Programming Connection

Care Re-engagement and Retention 


A study from the United States found that the addition of a part-time outreach coordinator in a clinic environment resulted in re-engagement in care for 44% of people who were previously lost to care. Of those who re-engaged, 50% were retained in care.

Outreach program in a clinical environment

In 2014, a part-time outreach coordinator was added to a clinical team in South Carolina. The person had a Masters in Clinical Counselling and experience working with people with HIV.

The coordinator worked to identify patients who were out of care (patients who had attended the clinic at least once from 2009 to 2014 but were not engaged in care in 2014). The coordinator then determined whether these patients were lost to care or if they had died, been incarcerated or had transferred care. Multiple sources were used to make this determination including electronic medical records, obituaries and personal communications.

Once a client was identified as lost to care, the outreach coordinator used the last known phone number to try to contact the client. If contact was made, the coordinator worked to re-engage the client in care. If there was no answer then a message was left. No confidential information was left by the coordinator and a phone number was provided, which connected to the coordinator’s secure direct cell phone that was not linked to the clinic. These precautions were taken to protect the privacy of the client.

If contact was not made by phone, the next step was a personalized letter mailed to the last known address. The letter only broadly offered help with re-engagement and included the contact information for the outreach coordinator. If contact was made by letter, the coordinator worked to re-engage the client in care.

If contact was not made through the letter, a home visit was attempted. If contact was made, the coordinator worked to re-engage the client in care. If contact was not made, a card was left with contact information for the outreach coordinator. If after this there was still no contact made, then return visits to the home were an option.  

The study

There were 1,242 adult patients enrolled in the clinic in 2014, and 233 of them were identified as out of care. Only 51% (119) of these were determined to be lost to care by the outreach coordinator. Almost all (99%) of those lost to care received a phone call. Of those who did not respond, 97 received a letter and 14 received a home visit.

The intervention re-engaged in care 44% of patients that were lost to care. In 2015, 50% of those who re-engaged were still retained in care (with at least one clinic visit that year).

What does this mean for service providers?

A low-touch outreach intervention has the ability to re-engage people into care and retain them in care. In most cases, the phone calls alone were successful at re-engaging patients – creating a low cost and time limiting approach.


Bean MC, Scott L, Kilby MJ et al. Use of an outreach coordinator to reengage and retain patients with HIV in care. AIDS Patient Care and STDs. 2017 May;31(5):222-226.