LINKING AND RETAINING HIV POSITIVE INDIVIDUALS IN MEDICAL AND SUPPORTIVE CARE
Katie HorstmannWake County Human Services
HIV/AIDS Case Management
Supervisor
BACKGROUNDWake County Human Services is the consolidation of programs
and services including social services, public health, mental health, job training, child support, housing and transportation.
Under One Roof is a collaborative effort between
Wake County Human Services Case Management/Bridge
Counselors and Alliance of AIDS Services- Carolina (AAS-
C).
Under One Roof
Bridge Counselors History• In 2001 the Did Not Keep
Appointment (DNKA) Rate among HIV + clients attending WCHS Clinic was the highest rate in eleven years.
• In 2002 we applied for Ryan White Part C funding to expand clinical services that included the creation of Bridge Counselor.
• In 2004 – Hired 1st Bridge Counselor (RWC Funds) who focused on getting new clients into care.
• In 2005 initiated “Lost to Care” (LTC) strategy.
5537
0
25
50
75
100
2003 2004
DNKA Rate
DNKA %
Source: WCHS CareWare
Bridge Counselors History
• In 2006 a second RWB Bridge Counselor was added.
• In 2007 first full year with two Bridge Counselors.
• In 2008 gained 3rd Bridge Counselor with 1 year grant from Hospital Alliance funding.
Source: WCHS CareWare
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
0
10
20
30
40
50
60 DNKA Rate
Bridge Counselor Role• Primary resource for newly diagnosed
individuals, HIV positive individuals transitioning care, and HIV positive individuals new to Wake County in need of care.
• Coordinate medical and support services for newly diagnosed individuals and those HIV positive individuals not connected to either.
• Provides initial HIV education, social work assessment, ADAP paperwork, and needed support service referrals.
• Track individuals who miss appointments and those lost to follow up at WCHS HIV Clinic.
• Acquire and maintain a working knowledge of community resources.
• Educate Medical Providers of BC Services and Resources
BC PROCESSES
Criteria Newly diagnosed
HIV positive HIV positive moving
into Wake County HIV positive
individual wanting to transition care to another HIV provider
Wake County Resident
Completed Bridge Counseling Agreement/Consent
Under One Roof1812 Tillery Place Suite 105Raleigh, NC 27604
You are eligible to receive the free services of a Bridge Counselor with Wake County Human Services. A Bridge Counselor is a short-term case manager for clients who are newly diagnosed with HIV. The Bridge Counselor will be available to discuss your feelings, questions, and concerns about HIV, as well as to inform you about disease progression and treatment options. Part of this process may be assisting you to find a suitable HIV health care provider.
The Bridge Counselor will also arrange transportation for your first clinic appointment and accompany you to the appointment if requested. In addition, the Bridge Counselor can assist you with other needs you may have, such as obtaining housing, food, disability, etc. Once you have accessed medical services with your HIV health care provider, the Bridge Counselor will discharge your case, or if needed, refer you to long-term case management.
The Bridge Counselors and their phone numbers are listed below:
Andrew Farr, 919-856-5318
Betsy Santiago-Lane (Bilingual-English/Spanish) 919-856-5278
By signing below you acknowledge that you have read or been informed of the Bridge Counselor services available to you. If you accept these services, you also give permission for the Bridge Counselor to obtain your lab tests and inpatient or outpatient medical records, as these are needed for referrals to HIV health care providers. This release of medical records will expire one year from the date of signature. Please sign and date whether you accept or decline these services.
I, ___________________________________, decline the services of the Bridge Counselor.
I, _________________________________, agree to accept the Bridge Counselor services. I also give permission for either of the above Bridge Counselors to obtain my lab tests and medical records. I understand that one of the Bridge Counselors will contact me within 48 business hours.
Date of Birth::______________________
Telephone Number(s)::____________________________________________________
Address::____________________________________________________
Client Signature _________________________ Date _____________________
Referral source Name/Agency/Telephone:_______________________________________________
BC PROCESSOnce BC’s consent is received a Bridge Counselor will contact client within 24- 48 hours.
To begin:• Coordinating medical and support
services for newly diagnosed individuals and those HIV positive individuals not connected to either.
• Initial HIV education
• Social work assessment
• ADAP paperwork
• Connecting to needed support services and referrals
2012 BC REFERRALS
Self; 35
DIS - State; 24
DIS - WCHS; 5
AAS-C; 20
WakeMed
Raleigh; 14
WakeMed Cary; 2
Rex Hospital;
1
Duke Raleigh;
2
Raleigh ID; 1
UNC; 1
DHHS; 1
ADAP; 3
Friend/Family; 9
Clinic A; 7
WCHS - Other; 5
DOC; 12
NCDPS/WCJ; 6
Healing Place; 1 Other/Unsure; 3
2012 WCHS BC Data
BENEFITS OF BRIDGE COUNSELING
Key strategic piece to engage clients for life in medical care
Higher percentage engaged in treatment
Lowered Community Viral Load
No show rate declined
Improved communication among agencies
Services provided in both
English and Spanish
Bridge Counselors has been adopted by the State of North Carolina as a Best Practice
LEVEL OF INTEGRATIONHIV Acuity Scale: is a tool that helps identify individuals level of need and standardize provision of services. Helps providers identify referrals needed and
how best to work with other providers serving the individual
Helps identify social determinants that obstruct individuals from achieving optimal health and personal outcomes
Helps prioritize staff workload base on clients total points
Helps program manage limited resources
WCHS HIV/AIDS ACUITY SCALE
1 2 3 4 5
1 2 3 4 5 Points
DisclosureClient has no issues with disclosing status to anyone
Client has disclosed status to mostly everyone in support system
Client has disclosed status to some of their support system
Client has disclosed status to one or two people in support system
Client has disclosed status to no one
Total Points
BRIDGE COUNSELORS AND HIV/AIDS CASE MANAGERS
Wake County Human Services
THANK YOU