Protocol Based Counseling: Past and Present

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Protocol Based Counseling Past and Present

• HIV Prevention Kick Off Meeting Austin, Texas
• September 11-12, 2007

2
Agenda

• Welcome and Introduction
• Background
• Overview of project
• General evaluation findings
• Current Activities
• Updates on Training and QA Standards

3
Background

• Revised HIV Counseling, Testing and Referral
  (CTR) Guidelines, November 2001

4
Background Contd

• CDCs Project RESPECT Evidence-based
  intervention showing significant reduction of
  STDs with protocol-based HIV prevention
  counseling
• RESPECT-2 Refined HIV prevention counseling
  protocol further developed counseling quality
  assurance methods

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RESPECT Methodology

• 5758 heterosexual, HIV-negative patients older
  than 14 years who came in for STD examination
• Five public STD clinics (Baltimore, Denver, Long
  Beach, Newark and San Francisco)

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Project RESPECT Results HIV Prevention
Counseling Effective
(pKamb, M.L., et al (1998) Efficacy of
risk-reduction counseling to prevent Human
Immunodeficiency Virus and sexually transmitted
diseases, JAMA, 280 (13)1161-1167
7
How could we translate this intervention into a
real-world setting?

• Risk Reduction Specialist support
• Supervisor support
• Practical tools

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Goals of the Project

• Develop and evaluate tools to support
  protocol-driven prevention counseling based on
  the RESPECT model
• Develop and evaluate QA procedures
• Better understand the barriers and facilitators
  of good prevention counseling

9
Introductions

• Coincides with new shift for adopting evidence
  based interventions (EBI) for all HIV prevention
  programs.
• Introduces cognitive dissonance.
• Behavior and beliefs conflict

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What was introduced during the project?

• Counseling protocol
• Training on the protocol
• Counseling tools
• Spiral book with goals and sample questions
• Laminated wheel
• Documentation form with space for RR plan and
  referrals
• Personal review form

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What QA activities were part of the project?

• QA protocol
• Emphasizing standardized preceptorship,
  observation, routine meetings, documentation
  review, and feedback on observations and
  documentation
• QA tools
• Supervisor observation tool
• RRS self assessment
• Chart abstraction and summary tools

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The Basics

• Protocol-based counseling (PBC) is an
  evidence-based intervention.
• There have been replicated studies that show this
  intervention reduces clients' risk behaviors and
  new STD infections.

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Elements

• The essential elements of a prevention counseling
  session include
• Introducing and orienting client to the session
• Enhancing client's self-perceived risk
• Exploring client's most recent risk
• Reviewing client's previous risk reduction
  experiences
• Summarizing patterns of risks and triggers
  (putting risk in context)
• Negotiating a realistic and acceptable risk
  reduction step

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Elements cont.

• Identifying sources of support and providing
  referrals
• Summarizing and closing the session
• In Texas, this intervention also includes
• Supporting test decision counseling (when
  appropriate)
• Providing results simply and supportively
• Introducing partner services (when appropriate)

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QA

• QA refers to actions taken by supervisors and
  program managers to ensure that the intervention
  is consistently implemented across risk reduction
  specialists and across settings.
• Quality assurance activities include
• ensuring risk reduction specialists receive
  training and other activities to further his/her
  development
• assessment of client satisfaction and client
  flow
• record keeping and
• evaluation activities including risk reduction
  specialist observation, feedback, and
  documentation review.

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Implementation

• Training developed for protocol, tools and QA
• Pilot site Supervisors and Risk Reduction
  Specialists trained in October 2003
• On-site and off-site TA provided for start-up
• Staggered and tailored implementation of
  protocol, tools, and QA
• Additional ongoing TA after start-up

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What Did We Want to Learn?

• Can you implement protocol-based prevention
  counseling with existing resources?
• Did the protocols and tools help them implement
  the intervention with fidelity?
• What were some of the facilitators and barriers
  of the implementation of the protocols?

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Evaluation Design

• Two data collection phases
• Pre- and
• Post-intervention
• Evaluation data triangulation Nine (9)
  complementary quantitative and qualitative
  instruments

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Results

• Lessons Learned

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Did the protocols and tools help implement the
intervention with fidelity?
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Observations Initial SessionGoals
P 22
Observations Follow-up SessionGoals
P 23
Significant changes seen in initial sessions
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Significant changes seen in follow up sessions
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Client Surveys Client Participation
P 26

• The protocol improved the quality
• of my counseling because I had
• a structure to make sure I wasnt leaving
  anything out.

-Risk Reduction Specialist
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Client Surveys Client experience
P 28
QA Activities by RRS
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Roll Out

• State-wide roll-out began May 2, 2005
• All DSHS HIV/STD and SAMSHA contractors
• Roll-out was completed August 2006
• PBC is the state mandated model of HIV prevention
  counseling as of May 2005.

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Protocol Based Counseling

• Changes to Protocol Book

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www.dshs.state.tx.us/hivstd/training/pctool.shtm

• Minor revisions
• Numbering of Goals and Tasks
• Some example questions were revised
• Additional space provided in some examples
• for a RRS to write his/her own examples or other
  items
• Re-ordered tasks in Goal 5 (Initial) and
• Goal 2 (Positive HIV) so there was a more
  logical flow to the tasks

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Protocol Based Counseling

• Changes to Training

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• PBC training is now 4 ½ days
• No longer have 5-day PBC Supervisor training
• 1-day Quality Assurance for Protocol Based
  Counseling
• Planned as needed either with one or more
  supervisor (often offered quarterly)
• More time spent on Counseling elements and Stages
  of Change
• Rapid Test protocol training can be provided
• 1-day training available
• Focus is on special considerations related to
  rapid testing and differences in protocols
• Provides skill-building opportunities as well

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Protocol Based Counseling

• Changes to Forms

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www.dshs.state.tx.us/hivstd/training/pctools.shtm

• Minor changes have been made
• Supervisor Observation forms (A1-A8) and Session
  Documentation forms (D1-D5) were revised to match
  the protocol revisions
• Self-assessment (B1-B8), personal review forms
  (C1-C2) and Session Notes forms (E1-E5) are
  optional forms with minor revisions
• For supervisors with seasoned and new RRS staff,
• forms A-1, A-3, B-1 and B-3 have versions with
  an o indicating these are the original
  observation forms used during the roll-out that
  can still be used with seasoned staff

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Protocol Based Counseling

• Changes to Quality Assurance Standards

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• Quality Assurance Standards have been revised
• Observation cycle has been changed to 441
  versus 551
• At least one observation must be done prior to
  training,
• A new RRS can complete his/her observation cycle
  prior to training if time allows
• For staff conducting Rapid HIV testing,
• 221 (Traditional)
• 221 (Rapid)
• If you have hired a seasoned RRS from another
  program, DSHS recommends a supervisor observe
• a minimum of 221 to ensure the RRS is
  conducting a session as you have instructed other
  RRS at your agency

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• Chart review schedule for new RRS
• For first 6 months, review 5 charts 2x/month
• This allows a supervisor to provide on-going
  feedback and guidance related to charting the
  session and the development of SMART risk
  reduction steps
• If you have hired a seasoned RRS from another
  program, DSHS recommends conducting chart reviews
  on this schedule to ensure the RRS is documenting
  the session and the RR step as you have
  instructed other RRS within your agency

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Protocol Based Counseling

• We are now instructing new RRS to do his/her very
  best to accomplish all goals and tasks,
  recognizing that tasks may not always happen in
  the exact order (as written) each and every time
• As comfort with the protocol grows, a RRS finds
  his/her style using the protocol
• At the same time, a client may discuss things in
  an order different than the order of the tasks
• Ideally, what we look for is
• Did the RRS attempt to cover the goals and tasks
  in order, without causing undue stress for the
  client?

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2008 Project

• Development of a bi-monthly
• Protocol Based Counseling Bulletin
• It will include several client scenarios from
  initial and/or follow-up sessions
• Client scenarios will be gathered from
  contractors funded to conduct Protocol Based
  Counseling
• Risk reduction specialists (RRS) will be asked to
  submit Specific, Measurable, Appropriate,
  Realistic, and Timely (SMART) risk reduction
  steps that could be options for the particular
  client scenario
• This will provide a multitude of SMART risk
  reduction steps that could be used by a RRS when
  helping a client develop a step to reduce his/her
  HIV/STD/HCV risk
• All RRS who submit a SMART risk reduction step
  (bi-monthly), will be eligible for a drawing of a
  25 VISA gift card

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Questions?

• Contact your Field Operations Consultant
• or
• Tammy Foskey, Training Manager
• [phone] tammy.foskey_at_dshs.state.tx.us
• or
• Jeff Wagers, Program Specialist IV
• [phone] jeffrey.wagers_at_dshs.state.tx.us