Linkage to Care Specialists: Lessons learned during implementation of an intensive patient navigation program in Wisconsin

Issues: Only half of people living with HIV/AIDS (PLWHA) in Wisconsin as of the end of 2011 were engaged in HIV medical care.

Description: Wisconsin’s Linkage to Care intervention, implemented by the Wisconsin Department of Health Services, is designed to increase linkage and retention in HIV-related medical care among PLWHA in Wisconsin’s areas of highest prevalence and incidence. Full-time “Linkage to Care Specialists” were hired in HIV medical clinics and community-based organizations to work with small caseloads of clients who have active or potential barriers preventing them from engaging in HIV medical care. They provide intensive, short-term support (6-9 months), addressing barriers to care through provision and coordination of services, referrals and appointments, attending appointments with clients, and navigation of health care systems.

Lessons Learned: During the pilot phase of the project, Specialists indicated the need for a well-defined protocol, especially given initial role confusion and the important distinction between Specialists and existing case managers, and necessary changes to the program that may have not been understood by clients. Specialists indicated during the implementation phase that the program’s strengths included Specialists’ flexibility to provide intensive, patient-centered care and personalized social support. However, clients are therefore resistant to discharge due to the relationship built.

Recommendations: Qualitative and quantitative analysis of effectiveness is currently being conducted. Preliminary evidence of success indicates the potential benefit of incorporating short-term, intensive intervention for some high-need clients within the existing case management system. Smooth transitions to long-term case management will be imperative for sustainability.