1. Tacoma Needle Exchange Tier Based Care Coordination
Shantel Davis Operations Manager and Community Health Worker Point Defiance Aids Projects

2. Point Defiance Aids Projects
Tacoma Needle Exchange
Outreach based interventions/messaging
Care Coordination
Goals: Are person centered, and identified by participants and not CHWs
Outcomes:
Use Reduction/Abstinence
Access to housing
Utilization of Bad Date Hotline
Safer injection techniques
Trained in opiate overdose prevention and response
And more!

3. HCV can live on surfaces for up to 3 weeks.

4. Why CHW’s? The experts on our community, are from our community
Community health worker’s often come equipped with the skills to:
Help individuals, families, groups and communities develop their capacity and access to resources
Facilitate communication and client empowerment
Help health care and social service systems become culturally relevant and responsive
Help people understand their health condition(s) and develop strategies to improve their health and well being
Help to build understanding and social capital to support healthier behaviors and lifestyle choices
Deliver health information using culturally appropriate terms and concepts
Link people to health care/social service resources
Provide informal counseling, support and follow-up
Advocate for local health needs
CHW’s working in this field are often peers

5. Tiers
Utilizing tiers
Expertise among CHWs vary across our teams
Using tiers helps to ensure we are proving appropriate and competent care
Tiers help to identify when external support/referral is needed
Based on Assessment, client is identified as Tier 1, 2, or 3. Tier designations are simply a useful tool for care coordinators and should not be shared with participant.
Note: A participant can be Tier 3 with Tier 1 needs, making regular check-in and collaboration among care coordinators and van staff crucial.

6. Tiers Cont Tier 1: Tier 2: Tier 3:
Health insurance (enrollment, switching plans, renewing, troubleshooting)
Primary care, specialist, clinic (finding, switching, and scheduling)
Hepatitis C testing
Intake paperwork (CHC, methadone, etc.)
Tier 2:
Transportation to initial appointment when no other transportation options
Applying for SSI/SSD
Birth certificate
Complicated & multiple Tier 1 needs requiring advocacy
Tier 3:
Housing
Locating participants
Long-distance transportation for participant health & advocacy needs
SMI clients (Seriously Mentally Ill)

7. Framing and Fitting Not just any linkages, not just any messaging
but ones that are appropriate and are participant centered
Community asset mapping
Make time to tour facilities, meet face to face with direct service staff, and attend/stay abreast to regular meetings.
Identifying the appropriate messaging as well. Motivational interviewing skills and knowledge of the transtheoretical model of behavior change are important tools when it comes to message framing meeting people where they are.
Taking into account individual and group cultures, biases, will help to ensure you are linking participants with the resources most aligned with their goals.

8. Tools and Documentation
Agency service menu assessment
Ensuring CHWs are operating within their scope of work
Start with either:
List of services your agency currently provides or
List of services your participants commonly request/utilize
Essentially, you are creating a screening tool
The amount of paperwork/documentation is dependent upon your agency as well as what services you are offering.
It is difficult for CHW’s or anyone in outreach to know when to say when. We see a need, and we try to meet it. That can cause burnout and ultimately the loss of a great advocate/worker.

9. What is taking place locally?
Number of TNE participants served so far 2018 (calendar year)
1,811 Unique
5,796 Encounters
Linkages/Education (FY17-18)
7,230
Tier 3 Care Coordination participants served so far 2018 (calendar year)
10 people enrolled into formal care coordination
419 additional encounters
2,511

10. Recognition
PDAP awarded the 2017 NASTAD Chairs Challenge award  NASTAD-National Association of State and Territorial AIDS Directors “The Point Defiance AIDS Project Care Coordination Initiative in Washington State provides care coordination services to address housing and treatment access needs for participants of SSPs. The program works to reduce stigma and impact social determinants of health through a harm reduction approach, ultimately increasing participants’ ability to meet their own HIV/HCV care goals.”
Received new to us funding sources, including County, City, and BHO support.
Thank you!
For more information or to request resources and/or templates please feel free to reach out: Shantel Davis