Programming Connection

STOP Outreach Team 

Vancouver STOP Project
Vancouver, British Columbia
2013

Introduction

“We take a community-wide approach to caring for people.”

“I’m pounding the pavement on outreach and I’m just trying to connect with my 30 clients as much as I can,” Jacey Larochelle, a registered nurse with the STOP Outreach Team, says of her typical workday.

She’s not alone. The interdisciplinary team of nurses, nurse educators, social workers, outreach workers and peers, all working with the support of a physician, was established in 2010 by the Vancouver Seek and Treat for Optimal Prevention of HIV/AIDS (STOP) Project to improve engagement in and linkage to HIV testing, care and support, and treatment. The STOP Outreach Team has proven to be one of the most important initiatives of the Vancouver STOP Project because it has facilitated an integrated system of care across the city for some of Vancouver’s most marginalized people.

The team focuses on four key areas. The first three are: expanding routine and rapid HIV testing in targeted settings; providing public health follow-up for partners of people who test positive; and educating and building capacity among service providers. The team is perhaps best known for its fourth focus: engaging and linking to care people who are newly diagnosed or who have been lost to care since their diagnosis.

“We aim to thread clinical services together to strengthen the continuum of care,” says Miranda Compton, the team’s manager. Through its engagement and linkage to services, the team attempts to fill in the cracks in the HIV continuum of care for people most likely to fall through them. “If a person’s needs are straightforward, then they are probably the wrong person for the team,” she adds. The team’s mandate is to offer short-term intensive case management as it links the most vulnerable people to the appropriate longer-term services in the community.

Because the team works exclusively on outreach, its members have the flexibility to be innovative with the strategies they use to engage clients. The outreach workers labour tirelessly to meet people wherever they are. The team’s physician does home visits for clients who cannot make it to a clinic, and the nurses are able to spend time building relationships and engaging clients. The team’s social workers address any barriers clients identify to their care, including housing, food security, social assistance benefits and immigration status.

The team’s greatest challenges are structural: a lack of adequate housing in Vancouver; wait lists for detox and recovery programs; and limited mental health services tailored to people with active addictions. But they are also individual: clients who don’t trust the healthcare system; clients with complex mental health and addictions; and clients who, understandably, are concerned with survival rather than addressing their HIV infection.

Despite the challenges, says Larochelle, “I think we are actually reaching a demographic that would otherwise not be getting healthcare.”