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in+care Newsletter

Issue 20

National Campaign to Improve Retention in HIV Care
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In This Issue
Patient Navigation Field Examples
Patient Navigation in Networks

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Data - National Averages*

(as of 08/02/13)

Gap Measure
(158 sites, 107,324 patients)


Visit Frequency Measure
(154 sites, 89,877 patients)


New Patient Measure
(155 sites, 6,558 patients)


Viral Load Suppression
(161 sites, 131,442 patients)


*data not unduplicated
Quick Links

Campaign Headquarters

National Quality Center (NQC)

New York State Department of Health AIDS Institute


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Fax: 212-417-4684


Website Updated!

 The in+care Campaign has recently updated its website to make searching for Retention Strategies and Tools easier for you! Visit the website today to explore the new area!

Patient Navigators and Retention


This newsletter issue examines patient navigation and how these programs impact retention in HIV care. Patient navigation is often put forward as a strategy to engage and retain patients in HIV care. However, it can take many forms and different types of patient navigation may be more or less successful in improving linkage to and retention in care. in+care Campaign webinars reflected the difference models of patient navigation. In addition, the Campaign has explored how both networks of providers and stand-alone providers can go about implementing impact patient navigation systems.
If you have implemented retention improvement strategies involving a patient navigation component and you would like to share with the Campaign, please spend five minutes to report them at this link.
Upcoming Events
in+care Campaign staff are busy putting together webinar calls for you and your staff. Stay tuned for more information and details as these calls are scheduled.



+ Next Campaign Performance Data Submission

October 1, 2013



+ Next Improvement Update Form Submission
September 16, 2013
Keep up-to-date with the latest in+care events through our webpage: http://incarecampaign.org/index.cfm/75283


HIVQUAL Brief Issue 9 Now Available!

Mortality rates are one of the most commonly used outcome measures to judge the effectiveness of care, but knowing their limitations is key for understanding their relevance to the quality of care provided in a health care organization or by specific providers. HIVQUAL Brief 9 highlights work performed at the University of Colorado-Denver and University Hospitals of Cleveland - two Ryan White funded providers - to demonstrate the potential for small teams to improve clinic operations activities by tracking and examining population mortality rates. Both programs have utilized their data and findings to implement system changes with the goal of improving patient outcomes.


Click here to review HIVQUAL Brief Issue 9.

Patient Navigator Programs: Examples from the Field

Because organizations, patient populations, and service delivery models vary widely, patient navigator programs that are designed to help retain people living with HIV in care are also very different. Here are three examples of patient navigator programs that share the same goal of helping women living with HIV remain in care.  All three programs received funding to develop their patient navigator model through the HRSA HIV/AIDS Bureau Special Projects of National Significance (SPNS) Enhancing Access to and Retention in Quality HIV/AIDS Care for Women of Color Initiative.

Ruth M Rothstein CORE Center (Chicago, IL)

The CORE Center uses a peer patient navigation model-the Patient Navigator reflects the population they serve.  These full-time employees provide long-term support to patients. From their initial contact with the organization, patients are assigned to a patient navigator who provides a variety of support functions. They help new patients complete forms, remind patients of upcoming appointments, educate patients about HIV, provide treatment adherence and prevention tips, and provide psychosocial support. Participation is often a very empowering experience for the peer patient navigator and allows her to provide a sisterhood that others cannot. In turn, the peer patient navigators can serve as healthy role models for the other women. The patient navigators have had a significant impact on entry and retention in care-84% of those receiving navigation support enter care within 60 days and the retention rate for those women participating in the project is nine times that of women who are not receiving patient navigator services.

Special Health Resources for Texas (Longview, TX)
Special Health Resources provides HIV-related services to 1,200 patients in 23 counties in rural Texas. Approximately one third of the patients are women. To support the engagement and retention of women of color in HIV medical care, a social worker provides intensive case management. Given the rural environment of the service area, the women often need a significant amount of support. HIV-related stigma can be very strong in rural areas and the women often feel extremely isolated. The social worker becomes an anchor and contacts patients twice each week, either by phone or home visits. The model also includes support groups for the women and transportation to facilitate retention in care. In their interaction with patients, the social workers emphasize each woman's individual strengths and how these qualities can be used to help retain patients in care. Disclosure of HIV status to partners is one of the most significant challenges for patients. The social workers also focus on prevention education and teach women how to interact with their partners.  

Guide to Healing at University of North Carolina (Chapel Hill, NC)

The Guide to Healing program targets African American women living with HIV that are entering or re-entering care. This nurse-based model is designed to provide an intensive, short-term intervention (approximately 6 months) that provides the patients with the skills needed to remain in care and achieve viral suppression. The nurse navigator seeks to build a personal connection with the women. Making this connection early in the patient's engagement in care will hopefully create a sense of connection to the clinic and the rest of the staff. This relationship building starts with an orientation to care. The nurse meets with newly enrolled women to explain what will occur at the first appointment and answer any questions. Over the next few months the nurse regularly checks with patients by phone-calling before and after appointments or when the patient starts a new medication. The nurse also refers patients to other resources and follows up with patients to ensure that they have been successful in accessing these resources. Once the patient is successfully engaged in care, she is transitioned out of the program.  

Patient Navigators: The Network Perspective

Organizations with effective patient navigator programs emphasize the importance of tailoring a program to the unique needs of the organization and the patients served. So what do you do if you are implementing a patient navigator program across a network of providers? In 2009, the New York City Department of Health and Mental Hygiene, with Ryan White Part A funding, began implementing a Care Coordination program with patient navigation as the cornerstone of the model. Over three thousand patients maintain active enrollment across 28 agencies (approximately 50 sites). While there is a standard protocol for patient navigation services, there is also room for flexibility since the providers vary widely. There are hospital-based programs as well as community-based organizations. The Care Coordination program, which is designed to link clients to care and keep them in care, is based partially on a community health worker model with the navigator integrated into the care team.


The patient navigators are key players on the care team and have the most interaction with clients. While patient navigators must reflect the community they serve, they are not necessarily people living with HIV. Services provided include health promotion (a comprehensive curriculum with 16 modules), basic case management services, and accompanying clients to their various appointments. Patient navigators may follow up with patients in their homes and can even provide directly observed therapy (DOT) to ensure that clients adhere to their medications. Depending on the needs of the clients they serve, caseloads can vary from 14 to 20 clients per patient navigator. Some agencies have DOT specialists who each serve as few as seven clients.


Despite the diversity of agencies, the Department takes steps to standardize patient navigation services. There are suggested job qualifications and a job description. There is also a standard protocol for patient navigators. The protocol includes requirements for training for new staff and existing staff and ongoing clinical supervision.


Because health promotion is such an integral part of the model, the Department conducts training of trainers with agency staff to support their Care Coordination teams in the health promotion curriculum. Each agency has at least two staff (e.g., program director, care coordinator, or patient navigator) trained in the health promotion curriculum. The trainers then conduct health promotion training at least bi-monthly with all Care Coordination staff at their agency.


An essential element of the Care Coordination program has been the provision of ongoing technical assistance to network agencies. One of the most important areas for technical assistance has been field safety, since field work is new for many agencies. In addition, as navigators worked with clients it became apparent that they needed additional training in the areas of substance abuse and mental health. Navigators have required training around cultural competency, including LGBT issues and they have benefited from training in program administration skills such as data entry. Project Officers from the Department also work one-on-one with agencies in response to specific program needs.


The Department uses various measures to evaluate the effectiveness of navigators. Quantitative data are collected on a variety of indicators such as the number of home visits or educational sessions. The surveillance registry is used to conduct outcome evaluation, using indicators such as viral load or CD4 count. Care Coordination services are also assessed in client satisfactions surveys, which rank it very high.


Introducing patient navigators into the medical care team has involved a major cultural shift for many agencies. During the initial implementation, to ensure buy-in, the Department devoted significant time to educating medical providers about the role of the navigator. Medical providers quickly saw the benefits of the program in terms of increased patient engagement in care. Agencies have also had to be flexible in implementing the model. Some patients require much more support than others, which affects in caseload size. In addition, much "legwork" is required for successful navigation. Navigators are often out in the field, which may not always translate into a lot of contact with the client. However, the effort is appreciated by clients. When navigators do home visits, if they do not connect with the client they leave a note. Anecdotally, clients have reported that the level of interaction they have with navigators motivates them to remain in, or in some cases, come back to care. While it may be labor intensive, the results warrant the effort. Newly diagnosed patients enrolled in these services are roughly 25% more likely to be retained in care and roughly 50% more likely to achieve viral suppression than newly diagnosed patients not enrolled in these services.

Connect. With patients.
Collaborate. With a community of learners.
Change. The course of HIV. 

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