLORE AND THIS IS ONE OF A NUMBER OF DIFFERENT FRAMEWORKS WORKS THAT PEOPLE USE TO SAY HOW SHOULD YOU BUCKET WHAT YOU'RE LOOKING AT FOR THE CONTEXTUAL FAX TORKSZ ALL THE THINGS THAT ARE NOT PART OF YOUR INTERVENTION OR IMPLEMENTATION STRATEGY THAT WILL EITHER HINDER OR HELP YOUR STUDY GO WELL AND FINALLY AS YOU SPREAD LOOK THE ATHINGS AT THE OUTER SEGHTD, THE INDIVIDUALS -- SETTING, THE INDIVIDUALS INVOLVED, PROCESS FOR IMPLEMENTATION, INNER SETTING, FINALLY HOW DOES THIS AFFECT YOUR INTERVENTION. IT'S NOT NOT A SIMPLE THING TO DO, TRY NOT TO MEASURE EVERYTHING OTHERWISE YOU'LL ONLY BE MEASURING, BUT TRYING TO UNDERSTAND WHAT ARE THE THINGS THAT ARE MOST IMPORTANT, THE THINGS THAT DRIVE YOUR IMPLEMENTATION STRATEGY, WHAT THINGS DO YOU HAVE TO CHANGE IN THESE CONTEXTUAL FACTORS BEFORE YOU START, IF YOU WANT TO PAY COMMUNITY HEALTH WORKERS AND THERE'S NO DPUNGD, YOU BETTER GET SOME FUNDING BEFORE YOU ACTUALLY DO IT AND WHAT ARE THE THINGS THAT ARE ESSENTIALLY NON STARTERS, IF YOU HAVE A GOVERNMENT THAT SAYS NO COMMUNITY HEALTH WORKERS, IT WILL BE VERY HARD TO EVER IMPLEMENT SOMETHING THERE. WE HEARD A LOT ABOUT THIS YESTERDAY, WE ARE FAMILY, THEY DID VERY DEEP FORMATIVE WORK ENGAGING STAKEHOLDERS TO UNDERSTAND THE COMMUNITY AND CULTURES, COMMUNITY AND STATE, WE LEARNED VERY INTERESTING THINGS ABOUT TEXAS AND REPORTING SEXUAL ACTIVITY IF YOU'RE A MINOR, THE ACTORS IN TERMS OF UNDERSTANDING WHO THE COMMUNITY HEALTH WORKERS WERE AND THE IMPLEMENTATION STRATEGIES WHERE THE INTERVENTIONS WERE DELIVERED AND SIMILARLY FOR THE M HEALTH THINGS AS SIMPLE AS THE PHONE TYPES THAT PEOPLE HAVE AND THE NETWORK COVERAGE. SO WHEN YOU DECIDE THAT YOU ACTUALLY WANT TO STUDY THE IMPLEMENTATION AND INTERVENTIONS THERE'S A RANGE OF DECISIONS YOU HAVE TO MAKE BASED ON YOUR PRIMARY GOALS, ARE YOU INTERESTED IN THE EFFECTIVENESS OF THE INTERVENTION, EFFECTIVENESS OF YOUR IMPLEMENTATION STRATEGIES, UNDERSTANDING WHAT HAPPENED OR WHY OR ALL THREE OF THOSE THINGS THE DISPITIONZ THAT YOU NEED -- THE DECISIONS THAT YOU NEED TO MAKE ARE VERY SIMILAR THAT YOU DO WITH RESEARCH BUT HAVE POTENTIAL DIFFERENT ANSWERS, THINGS LIKE STUDY DESIGN, TIMING , PRIMARY FOCUS AND THE DATA NEEDED, YOU CAN HAVE RCT'S, WE HEARD A NUMBER OF DIFFERENT THINGS OF IMPLEMENTATION STRATEGIES, QUASI EXPERIMENTAL DESIGN, WE ALSO HEARD ABOUT USING OBSERVATIONAL BEFORE AND AFTER, WHAT'S YOUR PRIMARY FOLK HUSBAND, THERE ARE SOME VERY GOOD EXAMPLES OF -- FOCUS, THERE ARE SOME VERY GOOD EXAMPLES OF HYBRID DESIGNS, FOCUSING MORE ON EFFECTIVENESS AND A LITTLE BIT ON STRATEGY, AND MIXED METHODS ARE ALMOST ALWAYS NEEDED, SOMEBODY WHO COMES FROM QUANTITATIVE BACKGROUND, I'VE BEEN DRAGGED SLIGHTLY KICKING AND SCREAMING AND NOW FULLY EMBRACED, THANK YOU, QUALITATIVE METHODS, ALTHOUGH I ALWAYS DO IT WITH SOMEBODY ELSE HELPING ME ALONG. SO SORT OF IN CLOSING, I JUST WANTED TO TALK TO MARY YESTERDAY ABOUT THESE ARE SOME OF THE LARGE NUMBER OF RESOURCES, OBVIOUSLY I'M A LITTLE BIT BIASED TOWARDS NORTHWESTERN BUT SOME VERY GOOD IMPLEMENTATION SCIENCE SORT OF 101 AND 201 IN ADDITION ALONG WITH HOPKINS AND SOME OTHER PARTNERS BEEN FUNDED TO ACTUALLY PROVIDE THROUGH THE CENTER FOR AIDS RESEARCH SOME ADDITIONAL IMPLEMENTATION RESEARCH RESOURCES, PSMG, PREVENTION SCIENCE AND METHODOLOGY GROUP IS A VIRTUAL NETWORK OF A NUMBER OF RESEARCH ERS, IT'S THE NEW SERIES IS STARTING BUT THERE'S A ONES WHICH HAVE ACTUALLY BEEN ARCHIVED WHICH ARE MORE BASIC IMPLEMENTATION RESEARCH, TDR TRAINING, OUT OF WHO AND MEASURE EVALUATION AND I'M SURE THERE'S MANY, MANY MORE THAT CAN BE ADDED TO THIS LIST. IN CONCLUSION, WE HAVE MANY ANSWERS TO THE EXISTING CHALLENGES IN ENDING THE HIV EPIDEMIC AND VERY IMPORTANTLY HOW TO INTERT BETTER INCIDENT GREAT COMMUNITY HEALTH WORKERS INTO ACHIEVING THIS GOACIALTION OUR CHALLENGE IS TO TRANSLATE THAT KNOWLEDGE INTO SUSTAINABLE EFFECTIVE ACTION AND AT SCALE, IMPLEMENTATION RESEARCH I WOULD ARGUE OFFERS US REALLY IMPORTANT TOOLS TO UNDERSTAND HOW AND WHY SOMETHING WORKED AS WELL AS HOW WE MIGHT ADAPT STRATEGY, HOW WE MIGHT ADAPT EFFECTIVE INTERVENTIONS AND IMPLEMENTATION STRATEGIES TO NEW SETTINGS AND NEW CONDITIONS WHETHER IT'S WHAT WE WOULD CALL SCALING OUT OR SCALING UP BUT IT HAS TO BE DONE WELL AND WITH STRONG STAKEHOLDER ENGAGEMENT IMPLEMENTATION RESEARCH CAN HELP US UNDERSTAND HOW TO ADAPT BETTER, HOW TO MEASURE BETTER, HOW TO IMPLEMENT BETTER AND HOW TO SCALE BETTER SO THIS KNOWLEDGE CAN ACCELERATE THE SPREAD OF THE APPROACHES YOU HAVE AND THE ONES YOU'LL HEAR ABOUT IN THE TALKS TO FOLLOW AND I THINK FOR ME IT'S REALLY ONE OF THE KEY NEXT STEPS TO HAVING COMMUNITY HEALTH WORKERS BE AND MEET THE PROMISE THEY HAVE TO HELPING US END THE HIV EPIDEMIC. THANK YOU. [APPLAUSE] >> OKAY. SO NEXT I WOULD LIKE TO ACTUALLY ASK MARY IRVINE IF YOU CAN COME UP. THERE YOU ARE, SORRY. NO NEW YORK CITY DEPARTMENT OF HEALTH AND MENTAL HYGIENE WHO WILL BE TALKING ABOUT PRACTICE DRIVEN RESEARCH TO EVALUATE AND OPTIMIZE AN HIV CARE COORDINATION INTERVENTION IN NEW YORK CITY, I WOULD ASSUME. I'M MARY IRVINE, I WORK IN THE CARE AND TREATMENT PROGRAM CRFT AT THE NEW YORK CITY DEPARTMENT OF HEALTH, I'LL BE TALKING ABOUT RESEARCH TO COORDINATE AND OPTIMIZE HIV CARE COORDINATION INTERVENTION WHICH USES COMMUNITY HEALTH WORKERS, DONE IN COLLABORATION WITH THE INSTITUTE FOR POPULATION SCIENCE IN POPULATION HEALTH AT THE UNIVERSITY OF NEW YORK SO WE ARE A GOVERNMENT ACADEMIC PARTNERSHIP. I'LL START OUT BY TALKING ABOUT THE PROGRAM ITSELF. IT IS RYAN WHITE PART A FUNDED, AND IT WAS LAUNCHED IN 2009 WITH 28 DIFFERENT AGENCIES, A MIX OF HIV COMMUNITY BASED CLINICS ARE HOSPITALS AND SOCIAL SERVICES COMMUNITY-BASED ORGANIZATIONS, MOSTLY BACK THEN IT WAS A LITTLE BIT MORE SLANTED TOWARDS HOSPITALS AND COMMUNITY CLINICS, BUT WE HAD AT LEAST ELEVEN COMMUNITY-BASED ORGANIZATIONS THAT WERE DOING THE WORK IN PARTNERSHIP WITH AFFILIATED PRIMARY CARE PROVIDERS, AND THE PROGRAM PROVIDES COMPREHENSIVE MEDICAL CASE MANAGEMENT, IT'S FUNDED UNDER RYAN WHITE PART A MEDICAL CASE MANAGEMENT TO PEOPLE WHO ARE SPECIFICALLY NEWLY DIAGNOSED, LOST TO CARE OR SPORADICALLY IN CARE, NEW TO CARE, SO NEVER PREVIOUSLY CONNECTED, NEW TO TREATMENT OR STRUGGLING WITH ART ADHERENCE AND THAT CAN BE MEASURED IN TERMS OF KNOWN BARRIERS LIKE SUBSTANCE USE AND MENTAL HEALTH ISSUES OR IN TERMS OF ACTUAL VIRAL LOAD OUTCOMES. SO THE MODEL HAS A NUMBER OF EVIDENCE-BASED COMPONENTS TO IT. WE ACTUALLY WORKED WITH PEOPLE IN THE PACT PROGRAM FROM BOSTON, IT WAS A PARTNERS IN HEALTH FUND ED PROGRAM TO INITIALLY DEVELOP IT IN 20 '07 TO -- IN 2007 TO 2009 AND ALL OF THESE SERVICES AND ACTIVITIES ARE ENGAGED IN BY COMMUNITY HEALTH WORKERS AS WELL AS OTHER MEMBERS OF THE TEAM, BUT IT PRIMARILY CONSISTS OF TRADITIONAL CASE MANAGEMENT, PATIENT NAVIGATION INCLUDING ACCOMPANIMENT TO APPOINTMENTS, A SORT OF STRUCTURED CURRICULUM FOR HEALTH EDUCATION AND COACHING TO ACHIEVE SELF-MANAGEMENT AND TREATMENT ADHERENCE SUPPORT INCLUDING MODIFIED DOT FOR THOSE WHO NEED IT AND ALL OF THOSE SPECIFIC COMPONENTS ARE SUPPORTED BY THE SORT OF ACTIVITIES YOU SEE ON THE OUTSIDE OF THE TRIANGLE WHICH ALL CONTRIBUTE TO CLIENT ENGAGEMENT IN THE PROGRAM AND COORDINATION BETWEEN MEMBERS OF THE INTERDISCIPLINARY TEAM SO THAT'S INFORMATION SHARING WHICH HAPPENS PRIMARILY IN CASE CONFERENCING AS WELL AS SORT OF ONGOING SORT OF INFORMAL SERVICE COORDINATION. COMPREHENSIVE ASSESSMENT OF THE CLIENTS' NEEDS AND RESOURCES AND THEN CARE PLANNING BASED ON THAT ASSESSMENT, IT'S A VERY SORT OF STRUCTURED PROCESS THAT IN THE CASE CONFERENCE ACTUALLY CLULZ THE CLIENT WHENEVER POSSIBLE AS WELL AS ALWAYS THE PATIENT NEVADA GATORS AND THEN OUTREACH INCLUDING INITIAL CASE FINDING, OUTREACH FOR CLIENT REENGAGEMENT WHEN CLIENTS DON'T MAKE IT TO A VISIT AND A LOT OF ONGOING HOME AND FIELD BASED WORK. THE TEAM MEMBERS ARE THE CARE COORDINATOR WHO SUPERVISES THE COMMUNITY HEALTH WORKERS, THE PATIENT NAVIGATORS, THE PATIENT NAVIGATORS WHO ARE RESPONSIBLE FOR MOST OF THE CLIENT FACING WORK, THE SORT OF PRIMARY PERSON INTERACTING WITH THE CLIENTS WOULD BE THE PATIENT NAVIGATOR AND THERE ARE USUALLY THREE OF THOSE OR MORE TO EACH CARE COORDINATOR, THE PROGRAM DIRECTOR IS RESPONSIBLE FOR SORT OF OVERALL QUALITY MANAGEMENT, FISCAL MANAGEMENT, REPORTING TO THE HEALTH DEPARTMENT, AND PRIMARY CARE PROVIDERS WHO ARE ACTUALLY NOT FUND UNDER OUR PART A PROGRAM, THEY'RE NOT PART OF THE BUDGETS BUT THEY ARE AN ESSENTIAL PART OF THE TEAM. IN 2013 WE WERE FUNDED THROUGH AN RO1 TO BEGIN TO STUDY THE EFFECTIVENESS AND COST-EFFECTIVE NESS AS WELL AS SOME OF THE MEANS OR MEDIATORS OF EFFECTIVENESS FOR THE CARE COORDINATION PROGRAM AND THAT WAS OUR FIRST WORK TOGETHER C YOU NY AND THE HEALTH CARE DEPARTMENT'S PROGRAM IN PH IB AND THAT WAS A PURELY OBSERVATIONAL STUDY, WE HAD TO CREATE A RETROSPECTIVE COHORT OF CLIENTS IN THE CARE COORDINATION PROGRAM AND THEN COMPARE THEM TO A GROUP OUTSIDE OF THE PROGRAM, SINCE THIS WAS ROLLED OUT ENTIRELY AS A SERVICES INTERVENTION, THERE WAS NO INITIAL PLAN WHEN IT WAS ROLLED OUT FOR A COMPARISON GROUP. SO WE USED TWO DATA SOURCES, ONE OF THEM WAS PROVIDER REPORTING TO THE HEALTH DEPARTMENT THROUGH A SYSTEM WE CALL E SHARE WHICH IS OUR LOCAL HIV SERVICES DATABASE AND IT CONTAINS INFORMATION ON EVERY CLIENT EN ROAMED IN THE CARE COORDINATION PROGRAM OVER TIME AND IT INCLUDES DEMOGRAPHICS, CLINICAL OUTCOMES, NEEDS RESOURCES SERVICE UTILIZATION, ALL SERVICES ARE TRACKED THROUGH THE SYSTEM, AND THE CONTRACTORS TO THE HEALTH DEPARTMENT UNDER RYAN WHITE PART A ARE ALL CONTRACTUAL LY REQUIRED TO SUBMIT PROGRAM DATA, MOST OF THE SERVICES ARE SORT OF -- MOST OF OUR PROGRAMS ARE FEE FOR SERVICE , SO REPORTING TO THE HEALTH DEPARTMENT IS SORT OF PART OF MAINTAINING THE PROGRAM 'S INCOME OR REIMBURSEMENT. AND THE OTHER MAJOR DATA SOURCE IS THE NEW YORK CITY HIV SURVEILLANCE REGISTRY WHICH CONTAINS INFORMATION ON ALL HIV DIAGNOSES IN NEW YORK CITY AND COMPREHENSIVE LABS, CD4 AND VIRAL LOADS FOR EVERYBODY RECEIVING HIV MEDICAL CARE IN NEW YORK CITY SO WE HAVE ACTUALLY ALL VIRAL LOAPPEDZ AT ALL LEVELS -- LOAPPEDZ AT ALL LEVELS SINCE 2005 AND SINCE THE PROGRAM BEGAN IN 2009 THAT MEANT WE COULD LOOK AT PEOPLE'S PAST CLINICAL OUTCOMES AS WELL AS GOING FORWARD FROM THEIR ENROLLMENT IN THE PROGRAM. OUR FIRST STEP WAS TO IDENTIFY A COHORT OF CLIENTS IN E SHARE OUR DATABASE, TOOK CLIENTS EN ROALDZ IN THE BEGINNING OF THE PROGRAM OF 2009 THROUGH MARCH OF 2013, ALLOWING US TO LOOK AT THREE YEARS OF OUTCOMES FOG ENROLLING MENT FOR EVERYBODY AND IDENTIFIED -- FOREIGN ROLLING FOR EVERYBODY, AND LOOKING AT CLINICAL DATA IN THE REGISTRY AND IDENTIFY PEOPLE NOT IN THE CARE COORDINATION PROGRAM BUT LOOKED LIKE THEY SHOULD HAVE BEEN ENROLLED IN CARE COORDINATION BASED ON MEETING THOSE ELIGIBILITY CRITERIA THAT I MENTIONED EARLIER AND ONE OF THE ADVANTAGES OF THIS PROGRAM IN TERMS OF RESEARCH WAS THAT THE ELIGIBILITY CRITERIA ACTUALLY VERY CLEARLY MAPPED TO NEW YORK CITY SURVEILLANCE DATA THAT WE HAVE. SO WE WERE ABLE TO IDENTIFY NEWLY DIAGNOSED, PEOPLE WHO ARE JUST NEW PRESENTING TO CARE, FIRST LABS SINCE DIAGNOSIS, PEOPLE WHO HAD HIGH VIRAL LOADS, WHO HAD GAPS IN CARE BASED ON DATES OF LABS, SO WE WERE ABLE TO IDENTIFY THOSE TWO GROUPS WHO LOOKED LIKE THEY -- ONE THAT WAS IN CARE COORDINATION, ONE THAT WAS ELIGIBLE BUT NOT IN CARE COORDINATION AND TRACK ALL OF THEIR CLINICAL OUTCOMES TO THE REGISTRY. SO THE USUAL CARE COMPARISON GROUP ONE OF THE FIRST THINGS WE HAD TO DO WAS IDENTIFY EYE TIME POINT FROM WHICH TO BEGIN FOLLOW-UP AND FOR THAT WE RANDOMLY ASSIGNED A SORT OF PSEUDOENROLLMENT DATE TO PEOPLE WHO MATCH THE CRITERIA FOR CARE COORDINATION BASED ON REGISTRY DATA AND ACTUALLY MATCHED THE DISTRIBUTION OF ACTUAL ENROLLMENT DATES FOR THE COORDINATION CLIENT COHORT IN THE COMPARISON GROUP SO WE WERE ABLE TO CONTROL FOR SECULAR TRENDS BECAUSE IN NEW YORK CITY WE SEE CONSTANT IMPROVEMENT IN VIRAL LOAD OUTCOMES. AND THEN IN ADDITION TO SORT OF ASSIGNING THOSE PSEUDOENROLLMENT DATES AND MATCHING ON DATES, WE MATCH FOR PROCEED FENCE TI FOR CARE COORDINATION ENROLLMENT, WE WERE LIMITED TO DATA THAT WAS IN THE REGISTRY SINCE THAT WAS THE ONE SOURCE AVAILABLE FOR BOTH GROUPS BUT YOU CAN SEE ON THE BOTTOM THE VARIOUS VARIABLES THAT WERE INCLUDED IN THE PROPENSITY SCORING SO WE ACCOUNT ED FOR DEMOGRAPHICS, CLINICAL VARIABLES AND VARIABLES INCLUDING THINGS LIKE THE PROPORTION OF PEOPLE IN THE NEIGHBORHOOD WHO ARE -- HARD TO HEAR, OKAY, PROPORTION OF PEOPLE IN THE NEIGHBORHOOD WHO ARE UNDER THE POVERTY LEVEL. THANK YOU. THEN WE ALSO MATCHED ON TREATMENT STATUS AT ENROLLMENT OR AT PSEUDOENROLLMENT, I'LL SHOW YOU WHAT I MEAN BY TREATMENT STATUS GROUPS. SO THIS IS OUR SORT OF INITIAL SHORT-TERM RESULTS ON VIRAL LOAD SUPPRESSION AT 12 MONTHS AFTER THE BASELINE TREATMENT STATUS GROUPS ARE PEOPLE WHO ARE NEWLY DIAGNOSED, PEOPLE WHO HAD NO EVIDENCE OF VIRAL SUPPRESSION THROUGHOUT 129-MONTH PERIOD BEFORE ENROLLMENT, PEOPLE WHO HAD INCONSISTENT VIRAL SUPPRESSION AND PEOPLE WHO HAD CONSISTENT VIRAL SUPPRESSION, THAT WAS ONE OF THE SMALLER GROUPS THROUGHOUT THE YEAR BEFORE ENROLLMENT. 41 PERCENT OF THE COHORT WAS THE GROUP THAT HAD NO EVIDENCE OF VIRAL SUPPRESSION IN THE ENTIRE 12 MONTHS BEFORE ENROLLMENT. AS YOU CAN SEE, THE PROGRAM SHOWED EFFECTIVENESS IN TERMS OF VIRL LOAD EXPRESSION AT 12 MONTH FOLLOW-UP FOR PEOPLE WHO WERE NEWLY DIAGNOSE AND HAD PEOPLE WHO HAD NO EVIDENCE OF VERSION IN THE ENTIRE YEAR BEFORE ENROLLMENT AND THERE'S AN OVER ALL EFFECT FOR SORT OF THE TOTAL COHORT BUT THOSE WERE THE TWO GROUPS THAT SPECIFICALLY BENEFITED. THEN WE LOOKED ALTHOUGH VIRAL LOAD VIRAL SUPPRESSION, HAVING EVERY SING ELG VIRAL LOAD BEING SUPPRESSED, 200 COPIES PER MILLILITER FROM THE 13TH MONTH TO THE 36TH MONTH AFTER THE STARTING POINT, EITHER ENROLLMENT OR PSEUDOENROLLMENT, WE GAVE THOSE FIRST 12 MONTHS FOR PEOPLE TO ESTABLISH CARE SO DIDN'T LOOK AT VIRAL LOAD VALUES FOR THE FIRST 12 MONTHS FOR THIS MEASURE AND WE HAD AN EFFECT ON DUR DURABLE VIRAL LOAD SUPPRESSION SPECIFICALLY FOR THE GROUP WHO HAD NO EVIDENCE OF VIRAL LODEN SUPPRESSION FOR THE YEAR BEFORE THE ENROLLMENT SO THE SUBGROUP BREAKDOWNS WERE PARTICULARLY CRITICAL FOR THIS. SO OUR CONCLUSIONS OVERALL FROM THIS SORT OF OBSERVATIONAL COHORT STUDY WAS THAT THE PROGRAM SHOWS SHORT AND LONG-TERM BENEFITS IN TERMS OF VIRAL EXPRESSION AMONG PREVIOUSLY UNEXPRESSED PEOPLE LIVING -- UNSUPPRESSED PEOPLE LIVING WITH HIV AND NEWLY DIAGNOSED INDIVIDUALS, BUT THERE'S ROOM FOR IMPROVEMENT. SOME OF THIS COMES FROM THE EXPERIENCE OF THE PROVIDERS WHO HAVE BEEN IMPLEMENTING THE PROGRAM SINCE 2009 WHO DPAIF A LOT OF FEEDBACK ABOUT PROGRAM FEATURES THAT WERE CUSHING CLIENT ENGAGEMENT AND ALSO PROVIDER ENGAGEMENT IN DELIVERING THE SERVICES, I'LL TALK MORE ABOUT THAT IN A MOMENT OVER A THIRD OF THE CLIENTS WERE DROPPING OUT OF THE PROGRAM IN THE FIRST YEAR AND THIS WAS NOT REALLY FROM GRADUATION BUT FOR OTHER REASONS. THE PROPORTION WITH DURABLE VIRAL SUPPRESSION WAS VERY LOW, 33 PERCENT OVERALL, DEMOCRACY SPITE 90 PERCENT OF THE COHORT ACHIEVING VIRAL SUPPRESSION AT LEAST ONCE IN THAT 13 TO 36 -MONTH PERIOD AFTER INITIATION AMONG CLIENTS WITHOUT EVIDENCE OF VEPTION THE YEAR PRIOR TONE ROLEMENT -- VIRAL SUPPRESSION THE YEAR PRIOR TONE ROLEMENT, ONLY 43 PERCENT RECEIVED VIRAL SUPPRESSION AND ONLY 21 PERCENT ACHIEVED DURABLE VIRAL SUPPRESSION, SO FINDING A NEED FOR MORE INTENSIVE PROBABLY AND MORE SUSTAINED SUPPORT IN THIS POPULATION APPROXIMATE, WHICH SPECIFIC SL A POPULATION THAT WAS SELECTED FOR ITS KNOWN BARRIERS TO CARE AND TREATMENT. SO WE REALIZE THE POTENTIAL FOR SHORT AND LONG TERM IMPACT AND THE DESIRABILITY FOR SCALING UP FURTHER COULD BE IMPROVED THROUGH SOME STRATEGIC CHANGES. NOW, THIS WAS ALREADY HAPPENING SORT OF ORGANICALLY AND THROUGH MEETINGS WITH THE PROVIDERS WHO DELIVER THE SERVICES. THE NEXT STUDY THAT WAS FUNDED BASED ON THIS SAME SERVICE MODEL IS CALLED PROMISES, IT'S ANOTHER RO12 STARTED IN 2018 -- RO1, STARTED IN 2018, SAME PARTNERS, CUNY AND THE BUREAU AT THE NEW YORK CITY HEALTH DEPARTMENT. SO IN THE CONTEXT IS THAT IN RESPONSE TO SORT OF THE FEEDBACK THAT WE WERE GETTING FROM PROVIDERS REALLY PRIMARILY FROM THE 28 INITIAL IMPLEMENTEDDERS AS WELL AS THE PLANNING COUNCIL AND THE EVOLVING SORT OF RESEARCH LITERATURE OUT THERE INCLUDING OUR OWN EFFECTIVENESS EVALUATION, WE NEEDED TO MAKE SOME PROGRAM REVISIONS TO THE MODEL AND THOSE WERE INCLUDED IN A LATE 2017 RESOLICITATION OF CONTRACTS, SO BECAUSE IT'S A RYAN WHITE PART A FUPPEDDED PROGRAM, WE'RE -- FUNDED PROGRAM , EVERY SEVERAL YEARS WE SORT OF REEF BID IT AND THAT'S AN OPPORTUNITY TO REDESIGN, SO THIS WAS REALLY A SORT OF TUPT REVISIT THE PROGRAM MODEL. -- OPPORTUNITY REVISIT THE PROGRAM MODEL. WE WANTED TO STUDY THE IMPACT AND IMPLEMENTATION OF THOSE CORRECTIONS TO ALREADY FORMED INTERVENTION H LOGISTICAL BARRIERS THAT PROVIDERS WERE FACE AND GO INCREASE PROGRAM ENGAGEMENT FOR THE STAFF DELIVERING THE SERVICES AND FOR CLIENTS AND INCREASE REACH FOR CLIENTS WHO HAVE THE REAL NEED AS WELL AS FIDELITY AND IMPLEMENTATION AND OVERALL EFFECTIVENESS. SO IN TERMS OF THE SPECIFIC CHANGES THAT WERE MADE, ONE OF THE MAJOR CHANGES WAS TO REMOVE A RIGID PROGRAM TRACK, TRACKS FOR PROGRAM ENROLLMENT, WHICH WERE ALSO INVOLVED IN SORT OF HOW WE WERE PAYING FOR THE SERVICES, IT WAS INITIALLY ON A PER MEMBER PER DAY REIMBURSEMENT STRUCTURE, VERY HARD TO MANAGE AND KEEP TRACK OF FOR THE ACTUAL SERVICE PROVIDERS WHO SPEND A LOT OF THEIR TIME TRYING TO ANTICIPATE REIMBURSEMENT RATHER THAN BEING ABLE TO FOCUS ON SERVICE DELIVERY, AND THE RIGID PROGRAM TRACKS MEANT THAT CLIENTS, IT WAS A LITTLE BIT LESS FLEXIBLE IN TERMS OF DOING DIFFERENTIATED CARE ACTUALLY KEEP IN MIND OF MEETING CLIENTS WHERE THEY WERE AT A GIVEN MOMENT AND ADJUSTING INTENSITY OF SERVICES ACCORDINGLY. SO THE TRACKS WERE DROPPED, THE PAYMENT STRUCTURE WAS CHANGED FROM PER MEMBER PER DAY TO BE FEE FOR SERVICE REIMBURSEMENT WITH SORT OF INCENTIVES ORECK NITION OF GREATER RESOURCE EFFORT GOING WITH THINGS LIKE HOME BASED SERVICES OR FIELD BASED SERVICES H IN ADDITION TO THAT, THE ELIGIBILITY CRITERIA WERE SHIFTED TO REEMPHASIZE PEOPLE WHO WERE PREVIOUSLY UN SUPPRESSED, CONSISTENTLY, APPEARS THE HIGH PRIORITY AND AN OPTION WAS ADDED FOR DELIVERING CI-ART, SO IMMEDIATE ANTI-RETROVIRAL TREATMENT WHICH REALLY INVOLVES A LOT OF COORDINATION WITH THE PRIMARY CARE PROVIDER, IN ADDITION AN OPTION WAS ADD FOR USING VIDEO CHAT TO DELIVER SPECIFICALLY ESPECIALLY THE HEALTH PROMOTION HEALTH EDUCATION AND A NEW PROTOCOL AND SET OF TOOLS WAS CREATED AROUND SELF-MANAGEMENT, INCLUDING A PAIR OF ASSESSMENT TOOLS FOR THE CLIENT AND THE PROVIDER TO ASSESS THE CLIENT'S SELF-MANAGEMENT SKILLS IN A RANGE OF DOMAINS RELATED TO TREATMENT ADHERENCE AND VISITS RELATED TO MANAGEMENT OF CARE OVERALL AND ACCOMPANYING PROTOCOL FOR COUNSELING BASED ON THE ASSESSMENT TOOL RESULTS. SO TOGETHER WE SORT OF ANTICIPATED THAT THESE KINDS OF CHANGES WOULD OVERALL INCREASE THE CLIENT CENTEREDNESS OF SERVICES AND INCREASE THE FLEXIBILITY AND BASICALLY HELP CLIENTS STAY IN THE PROGRAM LONGER, ONE OF THE THINGS WE FOUND WITH DURABLE VIRAL SUPPRESSION WAS THAT TIME IN THE THE DURABLE VIRAL SUPPRESSION MEASURE, SO RETENTION AND THEN THINGS LIKE I-ART THAT COULD ALSO AFFECT SORT OF SHORT-TERM OUTCOMES, TIME TO SUPPRESSION. IN PROMISE, SO THAT'S -- THE FIRST AIM IS OUR QUANTITATIVE SHORT-TERM OUTCOME AIM, AND IT'S A STEPPED WEDGE DESIGN TO COMPARE THE ORIGINAL AND THE REVISED MODEL OF CARE COORDINATION SPECIFICALLY ON TIMELY VIRAL SUPPRESSION WHICH WE DEFINE AS VIRAL SUPPRESSION WITHIN FOUR MONTHS OF ENROLLMENT THE WAY WE DID THIS WAS ANTICIPATING THE RESOLICITATION OF CONTRACTS, WE REALIZE THIS WAS AN OPPORTUNITY TO ROLL THINGS OUT IN A STAGGERED WAY AND HAVE HALF OF THE ORIGINAL PROGRAMS START WITH THE REVISED MODEL WHILE HAVING THE OTHER HALF OF PROGRAMS SORT OF REMAIN DELIVERING THE ORIGINAL CARE COORDINATION PROGRAM MODEL. AND THIS WAS CHALLENGING FOR A HEALTH DEPARTMENT, A LARGE BUREAUCRACY JUST TO FIGURE OUT HOW TO MANAGE IN EMPLEZ IT A CONTRACTUAL PROCESS AND PROCUREMENT, BUT WE WERE ABLE TO BUILD THE PLAN FOR RANDOMIZATION INTO THE RFP FOR THE NEW ROUND OF CARE COORDINATION CONTRACTS, AND THEN WE WERE ACTUALLY ABLE TO PROVIDE THE PEOPLE WHO SUCCESSFULFUL WERE AWARDED FOR THOSE CONTRACTS WITH THEIR ASSIGNMENTS TO EARLIER DELAYED START OF THE NEW MODEL. AND THE AGENCIES WERE MATCHED IN PAIRS BASED ON TIECH AGENCY, LOCATION OF AGENCY AND PROGRAM SIZE AND THEN WE USED A RANDOM NUMBER GENERATOR TO ASSIGN THEM IN EACH PAIR TO EITHER STARTING EARLY OR STARTING LATE WITH THE REVISED MODEL AND IT WAS JUST NINE MONTHS DIFFERENCE BETWEEN THOSE TWO START TIMES. THIS IS OUR SORT OF YIN YANG LEGO STYLE STEPPED WEDGE DESIGN GRAPHIC, AND AS YOU CAN SEE, THERE'S LIKE ONE PERIOD OF TIME NINE MONTHS WHERE WE'RE JUST LOOKING AT OUTCOMES DURING THE TIME WHEN NOBODY IS DLIMPG THE NEW MODEL, EVERYONE IS DOING THE ORIGINAL MODEL OF CARE COORDINATION, THERE'S A PERIOD WHEN BOTH GROUPS ARE DELIVERING PERIOD TWO WHERE BOTH GROUPS ARE DELIVERING THE REVISED MODEL OF CARE COORDINATION AND PERIOD ONE IS REALLY THE FOCUS IN TERMS OF THE COMPARISON OF THE ORIGINAL MODEL SIDE BY SIDE WITH THE REVISED MODEL OF CARE COORDINATION. WE DON'T HAVE FINDINGS YET FROM THE STEPPED WEDGE DESIGN, THAT WILL HAPPEN IN BASIC A YEAR FROM NOW BUT MEANWHILE WE'RE LOOK BEING AT AIM THREE WHICH IS REALLY TO UNDERSTAND IMPLEMENTATION EXPERIENCE, MIXED METHODS STUDY, USING PARTNERSHIPS WITH SIX OF THE IMPLEMENTING AGENCIES, THREE NEW , THREE EXPERIENCED, DOING A MIX OF DISCRETE CHOICE EXPERIMENTS WHICH I'LL SHOW YOU WHAT THAT IS BUT TO UNDERSTAND PRACTICE PREFERENCES FOR PROVIDERS AND CLIENTS' PREFERENCES, THANK YOU, THIS IS AN EXAMPLE OF THE SURVEY WE'RE ABOUT TO ROLL OUT FOR THAT UNDERSTANDING OF PREFERENCES OF CLIENTS AND PROVIDERS, THIS IS THE CLIENT VERSION ASKING ABOUT SPECIFICALLY FOUR AREAS, AND WHERE PEOPLE WOULD LIKE THOSE VIFTS TO HAPPEN -- VISITS TO HAPPEN. SO THE EARLY LESSONS ARE THAT EXPERIMENTAL DESIGN IS IT ACTUAL CHALLENGING TO IMPLEMENT IN THE CONTEXT OF REAL WORLD SERVICE DELIVERY BUT HAS BEEN POSSIBLE IN THE CONTEXT EVEN OF A LARGE GOVERNMENT AGENCY ROLLING OUT MULTIPLE CONTRACTS, FAIRING IN THE INTERVENTION WITH RANDOM ASSIGNMENT TO EARLIER DELAYED IMPLEMENTATION ALLOWS US TO SORT OF RIGOROUSLY EVALUATE SIDE BY SIDE TWO MODELS OF A PROGRAM THAT'S BEEN EFFECTIVE WHILE ENSURING THAT EVERYBODY HAS ACCESS TO SOME VERSION OF THAT PROGRAM AND KEEPING SORT OF A RAPID ROLL-OUT AND THIS IS NOT BUSINESS AS USUAL FOR THE HEALTH DEPARTMENT, WE HAD A LOT OF CHALLENGES AROUND THE RANDOMIZATION. AND OVERALL, BASICALLY THIS WAS MADE POSSIBLE BY A WILLING TONS REVISIT A PROGRAM THAT WAS ALREADY SHOWING SIGNS OF EFFECTIVE HNS AND WILLINGNESS TO SORT OF REVISE IT AND TEST IT OUT IN REAL WORLD SETTINGS. HEALTH DEPARTMENT AND UNIVERSITY PARTNERSHIPS THAT HAVE JOINT PLANNING RESEARCH IN ADVANCE OF A POLICY SHIFT OR PRACTICE INITIATIVE LIKE THIS NEW REBID CAN PRODUCE ANSWERS TO LOCAL IMPORTANT PUBLIC HEALTH QUESTIONS WITHOUT SUBSTANTIALLY SLOWING THE DESIRED PACE OF CHANGE AND WITH METHODS THAT SUPPORT KNOWLEDGE GENERATION AND INCLUDING SERVICE PROVIDERS IN THE PARTNERSHIPS HAS BEEN CRITICAL BOTH IN TERMS ACTUALLY REDESIGNING THE PROGRAM AND IN TERMS OF HELPING US PLAN FOR DATA COLLECTION AND STUDYING THE IMPLEMENTATION AND THE EFFECTIVENESS. AND OVERALL JUST TO SAY THAT EVEN EVIDENCE-BASED PROGRAMS HAVE TO CONTINUE TO EVOLVE AND STUDYING THAT EVOLUTION IS CRITICAL TO US BEING ABLE TO FIGURE OUT HOW TO DISSEMINATE THE BEST VERSION OF AN EVIDENCE-BASED PROGRAM. WHEW. SORRY. THANK YOU. [APPLAUSE] >> ALL RIGHT. SO I'M ABSOLUTELY DELIGHTED TO INTRODUCE TILL BARNIGHAUSEN FROM THE HIDE ELT BERING INSTITUTE OF GLOBAL HEALTH, TILL AND I HAVE KNOWN EACH OTHER FOR MORE YEARS THAN I CARE TO ADMIT, BACK TO SOUTH AFRICA, TALKING ABOUT HARMONIZING, HOW DO WE MOVE GLOBALLY. THANK YOU. >> THANK YOU SO MUCH LISA AND REBECCA FOR IF THE INVITATION, DOES THIS NICE PIECEWORK? I WILL GIVE A LITTLE BIT OF PERSPECTIVE MAINLY FOIKSED ON AFRICA, I'LL START WITH SOMETHING YOU'RE VERY FAMILIAR WITH, WHY ARE WE INTERESTED IN HIV TREATMENT? MERELY BECAUSE IT IS HIGHLY IMPACTFUL, SO WE'VE SHOWN HOW HIV TREATMENT IN A REAL LIFE LARGE SCALE SOUTH AFRICAN PUBLIC SECTOR IMPLEMENTATION ROLL-OUT IN PRIMARY CARE CLINICS IN RURAL AREA LEADS TO A VERY RAPID INCREASE IN LIFE EXPECTANCY, YOU SEE THE RED DOTS, THAT'S ONE OF THE MOST RAPID INCREASES IN LIFE EXPECTANCY WE'VE SEEN IN THE HISTORY OF PUBLIC HEALTH AT THE PACE OF AN ADDITIONAL ONE ADDITIONAL YEAR, IT HELPS WITH EMPLOYMENT AND THE ECONOMY, HERE WE'VE LOOKED AT THE EMPLOYMENT EFFECTS OF ERT, AGAIN THIS A REAL LIFE PROGRAM, ISSMENTS A QUASI EXPERIMENT WHERE WE COMPARE INDIVIDUALS TO THEMSELVES ON AVERAGE OVER TIME IN AN INDIVIDUAL EFFECT ANALYSIS AND THESE EMPLOYMENT PROBABILITIES DROPPING AS PEOPLE GET ONTO ART BECAUSE THEY GET SICK BUT THEN RAPIDLY RECOVERING OVER THE COURSE OF FOUR YEARS OR SO, BACK TO THEIR BASELINE LEVEL SO ART IS ALSO GOOD FOR EMPLOYMENT AND ART IS GOOD FOR THE HEALTH CARE SYSTEM, THIS IS A QUASI EXPERIMENT AGAIN IN A REAL LIFE SOUTH AFRICAN PUBLIC SECTOR PROGRAM WHERE WE COMPARE PEOPLE THAT'S ON THE X AXIS THREE FOUR YEARS BEFORE THEY GET ONTO ART, THESE ARE ALL HIV POSITIVE PEOPLE, 2,000 INDIVIDUALS, AND WE SEE THEIR HOSPITALIZATION UPTAKE, IT HOPS UP AT POINT ZERO ON THE X AXIS, THAT IS AGAIN THE YEAR IN WHICH YOU GET ONTO ART, THAT'S WHEN YOU ARE PARTICULARLY SICK AND OF COURSE SICKNESS DRIVES YOU INTOON AN -- INTO AN ART PROGRAM , BUT THEN IT DECLINES RAPIDY OVER A FEW YEARS TIME TO LEVELS FOUR TO FIVE TIMES LESS THAN LONG BEFORE ART, SO ART IS ALSO GOOD FOR THE HEALTHCARE SYSTEM AND ALSO FREEZE UP CAPACITY FOR OTHER THINGS IN THE SNR HEALTHCARE SYSTEM. ART IS STRUCTURALLY GOOD FOR SOCIETY, SHOWN IN A LARGE STUDY OF 3,000 ADULTS IN COMMUNITY FIXED EFFECTS ANALYSIS THAT ART ONE PERCENT INCREASE IN ART LEADS TO A ZERO POINT 7 PERCENT DECREASE IN THE SKIP GENERATION HOUSEHOLDS WE'VE SEEN IN MANY SUBSAHARAN AFRICA COMMUNITIES WHERE SOMEBODY INFECTED WITH HIV IN THEIR 20s DIES OF HIV IN THE THIRTSZ AND LEADS HOUSEHOLD BEE REFT OF A MIDDLE-AGED ADULT A BREADWINNER AND LEAVES GRANDPARENTS CARING FOR GRAMED CHILDREN, ART IS POWERFULLY COUNT ACTING THIS SOCIAL STRUCTURAL EFFECT AND I THINK IT WILL HAVE LASTING IMPACTED ON HUMAN AND ECONOMIC DEVELOPMENT IN MANY REGIONS IN THIS WORLD. SO WHY ARE WE INTERESTED IN COMMUNITY HEALTH WORKERS WHEN EVERYTHING IS WORKING SO WELL? SO ONE REASON IS OF COURSE A PURE ECONOMIC EFFICIENCY REASON AND WE ARE UNDER A LOT OF PRESSURE, I SIT ON THE SUSTAINABILITY COMMISSION, THE U N AIDS SUSTAINABILITY COMMISSION AND PEOPLE ARE WORRIED BECAUSE OF COURSE THE CLOVER FUNDING STREAMS ARE STAGNATE AND GO DECLINING WHILE THE NUMBER OF PEOPLE NEEDING ART IS STILL EXPONENTIALLY INCREASING BECAUSE WE ARE SO SUCCESSFUL IN SAVING PEOPLE'S LIVES, ONCE YOU ARE ON ART, YOU HAVE A LIFE EXPECTANCY INSTEAD OF ANOTHER TEN YEARS, ANOTHER 30 OR 40 YEARS, SO WE HAVE THESE STILL RAPIDLY INCREASING NUMBERS OF PEOPLE NEEDING ART BUT THE FUNDING LEVELS ARE AT BEST STAGNATING AND PROBABLY HERE IN THE EXAMPLE OF PEPFAR DECREASING AND THAT OF COURSE CREATES A FUNDAMENTAL PRESSURE FOR MANY GOVERNMENTS TO FIND ALTERNATIVE LESS COSTLY DELIVERY MODELS FOR ART AND I WANTED TO PUT A SLIDE IN HERE BY MY Ph.D. STUDENT HELL GA BRUNI, A NOW A AN ASSISTANT PROFESSOR IN TANZANIA WHO DID A SAVINGS WE CAN ACHIEVE IN TIMES IN TERMS OF SHARING TASKS BETWEEN NURSES AND COMMUNITY HEALTH WORKERS AND WE'VE LOOKED AT THAT IN A TIME AND MOTION STUDY IN DETAIL. THE SECOND MAJOR REASON IS THAT COMMUNITY HEALTH WORKERS ARE AVAILABLE BUT OTHER HEALTH WORKERS ARE NOT, IN POOR COMMUNITIES IN THIS WORLD. HERE IS A STUDY, IT'S BEEN OUT 15 YEARS OLD AND IT SEEMS A TRIVIAL POINT WHEN WE ADD A DIAMONDBACK -- WHEN WE ADD A DOCTOR OR NURSE, WE CAN REDUCE MATERNAL MORTAL TIRKS CHILD MORTALITY, OVERALL MORTALITY, IT SEEMS A TRIVIAL POINT TO MAKE BUT 15, 20 YEARS AGO THERE WAS A MAJOR POLITICAL MOVEMENT IN PART DRIVEN BY WORLD BANK CLAIMING THAT MOST HEALTH AND POPULATION HEALTH IS DETERMINED BY HYGIENE, SANITATION, ATTRITION SH OF COURSE -- NUTRITION, OF COURSE THESE ARE IMPORTANT DEEP DETERMINANTS BUT ALSO THE HEALTH SYSTEM CAN IN FACT SAVE LIVES, BUT THERE WAS A MOVEMENT MAYBE IN A POLITICAL COMPETITION BETWEEN WORLD BANK AND WHO IS THAT THE HEALTH SECTOR CONTRIBUTES VERY LITTLE TO LIFE EXPECTANCY AND TO MORTALITY, IN FACT, OF COURSE, THE HEALTH SYSTEM CAN CONTRIBUTE MASSIVELY TO HEALTH AND HIV TREATMENT HAS GIVEN US ONE VERY POWERFUL EXAMPLE, WE CAN SAVE LIVES BY ADDING DOCTORS AND NURSES, AND THIS STUDY IS ONE OF THE ONES THAT WENT INTO THE 2006 WHO WORKING TOGETHER FOR HEALTH, HEALTH REPORT, AND AT THE TIME THERE WAS A LOT OF ENTHUSIASM TO CREMPS THE NUMBERS OF -- INCREASE THE NUMBERS OF NURSES, MIDWIVES AND DOCTORS IN THOSE RESOURCE CONSTRAINED COMMUNITIES IN AFRICA AND VERY LITTLE HAS HAPPENED. THE ONLY RESOURCE THAT WE HAVE AN ABUNDANCE IN MANY AFRICAN COUNTRIES ARE IN FACT COMMUNITY HEALTH WORKERS AND HERE ARE A FEW NUMBERS, THESE ARE WHO ESTIMATES IN SOME COUNTRIES, WE HAVE AS MANY COMMUNITY HEALTH WORKERS PER POPULATION AS WE HAVE IN HIGH INCOME COUNTRIES, DOCTORS AND NURSES, SO AS A BENCHMARK IN THE UNITED STATES PER 1,000 POPULATION, WE HAVE 2.6 PHYSICIANS, IN GERMANY FOUR PHYSICIANS PER 1,000 POPULATION, IN UK THREE PHYSICIANS, IN ETHIOPIA WE HAVE 0.04 PHYSICIANS PER 1,000 POPULATION, THE ONLY HEALTH WORKER THAT IS AVAILABLE CLOSE TO THE LEVEL OF POPULATION CONCENTRATION OF PHYSICIANS IN HIGH INCOME COUNTRIES ARE IN FACT COMMUNITY HEALTH WORKERS, SO IF YOU EVER WANT TO ACHIEVE AT PRESENT HIGH COVERAGE WITH HEALTH SERVICES, UNIVERSAL COMPLEG FOR HIV, HYPERTENSION OR DIABETES, THIS IS A PROMISING CA DRE TO GO TO. AT THE SAME TIME AS YOU'VE SEEN IN MY PREVIOUS CHART THAT ACTUALLY SWAZILAND, THIS LITTLE DOT INSIDE HERE SOUTH AFRICA, SWAZILAND HAS A HIGH COMMUNITY HEALTH WORKER CONCENTRATION PER POPULATION IN THE TWO RANGE HERE AND EVEN IN SWAZILAND, AND THIS ALSO IS A MOTIVATION FOR OUR RESEARCH, THE COMMUNITY HEALTH WORKER PROGRAM, THE SO-CALLED RURAL HEALTH MOTIVATORS DO NOT ACHIEVE THE NATIONAL GOALS, WE HAVE DONE HERE A POMTION BASE, POPULATION BASE, POPULATION STUDY OF COMMUNITY HEALTH WORKERS REACHING HOMES AND HOUSEHOLDS IN SWAZILAND, IN ESAR TINA THE GOAL IS TO REACH EVERY HOUSEHOLD ONCE PER YEAR WITH ONE COMMUNITY HEALTH WORKER AT LEAST FOR SCREENING AND BASIC HEALTH PROMOTION AND COUNSELING AND SWAZILAND DOES NOT ACHIEVE THIS GOAL, IT DOESN'T EVEN HALF ACHIEVE IT, EVEN THOUGH IT IS AMONGST THE HIGH CONCENTRATION COMMUNITY HEALTH WORKER PROGRAMS AND EVEN THOUGH THEY ARE A POWERFUL AND IMPORTANT FORCE FOR HEALTH, AND REACH IS A I MEAN SPECIFICALLY FOR HARD TO REACH POPULATIONS AND STAGES IN CARE WHERE WE ARE STILL LOSING MOST OF PEOPLE NEEDING CARE AND HERE IS AN EXAMPLE FROM NATAL WHERE STILL UP TO THIS DATE THIS IS LONGITUDINAL HIV TREATMENT CASCADE ON THE X AXIS WE SEE FOUR YEARS, ON THE Y AXIS WE HAVE THE DIFFERENT STAGES IN THE CASCADE OR THE DIFFERENT DENOMINATORS, MOST ON YOUR LEFT-HAND SIDE ARE THOSE WHO ARE POSITIVE WHO NOW NEED TO KNOW BY HIV TESTING THAT THEY'RE HIV POSITIVE AND THERE WE ARE LOSING MOST IN THE LIPG AJ TO CARE STAGES, WE ARE ALSO LOSING MOST, THIS IS THE COLUMNS TO THE RIGHT IN THIS GRAPH, ONCE PEOPLE MAKE IT INTO THE HEALTHCRE SYSTEM INTO A CLINIC, THEY'RE DOING ACTUALLY QUITE WELL, GETTING ONTO ART AND ALSO BECOMING SUCCESSFULLY TREATED AND VIRALLY SUPPRESSED, THESE ARE ALL MY CUMULATIVE INSTANCES. SO COMMUNITY HEALTH WORKERS OFFER PROMISE IN THESE THREE REGARDS, THEY ARE AVAILABLE, THEY ARE POTENTIALLY ABLE TO REACH HARD TO REACH POPULATIONS, PEOPLE THIS THEIR HOMES -- PEOPLE IN THEIR HOMES, PEOPLE WHO DON'T MAKE IT NATURALLY TO A CLINIC AND THEY ARE A HEALTH WORKER CADRE THAT ON AVERAGE ACROSS SUBSAHARAN AFRICA RUNS ABOUT A TENTH OF A NURSE AND YOU KNOW THAT MOST HIV TREATMENT PLANS ARE NURSE IN SOUTH AFRICA, REPLACING SOME OF THOSE TIMES AND TASKS AND FUNCTIONS WITH COMMUNITY HEALTH WORKERS IS PROBABLY A GOOD IDEA. HERE IS A QUASI EXPERIMENT WHERE THE GOVERNMENT IN SOUTH AFRICA IN KWAZULANATAL, SOUTH AFRICA THE FIRST COUNTRY THAT WENT INTO THE PEPFAR TRANSITION IN 2009 TO 2013, STARTED TO LET GO, LAY HEALTH WORKER CADRE THAT WAS SPECIFICALLY TRAINED FOR HIV TASKS TO SUPPORT NURSES IN THE HIV TREATMENT, IT'S A QUASI EXPERIMENT BECAUSE THE HEALTH WORKERS STILL HAD CONTRACTS AND THEY NEEDED TO BE COMPLETED AND THE COMPLETION DATE IS RANDOM VERSUS OUR OUTCOME HERE IN THIS CASE HIV TESTING. SO WE SEE HERE DESCRIPTIVELY IN THIS ANALYSIS THESE LITTLE RED DOTS, FIVE HEALTH WORKERS, FIVE COMMUNITY HEALTH WORKERS, THREE ONE ON THE X AXIS WE HAVE TWO YEARS TIME, AN OBSERVATION PERIOD IN WHICH THEY WERE LET GO AND ON THE Y AXIS WE HAVE THE NUMBER OF HIV TESTS IN THESE DIFFERENT CLINICS AND NOW RANDOM VERSUS THE OUTCOME, THESE LAY HEALTH WORKERS SPECIFICALLY TRAINED FOR HIV WERE LET GO AND THIS IS THE EFFECT THAT THIS INTERVENTION HAS RESULTED AND IT LEADS TO ON AVERAGE 30 LESS HIV TESTS PER MONTH PER COMMUNITY HEALTH WORKER, THAT'S A LARGE NUMBER, WOMEN SUFFER MORE THAN MEN AND ADULTS SUFFER MORE THAN CHILDREN FROM THIS LOSS. ANOTHER APPROACH IS OF COURSE THE RCT AND LISA POINTED THAT OUT, WE DO THESE PRAGMATIC RCT'S , HERE WE'VE TESTED WITH PEER HEALTH WORKERS, AGAIN EDUCATED FOR HIV CAN DELIVER HIV SELF-TESTING AS A FUNCTION TO FEMALE SEX WORKERS AND AS YOU KNOW FEMALE SEX WORKERS ARE ONE OF THE MOST STIGMATIZED POPULATIONS WORLDWIDE IN THEIR ACCESS TO HEALTHCARE AND OF COURSE INCLUDING HIV HEALTHCARE AND HIV TESTING. SO HERE WE RANDOMIZE TO A PEER HEALTH WORKER PROVIDING HIV SELF -TESTING FACILITIES TO IT THE ABILITY TO PICK UP AN HIV SELF-TESTING CLINICS AND TO STANDARD OF CARE. AND INDEED AND IN OUR DESIGN STUDY PRECEDING THIS TRIAL, THIS IS WHAT WE WERE TOLD, USE A PEER HEALTH WORKER FOR THIS INTERVENTION AND INDEED WHAT THE DESIGN STUDY LED US TO DO THE PEER HEALTH WORKER IS MOST EFFECTIVE, YOU SEE HERE THE EFFECTIVENESS BARS, THE 30 PERCENT INCREASE IN TESTING AT ONE MONTH AND REPEATED TESTING WHICH IS IMPORTANT, SEX WORKERS ARE MEANT TO REPEATEDLY TEST TWICE EVERY THREE MONTHS, THE REPEATED TESTING FUNCTION IS EVEN MORE ENHANCED WITH A 50 PERCENT SHIFT IN THE PEER PROVIDED SELF-TEST, NOT IN THE FACILITY PROVIDED SELF-TEST, SO THE WORKER, THE PERSON MAKES A DIFFERENCE -- THE WORKER, THE PERSON MAKES THE DIFFERENCE. WE'VE LOOKED AT THE QUESTION FOR THE FIRST TIME WITH OUR COMMUNITY HEALTH WORKERS CAN PROVIDE HIV TREATMENT IN THE HOMES AND HUTS AND HOUSES OF PEOPLE RATHER THAN NURSES PROVIDING HIV TREATMENT IN CLINICS, IN DASALAM, THIS IS WORK INDUCED BY THE GOVERNMENT, THE GOVERNMENT ASKED US TO DO THIS BECAUSE TANZANIA AS YOU MAY HAVE HEARD IS THE MOST EXPENSIVE COUNTRY PER YEAR PER PATIENT IN ART IN SUBSAHARAN AFRICA, NOBODY REALLY KNOWS WHY, BUT THEY'RE LOOKING FOR ALTERNATIVE DELIVERY MODELS AND HERE THIS HIV TREATMENT PROVIDED BY COMMUNITY HEALTH WORKERS, THEY'RE CALLED HOME BASED CARERS IN DASAMALAN IN TANZANIA, LED BY A COMMUNITY BASISSED NURSE HERE ON THE RIGHT-HAND SIDE OF THE PICTURE, ON THE LEFT-HAND SIDE IS ONE OF OUR ACTUAL HAVING CONSENTED TO THIS PICTURE COMMUNITY HEALTH WORKERS AND THEY'RE MEETING ONCE PER WEEK IN CLINICS, THEY'RE GETTING A THREE-DAY TRAINING IN ADDITION TO THE 60-DAY CORE TRAINING THAT THEY ALREADY HAVE IN HIV TREATMENT FUNCTIONS, INITIATION, ART ADHERENCE COUNSELING, SIDE EFFECTS AND SO ON. WE RANDOMIZE THE ENTIRE CITY OF TASALAN, THE LARGEST CITY IN EAST AFRICA, ALL PRIMARY CARE CLINICS IN THE PUBLIC SECTOR THAT DELIVER HIV TREATMENT TO EITHER COMMUNITY DELIVERY BY A COMMUNITY HEALTH WORKER TO YOUR HOME OR STANDARD OF CARE NURSE- LED IN THE CLINICS AND IT'S A NONINFERIORITY TRIAL, EFFECT SIZE, SUPPRESSION, THE STANDARD OF CARE IS IN THE MIDDLE OF THE NONINFERIORITY MARGIN, IT'S ONE-SIDED CONFIDENCE INTERVAL BECAUSE IT'S A NONINFERIORITY TRIAL, HAD WE POWDER IT OR DESIGNED IT AS A SUPERIORITY TRIAL COMMUNITY HEALTH WORKERS WOULD HAVE BEEN SLIGHTLY BETTER IN ACHIEVING VIRAL LOAD SUPPRESSION THAN NURSES IN CLINICS, SO WE CAN DO IT EFFECTIVELY. AND WHAT IS IMPORTANT AND THIS RELATES TO LISA'S POINT OF COURSE THESE ARE MIXED METHOD STUDIES, THEY'RE PRECEDED BY A DESIGN PHASE OF HUMAN CENTERED DESIGN AND THEN IN THE TRIAL WE NEST QUALITATIVE AND QUANTITATIVE, OTHER METHODOLOGICAL DESIGNS AND HERE IT'S A SIMPLE SATISFACTION SURVEY AND WE SEE THAT PEOPLE ARE HIGHLY SATISFIED WITH THE PROVISION OF ART IN THEIR HOMES RATHER THAN HAVING TO GO TO A CLINIC. THIS IS NOT A TRIVIAL POINT. I WAS WORRIED, GOVERNMENT WAS WORRIED THAT COMMUNITY HEALTH WORKERS ARE NOT WELL REGARDED BECAUSE PEOPLE KNOW THEY HAVE FAR LESS TRAINING THAN NURSES ACCIDENT A FEW MONTHS OF TRAINING VERSUS A FEW YEARS OF TRAINING, AND MIGHT NOT HAVE FELT THAT THEY SHOULD BE TREATED BY A COMMUNITY HEALTH WORKER RATHER THAN BY A NURSE, BUT IN FACT PEOPLE ARE HIGHLY SATISFIED WE ALSO TALKED ABOUT COMMUNITY HEALTH WORKER FOR A BROADER UNIVERSAL HEALTHCARE COVERAGE AND HERE IS A BIT OF EVIDENCE THAT OF COURSE IT IS EQUALLY NEEDED FOR OTHER CARE. HERE WE POOLED FOR THE FIRST TIME THE WHO STEP SURVEYS THAT ARE AVAILABLE BUT ONLY IF YOU ASK THE INDIVIDUAL PI'S TO CONTRIBUTE THE DATA TO SHOW HYPERTENSION CASCADE AND WHAT WE FIND HERE IS THAT SIMILARLY TO THE HIV TREATMENT CASCADE, MOST LOSSES IN THIS CASCADE TO EFFECTIVE CARE APPEAR IN THE TESTING, SCREENING AND TESTING DIAGNOSIS STAGES, I.E., THE STAGES THAT ARE EARLY IN THE CASCADE AND IN THE HOMES, IN THE POPULATION, NOT IN THE CLINIC. SO AGAIN, WE HAVE THIS LOSS AND HERE WE TEST IN CHINA WHERE THE COMMUNITY HEALTH WORKERS CAN MAKE A DIFFERENCE, THEY ARE TRAINED HERE TO GO TO HOMES, MEASURE BLOOD PRESSURE, DIASTOLIC, SYSTOLIC AND COUNCIL IN COUNSEL IN THREE DOMAINS, DIETARY, EXERCISE, GO TO A CLIN DMIK AND HAVE PROPER DIAGNOSIS, THIS IS JUST A SCREENING TEST. ON THE X AXIS THIS IS REGRESSION , CONTINUITY EXPERIMENT, INITIAL SCREENING VALUE OF HYPERTENSION OR BLOOD PRESSURE AND THEN WE SEE ON THE Y AXIS THE OUTCOME WE COMPARE PEOPLE IN A SMALL NEIGHBORHOOD AROUND THIS HYPERTENSION THRESHOLD 140 THE ONES ABOVE 140 ARE COUNSELED TO TAKE ACTION, THE ONES BELOW 140 SMT INTENT TO TREAT ARE NOT COUNSELED AND IT LEADS TO A SUBSTANTIAL DECREASE, JUST THIS INTERVENTION SCREENING PLUS COUNSELING IN PEOPLE'S HOMES LEADS TO A SUBSTANTIAL DECREASE HERE IN MINUS SIX TO MINUS ELEVEN MMHG BLOOD PRESSURE SYSTOLIC. WE'VE ALSO SHOWN VERY QUICKLY, I HAVE TO COME TO AN END, THAT COMMUNITY HEALTH WORKERS CAN BE SUCCESSFUL IN DELIVERING MATERNAL CARE IN TANZANIA IN DAR SA LAM, THIS CARE MAY ALSO BE POLITICAL, HERE WE'VE SHOWN COMMUNITY HEALTH WORKERS GETTING ANOTHER FUNCTION MATERNAL AND CHILD CARE CAN IMPROVE SATISFACTION WITH A COMMUNITY HEALTH WORKER PROGRAM BUT ALSO WITH THE PUBLIC SECRETARY STORE HEALTHCARE SYSTEM IN GENERAL. AND MANY GOVERNMENTS I THINK REALIZE THAT THE POPULATION SATISFACTION WITH THEIR GOVERNANCE DEPENDS CRITICALLY ON THE POPULATION SATISFACTION WITH THE HEALTHCARE SYSTEM. SO COMMUNITY HEALTH WORKERS CAN BE GOOD FOR PUBLIC SATISFACTION. AND FINALLY A POINT ON HARMONIZATION IN SUBSAHARAN AFRICA AS I'M SURE IN THE UNITED STATES, HERE ARE MANY DIFFERENT PROGRAMS IN THE HIV SECTOR ACROSS SECTORS, COMMUNITY HEALTH WORKERS COME IN MANY DIFFERENT FLAVORS RANGING FROM THE HEALTHCARE EXTENSION WORKERS IN ETHIOPIA TO THE RURAL HEALTH MOTIVATORS IN ESWATINI AND COMMUNITY CARE WORKERS IN SOUTH AFRICA, THEY'RE ALL DIFFERENT TRAINED NOT COMPARABLE LIKE DOCTORS AND NURSES AND OFTEN THESE PROGRAMS ARE NOT INTEGRATED ACROSS THE NGO SECTOR AND THE GO SECTOR AND ACROSS DIFFERENT HEALTHCARE DOMAINS. SO THERE'S A LOT OF NEED TO IMPROVE INTEGRATION COORDINATION OF COMMUNITY HEALTH WORKER PROGRAMS, SO IN SUM, COMMUNITY HEALTH WORKERS COME IN DIFFERENT FLAVORS, COMMUNITY HEALTH WORKER PROGRAMS COME IN DIFFERENT FLAVORS TOO, THEY HAVE LIKELY THREE MAJOR ADVANTAGES VERSUS OTHER HEALTHCARE CADRES, THEY ARE RELATIVELY LOW COST, THEY ARE AVAILABLE IN MANY RESOURCE POOR COMMUNITIES WHERE WE NEED TO MAKE MASSIVE IMPROVEMENTS IN HEALTH AND THEY CAN BECAUSE THEY WORK IN COMMUNITIES, IN HOMES AND HUTS, REACH HARD TO REACH POPULATIONS, OLD AGE ADULTS, THEY CAN ALSO REACH IF THEY'RE THE RIGHT TYPE OF COMMUNITY HEALTH WORKERS STIGMATIZED POPULATIONS IN A NONSTIGMATIZING WAYS, SUCH AS REACHING FEMALE SEX WORKERS, EVIDENCE THAT COMMUNITY HEALTH WORKERS WITH COMMUNITY CARE. DOMAINS ARE HIV TESTING, HIV TREATMENT, MATERNAL AND CHILD HEALTH AND DIABETES AND HYPER TENSION CARE, AND I THINK WE'LL LEARN MUCH MORE IN THE FUTURE HOW WE CAN ALSO PROVIDE EFFECTIVE HYPERTENSION TREATMENT , IT SHOULD BE POSSIBLE , AND PARTIALLY EFFECTIVE DIABETES TREATMENT, COMMUNITY BASED UTILIZING COMMUNITY HEALTH WORKFORCES WORLDWIDE. THANK YOU TO OUR PARTICIPANTS AND COLLEAGUES AND FNG FUNDERS INCLUDING -- AND OF COURSE FUND ERS INCLUDING NIH. [APPLAUSE] OUR NEXT SPEAKER IS KENNEY M AES FROM OREGON STATE UNIVERSITY, HE HAD A CO-SPEAKER KEARA RODELA WHO COULDN'T MAKE IT TODAY BUT WE WANTED TO ACKNOWLEDGE HER AS WELL. ALL RIGHT. SO THE COMMON INDICATORS PROJECT , CHW COMMON INDICATORS PROJECT, ALSO SOMETIMES CALLED THE CI PROJECT, IT'S A NATIONAL INITIATIVE THAT FOCUSES ON DEVELOPING COMMON PROGRAM EVALUATION METRICS ACROSS THE U.S. TO STRENGTHEN THE SCIENCE REGARDING COMMUNITY HEALTH WORKER CONTRIBUTIONS TO HEALTH AND HEALTHCARE. AS A WHITE MALE UNIVERSITY PROFESSOR, I'M NOT THE IDEAL SPOKESPERSON FOR THIS PROJECT, I WANT TO GIVE ANOTHER SHOUT OUT TO KEARA RODELA ONE OF THE COMMUNITY HEALTH WORKERS WHO IS INVOLVED AND HELPS LEAD THIS PROJECT COULDN'T BE HERE BECAUSE SOMETIMES IT'S HARD FOR COMMUNITY HEALTH WORKERS TO LEAVE WHAT THEY'RE DOING, BUT ALSO WE HAVE NOEL WIGGINS AT THE OREGON COMMUNITY HEALTH WORKERS ASSOCIATION, EDI KIEFER AT THE UNIVERSITY OF MICHIGAN AND DPLOR YA -- GLORIA PASANO ALTHOUGH COMMONWEALTH AND SERVICES IN MICHIGAN HELPING TO LEAD THIS PROJECT AND WE HAVE AN EXPANDING NUMBER OF FOLKS INCLUDING COMMUNITY HEALTH WORKERS WHO ARE PARTICIPATING AND THAT WE HOPE WILL CONTINUE TO EMERGE AS LEADERS IN THIS PROJECT. SO WE HOPE THAT BY THE END OF THIS PRESENTATION, YOU'LL BE FAMILIAR WITH THE HISTORY AND ALSO THE CURRENT STATUS OF THE C I PROJECT, UNDERSTAND OUR SHORT AND LONG-TERM GOALS, BE FAMILIAR WITH THE DRAFT PROCESS AND OUT COME INDICATORS CURRENTLY IDENTIFIED IN THE PROJECT AND SHARE OUR EXCITEMENT ABOUT IT. WHY IS IT IMPORTANT TO IDENTIFY COMMON INDICATORS FOR COMMUNITY HEALTH WORKER PROGRAM EVALUATION , IN OTHER WORDS, FOR EVALUATING WHAT COMMUNITY HEALTH WORKERS ARE EXPERIENCING AND ACHIEVING? IT REALLY COMES DOWN TO ENHANCING THE UNDERSTANDING OF COMMUNITY HEALTH WORKER CONTRIBUTIONS AND CONVINCING FUNDERS AND PAYERS TO COMILT TO SUSTAINED INVESTMENT. -- COMMIT TO SUSTAINED INVESTMENT, BIGGER SUSTAINED INVESTMENT, THIS CAME UP YESTERDAY, WE'RE TALKING ABOUT A LOT MORE COMMUNITY HEALTH WORKERS WITH FULL FTE'S, JOB SECURITY AND WHAT THEY NEED TO BE SUCCESSFUL. A LITTLE BIT OF THE LOGIC BEHIND THIS PROJECT. SO WE KNOW THE DEMONSTRATED OUT COMES OF COMMUNITY HEALTH WORKER PROGRAMS ARE IMPRESSIVE, WE'VE BEEN SEEING THAT YESTERDAY AND TODAY, THE DATA KEEPS COMING IN, YET MANY PAYERS ARE STILL NOT PREPARED TO COMMIT TO SUSTAINED AND HIGHER LEVEL OF INVESTMENT IN COMMUNITY HEALTH WORKER PROGRAMS WITHOUT A BROADER AND MORE SYSTEMATIC EVIDENCE BASE, THEY WANT TO SEE LONGITUDINAL REALLY LONG-TERM STUDIES WITH SUSTAINED OUTCOMES AND POSITIVE RETURN ON INVESTMENT BUT FUNDERS TYPICALLY DON'T PAY FOR THESE. DEVELOPMENT OF THE EVIDENCE BASE HAS ALSO BEEN HAMPERED BY THE DIVERSE ARRAY OF INDICATORS THAT DIFFERENT PROGRAMS USE, WHICH MAKES IT DIFFICULT IF NOT IMPOSSIBLE TO PUT THE DATA TOGETHER FOR MULTIPE DIFFERENT PROGRAMS AND SHOW THE MASSIVE IMPACT OF COMMUNITY HEALTH WORKERS, AND A RELATED PROBLEM IS THE LACK OF ATTENTION TO PROCESS INDICATORS. WHAT COMMUNITY HEALTH WORKERS ARE DOING AS OPPOSED TO OUTCOME INDICATORS, WHICH HINDERS UNDERSTANDING OF WHAT COMMUNITY HEALTH WORKERS NEED TO BE SUCCESSFUL. SO WITH THESE KINDS OF CONCERNS IN MIND, BACK IN 2014, MEMBERS OF THE MICHIGAN COMMUNITY HEALTH WORKER ALLIANCE CONDUCTED A LITERATURE REVIEW INTERVIEWS WITH CHW'S AND CHW EXPERTS, THEY CONDUCTED FOCUS GROUPS, SURVEYS TO IDENTIFY PROCESS AND OUTCOME INDICATORS AND METHODS THAT THEY USE FOR CHW PROGRAM EVALUATION. SO THAT'S WHERE THIS GOT STARTED AND THEN IN 2015, MEMBERS OF THE OREGON COMMUNITY HEALTH WORKER CONSORTIUM IN PORTLAND, OREGON, BECAME AWARE OF THE WORK THAT WAS HAPPENING IN MICHIGAN AND OTHER RELATED EFFORTS AROUND THE COUNTRY. THE MICHIWA COLLEAGUES SAW BENEFIT IN THE WORKSHOP AND SUMMIT AND WERE EAGER TO PARTICIPATE SO IN OCTOBER OF 2015 MEMBERS OF THE OREGON COMMUNITY HEALTH WORKER CONSORTIUM ORG NIERMINGZED THIS TWO DAY SUMMIT IN PORTLAND THAT BROUGHT TOGETHER 16 COMMUNITY HEALTH WORKERS, RESEARCHERS, EVALUATORS AND PROGRAM STAFF FROM FIVE DIFFERENT STATES. OUR FACILITATORS THERE AT THAT SUMMIT USED POPULAR EDUCATION TO CREATE AN ATMOSPHERE OF TRUST, TO BALANCE PARTICIPATION AND POWER AND VOICES AROUND THE ROOM , AND AT THAT SUMMIT WE CAME UP WITH AN INITIAL LIST OF PROPOSED PROCESS AND OUTCOME CONSTRUCTS AND AN ACTION PLAN. USING THE TERMS CONSTRUCTS AND INDICATORS BEING I'LL DEFINE THOSE IN JUST -- CAIRKTS I'LL DEFINE THOSE IN JUST A SECOND, BEAR WITH ME, ONE THING I WANT TO EMPHASIZE HERE IS THAT WE CONTINUE TO USE POPULAR EDUCATION IN OUR MEETINGS AND IN OUR COLLABORATIONS. IN 2016 WE ORGANIZED AID APPROXIMATE PRECONVENTION WORKSHOP ALONGSIDE THE A PH A ANNUAL MEETINGS THAT DREW OVER 90 COMMUNITY HEALTH WORKERS AND STAKEHOLDERS TO FURTHER REFINE AND BUILD CONSENSUS ON THE LIST OF INDICATORS AND TWO SCIENTIFIC PRESENTATIONS ON THE CI PROJECT WERE ALSO PRESENTED AT THE ANNUAL MEETINGS, AND THIS BRINGS US UP TO DATE, CURRENTLY WE'RE JUST ENTERING A YEAR OF FUNDING FROM THE CDC VIA CONTRACT WITH THE NATIONAL ASSOCIATION OF CHRONIC DISEASE DIRECTORS, AND THIS FUNDING IS GOING TO ALLOW THE CI PROJECT TO ADVISE THE CDC ON HOW TO MORE SYSTEMATICALLY COLLECT DATA ON COMMUNITY HEALTH WORKER PROCESSES AND OUTCOMES AND ALSO CONTINUE TO FOCUS ON OUR PROJECT'S LONG-TERM GOALS, WHICH ARE THE COLLABORATIVE WIDE ADOCHTION A CORE SET OF COMMON -- ADOCHTION A CORE SET OF COMMON PROCESS AND INDICATORS TO SYSTEMATICALLY MEASURE THE IMPACTS OF COMMUNITY HEALTH WORKER FORCE AND SYSTEMATICALLY MEASURE THE PROCESS OF IMPACTS ACROSS COMMUNITY AND DISEASED AREAS. OKAY. SO HERE IS OUR LIST OF PROPOSED PROCESS CONSTRUCTS AND AT THE TOP OF THE LIST HERE WE HAVE THE FREQUENCY OF ENACTMENT OF THE TEN CHW CORE ROLES. THIS NOTES OUR ALIGNMENT WITH THE COMMUNITY HEALTH WORKER CORE CONSENSUS PROJECT, THE C3 PROJECT THAT WAS MENTIONED YESTERDAY. WE ALSO HAVE THE EXTENT TO WHICH CHW'S WORK WITH OTHERS IN THE SYSTEM, THE EXTENT OF THEIR INVOLVEMENT IN POLICY AND PROGRAM DECISION-MAKING PROCESSES, USE OF POPULAR EDUCATION IN INITIAL AND ONGOING CHW TRAINING, THE EXTENT TO WHICH CHW'S ARE INTEGRATED INTO HEALTHCARE TEEMENTZ, CHW'S OWN CONNECTIONS TO RESOURCES, ORGANIZATIONS, CHW FACILITATED PARTICIPANT OR PATIENT CLIENT CONNECTIONS REFERRALS ALTHOUGH ALL LEVELS, CHW'S OWN JOB SATISFACTION, SUPPORTIVE AND REFLECTIVE SUPERVISION OF CHW'S AND LAST BUT DEFINITELY NOT LEAST CHW'S LEVEL OF COMPENSATION AND BENEFITS. SO WE'RE USING THE TERM CONSTRUCTS HERE BECAUSE THESE ARE ALL THINGS THAT ARE REALLY IMPORTANT TO MEASURE, BUT WE DON'T NECESSARILY HAVE INDICATORS OR SPECIFIC SURVEY QUESTIONS THAT TELL US ABOUT THOSE UNDERLYING CONSTRUCTS. SO FOR EXAMPLE, THE EXTENT TO WHICH CHW'S ARE INTEGRATED INTO HEALTHCARE TEAMS, WHAT WOULD BE A GOOD SET OF QUESTIONS, SPECIFIC QUESTIONS THAT WE WOULD ASK IN DIFFERENT COMMUNITY HEALTH WORKER PROGRAMS TO KNOW ABOUT THE EXTENT TO WHICH THEY'RE INTEGRATED INTO THOSE TEAMS. NOBODY HAS REALLY DEVELOPED VALID INDICATOR FOR A LOT OF THESE CONSTRUCTS, INCLUDING THAT ONE, WHICH IS REALLY IMPORTANT, AND THAT'S A BIG PART OF THE WORK THAT REMAINS TO BE DONE. HERE IS OUR CURRENT LIST OF PROPOSED OUTCOME CONSTRUCTS, SO NOW WE'RE TALKING AT THE PARTICIPANT LEVEL OR PATIENTS, HOWEVER YOU WANT TO THINK OF THEM, WE TEND TO THINK OF THEM AS PARTICIPANTS, WE HAVE TRUST, SATISFACTION IN THE CHW RELATIONSHIP, SELF-REPORTED PHYSICAL MENTAL AND EMOTIONAL HEALTH, ACCESS TO HEALTH AND SOCIAL SERVICES, HEALTH KNOWLEDGE, ATTITUDES AND BEHAVIORS, PSYCHOLOGICAL EMPOWER MENT, SOCIAL SUPPORT, QUALITY OF LIFE, CIVIC ENGAGEMENT, SCUFORT ACCESS TO FOOD, WATER, HOUSING, TRANSPORTATION, ET CETERA, SECURITY, WHAT SOME PEOPLE MIGHT CALL ACCESS TO THE SOCIAL DETERMINANTS OF HEALTH, AND THEN COST OF CARE AND UTILIZATION OF HEALTH SERVICES. WE ALSO ENVISION THAT PROGRAMS WILL BE COLLECTING RELEVANT CLINICAL INDICATORS OF HEALTH, SO IN THE CONTEXT OF HIV, THOSE COULD INCLUDE THE KINDS OF THINGS, THE KINDS OF CAIRTSZ THAT WE'VE BEEN TALKING ABOUT -- INDICATORS THAT WE'VE BEEN TALKING ABOUT FOR THE LAST COUPLE DAYS LIKE CD4 COUNT, VIRAL LOAD, ET CETERA. AND THEN DOWN THERE AT THE BOTTOM, WE ALSO ENVISION OUT COMES AT THE POLICY AND SYSTEMS CHANGE LEVEL, WHEN YOU HAVE COMMUNTY HEALTH WORKERS WHO ARE SUPPORTED AND ORGANIZED AND SELF-ORGANIZE AND TRULY GENUINELY EMPOWERED, WE ENVISION THEM ALSO HAVING IMPACTS ON IMPORTANT POLICIES THAT IMPACT ON THE GENERAL HEALTH AND WELL-BEING OF POPULATIONS AND THEIR COMMUNITIES. SO THIS SLIDE WITH A WHOLE LOT OF BOXES AND ARROWS PARTLY ILLUSTRATES HOW WE'VE BEEN THINKING IN THE CI PROJECT, THIS IS A SORT OF VERY, VERY INTENTIONALLY AND NECESSARILY SIMPLIFIED LOGIC MODEL, SO ON THE LEFT-HAND SIDE YOU'VE GOT A SORT OF CONTEXT, WHAT EMPLOYING ORGANIZATIONS PROVIDE FOR COMMUNITY HEALTH WORKERS. MOVING OVER TO COMMUNITY HEALTH WORKER PROCESS INDICATORS THAT WE MENTIONED A COUPLE SLIDES AGO , THEN TO PARTICIPANT OUTCOME CAIRTSZ AND THEN FINALLY ON THE RIGHT TO THINGS -- INDICATORS AND THEN FINALLY ON THE RIGHT TO THINGS LIKE IMPROVED UTILIZATION OF HEALTH SERVICES AND RESOLUTIONED COST OF CARE. -- REDUCED COST OF CARE. NEFSLY A VERY SIMPLE MODEL HERE, WE ENVISION DIFFERENT FOLKS WORKING AROUND THE COUNTRY AS THEY DEVELOP THESE KINDS OF INDICATORS AS WE START TO DO A LOT MORE EVALUATION AND RESEARCH , PEOPLE WILL FILL IN THE GAPS HERE AND THERE WILL BE, YOU KNOW, A MESS OF ARROWS, A WHOLE BUNCH OF SPAGHETTI ON THIS KIND OF A SLIDE. SO TO DATE OUR CI WORKING GROUP INCLUDES MORE THAN 60 PEOPLE FROM 15 OR MORE STATES AND I HAVEN'T UPDATED THAT SLIDE LIKE I SHOULD, IT'S PROBABLY MORE ABOUT 70, 75 PEOPLE, GETTING CLOSER TO 20 STATES, WE MEET EVERY OTHER MONTH BY PHONE, BY WEB, WE'VE BEGUN ON IDENTIFY INDICATORS FOR EACH SCRUBLGHT OR IDENTIFY THE CONSTRUCTS THAT HAVE NO INDICATORS AND THAT NEED THEM DEVELOPED AND VALIDATED, WE PRIORITIZE SEEKING FUPGD IN 2019 AND 2020 AND CURRENTLY WE HAVE SOME INSTITUTIONAL SUPPORT FROM THE OREGON COMMUNITY HEALTH WORKERS ASSOCIATION AND OREGON STATE UNIVERSITY. PART OF OUR VISION IS THAT STATE CHW ASSOCIATIONS AND OTHER HEALTH SYSTEM ORGANIZATIONS AROUND THE COUNTRY WILL TAKE RESPONSIBILITY FOR DEVELOPING AND PROMOTING COMMON CAIRTSZ IN THEIR REGION AND SHARING WORK WITH PARTNERS AROUND THE COUNTRY , SO THE STATES THAT WE HAVE LISTED HERE ARE NOT NECESSARILY WHERE WE HAVE COMMON INDICATORS INITIATIVES HAPPENING BUT DEFINITELY PLACES WHERE WE'VE HAD A LOT OF EXPRESSED INTEREST. ANOTHER REALLY IMPORTANT PART OF OUR VISION I MENTIONED AT THE OUT SET BUT WANT TO EMPHASIZE IS THAT COMMUNITY HEALTH WORKERS WILL BE HIGHLY INVOLVED PARTICIPATING IN THIS PROJECT AS RESEARCHERS AND AS LEADERS. [APPLAUSE] >> THANK YOU. WHAT'S NEXT? WE NEED TO ESTABLISH BROADER CONSENSUS ON THE CI CONSTRUCTS AND INDICATORS, DEVELOP DEFINITIONS OF THOSE CONSTRUCTS, WE NEED TO PARTNER WITH MORE CHW ASSOCIATIONS ACROSS THE COUNTRY, COOPERATE TO DEVELOP AND TEST NEW METHODS NEEDED TO MEASURE THESE CONSTRUCTS, WE'RE ADVISING THIS YEAR CDC ON HOW TO SYSTEMATICALLY COLLECT DATA ON PROCESSES AND OUTCOMES AND CONVENING FACE TO FACE WORKSHOPS AND TELECONFERENCES, SO UPCOMING IN NOVEMBER JUST A DAY BEFORE A PH A GETS UNDERWAY IN PHILADELPHIA, WE'VE ORGANIZED A PRECONFERENCE WORKSHOP AND MEETING. THAT'S IT. I THINK I'M UNDER TIME. THANK YOU VERY MUCH. [APPLAUSE] >> THANK YOU, KENNEY, AND TO KEA RA REMOTELY. I'M SURE YOU ALL AGREE WITH ME THIS IS A HUGE, HUGE PROJECT AND I REALLY HOPE THE PARTNERING VISION CAN COME TO LIFE SOON AND FOLKS CAN ATTEND THAT NOVEMBER 3 PRECONFERENCE. WE'LL KEEP MOVING ALONG AND HEAR NEXT FROM JUDITH LONG IN THE UNIVERSITY OF PENNSYLVANIA REGARDING ASSESSING THE EFFICACY OF CHW AND INTEGRATING CHW'S INTO PRIMARY CARE. THANKS. >> THANK YOU. FIRST I WANT TO ACKNOWLEDGE MY COLLABORATORS, IN PARTICULAR, SH RA-A CANGO WHO SHOULD PROBABLY BE DOING THIS TALK, CAME TO ME AS A FELLOW WHEN WAS A JUNIOR FACULTY AT PENN SAYING I WANT TO CREATE A EXR COMMUNITY HEALTH WORKER PROGRAM AND OVER THE LAST TEN YEARS WE'VE WORKED TOGETHER TO CREATE IMPACT COMMUNITY HEALTH WORKER PROGRAM, WE DON'T ADDRESS HIV BUT I GUESS YOU WANT ED TO HEAR FROM SOMEBODY MAYBE WHO WAS DOING WORK IN THIS AREA WITHOUT SPECIFICALLY ADDRESSING HIV, AND WE HAVE -- WE WORK WITH A LOT OF PEERNLINGS A LOT OF OUR COMMUNITY HEALTH WORKERS BUT THIS HAS BEEN THE CORE GROUP OVER THE LAST TEN YEARS ON THIS SLIDE. SO THE SOCIAL DETERMINANTS OF HEALTH, I MEAN, I THINK WE ALL KNOW ABOUT THEM, THIS IS A LOT ABOUT WHAT THIS CONFERENCE IS TRYING TO ADDRESS IS THE CONDITIONS, ENVIRONMENT IN WHICH WE WORK AND LIVE AND WE KNOW THAT THEY REALLY IMPACT OUR HEALTH OUTCOMES AND MORE AND MORE HEALTH SYSTEMS ARE STARTING TO THINK ABOUT HOW DO WE REALLY ADDRESS THE SOCIAL DETERMINANTS OF HEALTH BUT IT'S BEEN A CHALLENGE, THEY HAVE HAD DIFFICULTY CREATING EFFECTIVE, STABLE SCALABLE PROGRAMS. MOST OF THE SOCIAL INTERVENTIONS THAT HEALTH SYSTEMS HAVE TAKEN ON HAVE BEEN INCONSISTENT AND HAVEN'T HAD VERY BIG IMPACTS ON HEALTH OUTCOMES. FREQUENTLY COMMUNITY HEALTH WORKERS HAVE BEEN AT THE CENTER OF THESE INTERVENTIONS, BUT THEY ARE OFTEN QUITE UNSTRUCTURED, THEY ARE OFTEN DISEASE-SPECIFIC, VERY DISEASE LIKE ONLY FOCUSING ON ONE DISEASE AND THERE HAS BEEN, I MEAN, I'VE HEARD ABOUT A LOT OF GREAT EVIDENCE, BUT THERE HAS BEEN SORT OF THE EVIDENCE IS NOW GROWING BUT IT HAS LACKED FOR A LONG TIME. SO AS I SAID OVER THE LAST TEN YEARS WE'VE BEEN WORKING TO, ME AND MY COLLEAGUES, TO CREATE THE IMPACT COMMUNITY HEALTH WORKER PROGRAM, AND WHAT WE THINK MAKES THIS INTERVENTION UNIQUE ARE BASICALLY THREE BIG ELEMENTS. FIRST, IT IS VERY PATIENT-CENTER ED. IT'S ALWAYS ABOUT SITTING DOWN WITH THE PATIENT OR THE CLIENT AND ASKING THEM WHAT DO THEY THINK IS GOING TO BE IMPORTANT FOR HELPING THEM GET HEALTHY OR HELPING THEM ACHIEVE THEIR GOALS , AND THIS IS A PICTURE OF ONE OF OUR COMMUNITY HEALTH WORKERS AND ONE OF OUR CLIENTS, AND SHE VERY MUCH SAID SHE WANT ED TO PLAI BASKETBALL, SO HERE IS -- PLAY BASKETBALL, SO HERE IS HER AND THE COMMUNITY HEALTH WORKER WERE PLAYING BASKETBALL AND THEN WHILE THEY WERE BREAKING, TAKING A BREAK, THEY APPLIED FOR HOUSING FOR HER SO THIS IS SORT OF PEOPLE, OUR COMMUNITY HEALTH WORKERS ARE GOING OUT IN THE COMMUNITY, THEY'RE ASKING THE PATIENTS WHAT DO THEY THINK THEY NEED AND REALLY TRYING TO SIT DOWN AND BREAK DOWN AND WORK WITH THEM WHERE THEY'RE AT AND ADDRESS THE ISSUES THAT THEY'RE FACING. THE SECOND THING IS WE'VE MADE THIS INTERVENTION, WHILE IT CAN BE VERY TAILORED TO THE INDIVIDUAL AND THE INSTITUTION, IT IS STANDARDIZED. WE HAVE CREATED STANDARDIZED TRAIRNTION SUPERVISION AND HIRING GUIDES, WHICH WE HAVE CODIFIED IN DETAILED MANUALS, WE HAVE ONLINE AND IN PERSON TRAININGS, AND WE HAVE CREATED A CERTIFICATE PROGRAM FOR OUR COMMUNITY HEALTH WORKERS. AND FINALLY, WE HAVE SOFTWARE FOR DOCUMENTATION AND REPORTING. ONE OF THE BIG ELEMENTS IS WE THINK IT'S VERY IMPORTANT TO ALWAYS DO QUALITY MONITORING, QUALITY CHECKING, WE'RE CONTINUOUSLY DOING THAT AND PROVIDING THE SUPPORT AND SUPERVISION TO THE COMMUNITY HEALTH WORKERS AS THEY GO OUT INTO THE COMMUNITY AND ENGAGE, SO IT IS QUITE A STRUCTURED PROGRAM. FINALLY, IT IS EVIDENCE-BASED. WE HAVE NOW PERFORMED THREE RANDOMIZED CONTROLLED TRIALS, AND WE'VE CONSISTENTLY SHOWN IMPROVEMENT IN SATISFACTION, IN MENTAL HEALTH, IN QUALITY ACROSS A RANGE OF CHRONIC DISEASED, THIS IS NOT A DISEASE SPECIFIC INTERVENTION, HOSPITALIZATIONS AND LENGTH OF STAY, AND WE'VE ALSO BEEN ABLE TO DEPLOIF THE IMPACT COMMUNITY HEALTH WORKER IN SEVERAL DIFFERENT ENVIRONMENTS, IN OUR UNIVERSITY HEALTH SYSTEM ACROSS THE WHOLE HEALTH SYSTEM, IN FQHC'S N OUR VA MEDICAL CENTER, SO WE'VE TAKEN IT TO DIFFERENT ENVIRONMENTS. THIS IS JUST TO GIVE YOU SOME EXAMPLE OF THE KINDS OF RESULTS WE'VE SEEN. SO THIS IS FROM OUR LAST STUDY, IN OUR LAST STUDY AT SIX MONTHS, A COMMUNITY HEALTH WORKER, WE HAVE SLIGHTLY DIFFERENT MODELS, SOME VERY SHORT MODELS WHERE A COMMUNITY HEALTH WORKER WORKS WITH A HOSPITALIZED PATIENT FOR TWO WEEKS, SOME FOR THREE MONTHS AND LONGER ONES WHERE THEY WORK FOR SIX MONTHS AND THEN CAN CONTINUE TO FOLLOW THE PATIENT IN SUPPORT GROUPS RUN BY THE COMMUNITY HEALTH WORKERS, BUT IN THIS MODEL WHICH WAS SIX MONTHS OF A COMMUNITY HEALTH WORKER, WE SAW THAT ON AVERAGE THE PEOPLE WHO HAD WORKED WITH THE COMMUNITY HEALTH WORKER HAD HAD 155 TOTAL -- OR THERE WERE 155 TOTAL DAYS VERSUS 345 TOTAL DAYS OF THE PEOPLE WHO GOT USUAL CARE , WHICH WAS AN ABSOLUTE REDUCTION OF 69 PERCENT, AND AT NINE MONTHS, THREE MONTHS AFTER THE COMMUNITY HEALTH WORKER -- THREE MONTHS AFTER THE PROGRAM HAD STOPPED FOR THAT INDIVIDUAL, THE NUMBER OF HOSPITALIZED DAYS WAS ROUGHLY ABOUT 300 TO OVER 450, WHICH IS A 65 PERCENT REDUCTION. WHEN WE LOOKED ALTHOUGH THIS A LITTLE BIT CLOSE -- AT THIS A LITTLE BIT CLOSER, WHAT WE REALLY SAW WAS THAT THERE WAS A BIG RUK IN THE MEAN LENGTH OF -- BIG REDUCTION IN THE MEAN LENGTH OF STAY FOR HOSPITALIZATIONS AND WHAT WE THINK HAPPENS THERE IS THAT WHEN THE TEAM KNOWS A COMMUNITY HEALTH WORKER IS INVOLVED, THEY FEEL MORE COMFORTABLE DISCHARGING THE PERSON OUT TO THE COMMUNITY AT A QUICKER RATE, WHERE THEY MAY HAVE HELD ONTO THEM IF THEY FELT THAT PERHAPS THE SOCIAL SUPPORT WASN'T THERE OR THE FOLLOW-UP WASN'T THERE. WHAT WE ALSO SEE WAS REPEAT ADMISSIONS, THE ODDS OF REPEAT ADMISSIONS, IF YOU HAD BEEN ADMITTED ONCE, THE ODDS OF HAVING ANOTHER ADMISSION WAS DECREASED, AS WELL AS 30-DAY RE ADMISSIONS, WHICH IS ONE OF THE MARKERS OF THE HEALTH SYSTEMS THAT IS VERY IMPORTANT TO THEM. SO THIS DRIVES A LOT OF THE COST S IN TERMS OF COMMUNITY HEALTH WORKERS, AND I'M GOING TO TALK ABOUT ROI IN A SECOND, BUT THE REDUCTION IN THE HOSPITALIZATIONS REALLY IS A SELLING POINT TO HEALTH SYSTEMS WHO WANT TO THINK ABOUT ENGAGING AND TRYING TO ADDRESS SOCIAL DETERMINANTS OF HEALTH. AS I SAID, WE ARE STRUCTURED, SO A TYPICAL TEAM HAS A DIRECTOR, A MANAGER, A COORDINATOR AND COMMUNITY HEALTH WORKERS, THE DIRECTOR IS REALLY RESPONSIBLE FOR HIRING, BUDGETS, CONTINUED QUALITY. THE MANAGER USUALLY A SOCIAL WORKER OR SOMEBODY WITH SOCIAL WORKER TRAINING, MANAGES THE CHW'S, THE COORDINATOR HELPS IDENTIFY AND ENROLL PARTICIPANTS INTO THE PROGRAM AND ALSO COLLECTS DATA ON A CONTINUAL BASIS FOR QUALITY, ONGOING QUALITY ASSESSMENT, AND THE CHW'S WORK WITH THE CLIENT. WE HELP ORGANIZATIONS BUILD DIFFERENT SIZES, SO WE CAN HELP YOU BUILD A SMALL OR A BIG PROGRAM, BUT SORT OF ROUGHLY SPEAKING, WE THINK OF ONE DIRECTOR, TWO MANAGERS, EIGHT CHW'S AND ONE COORDINATOR CAN WORK WITH 500-PLUS PEOPLE OVER THE COURSE OF THE YEAR. SO THAT'S SORT OF WHERE WE ROUGHLY FAWVMENT AS I SAID -- ROUGHLY FALL. AS I SAID, THE SMALLER YOU ARE, THE HARDER IT IS TO DO THAT. THE BIGGER YOU ARE, THE EASIER LITTLE TO SCALE. -- THE EASIER LTS TO SCALE. SO WE'VE DONE A BUNCH OF DIFFERENT ECONOMIC ANALYSIS AND HOPEFULLY ONE WILL BE COMING OUT IN PRESS VERY SOON BUT IT'S UNDER REVISION SO IT'S NOT OUT THERE YET, BUT IN GENERAL, WE'VE SEEN A SORT OF TWO TO ONE RETURN ON INVESTMENT. SO WHAT SOMETIMES HAPPENS IS PEOPLE GO OH, THIS IS AN EXPENSIVE PROGRAM. BUT WHEN YOU ACTUALLY START TO RECOGNIZE IT -- RECOGNIZE THAT YOU ARE REDUCING LENGTH OF STAY AND REDUCING HOSPITALIZATIONS, YOU QUICKLY START TO ACCRUE SAVINGS FROM THE PROGRAM. SO IT REALLY IS ACTUALLY A COST SAVINGS PROGRAM. WE TO DATE HAVE SERVED OVER 10,000 PATIENT IN THE PHILADELPHIA AREA AND ARE HELPING ORGANIZATIONS START TO IMPLEMENT THEIR OWN PROGRAMS. OUR LAST STUDY WAS FUNDED BY PAC ORI AND IF YOU HAVE A SUCCESSFUL STUDY YOU CAN APPLY FOR DISSEMINATION IMPLEMENTATION GRANT AND WE GOT ONE OF THOSE AND WE ARE WORKING WITH TWO OTHER VA'S AND A STATE MEDICAID PROGRAM TO LAUNCH OTHER COMMUNITY HEALTH WORKER PROGRAMS . WE HAVE A WEBSITE AND I'LL GIVE YOU THE LINK AT THE END, BUT THIS IS THE DOTS ARE WHERE ORGANIZATIONS AND INDIVIDUALS THAT HAVE DOWNLOADED INFORMATION FROM OUR WEBSITE AND THE HEARTS ARE WHERE WE ARE WORKING WITH ORGANIZATIONS TO HELP THEM IMPLEMENT THE IMPACT COMMUNITY HEALTH WORKER PROGRAM IN SOME MANNER. JUST TO GIVE YOU SOME SENSE OF HOW WE DO THIS, AS I SAID, WE DO TAILOR IT FOR WHOEVER WE'RE WORKING WITH, SO OUR FIRST STEP IS ALWAYS TO WORK WITH THE PEOPLE WHO WENT PROGRAM TO DETERMINE WHAT ARE THEIR GOALS. WE USE THEIR DATA TO HOTSPOT, TO TRY AND HELP THEM DETERMINE WHERE TO GEOGRAPHICALLY TARGET WITH THE CHW PROGRAM AND THEN WE DEVELOP A BLUEPRINT BEFORE EVEN GOING IN THERE IN WHICH WE REALLY TRY TO HELP THEM THINK THROUGH, THIS IS SORT OF AN IMPLEMENTATION BLUEPRINT FOR THE ORGANIZATION, AND IF THE ORGANIZATION IS INTERESTED, WE CAN ALSO INCLUDE AN INDIVIDUALIZED ROI ANALYSIS SO THEN THEY CAN FEEL CONFIDENT THAT THEY ARE GETTING THE RETURN ON INVESTMENT IN WHICH THEY HAVE -- IN WHI CH THEY'RE INVESTING IN, THE PROGRAM THEY'RE INVESTING IN. SO THAT WAS QUICK AND I'LL LET YOU CATCH UP, BUT I'LL JUST LEAVE IT THERE AND JUST SORT OF SAY THIS IS OUR WEBSITE, AND, YOU KNOW, WE'RE NOT DOING HIV IN PARTICULAR, BUT THIS IS NOT A DISEASE-SPECIFIC PROGRAM, AND VERY MUCH CAN WORK ON WHATEVER THE TARGET OR INTEREST OF THE ORGANIZATION. THANK YOU. [APPLAUSE] >> THANK YOU SO MUCH. SO YOU CAN GO SEE WE'RE MOVING FROM RESEARCH TO PRACTICE. OUR FINAL SPEAKER FOR THIS MORNING, WE'RE GOING ON POWER RIGHT THROUGH AND THEN PROBABLY TAKE A BREAK BEFORE WE PULL ALL THE MODERATORS BACK FOR A CAPSTONE DISCUSSION, IS ANT GONE DEMPSEY -- IS ANTIGONE DEMPSEY FROM HRSA, SHE'LL BE SPEAKING ON THE HRSA PERSPECTIVE FOR IMPLEMENTATION SCIENCE FOR HIV CARE, OPERATIONALIZING IMPLEMENTATION SCIENCE WITHIN THE RYAN WHITE PROGRAM. SO ANTIGONE. >> HI, EVERYONE. I WAS JUST ASKED TO EXPLAIN WHAT HRSA IS, WHICH I'M NOT SURPRISED BY. BUT MY NAME IS ANTIGONE DEMPSEY, FIRST, I HAVE TO APOLOGIZE, I FORGOT TO TAKE MY ALLERGY MEDS THIS MORNING SO IF I'M A LITTLE COUGHY, THAT IS WHY I'M NOT SICK HRSA IS THE HEALTH RESOURCES AND SERVICES ADMINISTRATION BUT MOST PEOPLE DON'T KNOW WHAT THAT IS, BUT WHAT WE DO IS WE HAVE THE RYAN WHITE HIV/AIDS PROGRAM THERE, WE RUN THE COMMUNITY HEALTH CENTER PROGRAM THERE, I'M SEEING SOME NODDING HEADS, MATERNAL CHILD HEALTH BUREAU IS ALSO THERE, RURAL HEALTH IS AT HRSA AS WELL, AND THEN 340B PROGRAM IS THERE, HOWLINGSED THERE AS WELL. SO WE DO IN HEALTH SYSTEMS STRENGTHENING. THERE'S A LOT OF REALLY IMPORTANT HEALTH PROGRAMS THERE. BUT I'M GOING TO TALK TODAY ABOUT NOW IT'S THE BIG ONE IN THE MIDDLE, IS THAT THE ONE? OKAY, GREAT. SO I'M GOING TO TALK ABOUT OUR WORK IN THE RYAN WHITE HIV/AIDS PROGRAM AND A LITTLE MORE RECENTLY WE'VE BEEN WORKING IN IMPLEMENTATION SCIENCE, BUT I HAVE TO SAY A LOT OF THE WORK THAT I'M GOING TO BE TALKING ABOUT HAS REALLY BEEN AROUND FOR MANY, MANY YEARS. I'VE BEEN WORKING FOR CLOSE TO 30 YEARS IN THIS FIELD, AND MY GOOD FRIEND AND COLLEAGUE OVER THERE DURRELL FOX YOU GOT TO HEAR FROM HIM YESTERDAY, WE HAVE BEEN WORKING TOGETHER IN THIS WORK, WE STARTED TOGETHER ON SPECIAL PROJECT, NATIONAL SIGNIFICANCE PROJECT IN 1993 WHICH WAS LOOKING AT YOUNG PEOPLE LIVING WITH HIV, SERVING OTHER YOUNG PEOPLE LIVING WITH HIV, AND I WAS AN EXECUTIVE DREK TOFER A VERY SMALL NONPROFIT THAT WAS -- DREK TOFER A VERY SMALL NONPROFIT THAT WAS ABLE TO SERVE FOR THAT. WHAT THOSE YOUNG PEOPLE WERE DOING, WHAT WE WERE DOING WAS COMMUNITY HEALTH WORKER WORK BEFORE IT WAS REALLY SORT OF CONCEPTUALIZED. ANOTHER THING THAT I THINK IS IMPORTANT TO UNDERSTAND IN TERMS OF THE CONTEXT OF IMPLEMENTATION SCIENCE IN PARTICULAR AND THE RYAN WHITE HIV/AIDS PROGRAM IS THAT THE RYAN WHITE PROGRAM WAS STARTED BY COMMUNITIES FIGHTING FOR SOMETHING THAT WAS MISSING, THAT PEOPLE WERE DYING AND THAT WE NEEDED SUPPORT, WE NEEDED SERVICES, MEDICAL SERVICES, SUPPORT SERVICES, IN THE BEGINNING THERE WASN'T TREATMENT , WE NEEDED RESEARCH. SO A LOT OF THE MODELS AND I'M PUTTING THOSE IN SOME QUOTES, AND I KNOW I SEE SOME OF YOU AROUND HERE WHO HAVE BEEN AROUND FOR MANY YEARS, REALLY STARTED FROM JUST PEOPLE, YOU KNOW, IN THEIR KITCHENS SAYING WHAT ARE WE GOING TO DO, INCLUDING DOCTORS, NURSES, YOU KNOW, COMMUNITY HEALTH WORKERS, AND THEN PEOPLE LIVING WITH HIV. SO THE MODELS THAT WERE SORT OF DEVELOPED WERE LOTS OF DIFFERENT KINDS OF EITHER COMMUNITY BASED MODELS OR MEDICAL SERVICE MODELS , AND THE RYAN WHITE HIV/AIDS PROGRAM WHICH IS FUNDED THROUGH -- WHICH WAS DEVELOPED THROUGH A LAW THAT WAS PASSED HAS SOME SORT OF, YOU KNOW, THERE'S RULES THERE AROUND HOW TO DO SERVICES AND HOW FUNDING IS DONE BUT THERE IS A LOT OF FLEXIBILITY AND SO HOW PEOPLE DID THEIR WORK IS REALLY BASED ON A TRIAL AND ERROR AND YOU GOT TO HEAR FROM NEW YORK CITY TALKING ABOUT IN THEIR PART A WHAT THEY'RE ABLE TO DO WITH THE PART A MONEY AND TRYING DIFFERENT MODELS, AND SO THE IDEA OF USING IMPLEMENTATION SCIENCE FOR US HAS REALLY BEEN KIND OF LOOKING AT OUR SPECIAL PROJECTS OF NATIONAL SIGNIFICANCE, WHICH IS A WONDERFUL PROGRAM AND IT'S BEEN AROUND FOR MANY YEARS, BUT IT WAS DEVELOPED 30 YEARS AGO, THAT MODEL, AND THE THINKING AROUND IT AND WE REALLY HAVE BEEN TRYING TO SHIFT, HOW CAN WE USE THAT MODEL DIFFERENTLY TO BE ABLE TO IN REALTIME AND MORE QUICKLY EVALUATE INTERVENTIONS, REALLY BEEN MODEL BASED AND I THINK MANY OF US KNOW WHEN YOU SEE ONE MOMGDZ AT AN ORGANIZATION, YOU SEE ONE MODEL, SO BEING ABLE TO REPLICATE THAT HAS BEEN VERY DIFFICULT FOR US. SO MOVING MORE TOWARDS IMPLEMENTATION SCIENCE IS REALLY LOOKING FOR US IS REALLY LOOKING AT HOW CAN WE DO THIS DIFFERENTLY AND ALSO MORE QUICKLY BECAUSE THE SPINS PROJECTS YOU WOULDN'T SEE ANY PAPERS ON THAT FOR ABOUT SIX YEARS AFTER IT STARTED AND IF YOU THINK ABOUT THIS EPIDEMIC 2019 AND WHAT WAS GOING ON SIX YEARS AGO AND WHAT'S HAPPENING TODAY, WE'RE IN IN A COMPLETELY DIFFERENT PLACE RIGHT NOW, FOR LOTS OF DIFFERENT REASONS. HERE IS A LITTLE BIT, YOU GUYS CAN READ MORE ABOUT THIS AROUND HRSA AND WHAT WE DO BUT REALLY THE MISSION OF HRSA IS REALLY TO SERVE, YOU KNOW, LOW INCOME UNDERSERVED POPULATIONS, NOT JUST HIV BUT, YOU KNOW, ACROBS THE FULL HEALTHCARE SYSTEM. THE VISION OF THE HIV/AIDS BURROW THAT MANAGES THE RYAN WHITE HIV/AIDS PROGRAM IS OPTIMAL HIV CARE AND TREATMENT FOR ALL, AND THAT VISION STILL HOLDS TRUE TODAY WHEN WE'RE TALKING ABOUT ENDING THE HIV EPIDEMIC AND I'LL TALK A LITTLE BIT ABOUT THAT LATER ON. I AM THE DIVISION DIRECTOR FOR AWR DATA GROUP SO THAT'S ALWAYS IMPORTANT FOR US TO BE ABLE TO SHARE OUR DATA BUT JUST TO UNDERSTAND THE IMPACT OF THE RYAN WHITE HIV/AIDS PROGRAM, WE SERVE OVER HALF A MILLION PEOPLE LIVING WITH HIV IN THE UNITED STATES AND OUR VIRAL SUPPRESSION FOR THOSE THAT ARE IN CARE IN THE PROGRAM, SO IT'S NOT THE FULL 500,000, IT'S ABOUT 340,000 , IS 86 PERCENT ARE VIRAL LY SUPPRESSED FOR THOSE WHO ARE IN CARE, ALTHOUGH THERE ARE MANY WHO ARE LOST TO CARE OUT THERE. AND WE ARE PREDOMINANTLY SERVING PEOPLE WHO ARE LOW INCOME AND THAT'S BECAUSE OF OUR LAW, THAT IS WE HAVE TO SERVE PEOPLE WHO ARE LOW INCOME, AND ALSO PREDOMINANTLY PEOPLE OF COLOR, WEESH REACHING SORT OF -- WE'RE REACHING SORT OF OUR MANDATE THERE. THIS IS AN INFOGRAPHIC THAT I LIKE TO SHARE BECAUSE IT SHOWS SORT OF WHERE WE WERE IN 2010 IN TERMS OF VIRAL SUPPRESSION AT .5 PERSIAN PERCENT TO NOW WHICH IS 8 --, AND EVEN THOUGH WE HAVE SEEN GREATER IMPROVEMENT, THERE ARE STILL DISPARITIES IF YOU SEE THE SOUTHERN STATES, IN A LOT OF DISCUSSIONS IN THE LAST FIVE YEARS HAVE BEEN ABOUT THE CHALLENGES THAT OUR SOUTHERN STATES HAVE FACED AND A LOT OF THAT HAS TO DO WITH HEALTHCARE INFRASTRUCTURE, YOU KNOW, IN GENERAL AND MEDICAID HAS NOT BEEN EXPANDED TO THOSE STATES AND THAT IS A LOT OF WHY THERE ARE THESE DISPARITIES. WITH OUR CLIENT LESM DATA THAT WE'VE BEEN COLLECTING, TO UNDERSTAND AND USE APPEARS A BASELINE WHERE ARE THE GAPS, WE ARE WE NOT REACHING THE MARK, WHERE CAN WE FOCUS OUR EFFORTS IN HRSA. STHS A DIAGRAM LOOKING AT VETIONZ AMONG CLIENTS YOU CAN SEE THE DOTTED GREEN LINE AND THEN BY AGE GROUP AND YOUNG PEOPLE IN OUR PROGRAM AND I THINK THIS HAS BEEN TRUE THROUGHOUT THE HISTORY OF THIS EPIDEMIC JUST HAVE STRUGGLED, THEY HAVE A LOT MORE DIFFERENT CHALLENGES WITH BEING ABLE TO STAY IN CARE AND STAY VIRALLY SUPPRESSED AND A LOT OF THAT IS JUST BECAUSE OF NORMAL ADOLESCENT DEVELOPMENT, IT'S NOT THAT THEY'RE BAD, IT'S NOT THAT, YOU KNOW, BUT THAT IS PART OF ONE OF THE CHALLENGES AND IN PARTICULAR WE HAVE GAPS FOR YOUNG PEOPLE BHO ARE PERINATALLY , WHO HAVE PERINATAL HIV BECAUSE BY THE TIME THEY'RE TEENAGERS IT'S JUST A NORMAL STAGE OF DEVELOPMENT TO TRY TO LIKE I WANT TO CHOOSE FOR MYSELF , I WANT TO CHOOSE MAYBE NOT TO TAKE THESE MEDS AND THEY GO THROUGH THAT STAGE OF DEVELOPMENT. BUT ANYWAY, THIS IS ONE GRAPHIC JUST TO SHOW HOW WE'VE BEEN FOCUSING SOME OF OUR EFFORTS ALSO IN YOUNG PEOPLE IN PARTICULAR LOOKING AT WHERE CAN WE IMPROVE THERE. HOURSING IS ANOTHER REALLY IMPORTANT CHALLENGE IN THE UNITED STATES FOR THE POPULATION S THAT WE'RE SERVING AND YOU CAN SEE THE DISPARITY THERE. I'M JUST GOING TO RUN THROUGH THESE BECAUSE I KNOW I ONLY HAVE ABOUT TEN MORE MINUTES. THEN IN PARTICULAR WHEN WE LOOK AT SO THERE HAVE BEEN IMPROVEMENTS FOR BLACK MSM OR BLACK MEN WHO HAVE SEX WITH MEN AND ALSO AFRICAN AMERICAN BLACK TRANSGENDER WOMEN THAT WE SERVE IN THE PROGRAM, WE'VE MADE SOME GREAT IMPROVEMENTS HERE, BUT THERE'S STILL DISPARITIES WHEN YOU SEE OVERALL COMPARED TO THE OVERALL POPULATION OF RYAN WHITE SO A LITTLE BIT ABOUT THE EVOLUTION OF AND I KIND OF TOUCHED ON THIS, BUT BEFORE I DO THAT, THOUGH, I WANT TO PAUSE THERE FOR A MINUTE BECAUSE AT THE BEGINNING I WANTED TO INTRODUCE STACY COHEN WHO IS HERE, STACY STAND UP SO EVERYBODY CAN SEE YOU. SO STACY IS HERE WITH ME FROM HRSA, SO I'M POINTING HER OUT BECAUSE SHE IS A PERSON THAT YOU IF YOU WANT TO FOLLOW UP ON ANYTHING, YOU'LL BE TALKING TO HER BECAUSE STACY IS OUR LEADER, SHE ACTUALLY PUT TOGETHER ALL OF THESE DATA SLIDES, SHE'S BEEN OUR LEADER ON PUTTING OUT OUR DATA, BUT ALSO ON OUR IMPLEMENTATION SCIENCE WORK, STACY AND HER TEAM IN MY DIVISION, SO IF THERE ARE ANY TECHNICAL QUESTIONS, STWAI SI WILL BE THE PERSON TO BE ABLE -- STACY WILL BE THE PERSON TO BE ABLE TO ANSWER THOSE, SO STACY, THANKS FOR BEING HERE. SO ONE OF THE THINGS AROUND ENDING THE HIV EPIDEMIC AND THIS PRESENTATION IS NOT ON THAT SO I'M NOT GOING TO GO INTO A LOT OF DETAIL, BUT I THINK THAT THIS TIES IN VERY NICELY TO WHAT YOU'VE ALL BEEN TALKING ABOUT BECAUSE ONE OF THE THINGS THAT WE'RE LOOKING AT AROUND THIS INITIATIVE IS FOR RYAN WHITE IN PARTICULAR, WE ARE DOING A PRETTY GOOD JOB OF PEOPLE WHO ARE IN CARE, AS YOU CAN SEE IN TERMS OF OUR VIRAL SUPPRESSION OUTCOMES, BUT FOR THOSE PEOPLE WHO ARE DIAGNOSED AND NOT IN CARE, NOT DIAGNOSED, THOSE WHO HAVE BEEN IN CARE, LAST CARE, THERE WAS A PRESENTATION EARLIER ON DURABLE VIRAL SUPPRESSION, BEING ABLE TO HELP PEOPLE STAY VIRALLY SUPPRESSED, THAT'S WHERE THIS INITIATIVE FOR US WILL BE FOCUSING ON. AND THAT'S WHY, YOU KNOW, I'VE BEEN OUT ON A FEW DIFFERENT COMMUNITY ENGAGEMENT EVENTS WITH THE C DP C DIRECTOR AND HE'S BEEN TALK -- CDC DIRECTOR AND HE'S BEEN TALKING A LOT ABOUT DISRUPTIVE INNOVATION AND THAT WE HAVE TO HAVE DISRUPTIVE INNOVATION TO BE ABLE TONED THIS EPIDEMIC. WE CAN'T JUST EXPECT PEOPLE TO COME INTO THE SAME SYSTEM AND EXPECT THAT WE'LL GET DIFFERENT RESULTS. THAT'S WHY I THINK THE TIMING OF THIS PAST FEW DAYS IS REALLY WONDERFUL BECAUSE WE HAVE TO LOOK THE ADIFFERENT MODELS, AND COMMUNITY HEALTH WORKER MODEL HAS BEEN OUT THERE FOR MANY YEARS BUT I DON'T THINK THAT IT'S REALLY BEEN BROUGHT TO SCALE IN THE WAY THAT IT CAN BE, IN PARTICULAR IN THE RYAN WHITE CONTEXT, BUT WE HAVE TO DO THINGS DIFFERENTLY, WE HAVE TO BE WILLING TO TRY DIFFERENT THINGS AND DIFFERENT STRATEGIES, AND ALSO SOMETIMES WHAT'S OLD IS NEW, A LOT IN THE VERY BEGINNING WE DID A LOT OF THIS KIND OF PEER-BASED, PEER NAVIGATOR WORK AND WE MOVED TO A MUCH MORE MEDICAL MODEL FOR MANY YEARS, WHICH, YOU KNOW, I UNDERSTAND BECAUSE TREATMENT HAPPENED AND WE NEEDED PEOPLE IN CARE, BUT WE LOST A LITTLE BIT OF THAT HEART AND WE LOST A LITTLE BIT OF THAT INNOVATION, SO NOW WE'RE COMING FULL CIRCLE BACK TO WE NEED TO GO BACK TO THAT INNOVATION AND GO BACK TO THAT HEART F WE'RE GOING TO REACH THESE GOALS, WHICH ARE VERY AGGRESSIVE, YOU KNOW, BUT I THINK THAT WE CAN LEARN A LOT FROM WHAT'S HAPPENING GLOBALLY BECAUSE THERE ARE COUNTRIES THAT ARE REACHING THESE GOALS AND WE HAVE TO ALSO LOOK TO THAT. SO I SAW SOME GREAT MODELS AROUND COMMUNITY HEALTH WORKERS GLOBALLY. I DID WANT TO, SO IT'S GREAT THAT MICHAEL IS HERE FROM NINMH UP THERE AND RECENTLY AS PART OF THIS WORK FOR US AROUND IMPLEMENTATION SCIENCE IS WE WERE ABLE TO AND WE WERE VERY GRACIOUS INVITED INTO A WORK GROUP THAT CDC HAD BEEN DOING WITH NIMH AROUND IMPLEMENTATION SCIENCE AND AS WE STARTED TO HRSA STARTED TO THINK AND TALK ABOUT THIS, WE HAD DISCUSSIONS WITH OUR COLLEAGUES AND PARTNERS AND WE WERE ABLE TO JOIN THAT WORK GROUP AND IT HAS EXPANDED EVEN MORE NOW BECAUSE NOW IT'S TIED TO THE INITIATIVE, SO NOW WE HAVE A MUCH LARGER GROUP. BUT THAT'S BEEN VERY HELPFUL FOR US BECAUSE WE WANT TO TRY TO ALIGN OUR THINKING AND NOT JUST HAVE IT BE HRSA OVER HERE AND NI H OVER HERE AND CDC IN PARTICULAR OVER THERE BECAUSE OF THEIR HISTORY WITH DOING THE EBB IES AND THE DEBBIES AND WE ARE REALLY TRYING TO -- THAT'S SHORTHAND FOR SOME OF THE INTERVENTIONS BASED WORK THAT CD C HAS BEEN DOING AROUND BEHAVIORAL HEALTH INTERVENTIONS. SO I DON'T THINK YOU'RE AS INTERESTED IN THIS STUFF BECAUSE WE TALKED ABOUT DEFINITIONS AND LISA THANK YOU, WE ALL HAVE DIFFERENT DEFINITIONS, BUT FOR US WE REALLY WANTED TO COME UP WITH SOME DEFINITIONS THAT ALIGNED WITH WHAT CDC AND NIMH HAS BEEN DOING SO REALLY WE'RE LOOKING AT DIFFERENT INTERVENTION STRAT STRATEGIES AND AGAIN GOING BACK TO THE SPINS MODEL WE REALLY NEED TO DO TALK ABOUT STRATEGIES OR INTERVENTIONS AS OPPOSED TO MODELS FOR OUR DEVELOPMENT AND THEY CAN BE AT ALL DIFFERENT LEVELS BUT WE'RE ALSO LOOKING AT SYSTEM STRATEGIES AND I HEARD, YOU KNOW, TALKING ABOUT HOW DO YOU MAKE SURE THAT YOU HAVE THE RIGHT PEOPLE AT THE TABLE TO LOOK AT POLICIES AND TO LOOK AT HEALTHCARE SYSTEMS IN A CITY OR A STATE, THESE ARE ALL VERY IMPORTANT DIFFERENT KINDS OF STRATEGIES THAT WE'RE GOING TO NEED. AND THEN ALSO, YOU KNOW, LOOKING AT THE DEMONSTRATED EFFECTIVENESS AND THAT'S SOMETHING THAT DEPENDING ON HOW MUCH EVIDENCE THERE IS, YOU KNOW , YOU HAVE TO SORT OF BALANCE WITH WHAT YOU HAVE AND DON'T HAVE, BUT THAT'S SOMETHING THAT WE HAD TO DEVELOP CRITERIA WHEN WE LOOKED AT FOR SOME OF OUR PROJECTS WHAT ENTER SWRENGS ES WILL -- INTERVENTIONS WILL WE HAVE AS A PART OF OUR PROJECT. THEN THE OTHER PIECE IS THAT FOR US, WE HAD TO SORT OF DEFINE WHAT IS AN EVIDENCE-BASED INTERVENTION, EVIDENCE INFORMED INTERVENTION VERSUS EMERGING STRATEGIES, AND EMERGING STRATEGIES ARE ALSO VERY THING, WE DON'TMENT TO HAVE THIS HIERARCHY AS ONE IS BETTER THAN THE OTHER BECAUSE EMERGING STRATEGIES ARE THE GRASSROOTS, THAT'S WHAT PEOPLE ARE DOING ON THE GROUND, MIKE AL MUKHERJEE IS HERE, THERE YOU ARE TRRKS CLINIC LEVEL, THAT HAS TO BE A PART OF IT, I SEE ALL THESE PIECES CONVERGING TOGETHER AND ARE USEFUL IN DIFFERENT WAIPS AT DIFFERENT TIMES SO WHAT WE'VE BEEN TRYING TO DO IS REALLY LOOK AT THE METHODS AND TECHNIQUES AND THAT WAS ALREADY TALKED ABOUT BUT THAT'S REALLY THAT PRACTICE, HOW AND THIS WORK AND HOW DOESN'T IT. IT'S ONE THING TO TEST SOMETHING IN A CONTROLLED STUDY WHERE YOU HAVE 12 VISITS AND PEOPLE ARE COMING IN AND THEY'RE GETTING REIMBURSED FOR THEIR TIME, AND I'VE BEEN A STUDY PARTICIPANT, AND YOU GOT PEOPLE CALLING YOU MAKING SURE YOU'RE THERE, YOU KNOW, LIKE EVERY FIVE MINUTES, AND YOU JUST CAN'T REPLICATE THAT LEVEL OF LIKE CARETAKING FOR LACK OF A BETTER WORD IN THE REAL WORLD WITH THAT. SO WE CREATED A GENERAL FRAMEWORK AND A LOT OF THAT IS BASED ON IDENTIFYING OUR GAPS IN CARE BY OUR DATA, I TALKED ABOUT THAT A LITTLE BIT, SO IDENTIFYING EXISTING INTERVENTIONS BY THE QUALITY OF EVIDENCE AND THE RELEVANCE OF THE INTERVENTION FOR THE POPULATION, AND THEN THIS IS I WANT TO PAUSE HERE FOR A MINUTE, ONE OF THE THINGS WE'VE REALLY BEEN DISCUSSING IS UNDERSTANDING FOR AN VER INTENTION WHAT ARE THE CORE ELEMENTS AND HOW CAN IT BE TAILORED AND ADAPTED AND I REALLY LIKE TO THINK ABOUT THIS, I DON'T KNOW IF ANY OF YOU HAVE STUDIED WINNECOTT BUT HE WAS A PSYCHOLOGIST IN THE 60s AND '70S AND WROTE THIS THEORY AROUND THE GOOD ENOUGH MOTHER SO THAT THERE'S A THING THAT YOU DON'T HAVE TO BE PERFECT, YOU CAN JUST BE THE GOOD ENOUGH MOTHER AND YOU HAVE A HOLDING SPACE THERE FOR YOUR CHILD AND BEING A MOTHER, I'VE TAKEN -- BUT IT'S NOT ABOUT YOU HAVE TO BE STRICT. WHERE CAN YOU SHIFT THINGS AROUND, LIKE YOU CAN BE A LITTLE BIT MORE LOOSE. IT'S NOT LIKE YOU HAVE TO BE EXACTLY, YOU KNOW, A CERTAIN MODEL TO BE RIGHT, RIGHT AND AND THAT I THINK CDC HAS BEEN CHALLENGED WITH SOME OF THEIR EB BIES BECAUSE IT WAS LIKE YOU HAVE TO DO IT THIS WAY AND ONLY FOR THIS POPULATION, SO THAT'S WHERE -- AND I THINK AND I KNOW TALKING WITH MY COLLEAGUES, THEY'RE RE-LOOKING AT THAT. SO FOR US, THAT'S REALLY WHAT WE'RE TRYING TO DO. WHAT IS A GOOD ENOUGH INTERVENTION TO BE ABLE TO GET TO WHAT WE'RE DOING, THAT WE CAN -- AND ST ACY IS KEEP IN MIND OF SHAKING HER HEAD LAUGHING AT ME A LITTLE BUILT BUT THAT'S OKAY. -- A LITTLE BIT, BUT THAT'S OKAY SO THIS IS SORT OF OUR MODEL THAT WE'VE BEEN USING AROUND, YOU KNOW, WE'VE IDENTIFIED THE STRATEGY LOOKING AT HOW SYNTHESIS ADOPTED, THE CONTEXT, HOW PEOPLE ARE ENGAGED AND THEN THE OUTCOMES, SO LOOKING AT VIRAL SUPPRESSION AND RETENTION AS THE MAIN OUTCOMES. ANOTHER PIECE OF THIS AND ONE MINUTE IS WE ARE WORKING WITH A COMPILATION THAT WILL BE AN ONLINE COMPILATION THAT WILL INCLUDE EMERGING STRATEGIES ALONG WITH DIFFERENT EVIDENCE-BASED INTERVENTIONS WHERE YOU CAN SEARCH AND SAY I AM TRYING TO, YOU KNOW, LOOK AT RETENTION STRATEGIES FOR X POPULATION AND YOU WILL BE ABLE TO FIND DIFFERENT SORT OF IMPLEMENTATION MANUAL OR WHATEVER RESOURCES ARE AVAILABLE , AND THAT'S NOT AVAILABLE YET, BUT THAT'S WHAT WE'RE WORKING TOWARDS, SO THIS IS ALL KIND OF CONVERGED TOGETHER. REALLY QUICK -- OH, I WANT TO GO BACK REALLY QUICK. SO THESE ARE JUST SOME OF OUR -- SOME OF THE PROJECTS THAT WE'VE BEEN DOING OVER THE LAST FOUR YEARS THAT HAVE LED INTO WHERE WE ARE TODAY, AND BUILDING FUTURES FOR YOUTH IS ONE THAT WE DID WHERE WE HIRED -- WE MADE SURE THAT YOUNG PEOPLE LIVING WITH HIV WHO WERE EXPERTS ALREADY WORKING IN THE FIELD WERE HIRED AS CONSULTANTS TO WORK WITH ORGANIZATIONS SERVING OVER 50 YOUNG PEOPLE WITH HIV, WE IDENTIFIED SITES THAT HAD HIERL VIRAL SUPPRESSION RATES AND LOWER ONES TO LOOK AT THE DIFFERENCES, BUT FOR US ALSO MAKING SURE THAT THE PEOPLE WHO WERE THERE TRYING TO SERVE ARE PART OF THIS DISCUSSION AND PART OF DEVELOPING THE PROTOCOLS FOR GOING ON SITE VISITS AND ALL OF THAT WORK. SO JUST ONE -- REALLY QUICKLY BECAUSE I KNOW I'M OUT OF TIME, BUT FOR ONE OF OUR PROJECTS THAT STACY HAS BEEN LEADING UP WITH ONE OF OUR COLLEAGUES THE E2I PROJECT AND I CAN'T TELL YOU THE FULL NAME BECAUSE IT'S TOO LONG, I CAN NEVER REMEMBER T BUTS WE ARE TESTING FOUR DIFFERENT INTERVENTIONS USING IMPLEMENTATION SCIENCE AND LOOKING AT BLACK MSM, TRANSGENDER WOMEN, LOOKING AT TRAUMA AND ALSO BEHAVIORAL HEALTH INTERVENTION SO THOSE ARE FOUR SORT OF COMPONENTS, THERE'S 25 IMPLEMENTATION SITES AND WE BRING PEOPLE FOAG, WE BRING ALL THE TEAMS TOGETHE EVERY SIX MONTHS TO LEARN IN REALTIME WITH EACH OTHER, AND I WAS IN ONE OF THE SESSIONS AND I JUST THOUGHT THIS WAS JUST WONDERFUL TO BE ABLE TO SEE THE QUESTIONS THAT THEY WERE TALKING WITH EACH OTHER IN REALTIME ABOUT, YOU KNOW, IS IT APPROPRIATE TO END THE INTERVENTION IF THE PERSON IS VIRALLY SUPPRESSED, IF THEY DPINLT COMPLETE THE -- IF THEY DIDN'T COMPLETE THE SIX SESSIONS , MAYBE THEY DIDN'T NEED ALL SIX SESSIONS, ALL TALKING WITH EACH OTHER, IMPLEMENTING, ALSO THINGS AROUND BOUNDARIES AND SOCIAL MEDIA AND THEY'RE ALL TALKING ABOUT HOW DO WE DO THIS HERE AND WHAT ARE DIFFERENT STRATEGIES THAT WE USE AND WE'RE TRYING ON CAPTURE ALL OF THAT TO BE ABLE TO DOCUMENT THAT. AND THEN THESE ARE A NUMBER OF THE DIFFERENT INTERVENTIONS THAT EITHER WE'RE TESTING OR HAVE BEEN TESTED IN SPINS, THEY HAVE KEY ROLES FOR COMMUNITY HEALTH WORKERS IN STAFFING AND THE ENTER VEKSZ AND LAST THING I WANT TO SAY AROUND THAT IS I HAVE AT THE U.S. CONFERENCE ON AIDS THE BIGGEST THING THAT I HEARD THERE WAS I HAD NEVER HEARD COMMUNITY HEALTH WORKERS TALKED ABOUT MORE THAN IN THAT LAST CONFERENCE AND THAT THEY BE PAID A LIVING WAGE, GIVEN HEALTH INSURANCE AND TREATED WITH THE RESPECT AND DIGNITY THAT THEY SHOULD BE AS KEY STAFF MEMBERS OF THESE ORGANIZATIONS, AND THAT CAME THROUGH LOUD AND CLEAR TO MANY FEDERAL LEADERS AND ALSO ORGANIZATIONAL LEADERS, SO THERE'S A MOVEMENT HERE, AND I THINK THAT'S IMPORTANT. SO THIS IS WHERE YOU CAN LEARN MORE, I'M SURE YOU GUYS WILL GET THE SLIDES, DIFFERENT LINKS, SO THANK YOU VERY MUCH. [APPLAUSE] >> I WANTED TO MAKE A QUICK POINT, ANTIGONE REFERENCED CDC'S WORK A LOT AND I WANTED TO ADD THE COME PEND COMPENDIUM OF -- COMPENDIUM OF EVIDENCE-BASED INTERVENTIONS AND BEST PRACTICES, WE HAVE EXPANDED MUCH BEYOND THE ORIGINAL DEBBIES , SO I JUST WANT TO LET PEOPLE KNOW IT'S NOT EXACTLY THE SAME, IMED, BUT WE HAVE AN -- I UNDERSTAND, BUT WE HAVE AN EVIDENCE INFORMED CATEGORY JUST LIKE HRSA, AS WE EXPAND OUR RESEARCH FROM THE RISK REDUCTION INTERVENTIONS AND MEDICATION ADHERENCE TO LINKAGE, REEN GEAJ MENT -- REENGAGEMENT AND CARE, RETENTION AND CARE, IT WAS A VERY EMERGING LITERATURE AND WE DOPPED A SERIES OF CRITERIA THAT WE CALLED EVIDENCE INFORMED , EVERYTHING FROM DIFFERENT KINDS OF DESIGNS, PROCEED, POST ARE FINE, AND VARIOUS CRITERIA AND MARY'S WORK , I THINK YOU MIGHT BE -- I DON'T KNOW IF YOU'RE EI OR EBBY IS IN THERE, SO I JUST WANTED TO LET PEOPLE KNOW THAT YOU CAN FIND A WHOLE SLEW OF NEW SORT OF APPROACHES AND STRATEGIES, WE HAVE A STRUCTURAL INTERVENTIONS CHAPTER THERE AS WELL. SO WE HAVE EXPANDED TO LOOKING AT EMERGING EVIDENCE AS WELL AS THE MORE WELL DEFINED EBBIES. THANKS. >> GREAT. I'M ALSO, RE BECK CARKS JUST SORT OF WONDERING BS A LOT OF FOLKS WERE PUTTING VARIOUS WEBSITE AND RESOURCES ON THEIR SLIDES SO I'M WONDERING IF IT WOULD BE HELPFUL FOR PEOPLE TO KIND OF PULL ALL THOSE TOGETHER INTO A SINGLE DWOWMENT TO SCARE -- INTO A SINGLE DOCUMENT TO SHARE. >> GREAT, THANK YOU. I REALLY ENJOYED ALL THE PRESENTATIONS THIS MORNING, SO A QUESTION, WE HEARD FROM THE FIELD YESTERDAY PROGRAMS AND PROJECTS THAT ARE BEING IMPLEMENTED, I GUESS MY QUESTION THINKING TOWARDS OUR FUNDERS IN THE ROOM, FROM NIH AND CDC AND HRSA, WHAT ARE THE PRESSING SCIENTIFIC QUESTIONS? SO WHAT IS THE SCIENCE THAT NEEDS TO GET DONE TOWARDS THE LARGER EHE INITIATIVE, AND I THINK WITH THE FRAMING, WE OFTEN HEAR ABOUT FROM DISCOVERY TO IMPLEMENTATION AS A 17 YEAR KIND OF GAP, SO FRAMING THE SCIENCE, WHAT ARE THE PRESSING QUESTIONS THAT NEED TO BE ANSWERED DOMESTICALLY AROUND COMMUNITY HEALTH WORKERS AS IT PERTAINS ON EHE? >> I WANT TO ADD ONTO THAT QUESTION, AROUND EBBIES AND DEBBIES AND EVIDENCE INFORMED, IS THERE ANY EVIDENCE OUT THERE, WHICH ARE THE ONES THAT HAVE SUCCESSFULLY SPREAD, SO THE IMPACT OF THE STUDY OR OF THE INITIAL THING, DO WE KNOW, OH, THIS PARTICULAR EVIDENCE-BASED INTERVENTION HAS SPREAD TO 15 STATES, 20 STATES, WHAT KIND OF VOLTAGE DROP, IS THERE ANY RESEARCH THAT'S ACTUALLY HAPPENING AROUND THAT? I DON'T KNOW IF YOU KNOW MAYBE. >> REGARDING YOUR QUESTION, I DON'T KNOW, BUT IT'S AN INTERESTING QUESTIO TO THINK ABOUT. I THINK IT WOULD -- YEAH. I MEAN, YOU HAVE TO DO SORT OF A META AND YOU WOULD HAVE TO GO INTO HOW MANY, YOU KNOW, WAS THERE FIDELITY TO THE INTERVENTION AND ALL THAT, BUT YEAH, I DON'T KNOW THE ANSWER TO THAT QUESTION. I GUESS I'M THE ONLY FEDERAL AGENCY SITTING UP HERE, SO TO MICHAEL'S QUESTION. YOU KNOW, IFORTS REALLY EASY TO KIND -- IT'S REALLY EASY TO COME UP WITH SOME QUESTIONS AND SAY THESE ARE THE QUESTIONS BUT I THINK THE WAY WE'RE REALLY TRYING TO A APPROACH THIS IS WE HAVE TO DO THIS ON A LOCAL BASIS , RIGHT? SO EACH LOCALITY EITHER COUNTY OR CITY OR STATE REALLY IT'S GOING TO BE DIFFERENT, THE QUESTIONS ARE GOING TO BE DIFFERENT, SO I THINK WHAT'S MOST PRESSING TO US IS MAKING SURE AT THAT THE RIGHT PEOPLE ARE ENGAGED AND INVOLVED IN COMING UP WITH THE RIGHT QUESTIONS TO BE ABLE TO ADDRESS WHAT'S GOING ON WITH FOLKS NOT BEING IN CARE AND SO FOR DIFFERENT COMMUNITIES I THINK THOSE QUESTIONS WILL BE DIFFERENT THINGS AND I THINK THAT IT WILL BOTH BE AROUND ROLE OF SAY COMMUNITY HEALTH WORKERS OR PATIENT NAVIGATORS BUT ALSO WHAT ARE THE SYSTEMATIC CHALLENGE BARRIERS, WHAT ARE THE SYSTEMS BARRIERS BECAUSE IN ONE STATE YOU MAY HAVE MEDICAID AND ANOTHER YOU MAY NOT, YOU KNOW, AND MEDICAID MAY PAY FOR COMMUNITY HEALTH WORKERS IN ONE STATE, SO I THINK THE MOST PRESSING THING IS HOW CAN WE MOVE THE BAR AND I THINK WE'VE BEEN IN KIND OF A HOLDING PATTERN FOR MANY YEARS IN HIV BECAUSE WE JUST HAVEN'T HAD THE POLITICAL WILL TO PUSH, RUN THE -- USE HIV, HAVEN'T WE'VE HAD THE TOOLS FOR LAST FIVE YEARS WITH TREATMENT INTERVENTION BUT HAVEN'T HAD THAT PUSH FOR SOMEBODY TO SAY NO LET'S DO IT AND WE'LL DO IT IN TEN YEARS WHICH IS REALLY GIVING US ALL AN OPPORTUNITY ON SAY WHAT ARE THOSE QUESTIONS AND HOW DO WE ADDRESS THOSE TO MAKE DIFFERENT CHANGES. OTHER PEOPLE WANT TO RESPOND? >> WHAT YOU SAID AND ALSO FROM THE PERSPECTIVE SIMILAR QUESTIONS AND ISSUES, FROM THE CLOVER PERSPECTIVE. BOTH ON THE DOMAIN QUESTION SIDE AND ON THE METHOD SIDE I THINK THREE RESEARCH STREAMS WOULD BE IMPORTANT, ONE IS DESIGN RESEARCH AND CO-CREATION WITH POLICYMAKERS, THE SECOND ONE IS THE SCIENCE CF TRANSFER, WE CANNOT GENERALIZE AS YOU SAID, IT IS CONTEXT SPECIFIC, COMMUNITY SPECIFIC BUT IF YOU CANNOT USE ANYTHING THAT CAN BE -- CBT PRODUCE ANYTHING THAT CAN BE TRANSFERRED, WE ARE NOT IN A GOOD PLACES IN SCIENCE, MAYBE TRANSFER ABILITY AND WE NEED TO UNDERSTAND WHAT RLT SYSTEMS FACTORS THAT YOU MENTIONED, WHICH MAKE IT LIKELY THAT IT WILL ALSO WORK IN THIS TYPE OF COMMUNITY BUT NOT IN THE OTHER COMMUNITY SO THIS SCIENCE OF TRANSFER AND SMART NON GENERALIZE ABILITY AND RELATED TO IT IS OF COURSE WHAT ALSO WAS MENTIONED IN THESE TALKS TODAY, HOW MUCH ADAPTATION DO WE ALLOW AND HOW MUCH IS FIDELITY PUSHED FOR BECAUSE LOCALLY PEOPLE KNOW WHAT WORKS, RIGHT? SO AT A HIGHER LEVEL OF OBSTRUCTION, IT CAN BE -- THERE CAN BE HIGH LEVELS OF FIDELITY AT THE LOW LEVEL OF ACTIVITIES AND PRECISE TASKS MAYBE THERE SHOULDN'T BE, AND PEOPLE WILL KNOW THE LAST ONE IS JUST THE SIGNS OF SCALE, SO HOW DOES IT WORK AT MASSIVE SCALE AND THAT NEEDS, BOTH METHODS DEVELOPMENT AND DOMAIN RESEARCH? TO THE NATIONAL LEVEL GOING TO THE GOVERNMENT AND CONVINCING IN THE STATES I THINK THAT WOULD BE A STATEMENT GOVERNMENT, RIGHT? CONVINCING A STATE TO DO WITH SCIENCE, THE SCALED VERSION. >> MY NAME IS PEYTON WILLIAMS AND I'M A CHW AND ALL OF THE PRESENTATIONS WERE VERY INSIGHT FUL AND YOU GUYS FRAME IMPLEMENTATION SCIENCE, I'M GLAD I DON'T HAVE TO TAKE A POP QUIZ ON IT. [LAUGHTER] IED TO DIRECT MY QUESTION TO DR. MAES AND I HEARD YOU TALK ABOUT SCRUBLGHTS FOR HOW A CHW IS INTEGRATED -- CONSTRUCTS FOR HOW A CHW IS INTEGRATED INTO A HEALTHCARE TEAM. I KNOW FOR MYSELF IN A RYAN WHITE ENVIRONMENT, I HEAR ADMINISTRATION TALK ABOUT PROGRAM INCOME FROM 340B AND THINGS LIKE THAT SO I KNOW THAT WE ARE STILL HOUSED SO MUCH UNDER CASE MANAGEMENT. AUTO SO I DON'T KNOW IF YOU COULD POLL OR THINGS LIKE THAT AS FAR AS YOUR SURVEYS TO FIND OUT HOW THEY ARE INTEGRATED AFTER THE GRANT IS GONE, BUT THOSE ARE JUST SOME THOUGHTS I WANTED TO SHARE WITH YOU. >> IN RESPONSE TO THAT, WE NEED TO ASK YOU AND OTHER COMMUNITY HEALTH WORKERS WHAT IS THE WAY YOU WANT -- WHAT KIND OF QUESTION WOULD YOU WANT TO BE ANSWERING ON A SURVEY TO TELL PEOPLE ABOUT HOW YOU FEEL AS A MEMBER OF THE CARE TEAM AND HOW INTEGRATED YOU FEEL. SO IT'S REALLY NOT A QUESTION FOR ME, BUT I REALLY APPRECIATE THE COMMENT AND THE INSIGHT THAT YOU AND OTHER COMMUNITY HEALTH WORKERS COULD BRING TO ANSWERING THAT QUESTION. >> THANK YOU SO MUCH FOR YOUR QUESTION. I JUST WANT TO ADD BECAUSE I THINK PART OF WHAT YOU'RE TALKING ABOUT, SO IN THE RYAN WHITE STATUTE WE HAVE CERTAIN NAMES FOR SERVICE CATEGORIES SO YOU HAVE TO USE EITHER A CASE MANAGER, YOU KNOW, THE SERVICE IS CALLED CASE MANAGEMENT OR MEDICAL CASE MANAGEMENT, BUT MANY TIMES PEER NAVIGATORS OR COMMUNITY HEALTH WORKERS ARE HIRED UNDER THAT SERVICE CATEGORY, I THINK IS THAT WHAT YOU'RE KIND OF TALKING ABOUT? SO THAT KIND OF -- AND WE'RE ALWAYS TRYING TODAY INDICATE PEOPLE, LIKE US USE COMMUNITY HEALTH WORKERS, IT'S JUST THIS SERVICE CATEGORY, SO I THINK TRYING TO MAKE SURE THAT YOU'RE CAPTURING ALL THE RIGHT PEOPLE IN YOUR SURVEYS WITH THAT UNDERSTANDING IN THE RYAN WHITE PROGRAM THAT THOSE PEOPLE MAY BE CALLED CASE MANAGERS BUT THEY'RE DOING COMMUNITY HEALTH WORKER WORK. SO I THINK THINKING ABOUT THAT A LITTLE BUILT. >> N NEW YORK CITY WE'VE INTEGRATED PATIENT NAVIGATION AND THUS COMMUNITY HEALTH WORKERS INTO MORE AND MORE OF OUR PART A SERVICE CATEGORIES GOAR, SO WE REALLY SORT OF -- IT WAS A CORE FEATURE OF OUR MEDICAL CASE MANAGEMENT CARE PROGRAM, EXPANDING TO NONMEDICAL CASE MANAGEMENT IN OTHER MODELS, I KNOW THAT ONE OF THE THINGS WE'RE SEEING IS PATIENT NAVIGATORS BECOMING CARE COORDINATORS BECOMING SORT OF CASE MANAGERS BASICALLY SUPERVISING COMMUNITY HEALTH WORKERS WHO ARE NOW IN THE POSITION THAT THEY INITIALLY OCCUPIED AT THEIR AGENCY, AND YEAH, IN TERMS OF SUSTAINABILITY , THE NICE THING ABOUT RYAN WHITE PART A IS IT STAYS WITH US SO FAR LONG-TERM, WE CONTINUE TO HAVE THE GRANT SO IT'S NOT SORT OF LIKE BEING A STAFF MEMBER OF A STUDY TEAM AND THEN THE STUDY ENDS AND WHAT HAPPENS TO YOU, IT'S SORT OF REALLY INTEGRATED, FULLY INTEGRATED INTO THE PROGRAMS AT THE FUNDED AGENCIES FOR PART A. >> I WOULD JUST SAY, SO I DO SOME WORK AT THE VA AND I THINK ONE OF THE PROBLEMS THAT WE SEE IS LIKE WE'VE TRIED TO PUT COMMUNITY HEALTH WORKERS UNDER CASE MANAGEMENT UNDER NAVIGATORS , I THINK THAT WE'RE GETTING ENOUGH OF A WORKFORCE AND ENOUGH EVIDENCE THAT IT SHOULD BE ITS OWN NAME, IT SHOULD BE A VALIDATED NAME, IT SHOULD BE ITS OWN JOB WITH GOOD PAY, WITH GOOD BENEFITS, AND LIKE THE FACT THAT WE ARE STILL LIKE TRYING TO PUT IT INTO SOMETHING SO THAT IT CAN BE COVERED IS JUST WRONG, IT'S JUST NOT ACCEPTING THAT THESE ARE A VERY VALID AND IMPORTANT WAY TO HELP MANAGE OUR PAIRKTS OUR CLIENTS AND ADDRESS A -- PATIENTS, OUR CLIENTS AND ADDRESS A LOT OF THE SOCIAL ISSUES THAT THESE PATIENTS ARE FARRISING. >> THANK YOU. JUST TO FOLLOW UP ON IT AND I THINK WE HAD A LITTLE LAUGH ABOUT THE GOOD ENOUGH MOTHER, SO WE TALK ABOUT PERFECTLY GOOD ENOUGH EVIDENCE, SO IT'S NOT JUST GOOD ENOUGH BUT IT'S ACTUALLY PERFECTLY GOOD ENOUGH FOR THE POINT AND I THINK TO REFLECT ON THAT AND I WAS ALSO REALLY STRUCK BY THE FACT THAT TILL, THAT DAR SA LAAM THAT IT WAS THE POLICYMAKERS THAT SAID WE NEED THIS RESEARCH AND THAT'S THE POLICY WE NEED TO HAVE AND WE NEED FROM THE POLICYMAKERS AND POLITICIANS I'VE LEARNED OVER TIME THAT HAVE DIFFERENT EVIDENCE NEEDS, WHAT IS THE EVIDENCE THEY WOULD NEED SO THAT UNDER PART A OR RYAN WHITE FOR EXAMPLE THERE ALL OF A SUDDEN APPEARS A COMMUNITY HEALTH WORKER FIELD, THAT UNDER CMS THERE APPEARS A COMMUNITY HEALTH WORKER FIELD, I DON'T KNOW THAT NECESSARILY EITHER RESEARCHERS OR IMPLEMENTERS NECESSARILY KNOW THAT ANSWER BECAUSE IT'S A VERY DIFFERENT KIND OF DISCUSSION, I THINK IN THAT GAP BETWEEN EVIDENCE AND POLICY THAT'S WHERE ANOTHER DOMAIN AND METHODOLOGY PERHAPS TILL THAT WE NEED MORE WORK TO DO. >> I WANT TO CLARIFY BECAUSE SO TO CHANGE THAT WOULD TAKE AN ACT OF CONGRESS BECAUSE IT'S IN OUR LAW. >> POLITICIANS, YEAH. >> IT'S REALLY WE HAVE COMMUNITY HEALTH WORKERS, IT JUST HAS TO GO UNDER A CASE MANAGEMENT SERVICE CATEGORY FOR REPORTING, SO WE HAVE COMMUNITY HEALTH WORKERS, BUT BECAUSE OF THIS STATUTE AND THEY NAME THE SERVICE CATEGORIES, IT CAUSES A LOT OF CONFUSION AND PEOPLE THINK THEY CAN'T, SO THAT'S WHY WE'VE BEEN TRYING TO REALLY BE CLEAR BUT IT'S A TIME TO -- I MEAN WHRKS THEY WROTE THIS, IT WAS IT 190 AND PEOPLE WEREN'T TALKING ABOUT COMMUNITY HEALTH WORKERS AT ALL, SO THEY COULD RE AUTHORIZE THAT BUT WE DON'T DO THAT, JUST TO BE VERY CLEAR, CONGRESS DOES, AND NOW IS A GOOD TIME FOR PEOPLE TO BE THINKING ABOUT IS IT TIME TO DO THAT. >> I JUST WANT TO ANSWER HOW SOUTH AFRICA IS ANSWERING YOUR QUESTION OF HOW DO YOU MEASURE INTEGRATION, SO IT'S TWO VERY SIMPLE VERY CRAZY SURVEY TOOL, SURVEY QUESTIONS, ONE IS ARE THE COMMUNITY HEALTH WORKERS GIVEN ANY SPACE IN THE CLINIC OR DO THEY HAVE TO MEET OUTSIDE? THAT'S ONE MEASURE OF INTEGRATION. THE OTHER IS WHAT DO THEY DO WITH THEIR DATA? DO THEY TAKE IT HOME? PAPER BASED DATA. SOME OF THESE PUBLIC HEALTH CLINICS HAVE COMMUNITY HEALTH WORKERS WITH BOXES AND BOXES OF YEARS OF PATIENT DATA AT HOME BECAUSE NOBODY IN THE CLINIC USES IT, SO PRETTY LOW BAR, BUT THOSE AE REALLY CONCRETE MEASURES OF INTEGRATION. >> HOW ARE YOU DOING? DURRELL FOX, EXCUSE ME, I GUESS I DON'T NEED A MIC, FROM JSI ATLANTA, ALSO LONG TIME CHW,IC I KNOW THE ANSWER -- I THINK I KNOW THE ANSWER TO THIS QUESTION BUT I'M GOING TO ASK IT, DO YOU KNOW OF ANY INSTANCES WHERE RETURN ON INVESTMENT SAVINGS HAVE BEEN INVELOCITIED INTO CHW FTE'S ANYWHERE AND IF NOT HOW DO WE FIND A WAY FOR THE LAST DECADE AND I'VE BEEN SEEING MORE AND MORE INFORMATION ABOUT ROI, TWO TO ONE, SOMETIMES BETTER, SOMETIMES WORSE, BUT YET THOSE SAVINGS GO SOMEWHERE, INTO THE ETHOSPHERE AND DOESN'T COME BACK TO SUPPORT THE CHW'S WHO IN SOME STUDIES HAVE BEEN A DIRECT CORRELATION BETWEEN THEIR INTERVENTION AND THE COST SAVINGS, SO HOW DO WE GET SOME OF THOSE DOLLARS REINVESTED INTO CHW'S FOR SUSTAINABILITY? THANK YOU. >> THANKS FOR THAT QUESTION. >> THAT'S HOW WE WORK WITH HEALTH SYSTEMS TO CONVINCE THEM NOT AROUND A RESEARCH STUDY, TO CREATE A PROGRAM. ALTHOUGH PENN WE HAVE A CENTER FOR COMMUNITY HEALTH WORKERS RG IT'S NOT A RESEARCH PROGRAM, IT HAS AT LEAST 30 COMMUNITY HEALTH WORKERS, 60 PEOPLE TOTAL AS EMPLOYEES, AT OUR VA NOW WE HAVE A COMMUNITY HEALTH WORKER PROGRAM, THIS IS NOT, YOU KNOW, THRS OUTSIDE OF RESEARCH STUDIES , SO I THINK THE RETURN ON INVESTMENT ANALYSES ARE VERY IMPORTANT FOR YOU TO BE ABLE TO GO TO A HEALTH CENTER OR HEALTH SYSTEM AND SAY INVEST IN THIS, NOT AS RESEARCH, BUT AS A DELIVERY MODEL. THAT'S WHERE THE MONEY GOES, THEY SEE THE RETURN ON INVESTMENT AND THEY SAY OKAY WE'LL INVEST IN THESE CENTERS WITH JOBS, WITH EVERYBODY HAS REAL JOBS, REAL BENEFITS AT OUR CENTER. THAT'S WHERE WE NEED TO HELP OTHER HEALTH CENTERS SET UP, WE GO TO THEM AND SAY LOOK WE'LL DO HEALTH ANALYSIS USING YOUR DATA IT MAY BE UP UP FRONT EXPENSIVE BUT YOU'LL SAVE SOME MONEY THAT AND THAT'S HOW YOU PAY FOR THIS NEW PROGRAM. >> WHAT YOU'RE TELLING ME IS THAT THERE IS INVESTMENT FROM THOSE SAVINGS GOING BACK TOWARDS FTE'S OF CHW'S LONG-TERM, IS THAT WHAT YOU'RE SAYING? I'M JUST TRYING CLARIFY. >> AT PENN, YES, IT'S A BIG UP FRONT INVESTMENT SO THESE ARE NOT THINGS THAT SHOULD BE LIKE OH, I'LL TAKE THIS AND THEN TAKE IT APART IN A YEAR. ANOTHER IMPORTANT THING TO SAY IS YOU HAVE TO BE THE PAYER TO SAVE THE MONEY. I'M DIVISION CHIEF OF INTERNAL MEDICINE I SEE NO RETURN ON INVESTMENT IF I'M GOING TO HIRE A COMMUNITY HEALTH WORKER SO ACTUALLY IT'S A HEALTH SYSTEM, SO THE HEALTH SYSTEM IS THE ONE WHO IS INVESTING IN THE CENTER FOR COMMUNITY HEALTH WORKERS BECAUSE OTHERWISE IT'S MONEY OUT OF MY BUDGET BUT NOT BACK INTO MY BUDGET SO YOU REALLY HAVE TO CONVINCE THE PERSON WHO IS SAVING THE MONEY TO SPEND THE MONEY. [OFF MIC] IN NEW YORK CITY, I KNOW THAT THE TEAM WITHIN THE YOU'RE BUREAU OF HIV THAT -- THE BUREAU OF HIV THAT DOES THAT OUTREACH IS CALLED THE FIELD SERVICES UNIT, SO NOT REFERRED TO AS DIS INTERIMLY, AND THEY ARE ESSENTIAL IN TERMS OF WORKING WITH PEOPLE WHEN THEY'RE FIRST DIAGNOSED, INTERVIEWING THEM, CONNECTING THEM TO CARE, AND THEN THEY'RE ALSO WORK WITH PEOPLE WHO HAVE FALLEN OUT OF CARE ACCIDENT USING THE SURVEILLANCE SYSTEM TO IDENTIFY THOSE FOLKS PARTICULARLY PRIORITIZING PEOPLE WHO HAVE HIGH VIRAL LOAD WHO ARE OUT OF CARE AND THEY DO A TON OF WORK I THINK PART OF THE DIFFERENCE IS THAT THEIR RELATIONSHIP IS A LITTLE MORE SHORT-TERM AND SO THEN IN OUR PROGRAMS IN RIELT WE HAVE THE OPPORTUNITY TO -- IN RYAN WHITE WE HAVE THE OPPORTUNITY TO CONTINUE WORKING WITH THE SAME CLIENTS OVER A LONGER PERIOD OF TIME IN A PROGRAM LIKE CARE COORDINATION SO IT'S SORT OF A HANDOFF FROM SOMEBODY WHO IS IN THAT SHORT-TERM FIELD SERVICES RELATIONSHIP TO SOMEBODY IS SORT OF EMBED IN A PROGRAM AND ABLE TO CONTINUE TO HAVE THAT LONG-TERM RELATIONSHIP WITH THE CLIENT. >> LAST QUESTION. >> MY NAME IS RICK BURZON, I'M WITH THE NATIONAL INSTITUTE OF MINORITY HEALTH AND HEALTH DISPARITIES AND I HAD A QUESTION FOR TILL AND FOR AN TI GONE, THE QUESTION IS -- AND FOR ANTIGONE, TILL, YOU HAD A NUMBER OF SUCCESSES USING THE COMMUNITY HEALTH WORKER MODEL IN THE INTERNATIONAL SETTING AND ANTIGO NE YOU HAVE IDENTIFIED A NUMBER OF SUCCESSS ON THE DOMESTIC SIDE, SO I'M WONDERING IF THERE'S COMMUNICATION BETWEEN THE INTERNATIONAL SIDE AND THE DOMESTIC SIDE BECAUSE THERE'S QUITE A LOT OF OVERLAP IN TERMS OF SUCCESSES AND MUCH OF WHAT GOES ON IN THE INTERNATIONAL SETTING I THINK COULD BE USED IN THE DOM DOMESTIC SETTING AND OF COURSE IT'S BEEN THAT WAY VICE VERSA SO I WAS WON DEREK IF YOU COULD COMMENT ON THAT JUST GIVE ME SOME INSIGHT INTO WHICH THE EXTENT TO WHICH THE INTERNATIONAL AND THE DOMESTIC SIDE ARE TALKING TO EACH OTHER. >> IT'S A GREAT IDEA, IT'S PROBABLY WHAT THE WORLD NEEDS, GLOBAL TASK FORCE, THERE'S SO MUCH TO BE LEARNED AND THE IDEA OF REVERSE INNOVATION IS VERY POWERFUL AND THERE'S SO MUCH EXPERIMENTATION GOING ON ALL OVER THE GLOBE AND WE'RE NOTLY LEARNING FROM EACH OTHER AND I THINK THE TECHNOLOGIES THAT ARE WITH US NOW, A LOT OF THE RESEARCH WE'RE CURRENTLY DOING IS ABOUT TABLET SUPPORTED, TABLET ENHANCED WITH CLINICAL ELECTRONIC PATIENT RECORDS CARRIED BY COMMUNITY HEALTH WORKERS ON TABLET, CONTINUING EDUCATION AND ALSO EU APPROACHES SO THESE THINGS ARE VERY TRANSFERABLE I THINK AND OF COURSE THE STATES COULD BE LEADING BUT COULD ALSO BE LEARNING AND SUCH, SO A PUSH BY WHO AND CLOVER FUND ON TRAIN ADDITIONAL THE NUMBERS VARY ONE MILLION, TWO MILLION, FOUR MILLION COMMUNITY HEALTH WORKERS OVER THE NEXT YEARS FOR SUBSAHARAN AFRICA AND I'M NOT SURE IF THAT NICKTIVE HAS STAGNATED OR IS CONTINUING WITH FORCE, CURRENTLY WE HAVE -- SO DOUBLING THE NUMBER OF COMMUNITY HEALTH WORKERS IN SUBSAHARAN AFRICA OVER THE NEXT FIVE OR TEN YEARS AND SO MUCH NEW APROASMS AND MODEL, TASK FORCE BUSINESS MODEL INNOVATION OR GRANTS THAT BRING US TOGETHER ACROSS THE GLOBE WOULD BE FANTASTIC. >> ACTUALLY WE DO HAVE A PROJECT CALLED THE BIDIRECTIONAL -- I'M FORGETTING, LESSONS LEARNED PROJECT, AND ACTUALLY IN THIS BUILDING ABOUT TWO MONTHS AGO WE DID BRING TOGETHER PEPFAR FUNDED SITES AND ALSO THOSE OF US WORKING IN THE RYAN WHITE HIV/AIDS PROGRAM AND WE SHARED LESSONS LEARNED AND SOME OF THE THEMES OUT OF THAT MEETING WERE COMMUNITY HEALTH WORKERS OR PATIENT NAVIGATORS, DIFFERENT WORDS WERE USED, BUT ALSO USING PHARMACISTS IN DIFFERENT WAY AND DISPENSING MEDICATIONS AND THEY TALKED ABOUT LIKE GOING AND BEING ABLE TO GIVE SIX MONTHS WORTH OF MEDICATIONS WHICH YOU CAN'T EVEN GET IN THE UNITED STATES ACTUALLY, SO THAT PROJECT IS UNDERWAY, I DON'T RUN THAT, BUT OUR COLLEAGUES IN OUR GLOBAL WORK GROUP DO, I'M HAPPY TO CONNECT ANYBODY WITH THAT, I'M NOT SURE OF THE LONG-TERM PLANS BUT WE'VE BEEN TRYING TO FIGURE OUT HOW DO WE ENGAGE IN THESE CONVERSATIONS BECAUSE OF THAT BI DIRECTIONAL LEARNING THAT WE SHOULD REALLY BE DOING. GREAT QUESTION. >> IT'S ABSOLUTELY RIGHT ON TARGET. I KNOW OF TWO OTHER INSTANCES, I KNOW OF AN HBI THAT'S FUND A RO1 SOME WORK THAT'S BEEN DONE IN CALIFORNIA AND APPLIED IN NIGERIA AND SIMILAR WORK TAKING ALSO THAT'S NORTH TO SOUTH AND SIMILARLY TAKING DIFFERENT STUDY TAKING COMMONWEALTH WORK HE MODEL FOR COMMONWEALTH IN TOGO AND APPLYING IN SOWTD BRONX, ENORMOUS AMOUNT OF LEARNING NOT JUST ABOUT LEARNING ABOUT POTENTIAL DIFFERENT IMPLEMENTATION STRATEGIES BUT ACTUALLY HOW TO DO IT IN A WAY THAT IS EFFICIENT AND EFFECTIVE BECAUSE IT'S NOT SIMPLE BUT I IMLEETLY -- COMPLETE AL AGREE WITH YOU I THINK IT'S AN ENORMOUS RESOURCE WE NEED TO LEVERAGE. >> I FIRST LEARNED ABOUT COMMUNITY HEALTH WORKERS IN ETHIOPIA WHERE I WAS DOING RESEARCH, I DIDN'T START LEARNING ABOUT WHAT WAS GOING ON IN THE U.S. UNTIL ABOUT SEVEN YEARS AGO AND ONE THING THAT REALLY STRUCK ME WAS THAT IN THE U.S. IS WE HAVE STATEMENT AND NOW AS OF THIS YEAR A NATIONAL ASSCIATION OF COMMUNITY HEALTH WORKERS AND LEARNING HOW IMPORTANT THAT SELF-ORGANIZING OF COMMUNITY HEALTH WORKERS HAS BEEN TO STARTING TO TAKE A LTTLE BIT OF CONTROL OVER THE AGENDA FOR RESEARCH AND IMPLEMENTATION AND SO FORTH. THAT WAS IMPRESSIVE, IT'S TOTALLY MISSING IN SO MANY PLACES AROUND THE WORLD, SO THINKING NOT JUST ABOUT SCIENTISTS IN THE GLOBAL NORTH AND SOUTH SHARING INFORMATION BUT THINKING ABOUT COMMUNITY HEALTH WORKER ASSOCIATIONS IN THE U.S. SHARING THEIR STORIES, SHARING THEIR STRATEGIES FOR ORGANIZING. >> SO I WANT THAT THANK ALL OF OUR SPEAKERS AND THE AUDIENCE FOR REALLY WHAT'S BEEN AN INCREDIBLY INNOVATIVE AND EDUCATIONAL SESSION. [APPLAUSE] I'M HANDING IT OVER. >> THIS COULD HAVE GONE ON FOR ANOTHER HALF AN HOUR, I WAS HAPPY OVER THERE IN MY CHAIR. I JUST WANT TO THANK ALL OF OUR SPEAK ERPZ AND THE GUESTS AND THE PEOPLE ONLINE THAT PARTICIPATED IN THIS MEETING TODAY, IT SOUNDS LIKE THE CONVERSATION HAS BEEN ONGOING AND WE'RE JUST TAKING IT FORWARD TRYING TO BRING PEOPLE TOGETHER, AND SO I GUESS, YOU KNOW, I'M THINKING WE MIGHT TRY TO FIGURE OUT A COMMUNITIES OF PRACTICE APPROACH TO THIS, I'M NOT SURE HOW ITZ GOING TO WORK BUT STAY TUNED ON OUR WEBSITE, MAYBE WE'LL HAVE FIGURED THIS OUTS, I ALSOMENT TO SAY DID ANYBODY SEE THAT SERIES, I DON'T KNOW IF IT WAS CALLED THE MOONSHOT THIS SUMMER, IT WAS A THREE PART SERIES ON PBS ABOUT HOW THEY IS DECIDED IN THE EARLY 60s THAT THEY WERE GOING TO LAND A MAN ON THE MOON AND IT'S DEFINITELY BIN GEABLE, BUT I FIGURE IF WE COULD DO THAT, YOU KNOW, WE CAN CERTAINLY DO SOMETHING LIKE THIS AND IT'S A LOT LESS DANGEROUS. SO AGAIN, THANKS TO EVERYONE. [APPLAUSE] >> OH, WAIT. >> OH, THAT WAS NOT THE CAPSTONE OKAY. NOW WE'RE GOING TO DO THE CAPSTONE PANEL. SORRY ABOUT THAT. WE'RE SUMMARIZING. WE'RE SUMMARIZING. SO LET'S HAVE ALL OF OUR FOLKS UP HERE THAT WERE THE MODERATORS FOR EACH OF THE PANELS AND WE'LL JUST DO A QUICK SUMMARY AND PERHAPS TAKE MORE QUESTIONS. IN TERMS OF THE LAST SESSION AND I THINK THAT A LOT OF IT SORT OF GOES BACK TO SOME EXTENT WHAT TILL HAD SAID WHICH IS THAT WE'VE ALL BEEN DOING HAD FOR IMPLEMENTATION RESEARCH IN SOME WAYS, THERE'S A LOT OF OVERLAP IN THE STUDIES PEOPLE HAVE DONE AND THE EVALUATION THAT'S BEEN DONE BUT THE CHALLENGE THAT WE HAVE NOW IS, THE CHALLENGE FOR REPLICATION I LIKE THE TERM WHAT'S OLD IS NEW SO THE QUESTION IS SORT OF HOW DO WE NOT JUST DO IT WITH DISRUPTIVE INNOVATION BUT KNOWING IF AND HOW IT WORKS AND HOW TO REPLICATE, I THINK THERE'S A BIG ROLE FOR IMPLEMENTATION RESEARCH THAT'S BEEN SEEN NOT JUST IN THIS LAST PANEL BUT SORT OF THROUGHOUT IN THE SENSE OF CHANGING HOW WE THINK ABOUT THE EVIDENCE THAT WE'RE PRODUCING, VALUE VALUING FEASIBILITY AND ACCEPTABILITY AND ADAPTATION NOT HOLDING FIDELITY AS THE SORT OF GOLD VERSION ACCIDENT I THINK THAT SOME OF THE KEY -- I THINK THAT SOME OF THE KEY LESSONS ALREADY BEING EMERGED IS THIS NEED FOR COMMON METRICS SO THAT& WHEN WE'RE TALK BEING HOW WE'RE MEASURING SUCCESS THAT THERE'S AT LEAST SOME COMMONALITY AND I WOULD ADD TO THAT DISCUSSIONS FROM YESTERDAY ABOUT ACTUAL EVEN COMMON TERMINOLOGY AND SORT OF CORE COMPETENCIES OF COMMUNITY HEALTH WORKERS THAT CAN BE SHARED. I THINK WE'VE LEARNED A LOT ABOUT THIS IDEA OF WHAT EVIDENCE IS NEEDED, YOU KNOW, WHEN DO WE NEED AN RCT, WHEN DO WE NEED TO MOVE BEYOND TO DOING SOME OF THE VERY INNOVATIVE WORK THAT NEW YORK HAS DONE IN TERMS OF ACTUALLY LEVERAGING EXISTING DATA TO UNDERSTAND WHAT WAS NOT JUST WHAT WAS WORKING BUT ALSO TO DRIVE CHANGE AND SIMILAR WORK THAT'S HAPPENING IN HRSA, AND THEN FINALLY I THINK THIS IDEA ABOUT HOW DO WE MOVE TO NEW SETTINGS AND SOME REALLY INTERESTING WORK THAT WE HEARD ABOUT FROM PENN ABOUT DEVELOPING THIS CONCEPT OF A CORE MODEL THAT CAN THEN BE SORT OF ADAPTED , DRIVE THE EVIDENCE THAT'S NEEDED TO INFORM HOW WE MOVE FORWARD AND AS WELL AS UNDERSTANDING AND VALUING THIS IDEA OF IMPACT IN TERMS OF HOSPITAL DAYS AND NOT JUST SORT OF COSTS BUT ALSO READMISSIONS AND ALSO I WOULD SORT OF POTENTIALLY ARGUE AS WELL UNDERSTANDING WHAT DOES THIS MEAN FOR THE PATIENTS AND FOR THEIR FAMILIES IN TERMS OF IMPROVED HEALTH. SO I AM VERY ENERGIZED BY THIS, IT'S REALLY EXCITING FOR ME TO SORT OF SEE THIS EVOLUTION IN HOW WE THINK ABOUT EVIDENCE, HOW WE TALK ABOUT EVIDENCE AND WHAT WE THINK AS I SAID THIS CONCEPT OF SORT OF PERFECTLY GOOD EVIDENCE TO KNOW WHEN WE CAN MOVE FROM ONE STAGE TO BROADER STAGES AND FROM STAGES IN THE SOUTH TO THE NORTH AND THE NORTH TO THE SOUTH BOTH WITHIN THE U.S. RECOGNIZING THE SORT OF CHALLENGES IN THE SOUTH BUT ALSO MORE GLOBALLY. MARY, ANYTHING ELSE? >> [OFF MIC] >> I THINK THAT'S WHAT WE DO AT NIH AND CDC, WE ARE TRYING TO FACILITATE THAT KIND OF KNOWLEDGE SHARING AND SO HEARING , YOU KNOW, FROM YOU, FROM YOUR CHILES IN NEW YORK CITY, JUST HOW DO YOU ADAPT THOSE, FROM JUDITH AND THE RCT'S AND THEN TURNING THAT INTO SOMETHING REALLY PRACTICAL AND USEFUL, IT'S REALLY GRATIFYING TO HEAR THAT. I DO THINK WE REALLY DO NEED TO DISSEMINATE THE LESSONS LEARNED BETTER AND DIFFERENTLY AND MAKE THEM DIGESTIBLE. I THINK THAT'S ONE OF THE BIGGEST NEXT STEPS, YOU KNOW, WHAT DO WE NEED TO DO TO GET THERE IN TEN YEARS, WE NEED TO MORE SESSIONS LIKE THIS, BUT IN MORE USABLE FORMATS PERHAPS. SO I THINK ONE SMALL STEP IS TO SHARE WHAT WE HAVE BEEN TALKING ABOUT BUT THEN SPREAD IT AROUND. ABOUT THAT, MAYBE WE CAN FIGURE OUT SOME PLATFORM THAT PEOPLE CAN KIND OF PEPPER THAT, BUT I THINK WE HAVE THE FORMS THAT KENNEY WAS TALKING ABOUT ALREADY AND THEN THIS KIND OF GLOBAL TASK FORCE IDEA IS REALLY VERY, VERY NEEDED. SO THANKS. >> A LOT OF THE THEMES THAT CAME OUT OF THE FIRST PANEL YESTERDAY WERE DISCUSSED THROUGHOUT THE CONFERENCE. I THINK THAT I'M REALLY LEFT WITH THIS ONE POINT THAT WAS BROUGHT UP IN THE LAST DISCUSSION AROUND POLICYMAKERS AND THINKING ABOUT HOW DO THEY AS WE THINK ABOUT TRANSLATING THIS PARTNER WITH OUR LOCAL POLICYMAKERS AROUND RESEARCH IN ACTION STUDIES AND THINKING ABOUT HOW CAN WE DESIGN STUDIES SO THAT THEY'RE INVOLVE IN THE PROCESS. WE'VE TALKED A LOT ABOUT THE IMPORTANCE OF ENGAGING COMMUNITY HEALTH WORKERS IN THE RESEARCH DESIGN AND PROCESS WHICH IS SURELY ESSENTIAL BUT AT THE SAME TIME WHO ARE THE OTHER STAKEHOLDERS THAT ALSO NEED TO BE AT THE TABLE SO WE CAN REALLY TRADGES LATE FROM PRACTICE INTO LIKE A BROADER SCALE POLICY WITHIN OUR STATES. -- REALLY TRANSLATE FROM PRACTICE INTO LIKE A BROADER SCALE POLICY WITHIN OUR STATEMENTS. >> YOU HAVE A LIST, YEAH. >> EARLY ON, THE ORGANIZING OF COMMUNITY HEALTH WORKERS, SO THE IMPORTANCE OF, YOU KNOW, YES, WE JUST WENT LIVE WITH OUR NATIONAL ASSOCIATION OF COMMUNITY HEALTH WORKERS, I'M ONE OF THE 19 BOARD MEMBERS, WE ALL HAVE JOBS, WE ALSO HAVE CONNECTIONS TO SOME OF THE STATE AND LOCAL CHW NETWORKS AND ASSOCIATIONS, SO WE'RE CONTINUING TO BUILD, WE HAVE AMBASSADORS IN 19 STATES AS WELL THAT ARE HELPING US, SO THE IMPORTANCE OF HAVING THAT NATIONAL GROUP IN THE CRITICAL NATURE AND I KNOW KEN TALKED ABOUT IT TOO OF WORKING WITH THE LOCAL NETWORK ASSOCIATIONS, RIGHT NOW SOME OF THE LANGUAGE THEY'RE USE NG HERE IS NOT REGULAR NOMENCLATURE FOR COMMUNITY HEALTH WORKERS THAT ARE IN THE FIELD, SO ONE OF THE THINGS AND CHALLENGES WE HAVE IS HOW TO INTEGRATE SOME OF THIS KNOWLEDGE BASE AND SOME OF THIS LANGUAGE THAT WE'RE USING HERE TODAY SO THAT WE CAN BE BETTER AGENTS OF CHANGE WITHIN OUR SPHERES OF INFLUENCE, WHICH ARE SOMETIMES CLINICAL AND SOMETIMES COMMUNITY BASED. I ALSO WANT TO NOTE THAT WE HAD ON THE PANEL A COMMUNITY BASED ORGANIZATION, A RYAN WHITE ORGANIZATION AND THEN WE HAD THE NEW YORK STATE PEER CERTIFICATION GROUP BUT SOMETIMES AS WE HAVE THE CONVERSATIONS ABOUT COMMUNITY HEALTH WORKERS, WE FOCUS MORE ON THE H AS OPPOSED TO THE C, COMMUNITY, SO I WOULD LOVE US TO FIGURE OUT HOW WE CAN USE SOME OF THIS KNOWLEDGE BASE AND USE SOME OF THE RESEARCH THAT PRIMARILY IS HAPPENING IN CLINICAL PLACES TO INFORM SOME OF THE THINGS THAT COULD BE HAPPENING IN COMMUNITY SITUATIONS. I THINK WE ALSO LEARNED ABOUT THE STRENGTH AND COURAGE OF FOLKS LIVING WITH HIV/AIDS BEING ENGAGED, SO THAT'S COMMUNITY HEALTH WORKERS AND PEOPLE LIVING WITH HIV/AIDS, SOMETIMES WE ARE THEY, THEY ARE US, IT'S THE SAME FOLKS BEING ENGAGED IN SOME OF THESE CONVERSATIONS AROUND RESEARCH, AND ONCE AGAIN, IT JUST GOES BACK TO HOW DO WE USE THE KNOWLEDGE THAT A LOT OF THE RESEARCHERS AND SCIENTISTS HAVE TO BUILD A CADRE, NEW CADRE OF CHW RESEARCHERS AND LEADERS AS KEN HAD ON ONE OF HIS SLIDES AND I THINK THAT WAS ONE OF THE VALUABLE TAKE HOME MESSAGES. THANK YOU. >> ALONG THOSE SIMILAR LINES AROUND KIND OF USING WHAT WE HAVE IN THE FIRST SESSION WE LEARNED ABOUT MULTIPLE CURRICULUM THAT WERE AVAILABLE, IMPLEMENTATION GUIDES, MATERIALS THAT HAVE BEEN DEVELOPED BY MANY FOLKS ACROSS DIFFERENT SETTINGS AND AS WE THINK ABOUT FUTURE IMPLEMENTATION STUDIES HOW CAN WE COME TOGETHER AS A GROUP, IF I'M IMPLEMENTING IN ONE REGION, YOU'RE IMPLEMENT NG ANOTHER REGION, CAN WE NOT COMBINE EFFORTS AND WORK COLLABORATIVELY TO HAVE LARGER SCALE PROJECTS? >> SO WE HAVE A COUPLE OF THINGS WE WANT TO TALK ABOUT FOR OUR PANEL, BUT I'LL START BECAUSE ONE OF THE THINGS WE TOUCHED ON WAS ALL THE RESEARCH THAT'S EITHER INTERNATIONAL AND SOMEONE JUST ASKED THE QUESTION ABOUT WHAT ARE SOME OF THE SIMILARITIES AND WHAT CAN WE TAKE INTO THE DOMESTIC CONTEXT, SO I WON'T REPEAT THAT PART OF IT, BUT THE OTHER PIECE IS THAT THERE'S A LOT OF RESEARCH FOCUSING ON COMMUNITY HEALTH WORKERS AND EVIDENCE FOR EFFECTIVENESS IN OTHER HEALTH DOMAINS. WE HEARD EARLIER IN OUR PANEL WE HEARD ABOUT RESEARCH FROM A LOT OF SUCCESS IN SCREENING FOR DIABETES, FOR CANCER, FOR CARDIOVASCULAR AND HEART DISEASE AND THEN TILL TALKED ABOUT CREATING FOR SOMETHING ELSE IN -- SCREENING FOR SOMETHING ELSE IN CHINA AND A LOT OF THOSE THINGS SO THERE'S REALLY SO MUCH NOT JUST INTERNATIONAL VERSUS DOMESTIC BUT WHAT WE KNOW FROM OTHER HEALTH AREAS, I THINK WE HEARD FROM SOMEONE FROM THE NEW YORK TRAINING PROGRAM THAT HERE IS THE ADDITIONAL THINGS YOU ARE NEED TO DO IF YOU'RE HIV, THERE'S SOME ADDITIONAL ISSUES WITH POPULATIONS, WITH HISTORY OF STIGMA, WITH RELATIONSHIPS WITH DIFFERENT PARTS OF, YOU KNOW, DIFFERENT AGENCIES OR PROVIDERS SO I THINK THERE ARE DIFFERENCE BUT THERE ARE SIMILARITIES AND I THINK REALLY TAKING A REALLY STRONG LOOK AT WHAT WE CAN LEARN FROM THE WORK AND THE EVIDENCE BASE IN OTHER HEALTH AREAS AND MAKE A -- AND THEN IDENTIFY WHAT MAY BE VERY DIFFERENT, WHAT WE HAVE TO DO TO ADAPT IT FOR HERE WOULD BE VERY HELPFUL FOR US IN MOVING FORWARD THE EVIDENCE BASE. I HAD SOME OTHER OBSERVATIONS TOO, I DON'T REMEMBER. >> YEAH, THANK YOU. WELL, I WAS REALLY EXCITED TO BE A PART OF THIS MEETING. THIS COMES AT A GREAT TIME WHERE IT'S CLEAR THAT COMMUNITY HEALTH WORKERS ARE MOBILIZING AS A DISCIPLINE AND ALSO WHERE THERE'S MORE INTEREST AN EVER ABOUT THE ROLE THEY MIGHT PLAY WITH RESPECT TO IMPROVING HIV CARE ESPECIALLY AT THIS TIME WITH THE FEDERAL ENDING THE EPIDEMIC INITIATIVE SO IT JUST SEEMS VERY TIMELY AND I THANK NINR FOR LEADING THE CONFERENCE AND ALSO OER FOR SPONSORING IT, ALSO EVERYONE'S PRESENTATIONS, THEY WERE UNIFORMALLY OUTSTANDING. THREE THINGS I HEARD, IF WE'RE INTERESTED IN ADVANCING THE SCIENCE IN A WAY THAT CAN DMF OUR PRACTICE, ONE -- THAT CAN INFORM OUR PRACTICE, ONE WOULD BE WE STILL NEED NOR EVIDENCE ABOUT THE IMPACT THAT COMMUNITY HEALTH WORKERS CAN HAVE ON HEALTH OUTCOMES IN HIV, WE HAVE SOME OF THOSE STUDIES BUT THE EVIDENCE BASE CAN BE STRONGER AND IT'S IMPORTANT TO DO THAT NOT JUST FOR THE SAKE OF A SCIENCE BUT ALSO TO HELP ESTABLISH THE VALUE THAT THESE KINDS OF COMMUNITY HEALTH WORKERS CAN OFFER FOR US TO STRENGTHEN THE PUBLIC HEALTH AND TO CONVINCE PAYERS TO FURTHER INVEST IN THIS KIND OF DISCIPLINE AND THESE KINDS OF APPROACHES. BUT BEYOND THE KIND OF IMPACT THAT COMMUNITY HEALTH WORKERS CAN HAVE, I GUESS I ALSO HEARD CALLS FOR BETTER UNDERSTANDING JUST WHETHER THEY HAVE IMPACT& BUT HOW, HOW THEY HAVE IMPACT. SO WE HEARD THAT TODAY FROM KENNEY MAES WHO WAS WORKING ON IDENTIFY PROCESS MEASURES FOR COMMUNITY HEALTH WORKERS. YESTERDAY LAURA NYBLADE TALKED ABOUT IMMEDIATELY ACTIONABLE ITEMS OR, YOU KNOW, SOME OF OUR RESEARCHERS WOULD TALK ABOUT TARGETS OR MEDIATORS, SO WHAT ARE THOSE ACTIVE INGREDIENTS THAT REALLY CREATE IMPACTED AMONG COMMUNITY HEALTH WORKERS, THEIR SATISFACTION WITH THEIR JOBS, THEIR DEGREE OF THEIR INTEGRATION INTO THE HEALTHCARE SYSTEM. SO IT'S BOTH ABOUT IMPACT AND THEN HOW WE MAKE IMPACT AND TO ME THE THIRD ONE, LAST ONE, WOULD BE ABOUT THE NEEDS OF THE COMMUNITY HEALTH WORKERS THEMSELVES, AND WE HEARD ABOUT, YOU KNOW, THE NEED TO -- HOW SELF-CARE IS SOMETIME THE THING THAT A COMMUNITY HEALTH WORKER GETS TO LAST, IF AT ALL. SO WAYS THAT WE CAN HELP SUSTAIN AND PROMOTE PEOPLE'S WORK IN THIS AREA IN A WAY THAT IS EFFECTIVE AND ALSO ENRICHING, MODELS WHERE WE CAN BETTER INTEGRATE THEM INTO CARE AND MAKE THEM A PART OF CARE TEAMS, YOU KNOW, SO AND THEN I THINK ALSO THAT RELATES TO NOT JUST DOING RESEARCH ON COMMUNITY HEALTH WORKERS BUT DOING RESEARCH WITH COMMUNITY HEALTH WORKERS. I THINK THAT WAS ALSO A THEME HERE AND IT WAS REALLY TERRIFIC TO SEE SO MANY OF THE PRESENTATIONS WHICH WERE DUAL IN , YOU KNOW, BY BRINGING BOTH A RESEARCHER OR A PRACTITIONER ABOARD WITH A COMMUNITY HEALTH WORKER, I WAS REALLY, REALLY PLEASED TO SEE THAT. [APPLAUSE] >> EMMY EMILY AND I ARE REMIT TING PANEL NUMBER 3, SO BEFORE THAT, I WANT TO TAKE A SECOND TO SAY THANK YOU TO REBECCA FOR ORGANIZERRING THIS WITH THE STEERING COMMITTEE, YOU DID A GREAT JOB, REBECCA, SO THANK YOU, A ROUND OF APPLAUSE FOR REBECCA. [APPLAUSE] PANEL 3-RBGS OUR PANEL REALLY FOCUSED ON PATTERN SHIPSZ AND I THINK THAT WAS PROAIVEL THE THING THAT WAS MOST DISTINCTIVE ABOUT OUR PANEL, I THINK WE HAD EXAMPLES OF HEALTH PARTNERSHIPS AND THEN ALSO I CALL IT INSTITUTIONS BUT PERHAPS THE BETTER WORD IS COMMUNITY, THE C THAT'S OFTEN OMITTED ASK THEN ALSO CONTEXT AND WE HAD THREE EXAMPLES, WE HAD ONE EXAMPLE THAT WAS REALLY A REPRESENTATION OF SORT OF FAITH BASED INITIATIVES AND SORT OF THE PARTNERSHIP BETWEEN PASTOR AND HEALTHCARE AND UNIVERSITY SETTING, WED THE HOUSE BALL COMMUNITY WHICH WAS ANOTHER TERRIFIC EXAMPLE AS WELL AS A TRANSNATIONAL CONTEXT U.S. MEXICO BORDER AND ISSUES OF LATINO POPULATIONS LIVING ON THE U.S. SIDE ALONG THE U.S. MEXICO BORDER TRAFNLGT I THINK A COUPLE THINGS STOOD OUT, I THINK OBVIOUSLY THERE WAS A BIG PUSH ON OUR PANEL AMONG COMMUNITY BASED RESEARCH IMPLEMENTATION APPROACHES, THE IDEA THAT IN ORDER TO REACH PEOPLE THAT IT'S GOING TO TAKE MEANINGFUL INVOLVEMENT AND THAT MEANINGFUL INVOLVEMENT MEANS IN ALL ATION SPECULATE OF HOWEVER WE'RE DEVELOPING OR IMPLEMENTING OUR PROGRAMS, I THINK LINDA EXTENDED THAT, I THINK THINKING INITIALLY CHW INVOLVEMENT, I THINK LINDA HAS TAKEN IT FURTHER WITH ALL STAKEHOLDERS. I THINK WHAT WAS ALSO STRIKING WAS AT THE VERY START OF THE CONFERENCE WE SORT OF HEARD AGAIN ABOUT THE COMMITMENT TO ENDING THE EPIDEMIC AND THE PLAN AND REALLY HIGHLIGHTING WHERE THERE ARE DISPARITIES, THE PRESENTATIONS IN OUR PANEL REALLY I THINK EMPHASIZED SOME KEY POPULATIONS THAT STILL ARE NOT FAIRING WELL DESPITE ALL OF OUR PROGRESS AND I THINK THERE WAS SOME ENTHUSIASM AND EXIEVMENT ABOUT THE POTENTIAL IMPACTED OF COMMUNITY HEALTH WORKERS IN ADDRESSING SOME OF THESE DISPARITIES. JOHN REMINDED US OF YOUNG PEOPLE AND SORT OF THE OMISSION OF YOUNG PEOPLE, I CERTAINLY HAD A PUSH AROUND THE LATINO COMMUNITY AND INCREASED INCIDENCE AND I THINK THE FIRST PRESENTATION WHERE WE LOOKED AT AFRICAN AMERICANS AND THE PRESENTATION REALLY ON THE COMMUNITY, SO I THINK I WILL STOP THERE. >> I'LL JUST ADD A COUPLE OF KEY THEMES THAT I THINK WERE THREADED THROUGHOUT THE PRESENTATIONS AND IN THE FOLLOW-UP DISCUSSION. I THINK ONE WAS A REALLY IMPORTANT QUESTION THAT EMERGED DURING THE FIRST PANEL, THE FIRST DISCUSSION AROUND CULTURAL HUMILITY OR HUMBLENESS, AND THE NEED FOR ACADEMIC AND COMMUNITY BASED PARTNERSHIPS AND RESEARCH ENDEAVORS TO ALWAYS TAKE THAT INTO ACCOUNT, PARTICULARLY WHEN WE'RE INVITED INTO NEW PLACES AND INSTITUTIONS. I THINK ANOTHER PIECE THAT EMERGED DURING THE DISCUSSION WAS THE IDEA AROUND REACHING INTO THE COMMUNITY AND FINDING THE EXISTING HUMAN CAPITAL OR RESOURCES WITHIN THE COMMUNITIES THEMSELVES AND THE NETWORKS OF SOCIAL RESOURCES THAT ARE THERE AND ACTIVATING THOSE NETWORKS, SO AGAIN TAKING THIS NOTION OF INTERVENTION AND BRINGING THAT UP, AND THEN FINALLY I THINK SOME OF THE WORK YOU'VE BEEN DOING VINCENT ON THE BORDER, AS WELL AS I THINK THE OVERALL QUESTION AROUND MEDICAID EXPANSION THAT KEEPS COMING UP OVER AND OVER AGAIN THROUGHOUT THIS CONFERENCE HAS BEEN ABOUT THE CONTEXT OF THE POLICY LEVEL AND HOW THAT INFRINGES ON OUR ABILITY TO WORK ATE COMMUNITY LEVEL AND THE NUMBER OF RESOURCES THAT ARE AVAILABLE AND THE DAY TO DAY LIVES OF PEOPLE WHO ARE LIVING WITH HIV AND THEIR ABILITY TO ACCESS RESOURCES EVEN IF THEY ARE ACTUALLY IN THE COMMUNITY. [APPLAUSE] >> OKAY, NOW, NOW, JUST TAKE THAT MOONSHOT PART FROM EARLIER AND TAKE THAT WITH YOU. WE CAN DO THIS. THANK YOU ALL FOR COMING. THAT CONCLUDES OUR CONFERENCE. [APPLAUSE] STRENGTHENING THE IMPACT OF COMMUNITY HEALTH WORKERS ON HIV CARE AND VIRAL SUPPRESSION. THANKS SO MUCH.