Programming Connection

STOP Outreach Team 

Vancouver STOP Project
Vancouver, British Columbia
2013

Lessons Learned

  1. “An already developed infrastructure.” In order for a team such as this to be effective, a strong network of pre-existing and effective HIV treatment, care and support services, housing, food security and mental health and addictions services needs to be available.
  2. “Our role is to provide a bridge for clients to link back into the existing system of care.” The STOP Outreach Team provides an option to help re-engage clients who are lost to care and engage newly diagnosed people in services. By offering complementary services, the team can reduce the cracks in the system through which the most vulnerable may fall.
  3. “Easy to penetrate and easy to navigate.” The team operates as a full-service primary care team. The team removes the logistical barriers to care by shifting those burdens from the patient to the clinical team, including the requirement to come to the clinic for care.
  4. “We take our services to our clients wherever they are.” The fact that the team works exclusively on outreach for its engagement and linkage component is key to its success in supporting clients. It provides the team the flexibility to spend extra time with clients to build strong therapeutic relationships and link them to long-term supports.
  5. “We are able to meet clients where they are and guide them on the journey toward health.” The team provides non-judgemental services tailored to the needs of its clients. This client-centred approach allows clients to determine their own priorities with team members acting as facilitators.
  6. “We take a community-wide approach to caring for people.” While collaboration with other service providers has been challenging, the team’s ability to collaborate is also a strength. The team works closely with peers, clinicians, hospitals and community organizations to coordinate services and develop a discharge plan.
  7. “One phone line.” The outreach team has a 24-hour phone line for clients and service providers that allows them to access after-hours support. This allows clients to contact the team when they require assistance and allows the team to assess and respond to clients’ needs immediately. The line also allows service providers to contact the team when their clients have re-appeared after having been unreachable, when their clients have run out of medications or when they need information about how to connect with other services.
  8. “A group of passionate people who want to do this work.” The team consists of dedicated and competent individuals with a desire to provide the best service in an autonomous and often complex environment.
  9. “Things all changed at the same time.” The success of the team in supporting clients to engage in care has been, in part, due to the scaling up of an already developed treatment, care and support infrastructure that happened simultaneously with the creation of the team. This provides the team with options when trying to link clients to necessary services and programs. This investment in the system has had a direct impact on the successes observed in clients.