Inova Health System - Inova Juniper Program

Overview

In 1988, Inova Health System established the Inova Juniper Program to address the HIV/AIDS epidemic in the region. Inova Juniper Program provides a full complement of comprehensive outpatient ambulatory medical care, nurse and social work medical case management, mental health services, substance abuse counseling, specialty medical care, oral health care, nutritional services, and medical transportation for more than 1,300 uninsured and underinsured people living with HIV disease in the suburban Virginia region. Inova Juniper Program staff manages clients through the complete life cycle of their disease with the goal of enhancing quality of life by helping them to maintain health and delay the onset of disease and disability.

Northern Virginia is part of the Washington, D.C. Eligible Metropolitan Area (EMA). Identified by the Centers for Disease Control and Prevention (CDC) and the Health Resources Services Administration (HRSA) as one of the areas most heavily impacted by the HIV/AIDS epidemic, the region receives Ryan White Parts A, B, C and D funding. Northern Virginia accounts for approximately 29 percent of AIDS cases reported in the EMA (Washington AIDS Partnership, 2010).

The number of persons living with HIV disease continues to escalate in Northern Virginia, placing an increasing burden on the health care system. In Northern Virginia, the cumulative number of persons living with HIV/AIDS increased by 6.3 percent from 2008 to 2010, from 6,208 to 6,598. The number of new AIDS diagnoses among females ages 20 to 29 in Northern Virginia increased by 45 percent between 2008 and 2010. This increase was most notable in Fairfax and Loudoun Counties (VDH, 2012).

In Northern Virginia, Black/African Americans account for the largest share of new HIV infections (45 percent) (VDH, 2011). In addition, there has been a 12.2 percent increase in the number of Hispanics living with HIV/AIDS, between 2008 and 2010. New HIV infections among Hispanics account for 24 percent of total HIV diagnoses in Northern Virginia. The largest increases in persons living with HIV/AIDS in the region have occurred in specific pockets. Fairfax County experienced a 12 percent growth in persons living with HIV/AIDS from 2008 to 2010 (from 1,652 to 1,859), with the greatest increase occurring in the Hispanic and Black/African-American populations. There was a 17 percent increase among Hispanics living with HIV/AIDS in Loudoun County and a 23 percent increase in Prince William County. Northern Virginia data indicates that Men Having Sex with Men (MSM) accounted for 60 percent of new HIV diagnoses, compared with 56 percent for the state, for 2010 (VDH, 2011), reflecting the need to target risky behavior.

In Virginia, persons with lower income are less likely to seek any care and more likely to drop out of care. By age at time of diagnosis, unmet need was reported to be greatest for persons 13 to 19 and 20 to 29. For persons 20 to 29, unmet need may be higher because this age group (especially among males) is the least likely to have routine evaluations with a physician. Developmental stages that lend themselves to youthful notions of invulnerability and overall health may account for tendencies by this age group to not seek medical care.

Impact

Major accomplishments of Inova Juniper Program through December 2012 include:

• Provided services to 1,381 clients living with HIV/AIDS
• Provided 26,435 patient visits
• Maintained a 0 percent HIV transmission rate from pregnant mothers to their newborn babies
• Expanded the program to Loudoun County and opened a new clinic in Leesburg
• Transitioned all patients that Loudoun County Health Department previously managed into the program to ensure that more comprehensive services were available to patients in that region.
• Expanded the CDC testing and counseling programs in the emergency departments to include not only Alexandria Hospital and Mt. Vernon Hospital but also Fairfax Hospital
• Began providing prevention services; throughout the year, the new prevention program received funding for MAI Part B for community health workers to provide linkage to care, Healthy Relationships: Prevention for Positives, and the Gay Men’s Health Collaborative to provide community-based primary prevention for gay men of color
• Received NQCA certification as a medical home
• Went “live” on Epic as its new electronic medical record
• Conducted 138 education programs that reached1,614 participants, and provided 234 clinical consultations

Challenges/success factors

• As a result of advancement in drug therapies, HIV has changed from a fatal illness to a chronic disease. Clients are living longer but with complicated medical side effects and a greater need for chronic care management. Inova Juniper Program staff have responded by developing expertise in chronic care management.
• Racial and ethnic diversity is more pronounced in Northern Virginia than it is in the rest of the state. With increasing diversity, economically disadvantaged populations and multiple languages, the need for access to culturally appropriate, flexible health care continues to grow. According to the 2010 U.S. Census, Northern Virginia is home to more than 2.2 million people, 47 percent of whom are of minority race. More than one in five residents is foreign born. Northern Virginia’s percentage of foreign-born residents is twice the national average and the state rate. Twelve percent of households in Manassas have family members who have difficulty speaking and understanding English (Community Foundation for Northern Virginia and Voices for Virginia’s Children, A Portrait of Children in Northern Virginia, 2010). Census figures indicate increasing proportions of Asians and Hispanics and declining rates of Caucasians between 2008 and 2010. Collectively, Northern Virginia’s 646,366 foreign-born residents speak more than 100 languages. According to 2011 statistics from the Fairfax County Public School System (the largest one in the D.C. Metro area), 56.1 percent of the County’s students were of ethnic minority background, and more than 23,000 students were enrolled in ESOL classes. According to the 2010 U.S. Census, 31 percent of the Northern Virginia population speaks a language other than English in their home.
• To widen access, services are provided in Springfield plus five additional sites throughout the region. Other sites are located in Dumfries, Manassas, Arlington, Herndon and Leesburg. A satellite office is in Mt. Vernon.
• One of the most challenging aspects of providing care to HIV-positive clients is to keep them engaged in care. Many times, this is a result of mental health issues, substance abuse, or the lack of stable, safe, affordable housing and the resources for clients to take care of their basic needs. The program provides a consumer advocate to conduct outreach to clients, often based on “no-show” reports compiled from physician-provided data.

Future direction/sustainability

Inova Juniper Program is funded by the Ryan White Treatment Modernization Act, Women’s Interagency HIV Study, Fairfax County, and the Virginia Department of Health. In 2006, the program began billing for clinical services on behalf of clients; it also uses a sliding-scale fee, as required by the Ryan White Modernization Act. The health system contributes to costs not covered by grants, such as support staff, rent, utilities, and office supplies. The health system’s Foundation has a Patient Care Fund, which helps cover patient care expenses that are not covered by other funding streams.

Advice to others

• Start small with the goal of meeting immediate medical needs. You can add more medical services and clients as the program successfully grows.
• Have a roadmap for executing a coordinated approach for delivering medical care.
• Be knowledgeable about the neighborhoods where clients live and work.
• Take the time to understand your clients and their needs.
• Hire culturally congruent staff so clients can identify with their medical care provider.
• Build community partnerships for volunteer and financial support.
• Don’t be afraid to change your roadmap when things are not working well, so that you ensure you are providing the best possible medical care to those with the most need.

Contact: Barbara Lawrence
Director
Telephone: 703-321-2668
E-mail: barbara.lawrence@inova.org