Intercambios

Founded in 2008, Intercambios Puerto Rico is a grassroots organization based in Fajardo that provides community-based drug user health services rooted in social justice, community engagement, and eradicating the social stigma related to drug use and poverty. Intercambios advocates for the social integration of marginalized groups—particularly people who use drugs, are unhoused, and/or trade sex—through health services, education, advocacy, and research. Originally organized by a team of volunteers, the majority of whom were former injection drug users, Intercambios is committed to a harm reduction model as it provides syringe exchange services and empowers its participants to be personal and community advocates for change.

Intercambios currently serves 14 municipalities in eastern Puerto Rico, distributing over 250,000 syringes annually. In Puerto Rico, HIV rates are among the highest in the U.S., with a high proportion of new diagnoses related to injection drug use. High rates of HIV and HCV are impacted by structural challenges such as historical underfunding, lack of reliable transportation, and stigma against people who use drugs from medical professionals and community members. Intercambios initiated the project familiar with the many barriers of limited healthcare infrastructure on the island and disruption to services and dislocation of people due to Hurricane Maria. There is also a lack of accessible health care providers, both in terms of administrative/policy barriers as well as the need for transportation, particularly for evidence-based SUD treatment such as MOUD. Intercambios had an existing referral system prior to starting the project but anticipated that these resources would allow them to support the cost of transportation to needed services and a full-time patient navigator to do more intensive case management, including following up and making and accompanying participants to appointments.

Initial implementation of patient navigation was difficult as Intercambios tried to put appropriate staffing and protocols in place while also navigating the early months of the COVID-19 pandemic. Over time and through experience, the patient navigator developed their own approach to time and workload management – spending three days a week offering direct community outreach and two days for individual follow-ups and administrative work.

Intercambios had some existing case management capacity across several projects/funding streams, and it was a priority to move towards better internal coordination and integration across projects, many of which serve the same participants. With dedicated resources, Intercambios was able to build an integrated case management structure informed by harm reduction philosophy to better serve participants with multiple, complex needs by connecting them to services both internally (services provided by Intercambios) and externally. Intercambios instituted weekly case conference meetings, led by the patient navigator, during which staff could discuss the needs of individual participants. These meetings became even more important as Intercambios expanded during the course of the project, from 13 to 21 staff, including additional case managers and peer navigators, a clinical psychologist, a clinical social worker, an additional nurse, and a doctor who planned to offer in-house buprenorphine prescribing. Building this internal capacity has been crucial yet has presented challenges as Intercambios strives to ensure that new staff, many of whom are new to working in a community-based harm reduction program, maintain a harm reduction philosophy and approach.

Like other patient navigation project sites, Intercambios found that stigma and discrimination against people who use drugs and trade sex from medical providers and community health workers were a barrier to receiving quality care. Intercambios strengthened many community connections with external providers, particularly FQHCs and regional hospitals. The patient navigator learned each service providers’ processes and protocols and developed effective working relationships with staff. Part of the focus of navigation beyond linking to services has been to ensure that each participant is able to make informed decisions and take ownership over their health and engagement in care.

Some of the major implementation challenges included the effects of natural disasters (such as earthquakes and Hurricane Maria), health risks and service landscape changes due COVID-19, and the existing lack of healthcare and transportation infrastructure in Puerto Rico. Alongside these factors, institutionalized stigma towards people who use drugs intensifies the complexity of accessing services and continuing care for PWUD. Despite noticing increased treatment readiness especially towards the beginning of the pandemic, Intercambios participants faced significant challenges with access to evidence-based OUD treatment. The patient navigator arranged transportation to and from methadone clinics, the closest of which is an hour away in San Juan, particularly for new patients who were not yet allowed to receive take-home doses.

Although Intercambios was able to gradually build more internal capacity to deliver services, much of the patient navigation role required coordination with external organizations that do not have a harm reduction perspective. Even after going through the process to help a participant get access to a service, often the service provided is not adequate because of lack of competence for treating PWUD, for example hospitalizing opioid dependent patients for multiple days without providing MAT or pain management medications. During the second year of the project, Intercambios noted that many participants had worsening physical health and chronic conditions, due to years of not accessing medical care—avoiding the hospital for fear of contracting COVID, stigmatizing treatment, or simply due to inaccessibility.

During the project period, Intercambios enrolled 56 individuals in patient navigation. Patient navigation encounters by service requested are listed in the table below.

Intercambios Patient Navigation Encounters (March 2020 – February 2022)

Total Patient Navigation Enrollment – 56

The navigator met with a participant in April of 2020 who requested a referral to a methadone clinic. After providing the referral, Intercambios scheduled an intake appointment for the participant and provided transportation to the methadone clinic in San Juan, more than an hour each way from their site in Fajardo. The participant received her first dose of methadone in May. The navigator then coordinated with a counselor from the methadone clinic to discuss the participant's next steps. Because they had just initiated treatment, the methadone clinic policy would not allow take-home doses, so Intercambios worked with the participant to arrange transportation to the clinic and back every day.

Intercambios frequently provided this kind of navigation because of the many difficulties with accessing methadone treatment. The patient navigator also personally accompanied participants to the clinic multiple times to clarify shifting policies and assess and troubleshoot barriers, such as refusing to accept new intakes, not allowing take-home doses, requiring a negative covid test prior to intake, and being discharged from treatment after “failing” too many times. On top of routine case management activities, the patient navigator had to expend a lot of time and energy advocating for participants with providers and within health systems, for example consulting directly with providers or contacting directors and administrators to clarify policies/practices and push for change.

To ensure that participants have access to comprehensive and non-stigmatizing services, Intercambios has built a robust patient navigation program and expanded capacity to offer services in-house. The project experience provided a crucial opportunity to focus on coordination across the organization’s various programs and services. One focus for ongoing patient navigation is to increase participant access to treatment for hepatitis C. This will require a better understanding of the provider landscape and agreements with relevant external organizations. 

Intercambios is continuing to enhance clinical services, while intentionally cultivating their core harm reduction philosophy, with the goal of providing street-based buprenorphine. Long-term, they are considering working towards billable services to enhance sustainability and reduce reliance on grant funds.