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Linkage to Care Case Management Program Purpose and Problem Overview

Linkage to Care Case Management Program Purpose and Problem Overview. 40-60% of newly diagnosed HIV+ not in care Late diagnosis is frequent Passive referrals less effective Missed opportunities for earlier care, interventions Complexity of patients lives = barriers to care

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Linkage to Care Case Management Program Purpose and Problem Overview

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  1. Linkage to Care Case Management ProgramPurpose and Problem Overview • 40-60% of newly diagnosed HIV+ not in care • Late diagnosis is frequent • Passive referrals less effective • Missed opportunitiesfor earlier care, interventions • Complexity of patients lives = barriers to care 96% in the KC site study had no personal help with their HIV diagnosis and care. • 62% would depend solely on an HIV professional • 34% perceived they would have no help

  2. Linkage to Care Activities 90 Day, Intensive Intervention: • Health Literacy, Disease & Treatment 101 • Identify patient strengths that facilitate care • Identify barriers to care • Set goals for HIV tx • Negotiate complicated care system • Attend appointments; debrief with patient; identify long term payer source • “Graduated Disengagement” & “Active Handoff” LINKAGE: Access to Medical Care BARRIERS TO CARE Personal: Lifestyle Health literacy Internal Poverty System: Complicated systems Availability Costs Person Newly Diagnosed HIV+ ENGAGEMENT:Long term engagement in medical care

  3. Linkage to Care Outcomes Review of Results :Antiretroviral Treatment Access Studies (ARTAS II) NAT’L STUDY RESULT:78-79% in care at 6 months (compared to 40-60% without intervention)* CONCLUSION: This short-term intensive model successfully links recently diagnosed HIV-infected persons to medical care rapidly In KC: • 89% still engaged in care at 6 months • (attended appointment with a M.D., D.O., N.P. et al) • 84% still engaged in care at 12 months • (attended appointments, including labs or medications consultation with a M.D., D.O., N.P. et al) *J Acquir Immune Defic Syndr. 2008 Apr 15;47(5):597-606.

  4. Typical LTC Case • Referring Sites • Hospitals • Health Depts (KC, Jx, Jo, Wy, MO) • Publicly Funded Testing Sites • KCFHC • Med Offices/Other • Self Referral HIV Diagnosis Page Linkage to Care – 20m response Initial Response – meet with patient and diagnosing provider Intervention - Enrollment or Referrals Linkage to Care - 90 Day, intensive intervention of LTC Case Management 87% COMPLETE: Graduate to long term HIV Case Management Services, continue engagement in care 8% COMPLETE: Graduate to self-sufficiency, continued HIV care with own resources 5% NOT COMPLETE: Lost to Care, Unable to Contact, Disengaged from Program; continued attempts to reach client for re-engagement 84% of graduates still in care after 12 months.

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