Hennepin County Ryan White newsletter summer 2021

ryan white

August 10, 2021

In this issue

2020 Ryan White Provider QI project overview and highlight



In 2020, 12 Hennepin County contracted Ryan White Providers worked toward 30 quality improvement projects. Of these 30 projects:

  • 11 projects met their aim
  • 8 project aims weren’t met but helped make an improvement
  • 11 aims were not met
  • 9 projects saw a worse outcome than baseline

Considering 2020 was a year of rapid pivoting, addressing a global COVID-19 pandemic, trying to catch up and address a local HIV outbreak, these outcomes are amazing. The 30 projects addressed several areas including:

  • 6 on viral suppression
  • 5 on disparity reductions
  • 8 on retention in care
  • 3 on linkage to care
  • 2 on data
  • 1 on cultural responsiveness
  • 1 on consumer engagement

As always these projects help providers and our quality management program learn about what works and what doesn’t.  As Oprah said, “Failure is a great teacher, and, if you are open to it, every mistake has a lesson to offer.”

Open Arms project

One of 11 projects that met their aim was from Open Arms whose goal was to increase the percentage of their Ryan White clients who have contact with Registered Dietitians (RDs) by 7% (from 15% to 21%).

By the end of the year Open Arms Registered Dietitians connected with 42% (154) of their Ryan White Clients an outcome that was double their goal.

How did they do it? 

In their staff’s own words, “In 2020, Open Arms RDs made a focused effort to reach more of our HIV clients. The RDs made phone calls to new and long-term HCRW clients to offer nutrition counseling. Many clients did not realize what nutrition counseling entailed, so these calls were a great opportunity for the RDs to explain the variety of topics that could be covered such as managing side effects from their health condition(s) or medications, ways to reduce blood pressure and/or cholesterol, ways to control blood sugar levels through food, identifying healthy portion sizes, learning about what is included in a balanced plate, etc. Making clients aware of the topics that could be discussed helped to increase our participation.

Additionally, during the COVID-19 pandemic, clients were home often and available to speak over the phone. The convenience of a phone call likely helped to increase our contact with our HIV clientele. We plan to continue our nutrition team outreach efforts to our Ryan White clients, while prioritizing those who are deemed as “high risk” based on our reporting procedures.”

Congratulations to Open Arms for setting your aim and making it happen!

Spotlight: Sub-Saharan African Youth & Family Services of Minnesota (SAYFSM)


The following is a Q&A with Ephraim Olani, Elizabeth Gerbi, and Aster Tesema.

Q. Please describe the work ongoing at SAYFSM; what are the main things you are working on?

We offer an array of services where one service often augments our other programs. Client outcomes are successful due to these multiple interrelated programs. The more programs the clients participate in, the better the outcomes.

We are working on accessibility. Do clients access our programs? If not, what do clients need to access programs?

We invite speakers on various issues. When we hear about gaps in mental health (MH) services, we include that topic in our Psychosocial Support Services (PSS) program. We also evaluate clients in PSS for opportunities to refer and coordinate with MH providers.

Q. SAYFSM has better outcomes for RW clients than other organizations delivering similar services do; what do you attribute to your successes?

We have a great staff, especially our medical case managers, who go above and beyond for their clients.

Something very important to our success is that we have no staff turnover, which influences the success of client outcomes. Staff really care about their clients and one thing I know is everyone here works as a team. When we hire, we look for staff that want to serve the people, not just staff. We look at our work as a service for the community, not just as work. When I talk to clients and see their smiles when they leave, I know our staff is doing good work.

The relationships we have with clients is also key to our success. We understand what is culturally appropriate while maintaining professional boundaries. We have also established trust; clients trust our advice. Relationships matter when delivering services.

We regularly follow-up with clients several times a week (and sometimes daily!) to ask if they have access to the services they need.

"Work is exciting every day. Clients come with 'small things,' but they are not 'small things,' because its big for them. We have a common understanding and they trust us," says Elizabeth.

Adds Aster, "Our clients need attention. They need someone who speaks the language and to feel like family. They need to talk to someone who will listen to their concerns. So often, people may not understand our clients due to language barriers and cultural barriers, so our clients believe in us to help them."

Q. What challenges have you had?

Our clients have high expectations for us, so we must manage those expectations and make sure clients understand the system we operate under.

Not having enough resources is a challenge for us. We cannot fulfill all client needs.

Q. Is there a client success story that you can share?

A client requested help to apply for citizenship that they had been trying to get for almost two years. When they came to us, we immediately assisted her and her case has moved forward.

We always check our clients viral load data in CAREWare and another client had a viral load amount of 52,000. So, I called her and I invited her to the office. I Let her know it’s dangerous, even if she gets the common cold, to have a viral load that high. Because I was able to get through to her she went to the doctor and got on treatment. She is now undetectable.

We have another client who doesn’t know how to take the bus. This is likely due to literacy skills. Some clients don’t know how to read the numbers, or understand intersections, and don’t know how to get around. It is vitally important that a client can be self-sufficient, so one of us had take the bus with her to teach her how to navigate on her own.

Spotlight: Bill Larson, Pharm.D., Allina - MCM treatment adherence



Q. Allina has better outcomes for RW clients than other organizations delivering similar services do; what do you attribute to your successes?

The use of adherence packaging has been successful.

Relationship building is important and I’ve gotten to know the older clients well, some over 12 years.

There seems to be an element of trust between myself and clients. They know that I am there to help them, not to sell them something or harass them. Just to make sure they are there to get the best care.

I do consistent follow-up with clients, at least twice a year. For newer or more complex clients, I will meet with them monthly or more.

It’s always advantageous when we are able to meet with clients in person.

The expansion of virtual visits during the pandemic will be an advantage going forward. A lot of clients are able to have virtual visits. In-person visits are still helpful, because doctors/providers can order client labs and the client can get them done right away.

Making sure clients do their labs. Without the labs, viral loads, we don’t know how a client is doing with their treatment and medications.

Q. What challenges have you had?

Getting labs during COVID, stigma, substance use, mental health issues, and lack of housing are the main challenges I see right now.

Q. What are you most proud of in your work?

I have great relationship with black clients, both African American and African-born. I completed a fellowship with the Black AIDS Institute's African American HIV University, and it opened my eyes to issues facing the African American and African-born communities. My eyes are opened to how we can better and more closely work with our community, especially with faith leaders, young MSM, and trans individuals of color. I am proud that we are serving our community the best we can with a lot of room for improvement.

Q. Is there a client success story that you can share?

Jay (a pseudonym) is young, works a full-time job, travels, and is very positive. However, taking meds everyday was a struggle. Jay wanted to take them during the day but would sometimes forget. I wondered if he ever is going to figure this out. Like I’ve done for other clients, I gave Jay a sports watch and set the alarm as a reminder to take his meds. He really liked the watch and started to take his meds on time. He has been undetectable for two years.

Additionally, Ryan White pays for pill boxes and men’s and women’s sport watches. People don’t always show up for their appointments, but these tools help many people.

MCHACP assessment



In early 2021, leadership on the Minnesota Council for HIV/AIDS Care and Prevention requested technical assistance through the IHAP TAC to participate in an assessment of the effectiveness of the Minnesota Council for HIV/AIDS Care and Prevention (MCHACP).

Over a six-months period, a team from HealthHIV conducted a mixed-method assessment of the council’s structure, bylaws, responsibilities, and function and how these operations allow us to carry out our mission and achieve our goals to end the HIV epidemic in Minnesota.

The final report highlights areas in which MCHACP is successful and areas for improvement. The next steps in the process will include a review of the final report with MCHACP’s Executive Committee in order to implement the findings from the report, as well as determining where MCHACP can benefit from additional technical assistance offered by the HealthHIV team. Read the full report here: http://www.mnhivcouncil.org/executive.

Strengths of MCHACP:

  • A diverse membership that is representative of the local HIV epidemic, and includes groups that can be more difficult to engage like people who currently inject or formerly injected drugs, people currently or formerly experiencing homelessness, people who have engaged in sex work, and people with viral hepatitis
  • Bidirectional communication between MCHACP and the government entities
  • Member satisfaction
  • Successful meetings

Areas for improvement:

  • Addressing disparities linked to social determinants of health like poverty, unequal access to health care, lack of education, stigma, and racism
  • Better understanding of information related to roles and responsibilities of MCHACP
  • Promoting equity among members
  • Lack of broad outreach for member recruitment

Join the MCHACP



Membership on the Minnesota Council for HIV/AIDS Care and Prevention (MCHACP) is, by law, reflective and representative of the local HIV epidemic. Currently, the council has numerous openings for council membership to fill unexpired terms.

Our current vacancies include:

  • Unaligned consumers who are Black or African American, White, trans or non-binary (unaligned consumers are defined as people with HIV who are not employed with, paid consultants, or board members of a provider agency that receives Ryan White funding)
  • People in Greater Minnesota (outside of the 13-county Part A TGA)
  • Person who is Hispanic
  • Person who is Asian or Pacific Islander
  • Representative of or formerly incarcerated person with HIV
  • State Medicaid representative

There are numerous benefits to joining the MCHACP:

  • Help people affected by and at risk for HIV
    • Improve services and access to care
    • Represent an underserved community or population
    • Create service standards of care
  • Get personal and professional benefits
    • Increase your awareness of HIV prevention, treatment, and services
    • Establish contacts and networks
    • Receive numerous training opportunities
  • Be a voice in program planning and implementation
    • Help determine the needs of populations living with, at risk for, or affected by HIV
    • Learn about and collaborate on HIV funding decisions

Apply today at https://survey.vovici.com/se/56206EE34E0D1C5D

Questions? Email HIVcouncil@hennepin.us or call 612-596-7894

More information at www.mnhivcouncil.org

About us

The Ryan White newsletter is issued semiannually and provides information about HIV services planning, contract administration, quality managment, CAREWare updates and training opportunities. Your feedback and suggestions for future issues are appreciated.

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