Programming Connection

STOP Outreach Team 

Vancouver STOP Project
Vancouver, British Columbia
2013

What is the Program?

The STOP Outreach Team is an interdisciplinary team of nurses, nurse educators, outreach workers, social workers, administrative support workers and peers all working with the part-time support of a physician. The team’s mandate is to expand low-barrier HIV testing services and to improve engagement in HIV treatment, care and support for some of the most marginalized people in Vancouver. Importantly, through their flexible, intensive case management approach, this clinical outreach team is a bridge to established HIV services across the city of Vancouver rather than the final destination for clients. While HIV testing and diagnosis volumes, treatment adherence and suppressed viral load are some of the key markers of success, the team uses a holistic model of care, which includes a person’s physical, mental and social needs.    

This approach means that the STOP Outreach Team works not only on the HIV-specific needs of its clients. The team also addresses psychosocial and other medical barriers before addressing a client’s HIV, and does so by supporting the client to prioritize their own needs. Taking a broad approach to achieving what is essentially a biomedical goal (preventing HIV transmission, diagnosing people early in their infection and supporting people living with HIV to be on treatment and achieve a suppressed viral load) has allowed the team to address the broader social determinants of health. These determinants affect their clients’ ability to prevent HIV, to access testing, to engage and link to care, and adhere to their medications once on treatment. Engagement with the team addresses these determinants and improves the likelihood that clients will remain engaged in prevention, testing, care and treatment.

The team focuses on four key areas:

  1. providing education and capacity-building opportunities to community agencies, healthcare practitioners and peers to improve or expand services;
  2. expanding rapid and routine HIV testing in targeted settings, such as mental health and addictions services, in First Nations communities in the Vancouver Coastal Health region, in gay bathhouses, in the justice system, in supported housing, and in abortion and youth clinics;
  3. providing public health follow-up for partners and other contacts of people who test positive (in collaboration with Vancouver Coastal Health Communicable Disease Control); and
  4. engaging and linking people to care who are newly diagnosed or who have been previously diagnosed and lost to care and who require support to link to existing HIV and psychosocial services. 

The team improves linkages between services that already exist in the community by offering intensive case management for clients to help them navigate the system. This support may only last a few weeks and includes referrals and accompaniment to culturally appropriate services (for example, clinics that specialize in the health of gay men), or it may last longer and provide intensive case management for people with complex barriers to accessing healthcare. Services for these individuals typically last between four and six months, and clients can return to the team’s caseload should they need the added individualized support.

The STOP Outreach Team also has nurses, outreach workers and case managers embedded in other programs in Vancouver. The focus of this case study is, however, on the staff whose primary work site is the STOP Outreach Team office and does not cover the work of team members who are embedded at other sites.  For more information on programs hosting embedded staff, please see the Maximally Assisted Therapy Program case study.