WORLD Develops New Outreach Program to Positive Women Lost to Medical Care

National statistics indicate that many HIV treatment programs experience a greater than 30 percent rate of clients lost to follow-up (who drop out of care) each year. This situation compromises an individual's health status, and also has an impact on overall community and public health. Here in Alameda County, the Family Care Network (of which WORLD is a member) has identified at least 225 women who have been lost to follow-up. In an effort to reach out to these women and reduce the gaps in health care that they face, WORLD has taken leadership to develop a collaborative project called LINC, (Linkage Improvement for Network Clients). Through a three year grant made possible by the Office of Minority Health, LINCs will work to establish and reinforce linkages with clients lost to follow-up from FCN, as well as newly diagnosed African American and Latina women, children and adolescents.

The goal of the project is to improve health outcomes for hard-to-reach HIV+ women and youth in Alameda and Contra Costa counties. LINCs is providing two Client Navigators to bridge the gap between clients and health providers, and will focus on the following objectives: 1) enhance access and utilization of FCN primary care services, 2) improve participation in continuum care services, and 3) promote healthy behaviors.

A total of 220 clients will be targeted over the course of three years (145 known FCN clients lost to follow-up plus 75 newly diagnosed clients). Client Navigators will do outreach to hard-to-reach HIV+ women and youth by targeting drop-in centers, methadone clinics, needle exchanges, medical marijuana dispensaries, and other agencies which provide services and subsidies to clients, as well as doing street outreach when and where necessary. Local testing sites will be targeted to identify newly diagnosed women, fathers and youth. Once clients are identified, Navigators will begin building a relationship with clients, assessing needs and capacities, identifying barriers to care, and will begin to establish a plan for overcoming these obstacles based on the abilities of the individuals. Activities will include life/health goals and plans, health education, and life/health skills development. Navigators will assist clients in setting appointments and accompany them to appointments. They will also act as a go-between with providers to ensure that clients' needs are being met, and that barriers to care are addressed.

The caseload for Navigators will be transitional and focus on short-term strengths-based case management practices. Moreover, the goal will be to establish systems of services with other care providers (peer advocates, case managers, nurse practitioners, and doctors) that will support a client's long-term health and care. Towards this effort, Case Managers with Highland Hospital and East Bay AIDS Center have been subcontracted to coordinate care with Client Navigators. WORLD's Peer Advocates will also work with the Navigators to transition clients to longer-term continuum care and support services. WORLD is excited to begin this work with women who may be isolated and truly in need of the message "you are not alone" as they move toward improved health and resources.

Bridget Hughes is LINC's Project Director.

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