Programming Connection

Immunodeficiency Clinic (IDC) 

St. Paul's Hospital
Vancouver, British Columbia
2013

How Does the Program Work?

Accessing the IDC

Referrals

Referrals can be made by general practitioners and clinics with HIV-positive patients, specialists, public health nurses, AIDS service organizations (ASOs) and other community-based organizations. The STOP Outreach Team, an interdisciplinary clinical team responsible for improving engagement and linkage for people with the most complex barriers to care, also makes referrals to the IDC. Additional referrals come from services within St. Paul’s Hospital, including the HIV acute care unit and the IDC’s point-of-care testing service. However, a referral from a healthcare provider is not required to access IDC’s services, and many patients self-refer.

Intake

A social worker performs the intake assessments in person or over the phone. The goals of the intake process are to:

  • facilitate low-threshold access to care by assessing the patient’s needs and barriers and establishing a rapport
  • ensure rapid entry into care for patients who have recently tested positive for HIV and for those with emergency antiretroviral needs (e.g., patients whose supply of antiretrovirals has run out)
  • begin ongoing processes of education and self-management by providing basic information about how the clinic works and what services are available
  • assess the suitability of the IDC to the patient’s needs and link people who would be better served elsewhere or could access care closer to home to alternate care providers, ensuring that they have an appointment before disengaging with them

The intake worker also does a brief psychosocial assessment, paying attention to issues that could make it difficult for the patient to access care, including mental health issues, substance misuse, inadequate or inappropriate housing, immigration issues and proximity to Vancouver. Through this assessment, the social worker assesses the urgency of the referral. If during this assessment the social worker feels that the IDC is not the right place for the patient to receive care, they provide support and linkage to more appropriate services in the community. IDC’s strong relationships with primary care providers in the community, many of whom were trained at the IDC, allow staff to find the right provider for patients who would be better served in a community setting.

When a person presents at the clinic with pressing medical needs, a nurse will be called in to do the follow-up appointment, called the nursing first contact visit, immediately. When a person has been assessed as stable, efforts are made to schedule follow-up appointments within a week.

Nursing first contact visit

Once an intake assessment has been made and the patient is enrolled in the IDC, the social worker schedules a nursing first contact visit. This 60-minute appointment takes place before the patient’s first appointment with an IDC doctor to ensure that results of blood work that the nurse performs (CD4 count and viral load) or other tests are available. During this appointment, all patients receive an orientation to the clinic’s policies, hours and services.

The nurse also builds on the information the social worker collected during intake and makes referrals as needed for mental health and addictions counselling and for counselling on how to access resources such as housing. Most importantly, the nurse provides HIV education, explains viral load and CD4 counts are, and discusses treatment initiation, HIV transmission, HIV disclosure and safer sex. Nurses encourage patients to engage actively in their care by bringing any questions or concerns they have to the clinic. The nurse also introduces the patient to the peer navigators housed at the IDC, who provide support services to patients.

Care is taken to match patients with doctors on the basis of the patient’s specific needs and preferences. Patients are usually matched with a doctor and attend their first appointment with their doctor within a week of the nursing first contact visit. If medical care is required during the first contact visit (because medication must be initiated or renewed or other urgent medical needs must be addressed), the patient will see one of the doctors covering drop-ins.

Clinical services

Nursing services

In addition to offering HIV primary care through the clinic’s physicians, IDC provides nursing services to patients that do not require them to make an appointment with a doctor. The availability of nursing services has enabled IDC to become more accessible by expanding the number and types of appointments and drop-in slots available to patients. It has also improved the quality of care offered and reduced physician workload. It allows both physicians and nurses to work to the full scope of their practice.

Nurses offer education on sexually transmitted infections; blood work; anal Pap smears, cervical Pap smears and female breast examinations; immunizations and tuberculosis skin tests; wart treatment; wound care; and individualized and non-judgmental HIV education and support services.

Hepatitis C services

Many of the IDC’s patients live with HIV and hepatitis C virus co-infection. The IDC has two hepatitis C specialist nurses who support patients going through treatment. Only a small percentage of patients with co-infection are currently in the hepatitis C treatment program because some patients are not yet ready to undertake treatment or treatment is not clinically indicated for them. The IDC also provides hepatitis C services to people with co-infections who are not IDC patients.

The IDC’s hepatitis C services include assessing treatment readiness, providing treatment and monitoring blood work and treatment side effects. Patients needing added support while on treatment have access to a social worker and can be referred to community organizations that run support groups for people in treatment.

Point-of-care testing

Since 2010, the IDC has offered a point-of-care testing service for anyone in Vancouver wanting to get tested for HIV. This service was introduced as part of the STOP Project’s commitment to expanding HIV testing options. Although clinic administrators thought the clients for this service would primarily be HIV-negative partners in serodiscordant couples, the service has been accessed by a variety of people. Gay men and other men who have sex with men are the predominant group accessing this service.

To promote the roll-out of this service, the IDC advertised in the hospital, in the community and through online forums. On average, nurses provide between 50 and 60 point-of-care tests a month at the IDC. As of November 2012, 2% of the tests conducted through this service were positive.

Despite the implementation of streamlined pre- and post-test counselling protocols in British Columbia, the IDC continues to offer in-depth counselling and education services as part of its point-of-care testing. Clinic staff feel that testing offers a key opportunity to provide tailored risk-reduction counselling, both to individuals and to couples.

When someone receives a preliminary positive test result, the IDC’s community of care provides the support the patient needs. Confirmatory blood work and other baseline blood work is collected immediately. The patient is offered the services of a peer navigator, and if the person decides to remain in care at the IDC, an intake assessment and a nursing first contact visit are conducted as soon as possible. The IDC’s goal is to ensure that everyone is linked to care, so if a person does not want to receive care at the IDC, staff ensure that follow-up care outside the clinic is arranged.

Non-occupational post-exposure prophylaxis (nPEP)

Since 2012, the IDC has offered assessments to determine whether post-exposure prophylaxis is needed for high-risk non-occupational exposures to HIV and has provided follow-up support for those prescribed such prophylaxis in the community. Referrals for this service come from the emergency department at St. Pauls’ Hospital, from the BC Centre for Disease Control and from community clinics. This service is currently being offered as a pilot (2012-2013) in conjunction with the BC Centre for Excellence in HIV/AIDS.

Social work at the IDC

Social workers provide comprehensive wraparound support services and coordinate intensive case management for the IDC’s patients. With a referral from their healthcare provider, people living with HIV who receive care in the community can also access the IDC’s mental health team and intensive care management service.

Psychosocial support

In addition to coordinating and assessing new intakes, social workers provide addictions counselling and referrals to detox and treatment, adjustment and relationship counselling, crisis intervention, and resource counselling, including support for housing and social assistance applications.

Support groups

Support groups have been a service of the IDC since the 1980s. In the early years the groups focused on death and bereavement, but as effective treatments became available they shifted focus.

Currently, a single support group operates out of the IDC. The focus of the group is on aging and surviving long-term with HIV, and the group is open to anyone in the community living with HIV. The group meets weekly at St. Paul’s and is facilitated by an HIV-positive peer and a social worker.

Intensive case management

The IDC’s intensive case management service is one of the clinic’s most critical tools to keep IDC patients with complex needs engaged in care. This service provides highly individualized services to those who experience the most entrenched barriers to care as a way to improve retention and adherence. In addition to being available to IDC patients, the service is available to people living with HIV who receive care and treatment in the community.

As of November 2012, 111 patients have been identified as needing intensive case management. Members of the clinic’s team refer patients for case management whom they think would benefit from having a more intensive level of support. Referrals are done through a referral form. The case management team includes a physician, the clinical nurse leader, a case management nurse, the addictions nurse, the mental health nurse, the addictions counsellor and social workers.

Through the referral process, the team determines why the patient needs to be case managed and identifies their specific barriers to engagement. The most frequent reasons for referral to case management are poor engagement in care, complex medical needs, complex psychosocial needs and frequent emergency department visits.

Each case management plan is individualized. Interventions include offering appointment reminders and accompaniment; providing resource counselling (concerning housing, food security programs and social assistance); coordinating care; and coordinating medication dispensing in the community. For some of these patients, this individualized care includes an outreach component. While the social workers have some flexibility to do this type of work, currently the IDC relies on the STOP Outreach Team to provide outreach services.

Mental health team

The IDC offers the services of a mental health team as part of its comprehensive HIV services. The team includes a mental health nurse who assesses new referrals and provides crisis intervention and counselling; a part-time physician who provides initial assessments and medication initiation; a team of part-time psychiatrists who provide assessments, diagnostic clarification, medication management and supportive therapy; and a psychologist who provides psychotherapy and treatment for depression and anxiety and counselling for patients receiving hepatitis C treatment. The team also includes an addictions counsellor who provides harm reduction and substance use counselling, resource support and referrals for treatment and a team of social workers who provide counselling on diagnosis adjustment, grief, relationships, stigma and trauma and who provide intensive case management and support.

Referrals are accepted from the IDC and from community healthcare providers. As part of its commitment to improving HIV care throughout Vancouver, the IDC accepts referrals for mental health care for HIV-positive patients who do not receive primary care at the IDC. Each new referral is discussed at a weekly team meeting and a decision is made about who will lead the initial management of the patient. Once a referral has been accepted, the patient is contacted directly for an appointment.

Peer navigator services

The IDC has four part-time peer navigators. These are people living with HIV who offer support to those seeking services at the clinic. These navigators are a part of the Peer Navigator Program, which is a partnership between the IDC and Positive Living BC. Peer navigators are available daily and most interactions happen on a drop-in basis. As of November 2012, the program was staffed by a woman and three gay men. Effort has been made to engage navigators with whom IDC patients will identify.

The peer navigators’ office is located in the middle of the clinic, close to the waiting room and the reception area. It’s an open office filled with resources, and patients are encouraged to drop in. Navigators will also go out into the waiting area and make themselves available when drop-in volume is light. IDC staff often introduce new patients to the navigators. When a patient receives a positive HIV test result at the clinic, staff ask them if they are interested in meeting someone who is HIV-positive as part of post-test counselling.

One of the navigators’ primary roles at the IDC is to help patients understand their diagnosis and what it means to live with HIV. This includes helping people living with HIV and struggling with their diagnosis to come to terms with it. Although clinicians explain the clinical meaning of a positive diagnosis to patients, it is often in talking to the navigators after their diagnosis that patients begin to understand what it means to live with HIV, what it means to be on treatment and how to be engaged with their own care.

The peer navigators also play a significant part in ensuring that patients remain engaged in care. Navigators facilitate the parts of care that patients find most challenging. For those who find waiting for appointments overwhelming, the navigators offer their office as a space to chat and wait. For those who are challenged by interactions with medical authorities, navigators offer to accompany them to their appointments or make themselves available for debrief once the appointment is finished. Despite the IDC’s low-barrier nature, some patients relate better to the navigators than to the clinicians. In this regard, the presence of the navigators makes the IDC seem less institutional and less intimidating.

IDC as part of the Vancouver community of care

The IDC is an integral part of the wider Vancouver HIV community. It is active on the HIV clinical practice council and is a member of the Pacific AIDS Network. Staff are active at AIDS community rounds and AIDS care rounds (hosted by St. Paul’s), both of which are attended by clinicians and community groups.

Preceptorships

Perhaps the most crucial way in which the IDC contributes to Vancouver’s HIV community of practice is through the training opportunities it offers to family physicians and nurse practitioners seeking additional training in HIV primary care. The objective of this program, which is offered in conjunction with the BC Centre for Excellence in HIV/AIDS, is to enhance the skills of primary care providers to provide care and treatment for people living with HIV/AIDS, by improving knowledge of diagnosis and treatment management, of antiretroviral therapies and of medical complications and treatment failures. By enhancing the ability of family physicians to provide HIV primary care in the community settings, the IDC has allowed patients to receive integrated care, from diagnosis to treatment management, through their primary care providers.

Next steps

Each of the STOP-funded initiatives at the IDC (the additional nurses and social worker, the peer navigators, the dietitian, the extended hours of operation and point-of-care testing) has been embedded in the clinic’s services and will continue as part of the clinic’s comprehensive care after the STOP Project is completed in March 2013.