Achievements & Lessons Learned-S: University of Nevada School of Medicine

Knowledge Item: CA-Initiative Impact-99S
Major Achievements and Lessons Learned: 1994-1999

University of Nevada School of Medicine

The University of Nevada School of Medicine project has prevented or slowed wasting syndrome experienced by individuals living with HIV/AIDS.

In 1999, the Evaluation and Dissemination Center asked each project to state its major achievements and the lessons it had learned from conducting the project. Those stated achievements and lessons learned are reproduced here (with minor editing) as reported to the Evaluation and Dissemination Center. The summary statements given here are those aspects of the program's experiences that the Project Director wished to emphasize.

*Achievement 1:* Protocols and procedures for providing nutrition assessment and counseling services have been developed.
Key Elements for Success: a) Flexible, creative nutrition staff and clients who were understanding and patient and who allowed for and facilitated continual change and experimentation with new ideas and procedures. b) Access to new ideas and latest research via national and international nutrition networks (formal and informal), HIV conferences, Internet, etc. c) Cooperative work with medical care providers to keep nutrition practices relevant and current with medical advances. d) Staff experience in other relevant nutrition subspecialty areas that allowed for crossover and testing of ideas/practices/materials in HIV/AIDS.	Factors that Limited Success: There are gray areas in this field with no clear answers or proven procedures. Often, it was necessary to just guess about what might work, try it, and make changes if something wasn't working well. Staffing schedules are somewhat staggered to accommodate needs of the clinic, clients, and staff (students), and communication about changes in procedures was not always timely or clear resulting in confusion and inconsistency in procedures.	Factors that Ensured Success: Efforts were made to keep up with most current findings and to be involved at the national level with other HIV nutrition leaders. Team members of the nutrition project worked cooperatively towards a common goal, adapted well to change, and kept the well being of clients as the overarching goals. A change in administration and staff of the medical clinic increased support for nutrition services for clients and made the environment friendly and cooperative.

Achievement 2: Nutrition services have become integrated into routine services available to clients.
Key Elements for Success: Scientific data support the importance of good nutrition in disease management in general and in HIV in particular providing the rationale for inclusion of nutrition services in HIV care. The larger HIV client/consumer culture encourages, advocates for and supports the inclusion of nutrition services as part of quality care.	Factors that Limited Success: The early medical clinic environment (both attitudinal and physical) presented barriers to fully implementing this project. The location, leadership, and administration of the medical clinic in which our project operates changed about mid-way through the 5 years, and many things had to be put on hold during the transition phase. The physical location of our project as moved three times, and we continue to have to adjust where we see clients (including moving equipment, staff, materials) creating some stress and confusion for both clients and staff.	Factors that Ensured Success: There was support for the project at the highest levels both from the administrators and medical director. Nutrition project staff were willing to be accommodating and patient with change and had interpersonal skills to deal with conflict and non-cooperation from earlier clinic nursing staff.

*Achievement 3:* There is a financial commitment to continue to fund nutrition services after completion of this SPNS project. ("Buy-in" has been achieved).
Key Elements for Success: The clinic (Board members, administrator, medical director, and staff) is committed to providing comprehensive, quality care. Nutrition services are viewed as part of the package, and have received support from clients. Relative to other types of HIV care, nutrition services are inexpensive.	Factors that Limited Success: None listed.	Factors that Ensured Success: The temporary nature of the SPNS project as a demonstration and pilot has been stressed throughout the 5 years, and clients and community agencies have periodically been reminded of the need for the community to carry on nutrition services.

*Achievement 4:* A mechanism (nutrition risk screening form) has been developed to identify and respond to the nutrition need of clients.
Key Elements for Success: Trained nutrition staff have focused efforts on identifying and "cataloging" the broad spectrum of factors that impact on nutrition needs using both questionnaire and interview methods. Periodic examination of these data have allowed for continual updating of factors to be screened for. Clear goal for eventual transition of nutrition screening from just SPNS clients to all clinic clients allowed for development of "user and clinic-friendly" format.	Factors that Limited Success: Hectic clinic schedule and almost continual transition, growth, and change in location, personnel, and scope of services divert attention from nutrition activities and limit staff willingness to take on any new responsibilities. Difficulties have been encountered in implementing the screening system for clients who are well-established in care versus those who are new to care.	Factors that Ensured Success: There was an understanding on the part of the staff that early identification and treatment of nutrition problems results in better patient outcomes. Involvement of entire staff in the development, testing, and refinement of a simple screening form and in deciding how to utilize and implement a screening system helped gain acceptance.

*Achievement 5:* A system has been developed to collect both quantitative and qualitative data that allow for continual program evaluation and redesign when necessary.
Key Elements for Success: Project investigators had previous experience with questionnaire design and data collection and analysis. The nature of this project allowed for change and retooling when necessary.	Factors that Limited Success: Radical improvements in HIV care, changes in environment, staffing, and procedures along with variable client retention limit the ability to fully understand the impact of nutrition services on patient health outcomes.	Factors that Ensured Success: There has been continuity in key project staff and a subset of clients who have regularly participated over the five years.

*Achievement 6:* Practical lessons from this project have been communicated to others who may be able to improve their care and/or services as a result of what we have learned.
Key Elements for Success: Presentation by team members representing different disciplines (medical, behavioral, nutrition) allows us to present different perspectives and reach a broader audience. Sufficient project and/or university funding and support was present to allow for travel to and presentation of findings at local, national, and international meetings.	Factors that Limited Success: Interruptions in continuous project implementation and early difficulties in obtaining staff cooperation in recruiting clients extended the time needed to gather necessary data to answer basic questions.	Factors that Ensured Success: We maintained a clear focus on the needs of clinicians and clients, and we worked to identify cost-effective, practical methods and tools to deliver nutrition services in the small outpatient HIV clinic. Cooperation and support from our state AIDS Education and Training Centers and contacts and involvement with national professional organizations were very important in accessing avenues for dissemination of findings.

1. Lesson Learned: Constant change and personnel needs must be anticipated and accommodated. Risk taking and trying new ideas are essential as is clear communication with clients and staff about why changes are occurring.

How related to achievements: An ability to deal with change and to understand the needs and priorities of the larger environment minimizes frustration and fosters a positive attitude that allows for progress in the face of difficulty.

2. Lesson Learned: The attitudes of clinic staff toward nutrition services are very powerful in determining their success (ability to reach and serve clients). Support from medical staff and administrators is essential.

How related to achievements: Good communication with clinic administrators and staff about the potential benefits of an "outside" project such as ours to both clients and to the larger mission of the clinic are needed on an ongoing basis to build support.

3. Lesson Learned: It is important to be visible in the community forums (as with consortia meetings, clinic meetings, etc.) to discuss successes of and continuing need for nutrition services and to specifically ask policy makers to include funding for their continuation.

How related to achievements: There are many competing and important needs in the HIV community and limited funds. Similarly, there are many demands on the time and attention of administrators. Constant reminders and assistance with budget projections are helpful in ensuring continued funding for nutrition services.

4. Lesson Learned: Clinics are busy, hectic places. Staff often feel overwhelmed with present duties, and client can be inundated with paperwork. Any new procedures or forms must be perceived as absolutely important and must be extremely short and simple.

How related to achievements: Acknowledgment and understanding of the needs and schedules of staff and clients set the stage for development of an efficient, simple system.

5. Lesson Learned: Project findings and outcomes need to be evaluated and examined cross-sectionally to account for distinct periods of HIV management (e.g. pre-PI vs. post-PI) and differences in extent of integration of nutrition services with medical care.

How related to achievements: Nutrition exerts effects on health and disease within an extremely complex system. Efforts to identify specific benefits resulting from nutrition services must attempt to control for the multitude of other potentially explanatory factors.

6. Lesson Learned: Clear, down-to-earth communication about what worked, what didn't and why is appreciated by both clients and caregivers. Sharing of tools developed and permission to adapt is also received with appreciation.

How related to achievements: We have been able to share our ideas and lessons learned with a wide audience. Our openness to share has also encouraged others to give us feedback and ideas that have enhanced what we do and what we have learned.

Completed by: Trudy A. Larson, M.D.
Last Updated: July 1999

Project Resource Page

University of Nevada School of Medicine

Evaluation Data

Service Population Demographics

Last Updated: August 02, 2001; data through June 15, 1999; analyses conducted January 2000.

Knowledge Base Citation: The Knowledge Base and this Knowledge Item were designed and authored by G. J. Huba, Ph.D.; in collaboration with Lisa A. Melchior, Ph.D.; A. T. Panter, Ph.D.; and the staff of The Measurement Group. Cite this work as "Huba, G. J., Melchior, L. A., and Panter, A. T. (1998 - 2001). The Measurement Group Knowledge Base on HIV/AIDS Care. On the World Wide Web: http://www.TheMeasurementGroup.com."

Questions or Comments: Contact The Measurement Group.

Use of Knowledge Base Information: Acceptable Uses and Limitations.

Collaborators from Participating Projects: Cooperative Agreement Steering Committee 1999.

Participating Projects: This Knowledge Base is based on the service delivery experiences of 27 Cooperative Agreement Projects on Innovative Models of HIV/AIDS Care. These projects and the Evaluation and Dissemination Center which produced this Knowledge Base were funded by the Health Resources and Services Administration (HRSA), HIV/AIDS Bureau (HAB) as Special Projects of National Significance (SPNS) between 1994 and 1999.

Why This Evaluation was Conducted: Editorial.

More Information: Design of this Knowledge Base.

Recommended Citation Format for Web Materials: American Psychological Association Publication Manual Section, Revised 2001.

Work on the Knowledge Base and the cross-cutting evaluation was supported in part by Grant Number 5 U90 HA 00030-05 from the Health Resources and Services Administration (HRSA), HIV/AIDS Bureau's (HAB) Special Projects of National Significance (SPNS). The contents of this Knowledge Base are solely the responsibility of The Measurement Group and do not necessarily represent the official views of HRSA or HRSA/HAB's Special Projects of National Significance nor may they represent the positions of the individual grantees whose projects are included in the cross-cutting evaluation.