This webinar discussed how to educate Nurse Practitioners who have completed Community Health Center. Inc’s NP Residency or NPs who have significant experience as a Primary Care Provider on the integration of specialty care for key populations, including: • HIV care • Hepatitis C management • Medication-assisted treatment for opioid use and other substance use disorders • Sexually transmitted disease (STI) screening and management • Lesbian, Gay, Bisexual, Transgender, Questioning, Intersex, Asexual (LGBTQIA+) health, including hormone replacement therapy and gender affirming care. Panelists: • Charise Corsino, MA, Program Director, Nurse Practitioner Residency Programs, Community Health Center, Inc. • Marwan Haddad, MD, MPH, AAHIVS, Medical Director, Center for Key Populations, Community Health Center, Inc. • Jeannie McIntosh, APRN, FNP-C, AAHIVS, Family Nurse Practitioner, Center for Key Populations, Community Health Center, Inc.

1. Integrating HIV Education
Thursday, April 28, 2022
1:00-2:00pm Eastern/10:00-11:00am Pacific
Charise Corsino, MA, Program Director, Nurse Practitioner Residency Programs, Community Health Center, Inc.,
Marwan Haddad, MD, MPH, AAHIVS, Medical Director, Center for Key Populations, Community Health Center, Inc.,
Jeannie McIntosh, APRN, FNP-C, AAHIVS, Family Nurse Practitioner, Center for Key Populations, Community Health Center, Inc.

2. Continuing Education Credits
In support of improving patient care,
Community Health Center, Inc. / Weitzman
Institute is jointly accredited by the
Accreditation Council for Continuing Medical
Education (ACCME), the Accreditation Council
for Pharmacy Education (ACPE), and the
American Nurses Credentialing Center
(ANCC), to provide continuing education for
the healthcare team.
A comprehensive certificate will be sent after
the end of the series, Spring 2022.
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3. Disclosure
• With respect to the following presentation, there has been no relevant (direct or indirect) financial relationship
between the party listed above (or spouse/partner) and any for-profit company in the past 12 months which
would be considered a conflict of interest.
• The views expressed in this presentation are those of the presenters and may not reflect official policy of
Community Health Center, Inc. and its Weitzman Institute.
• We are obligated to disclose any products which are off-label, unlabeled, experimental, and/or under
investigation (not FDA approved) and any limitations on the information hat we present, such as data that are
preliminary or that represent ongoing research, interim analyses, and/or unsupported opinion.
• This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of
Health and Human Services (HHS) as part of an award totaling $137,500 with 0% financed with non-
governmental sources. The contents are those of the author(s) and do not necessarily represent the official
views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit
HRSA.gov.
3

4. At the Weitzman Institute, we value a
culture of equity, inclusiveness,
diversity, and mutually respectful
dialogue. We want to ensure that all
feel welcome. If there is anything said
in our program that makes you feel
uncomfortable, please let us know via
email at nca@chc1.com
4

5. National Training and Technical Assistance Partnership
Clinical Workforce Development
Provides free training and technical assistance to health centers across the
nation through national webinars, learning collaboratives, activity
sessions, trainings, research, publications, etc.
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6. Objectives
By the end of this lecture, the participant will be able to
• Understand the need for expanding the current HIV clinical workforce.
• Discuss how to use an educational model or postgraduate training model to train
new NPs to integrate specialty care for key populations.
• Learn the fundamental components of these two major HIV training models
implemented at a community health center.
• CHC Project ECHO
• CHC Center for Key Populations NP Fellowship
• Gain awareness of importance of integrating other key populations competencies in
HIV programs (e.g. HCV, SUD/MAT, LGB and Transgender health, Homelessness).
• Discuss strategies for implementation of similar training programs at other clinics.
6

7. CHC Profile
Founding year: 1972
Primary care hubs: 17; 200+ sites
Staff: 1,200
Patients/year: 100,000
Specialties: onsite psychiatry, podiatry,
chiropractic
Specialty access by e-Consult
Elements of Model
Fully Integrated teams and data
Integration of key populations into primary care
Data driven performance
“Wherever You Are” approach
Weitzman Institute
QI experts; national coaches
Project ECHO®— special populations
Formal research and R&D
Clinical workforce development
CHC Locations in Connecticut

8. Center for Key Populations
8
The Center for Key Populations (CKP) is first center of its kind
that focuses on key groups who experience health disparities
secondary to stigma and discrimination and who belong to
communities that have suffered many barriers to healthcare.
The Center brings together healthcare, training, research, and
advocacy for: People who use drugs, the LGB and Transgender
populations, the homeless and those experiencing housing
instability, the recently incarcerated, and sex workers.
HIV Primary Care
& Testing
Hepatitis C
Screening and
Treatment
Medication
Assisted
Treatment for
Substance Use
Disorders
Health Care for
the Homeless
LGBTQ-focused
Health Care
Community
Drop-In Center
HIV PrEP
(Pre-Exposure
Prophylaxis
and PEP
Post-Exposure
Prophylaxis)
Sexually
Transmitted
Infections
CENTER FOR KEY POPULATIONS — Reimagining Primary Care

9. Background
• We have the tools to end the HIV epidemic. 1
• HIV testing, PrEP, and HIV Treatment as Prevention (U=U).
• Yet, ~36,800 people were newly diagnosed with HIV in 2019. 1,2
• One in three of the ~1.2 million people with HIV (PWH) in the U.S. are
not in regular care and not virally suppressed. 1,3
• The number of new HIV clinicians falls well short of demand, creating a
severe shortage and a crisis in access to care. 1,4,5
• PWH cared for by expert HIV clinicians have better outcomes. 1,6
9
1. HIVMA, HELP Act Fact Sheet, July 2020
2. Centers for Disease Control and Prevention. CDC HIV Prevention Progress Report, 2019. Available at: https://www.cdc.gov/hiv/pdf/policies/progressreports/cdc-hiv-preventionprogressreport.pdf.
3. Centers for Disease Control and Prevention. Understanding the HIV Care Continuum. July 2019. Available at: https://www.cdc.gov/hiv/pdf/library/factsheets/cdc-hiv-care-continuum.pdf.
4. Fauci AS, Redfield RR, Sigounas G, Weahkee MD, Giroir BP. Ending the HIV Epidemic: A Plan for the United States. JAMA. 2019;321(9):844–845. doi: https://doi.org/10.1001/jama.2019.1343.
5. Weiser J, Beer l, West B, et al. Qualifications, Demographics, Satisfaction, and Future Capacity of the HIV Care Provider Workforce in the United States, 2013–2014. Clin Infect Dis. 2016 Oct 1; 63(7): 966–975. doi:
10.1093/cid/ciw442.
6. Rackal, JM, et al. Provider training and experience for people living with HIV/AIDS. Cochrane Database Syst Rev. 2 2011;15(6):CD003938.

10. Background (cont.)
• About 50% of the 48 counties and 2 metropolitan areas and 6 of the 7
states hardest hit by HIV are in the South. 1,7
• A recent study of the HIV workforce in 14 southern states found more
than 80% of counties had no experienced HIV clinicians, with disparities
being greatest in rural areas. 1,8
• A study of the infectious diseases (ID) workforce found that 80% of
counties in the U.S. did not have an ID specialist. 1,9
10
1. HIVMA, HELP Act Fact Sheet, July 2020
7. U.S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis. 2016. State-Level Projections of Supply and Demand for Primary Care Practitioners:
2013-2025. Rockville, Maryland. Available at: https://bhw.hrsa.gov/sites/default/files/bhw/health-workforce-analysis/research/projections/primary-care- state-projections2013-2025.pdf
8. Bono RS, et al. HIV-Experienced Clinician Workforce Capacity: Urban-Rural Disparities in the US South. Clin Infect Dis. Mar 25, 2020. doi: 10.1093/cid/ciaa300.
9. Walensky RP, et al. Where Is the ID in COVID-19? Annuals of Internal Medicine. Jun 3, 2020. https://doi.org/10.7326/M20 - 2684.

11. Background (cont.)
• HIV Workforce is composed of the following:1,10
• ID specialists represent about 60%.
• Internists and family medicine physicians represent bulk of rest.
• Nurse practitioners (NPs)/physician assistants (PAs) play important and growing role.
• ID fellowship training programs not filling available slots nationwide.1, 11, 12
• 37% of training slots went unfilled in 2019.
• Improved in recent years with 82% of slots filling in 2022 (may be much needed boost secondary to
COVID-19).
• NPs are more willing to practice in urban and rural areas, provide care in a wider range of
community settings, and treat Medicaid recipients and other vulnerable populations. 13
• There also has been a rapid growth of NPs and PAs prescribing buprenorphine, especially in rural
settings. 14
11
1. HIVMA, HELP Act Fact Sheet, July 2020
10. Weiser J, Beer l, West B, et al. Qualifications, Demographics, Satisfaction, and Future Capacity of the HIV Care Provider Workforce in the United States, 2013–2014. Clin Infect Dis. 2016 Oct 1; 63(7): 966–975. doi:
10.1093/cid/ciw442.
11. Bonura et al. Factors Influencing Internal Medicine Resident Choice of Infectious Diseases or Other Specialties: A National Cross-Sectional Study. Clin Infect Dis. 2016 Jul 15; 63(2): 155–163. doi: 10.1093/cid/ciw263CID. 2016:63.
12. IDSA News. ID Fellowship Match Results: Slight Declines from Last Year. Dec. 23, 2019. Available at: https://www.idsociety.org/idsa-newsletter/december-23-2019/ID-Fellowship-Match-Results-Slight-Declines-from-Last-Year/.
13. Buerhaus PI, DesRoches CM, Dittus R, Donelan K. Practice characteristics of primary care nurse practitioners and physicians. Nurs Outlook. 2015;63(2):144-153. doi:10.1016/j.outlook.2014.08.008
14. Barnett ML, Lee D, Frank RG. In Rural Areas, Buprenorphine Waiver Adoption Since 2017 Driven By Nurse Practitioners And Physician Assistants. Health Aff (Millwood). 2019;38(12):2048-2056. doi:10.1377/hlthaff.2019.00859

12. Training the Next Generation: CHC Experience
• Need for HIV prevention and treatment services grew across CHC sites.
• Need for treatment of overlapping disciplines/co-morbidities emerging.
• Hepatitis C (HCV), Hepatitis B (HBV), Substance Use Disorder
(SUD)/Medication for SUDs, LGB Health, Transgender Health, STIs
• Ryan White-funded HIV clinical team, small and present at a few sites.
• CKP– provides direct care and serves as trainer/consultant for agency.
• Project ECHO
• NP Fellowship in HIV and Key Populations
12

13. Origins of Project ECHO
“The mission of Project ECHO is to develop the capacity to safely and effectively
treat chronic, common and complex diseases in rural and underserved areas
and to monitor outcomes.”
Dr. Sanjeev Arora
University of New Mexico

14. • Builds communities of practice
• Connects primary care providers with a panel of expert multidisciplinary faculty
• Improves access to specialty care
• Creates a force multiplier
Why Project ECHO?

15. Making the Case for ECHO:
Needs and Gaps
• Identify the needs
• Take stock of internal and local resources
• Present the gaps remaining
• Use data for provider/leadership buy-in; to demonstrate lack of access/quality care
• # of PWH in practice, in community; # of providers with expertise, with interest; etc.
• Propose solution, e.g. ECHO for provider support and training
• Find funding opportunities
• Ending HIV Epidemic
• Opioid crisis
• Know state and federal policies
• Scope of practice for non-MD providers
• Eg. Some states require MD co-signatures for NPs re buprenorphine
• Restrictions
• Eg. Requirement of GI/ID consultation for HCV medication
• ECHO can be used to overcome some of these barriers 15

16. What to Look For:
Components of a Successful ECHO
• Having a trained faculty (multi-disciplinary)
• Creating a learning community/safe
environment
• Understanding it is more than a webinar,
more than a consultation
• Addressing systemic/societal context
• Engaging providers at multiple levels of
knowledge and training from different
regions/agencies
• Having an ECHO coordinator
• Having case presentations
• Ensuring flexible didactic curriculum
• Responding to participant feedback

17. • Agency/senior leadership commitment
• Participant buy-in
• Access to technology
• Appropriate frequency and length of sessions
• Assigned coordinator/in-charge, e.g. blocking schedules, IT
• Active participation
• Building of internal expertise/training/sustainability
• Provider recruitment/retention
17
What to Look For:
Components of ECHO Participant Success

18. Implementation of ECHO Participation
• Make the case
• Secure senior leadership
commitment
• Obtain clinician buy-in
• Identify champions
• Find the “right” ECHO
• Consider: time zone, day/time,
frequency, focus/specialty of
ECHO
• Apply for funding, if possible
• Block protected time for providers
• Communicate/advertise ECHO to
providers, to community
• Actively recruit patients to receive care
• Eg. EHR data pulls
• Require case presentations
• Provide time for providers to prepare
cases
• Assess on-going utility to providers and
to clinic
18

19. CHC’s ECHO Learning Community
Since Jan 2012

20. Active ECHO Clinics
20

21. Technology Infrastructure
Webcam/
Computer
Tablet/
Smartphone
for End-Users
Cloud-based
Teleconferencing
Platform
(Zoom©)
Video
Conferencing
System for
ECHO Team
Recorded/
Catalogued
Sessions
Streaming
Sessions
CHC ECHO Platform

22. • CKP Expertise
• ECHO HIV/Key Populations
• Launched in 2012 to increase access to all sites.
• Emerged into ECHO Key Populations.
• Faculty for ECHO Key Populations:
• FP HIV specialists (MDs, NP), Psych NPs,
Behavioral health clinician, PharmD
• ECHO MOUD
• Launched in early 2013 to increase and support
MOUD prescribers across all CHC sites.
• Faculty for ECHO MAT:
• FP MD/NP, BH clinician, PharmD, MOUD
Program manager/Care coordinator
CHC Project ECHO:
HIV/Key Populations and MOUD
• Format:
• Brief lectures based on
curriculum
• Case presentations
• Clinical and programmatic
questions

23. The ECHO Model: Data
23

24. The ECHO Model: Data
24

25. MOUD & KP 2021-2022 Data
25
ECHO
Title
#of
Sessions
#of
registered
providers
# of
clinics
#of
states
#of
CME
hours
Practice
Setting
New
Knowledge
Personal Learning Needs
*For KP This is:
Information presented
addressed a professional
practice gap
Case
Recommendations
MOUD
2021-
2022
22 325 11 AZ, CA,
CT, NY,
RI
33 4.75 4.6 4.7 4.7
KP
2021-
2022
59 300 78 CT, KY,
FL, OH,
SC, AL,
NC, TX,
VA, PR,
TN, IL,
NY, MA,
LA
80.5 85%
Strongly
Agree
100%
Strongly
Agree
93% strongly agree 93% rate case
recommendations
as above average

26. CHC ECHO Model: Benefits
• Eliminates barriers: patients can access specialty care in a community-based setting
• Improves and ensures quality care
• Facilitates integrated primary and specialty care
• Helps battle/remove stigma
• Engages experts in various fields/settings (interdisciplinary team)
• Builds a longitudinal community of learners and mentors
• Multi-level teaching: faculty to participants, participants to other providers in org.
• Collaboration with and sharing of ideas among other HIV/MOUD programs
• Sharing and identifying clinical and non-clinical community resources
• Exposure to trainees; NP residency and fellowship training
• Provider recruitment/retention
26

27. ECHO Utility
• Works for practices with both low and high volume panels of patients with HIV
• High Volume Practice
• Quick learning curve
• Feeling of being supported
• Patient confidence in care
• Provides cases which serves as tool for others to learn
• Develop into expert in short period of time
• Low Volume Practice
• Examples: Rural, Urban with no available expertise
• Able to deliver quality care without being an expert
• Continued competency despite low patient volume
• Teaching Tool
27

28. Center for Key Populations (CKP)
Nurse Practitioner Fellowship

29. CKP Fellowship Objectives
• Train NPs in competent, compassionate, and respectful primary care for those
patient populations that experience health disparities secondary to stigma and
discrimination
• Create a CHC pipeline of primary care providers who deliver top quality care in the
disciplines of HIV treatment and prevention, HCV, substance use disorders, LGBTQI+
health, STIs, and homelessness AND support other clinicians at their sites in
providing these services.
29

30. • Dedicated supervision and mentorship during clinical practice
• Individualized weekly case review and didactic sessions
• Participation in Project ECHO sessions
• Involvement in Quality Improvement work
• Monthly Presentations to CKP Provider Team
• Completion of a Capstone project on a key populations-related topic
• Maintenance of part-time primary care clinical practice
• Training opportunities include HIV treatment and prevention, medications for substance
use disorders, STI management, HCV and HBV treatment, health care for the homeless,
and LGBT health and gender affirming hormone therapy
Core Components of the Fellowship
12 Months
Full-time
Employment
Training to Clinical Complexity and
High Performance Model of Care
Full Integration
into CKP team and
expert faculty

31. Additional Information About the Fellowship
• A one year salaried position with full benefits and commitment for a second year full-time
position at CHC upon completion of fellowship.
• Currently offered only to graduates of CHC’s year-long primary care NP residency (FNP or
AGNP specialties).
• https://www.npresidency.com/program/program-details-and-structure/
• In addition to CKP clinical rotations and other key populations-specific learning
opportunities the fellow maintains a part-time primary care practice (1.5-2 days per week).
• Fosters integration of key populations competencies into primary care practice
• Allows fellows to continue building their skills and independence as primary care NPs.
• Visit revenue helps support fellowship salary.
31

32. Sample Weekly Schedule
32

33. Benefits of the CKP Fellowship
• Fellow
• Increased competence/confidence
• Broader scope of licensing
• Leadership development
• Job satisfaction
• Organizational
• More convenient and cost-effective
to train specialists internally
• Decrease need for external referrals
• Recruitment and retention
• QI contribution/participation
• Patient
• Broader access to CKP services
across the state
• Continuity with PCP
• Increased trust, adherence, long-term
retention
• Bypass condition-specific clinics
• Anonymity and decreased stigma
33

34. Weekly One-Hour
Didactic Curriculum Examples
• Antiretroviral therapy (ART) drug
classes
• ART Initiation
• ART resistance mutations
• ART regimen choices in treatment-
experienced individuals
• Opportunistic infections
• Cardiovascular, renal and metabolic
complications of HIV and ARTs
• HIV and pregnancy
• HIV and aging
• HIV PrEP and PEP
• Gender affirming hormone therapy
• STIs
• HCV treatment
• Opioid use disorder treatment
• Medications for other substance use
disorders
• Chronic HBV infection
• Principles of harm reduction and
trauma informed care
34

35. Fellowship Evaluation Tool
Competency Domains Assessed
• Patient Care
• Knowledge for Practice
• Practice-Based Learning &
Improvement
• Interpersonal and Communication Skills
• Professionalism
• System-Based Practice
• Interprofessional Collaboration
• Personal & Professional Development
35

36. Fellowship Feedback
• Self-assessment using the competency tool at the beginning,
middle, and end of the program
• Qualitative reflection on the fellow’s experience quarterly
• Fellow assesses the faculty twice per year
36

37. Reflection from Fellows
• “I wake up every day deeply grateful for this fellowship. I have
learned so much already and find the content interesting and
energizing. I find such joy in key populations work generally, and
specifically working with Jeannie and Marwan. The care that they
provide and the relationships that they have built with their
patients inspire me every day.” –Marlene Edelstein, 2019-2020
37

38. CKP Fellowship at 5 years
• Our fifth class of fellows will graduate in August of 2022.
• To date all fellowship graduates are still currently practicing at CHC –
100% retention!
• Since September 2017, CKP Fellows have presented at 16 national
conferences combined.
• CKP Fellows have all credentialed as HIV Specialists with the AAHIVM by
the end of the fellowship year.
38

39. Clinical Innovations at CHC Led by CKP Fellows
• Gender Diversity and Resilience Program at Child Guidance Center
• An integrated medical and behavioral health program for transgender and non-binary youth
• CHC Refugee Health Program
• A collaboration with local refugee resettlement agencies in CT to complete refugee health
assessments and help newly arrived families establish medical care
• CT River Valley Farm Worker Health Program (CRVFHP)
• Farm-based medical and vaccination clinics on weekends for migrant and seasonal agricultural
workers
• Coming soon:
• Transitions clinic for recently incarcerated patients
• Mobile STI and MOUD clinics
39

40. Capstone Project
• An opportunity for the CKP Fellow to delve deeper into a relevant area of interest and explore its
practical application in an FQHC clinical setting
• One session (half day) per week is dedicated to the capstone
• Format varies
• Small, focused research study
• Quality improvement project
• Implementation of a new program
• Examples:
• Utility of oropharyngeal gonorrhea / chlamydia testing in women
• Nurse-driven protocols for STI testing and education
• Designing and implementing a transitions clinic for recently incarcerated patients
• Designing and implementing a refugee health program
40

41. CKP Fellows
Jeannie McIntosh
Yale University
NP Residency Class 2016-2017
Current roles:
FNP – CKP
NP Residency and CKP Fellowship preceptor
Didactic presenter
Project ECHO faculty
Meghan Garcia
Yale University
NP Residency Class 2017-2018
Current roles:
FNP – CKP / CHC New Britain
NP Residency preceptor
Didactic presenter
Terri Fleming
Johns Hopkins University
NP Residency Class 2018-2019
Current roles:
FNP – CHC Stamford, Norwalk,
Danbury and CGC GDR Program
NP Residency preceptor
Didactic presenter
Marlene Edelstein
Yale University
NP Residency Class 2019-2020
Current roles:
FNP - CKP
Kimberly Willet
Georgetown University
NP Residency Class 2020-2021
Current roles:
CKP Fellow
Jason Manto
Yale University
NP Residency Class 2020-2021
Current roles:
CKP Fellow

42. Examples of where CKP Fellows have
Presented and Published

43. Outcomes of the CKP Fellowship
• Fellows provide integrated primary care with enhanced knowledge in CKP core areas
at CHC sites across CT
• Fellows help train the next generation, becoming expert faculty of CHC’s NP
residency, CKP Fellowship and ECHO programs
• Fellows also provide leadership, education and support to other primary care
providers at CHC and beyond, helping PCPs build comfort and competence in caring
for key populations
• Fellows report increased job satisfaction, confidence and competence, as reflected in
their high retention rates.
43

44. Considerations for Starting Fellowship Program
• Internal expertise for clinical experiences and didactic education
• Adequate clinical exposure for various key populations
• Staffing: Clinical Faculty and Administrative Support for program operations
• Schedule accommodation for clinical mentors and for fellows
• Leveraging external community partnerships
• Designing formal evaluation process
• Exploring sustainable financial models
• Consider NP and other residency programs as initial pipelines
• Form associations with academic institutions
• Seek mentorship to establish a program
• National NP Residency and Fellowship Training Consortium
• Other clinics/programs with existing fellowships

45. Integrating HIV Education
at Your Health Center
• Identify the needs/gaps
• Include people of lived experience
• Mine internal and external local resources
• Include HIV education in all medical/clinical
curricula
• Build up competencies in related key
populations care
• HCV, substance use disorders, LGBTQI+
health, homelessness
• Promote continuing education for providers
• Webinars, grand rounds, conferences, CME
• Build an internal workforce pipeline
• Recruit medical staff with interest or expertise
to create/demonstrate demand
• Fellowship
• Find and/or provide opportunities to train staff
• Project ECHO
• Find one to join that works for your clinic
• Find, share, support ways to educate, train, and
expand the HIV workforce if we are to achieve
the end of the HIV epidemic
45

46. Questions?
46

47. Contact Information
47
For information on future webinars, activity
sessions, and learning collaboratives:
please reach out to nca@chc1.com or visit
https://www.chc1.com/nca