About Us
Antiretroviral therapy means that there are more people than ever 50 and older who are living with HIV. Mount Sinai’s Brookdale Department of Geriatrics and Palliative Medicine and the Institute for Advanced Medicine has responded to this need with a team-based approach with Comprehensive Care for Older Adults with HIV. On the team is a community health worker (CHWs) to improve patient care and enhance efficiency.
We use a series of 6Ms-informed assessments and screenings to help us understand the individual needs of patients as they age. This information is used to develop a care plan with appropriate clinical and community referrals. We address conditions that are common with aging such as memory and functional decline.
The CHW is the secret sauce of our model. We provide ongoing training and supervision to optimize the CHW role in patient care.
Who We Serve
Comprehensive Care for Older Adults With HIV receives referrals from HIV providers within the Institute for Advanced Medicine (IAM), an arm of the Mount Sinai Health System that operates 4 HIV clinics and has a legacy of HIV expertise. The IAM serves more than 9,000 patients from New York City and the surrounding areas. A little more than half (55 percent) of the patients are over age 50 and represent individuals of diverse backgrounds by race/ethnicity, gender, and sexual orientation. Most rely on public health insurance.
Is the Comprehensive Care for Older Adults with HIV Model right for your program?
Our program is a demonstration project and we are continually developing tools and strategies to help other organizations implement the model. We believe that other organizations can use our model to develop their own services for older adults with HIV, tailored to specific communities and organizations.
Our program model is flexible and can be modified to provide services to a wide range of patients. You may consider implementing a similar program if: you have a clinical population of older adults with HIV, and can identity some bandwidth to introduce aging-appropriate screenings and follow-up care plans.
Our Staffing
Our program sees patients once a week, though programs following this model may meet more or less often. Staff roles, however, remain constant. They are:
- Community health worker (CHW): Makes appointments, provides scheduling reminders, supports patients during program visits, administers some geriatric screening and assessment tools, conducts outreach and referral support, and offers culturally appropriate education around the principals of aging
- Geriatrician: Leads team, administers some geriatrics screens and assessments, creates care plan for patients, and co-supervises the CHW together with the social worker
- Registered nurse: Provides direct care to patients, offers health education, assesses symptoms, and completes elements of the geriatric assessments
- Social worker: Provides support for training, work, and competency for the CHW; performs additional psychosocial assessment and supportive counseling and referral information as needed
- Pharmacist: Assesses polypharmacy issues; performs medication reconciliation, interaction check, education, and management; and advises patient and clinician where applicable
- Program and data manager/evaluation team members: Reviews and collects data to assess program processes, impacts, and potential improvements with the team
- Patient liaison: Brings in the patient voice and lived experience to better align program design to patient needs. This is a typically a volunteer, though a stipend to pay for their time and effort is occasionally offered.
An Innovative Approach
Our providers have identified many opportunities to improve care at various stages of our relationship with patients. By incorporating a CHW on our team, we are better able to deliver and enable access to these services.
Before the Visit
In advance of the visit, the CHW will:
- Help with services such as transportation assistance to appointments, which supports patient engagement and decreases missed appointments
- Administer certain geriatric screenings and assessments.
During the Visit
During the visit, the CHW will:
- Build rapport with the patient
- Administer certain geriatric screenings and assessments, including for depression and anxiety.
- Support the team and overall visit workflow.
- Provide follow-up community resources listings and referral information as needed.
After the Visit
After the visit, the CHW will:
- Facilitate clinical and community referrals
- Coordinate appointments with other specialists
- Offer navigational support throughout the Health System
Measuring Success
For a program to continually improve, it is important to track how well it is doing. The program assesses process measures before, during, and after patient visits. It collects the following kinds of information, which can be tailored to a site:
Before the Visit
- Percentage of patients who receive one or two pre-visit calls
- Percentage of patients who get transportation assistance to attend appointments
During the Visit
- Percentage of scheduled patients receiving at least one pre-visit CHW call and also attend their appointment
- Percentage of patients who receive all appropriate geriatric screens from CHW (e.g., Activities of Daily Living, Instrumental Activities of Daily Living, FRAIL Scale, Patient Health Questionnaire 4 and 9, and Generalized Anxiety Disorder Questionnaire 7)
Post-Visit – No Shows
- Percentage of patients reached for follow-up rescheduling call by CHW after missing an appointment
- Percentage of patients reached by CHW with at least one follow-up strategy documented to re-engage in the program (such as setting up new appointments or receiving transportation assistance)
Post-Visit – Follow-up Referrals
- Percentage of patients receiving CHW follow-up support for referrals (e.g., additional information, social worker referral, referral for scheduling support, support with transport, and attending visit)
Intervention Outcomes
- Percentage of patients who received a community or clinical follow-up referral and engaged in them
CHW Training
- Percentage of assigned trainings completed by CHW
- Percentage of weekly supervision meetings completed with team member (e.g., geriatrician and social worker)
Program Partners
The Comprehensive Care for Older Adults With HIV model is collaborative. Our researchers have worked with organizations in several capacities:
- Institute for Advanced Medicine: Provides integrated primary and specialty care as part of its HIV program to more than 9,000 HIV-positive individuals. The Institute for Advanced Medicine cares for a wide variety of underserved patients and partners to integrate the geriatrics-HIV program within the practice.
- Brookdale Department of Geriatrics and Palliative Medicine: Offers comprehensive clinical services and programs that encourage healthy aging, treats those with chronic illnesses, and provides support and education for family members and caregivers. The Brookdale Department is a renowned leader in geriatrics and palliative medicine.
- Mount Sinai Departments of Neurology and Neuropsychology: Works with us to offer neurology and neuropsychology services to enhance referral pathways, ease referral barriers, and reduce clinical screening and assessment duplication.
- The Center: Offers a safe and affirming community center for LGBTQ+ New Yorkers to access lifesaving services and make meaningful connections.
- SAGE Serves: Provides LGBTQ+ clients with a range of services including meals, classes, case management, informational resources, veterans’ services, and social events. All are welcome, regardless of sexual orientation or gender identity.
- Senior Planet From AARP: Supports ongoing adult education, particularly in technology.