Linkage to Care for High-Risk Populations

Issues:

On July 13^th 2010 the National HIV/AIDS Strategy set forth a goal of increasing national linkage to care rates from 65% to 85%. Our organization annually tests 5500+ people with an average positivity rate of 2%. After hiring a dedicated Patient Navigator (PN) our linkage-to-care rate rose from 53% to 89% within 7 months. This high linkage-to-care rate has been continuously maintained for an overall average linkage-to-care rate of 90%.  This presentation will look at inputs and strategies used to create and sustain a successful linkage-to-care model. We will also discuss “best practices” the agency has used to engage/retain high-risk populations in medical care. 

Description:

Dually funded by the Primary Care and Prevention Departments, the PN provides a seamless transition from counseling/testing to primary medical care for all clients. Though the primary responsibility of the PN is to engage clients in care, the PN also establishes and maintains an evolving relationship with the clients while being a continual strong support system.

Lessons Learned:

Having a PN that is familiar with multiple departments and can ensure a smooth transition from one department to another is essential for successful linkage-to-care. Also, maintaining an ongoing relationship with clients after they’ve been engaged in care contributes to retention in care.

Recommendation:

The PN must be versatile, tech savvy, familiar with colloquialism, code switch, and most importantly, be persistent and sometimes relentless in their efforts. Using a rapid-rapid model of testing and having an on-call PN have proven to be components of our success.