Programming Connection

STOP Outreach Team 

Vancouver STOP Project
Vancouver, British Columbia
2013

How Does the Program Work?

The Vancouver STOP Project has expended significant energy on improving engagement and linkage services across Vancouver. The breadth and depth of its services, and its ability to reach the most vulnerable with HIV testing, treatment, and care and support, has made it integral to the new way that HIV services are being delivered in Vancouver since the start of the Vancouver STOP Project.

While the STOP Outreach Team provides discrete services, team members work closely together, developing individualized care plans for clients, meeting daily in the STOP Outreach Team office before heading out for the day, and supporting each other to provide the best possible care to clients.

Education for service providers

The team has HIV specialist nurse educators whose role is to provide training and support to service providers who want to offer routine or rapid HIV testing services in their practices. This sub-team within the STOP Outreach Team is known as the Targeted Testing Team. This team trains clinicians to offer testing and diagnosis in primary care clinics, in mental health and addictions services, in supportive housing, in First Nations communities in the Vancouver Coastal Health (VCH) catchment area, in the justice system where VCH is contracted to offer healthcare, and in youth and abortion clinics.

While the Vancouver STOP Project is currently training physicians in family practice and acute care to routinely offer HIV testing in their practice, these capacity-building initiatives are not initiated by the STOP Outreach Team’s nurse educators. For more information on the nurse educators’ role in expanding testing services in Vancouver, please see the Expanded Rapid and Routine Testing Case Study. For more information on other testing initiatives in Vancouver, see the Peer Testing Project, the HIV Testing in Family Practice, the HIV Testing in Dental Clinics and the HIV Testing in Acute Care case studies.

24-hour telephone line for clients and service providers

The STOP Outreach Team also runs a 24-hour telephone line for clients who are experiencing an urgent health issue, or service providers seeking support for clients. The purpose of the line is to ensure that the team is able to assess and respond to the needs of clients as they emerge. This is particularly important for a transient population of people who may frequently be in hospital or involved in the justice system. Ultimately, having the telephone line strengthens continuity of care by providing a round-the-clock resource for clients.

In addition, the line is also available for service providers looking for information. This includes information on how to diagnose an individual with HIV, how to access a client’s HIV test results, where to fill an emergency antiretroviral prescription for a client who has run out of ARVs or to ask for help in referring someone to psychosocial services. Service providers also call the line to report that a person for whom the team has been searching has resurfaced. In these instances, the STOP Outreach Team will make arrangements to meet the client at a certain time and place to connect with them.

HIV and STI testing

The team’s nurses organize and deliver testing clinics in a variety of settings including community organizations, in single room occupancy hotels, and at AIDS service organizations that serve highly vulnerable populations. They often use point-of-care (POC) tests to do this, which yield results in minutes and do not require individuals to return for their results. This is especially important in settings where people seeking testing experience significant and complex barriers to healthcare, and live in or frequent neighbourhoods with a high prevalence of HIV. These testing events are also opportunities to link people who are newly diagnosed to care and to reconnect people to care who know they are HIV-positive but have been lost to care.

In this regard, testing clinics are about more than just testing. These clinics provide low-barrier healthcare for the most marginalized people by bringing healthcare to the spaces most familiar to them and shifting the logistical burden of healthcare from the patient to the provider.

In addition, the team has increased efforts to provide low-barrier HIV testing to gay men and other men who have sex with men. They have done so through bathhouse testing, in which STOP Outreach Team nurses conduct HIV and STI screening in three of Vancouver’s bathhouses. Through close partnerships with the owners and management, a room in each bathhouse has been renovated into a clinical space and nurses offer HIV and STI testing and treatment there.

In July 2012, YouthCO and the STOP Outreach Team also launched Know on the Go, a mobile outreach service that offers HIV testing for gay men and other men who have sex with men in outdoor sex venues, such as parks. In the summer of 2012, this project provided HIV and STI screening during gay pride celebrations and, since the fall of 2012, the service has been available outside gay events, clubs and venues.

Like their other testing initiatives, the STOP Outreach Team’s gay men’s HIV testing programs aim to expand testing options for a group at high risk for HIV. In both of these models, a mix of point-of-care testing and standard lab testing is performed. For more information on these initiatives, please see the Mobile and Bathhouse HIV Testing Project Program Element.

Finally, the team’s nurse educators offer HIV testing at public events frequented by the general population, including events at the University of British Columbia and at Simon Fraser University. These are seen less as testing events by the team (though they do perform tests) and more as awareness-raising events about HIV and HIV testing. The goal of these events is to contribute to the normalization of the testing experience and to reduce stigma associated with HIV.

Public health follow-up

The team’s four public health-designated nurses can also assist the Vancouver Coastal Health Communicable Disease Control (VCHCDC) program with partner notification, contact tracing and referral services for people who are newly diagnosed with HIV. The VCHCDC is responsible for all public health follow-up after HIV testing in the region, and has nurses who specialize in offering this follow-up and supporting clients through the difficult process of diagnosis, partner notification and linkage with care. However, in rare instances where the VCHCDC nurses anticipate that a client will be particularly hard to find or engage, the STOP Outreach Team offers this service, using its knowledge of the community to locate them.  This integration between the two teams allows for greater flexibility in public health follow-up and supportive, client-centred work with the client and their contacts.

Engagement and linkage through intensive case management

The team is best known for its engagement and linkage services. It provides these services both to people who are newly diagnosed and to people who know their HIV-positive status, but are not linked to care. The team does this through intensive case management.

This case-management service is voluntary. It can last a few weeks, for people who experience some barriers to accessing HIV-specific services but who are generally able to self-manage their healthcare. Alternatively, it can be an ongoing process, especially for people who experience more complex, intersecting barriers to accessing HIV-specific services and who need additional help accessing healthcare.

First contact with the STOP Outreach Team

While some clients connect with intensive case management services through their HIV diagnosis by a STOP Outreach Team nurse at the various testing clinics the team organizes, most clients first become known to the team through a referral. Referrals for case management come from various services and programs around Vancouver. For people who are newly diagnosed, referrals can come from family doctors and acute care facilities, and mental health and addictions services.

Referrals also come to the STOP Outreach Team for people who already know their HIV status but have been lost to care. These referrals are often made by physicians at community health clinics in the Downtown Eastside, from the Immunodeficiency Clinic at St. Paul’s Hospital, from Vancouver Coastal Health’s Primary Outreach Services, from AIDS service organizations and from other agencies working in the neighbourhood.

Typically, these people are referred to the team because they are challenged by HIV medication adherence, have stopped taking their medications altogether, or they have not been seen by their primary care provider in months or even years. Referrals to the team are usually made through a referral form, though referrals are also made over the phone. The outreach workers act as intake workers for new referrals to the team.

Initial engagement with the STOP Outreach Team

Referrals to the team are assessed each morning at a team meeting known as the huddle. During the huddle, team members discuss new clients’ needs. If those needs are primarily medical, a nurse will take the lead in the client’s care. If they are psychosocial, a social worker will lead the team’s efforts. In most cases, the nurse or social worker will pair with an outreach worker, and the outreach worker will play a central role in executing the care plan, through initial engagement with the client and through accompaniment to appointments. Each client is assigned to two members of the team to ensure continuity of care. 

The huddle is also an opportunity for team members to discuss case management clients in general, coordinate activities and divide responsibilities. It also gives team members a chance to share their daily schedules with one another.

Locating and engaging potential clients

Following a referral and initial discussion about connecting with a potential client, the team member(s) assigned to the person will try to locate them in the community to introduce them to the team and its services. Sometimes, potential clients are very easy to locate, as they are already known to the team or their healthcare provider knows where they can be found. However, some other clients are harder to find.

Those clients who are more challenging to connect with tend to be people who require longer-term intensive case management. In these cases, one of the outreach workers takes the lead. Outreach workers use VCH’s health records systems to locate a person, sifting through recent entries in their health files to find a last known address. The outreach workers also contact prisons and jails to determine if the person is currently involved in the criminal justice system. Often, outreach workers leave messages for clients with the Ministry of Social Development, asking that the message be delivered to the client when they collect their social assistance cheque. The team also leaves notes with agencies where the client is known to hang out. Any inquiries into the whereabouts of a client respect the client’s confidentiality and simply say that someone is trying to contact them on behalf of their healthcare provider. No mention of HIV is made.

Once a person has been located, the team’s lead for the client establishes a connection with them. In many cases, this takes flexibility and persistence. Because the team works largely on outreach, members are free to be innovative with their strategies. This includes taking the person to lunch or for coffee, or spending a few hours with them to allow the new client to become comfortable with them. When a person refuses support, team members always leave the option to connect at a later date. The team often returns to the same client several times in order to establish a connection.

Once a client has accepted the team’s help, it is the team’s role to inform clients of all their options, provide education about HIV and HIV treatment and care, and discuss with clients all the different services the team can help them access. The client is always at the centre of the care and support offered to them. Team members follow the client’s lead in establishing priorities and making the appropriate linkages to services.

Short-term engagement with case management

Clients who are engaged on a short-term basis with the STOP Outreach Team tend to be more independent, better able to self-manage their healthcare and usually experience fewer barriers to engagement in healthcare than other clients of the STOP Outreach Team’s case management service.

The team’s involvement with these people usually lasts a few weeks and can include support with accepting a diagnosis, disclosure to family and friends, help finding a primary care provider and accompaniment to the first few appointments, or help re-engaging in care if the individual is not newly diagnosed. It can also include connecting the client with a peer navigator from Positive Living BC who can provide more long-term support. For more information on peer navigators, please see the Peer Navigator Program Case Study.

The team can ensure that clients who need it are receiving their full social assistance benefit, that they have adequate housing and have access to food banks and meal programs. Whenever possible, referrals to culturally appropriate services are made. Gay men, for example, are referred to medical and psychosocial services that specialize in LGBTQ communities.

Longer-term engagement with case management

For other clients, engagement with the team takes longer and more intensive case management is required. Typically, these clients have multiple and intersecting barriers to healthcare, including episodic homelessness, involvement in the criminal justice system, and mental health and addictions challenges. Although the average length of engagement is between four and six months, some clients have been on the team’s caseload for more than two years.

Clients who engage with the team for a longer period of time are often in need of more in-depth psychosocial and health support and management. This can include supporting applications for full disability benefits, for immigration status and for the Canadian Pension Plan. The team also makes referrals for better housing or for a shelter bed, and to meal programs. The team facilitates linkages between longer-term case management programs, such as programs at AIDS Vancouver and Positive Living BC. These organizations also have access to services that may not be offered by the team, such as food banks.

Dealing with psychosocial barriers to medical care is a key step for clients as they re-engage in HIV care. This process allows the team to build rapport and trust and improves clients’ capacity to address their healthcare needs by stabilizing income, housing and food security.

When a relationship has been established and a person’s psychosocial needs have been addressed, then the team can discuss healthcare with them and encourage them to start HIV treatment. Nurses and outreach workers spend their days connecting with clients, talking to them about treatment options, accompanying them to their medical appointments, providing daily medication support, and connecting clients with methadone and mental health and addictions services if they want them.

The role of the physician

The clinical work of the team is supported by a physician who spends three half days per week with the team. The physician’s role is to provide clinical support to the nurses as they care for their clients. He is responsible for reviewing all lab work ordered and is available by telephone to answer any questions nurses may have about their clients’ medical needs.

The physician is not involved in the care of all of the STOP Outreach Team’s clients. He usually sees clients whose needs are immediate or clients the nurses believe are unlikely to thrive under the care of another physician. Mostly, the physician sees patients at the community clinic at which he is based, though he does see about 10-20 percent of people requiring physician care at home or in the community.

The physician also acts as an educational resource for the team. The physician offers support and advice for their practice to allow nurses to provide the care their clients need. Biweekly, the physician meets with the team to review cases and relate learning points.

Discharge

Typically, clients are not discharged until their psychosocial needs are met and they have begun antiretroviral therapy, are well-established on their regimen and are seeing the benefits of treatment (reduced viral load or virologic suppression, and increased CD4 count). The team ensures that there is strong engagement and strong capacity to provide the kinds of support clients need before they are discharged from the team’s caseload. Depending on the client’s needs, they are discharged to a variety of primary care practices and enhanced services around Vancouver.

About 75 percent of the team’s clients need further intensive case management. If these clients live in supportive housing, they will often be discharged to the care of onsite nurses and social workers.   Others are discharged to intensive adherence support programs such as the Maximally Assisted Therapy Program at the Downtown Community Health Centre. For more information on this program, please see the Maximally Assisted Therapy Case Study.

Clients who are more independent are discharged to the Immunodeficiency Clinic at St. Paul’s Hospital or one of Vancouver Coastal Health’s community health clinics, all of which have HIV-trained physicians on staff. These clients are better prepared for self-management and do not need intensive case management or outreach to continue their engagement in treatment, care and support. For more information on the system of care provided by the Immunodeficiency Clinic, please see the IDC Case Study.

Next steps

In planning for the team’s future after March 2013, VCH is considering a model in which interdisciplinary teams that include a combination of nurses, social workers and outreach workers are embedded in pods in existing primary care programs and services around the city. In this model, pods may be responsible for specific populations and/or specific geographic areas.

This model builds on the work of team members already embedded in other programs. Such teams currently exist at the Maximally Assisted Therapy Program, the Downtown Eastside Women’s Centre and the PHS Community Services Society. Such a model would reduce overextension of staff and improve communication and collaboration between service providers and the team.