1. L INKING AND R ETAINING HIV P OSITIVE I NDIVIDUALS IN M EDICAL AND S UPPORTIVE C ARE Katie Horstmann Wake County Human Services HIV/AIDS Case Management Supervisor

2. BACKGROUND Wake County Human Services is the consolidation of programs and services including social services, public health, mental health, job training, child support, housing and transportation. Under One Roof is a collaborative effort between Wake County Human Services Case Management/Bridge Counselors and Alliance of AIDS Services- Carolina (AAS-C). Under One Roof

4. Bridge Counselors History In 2001 the Did Not Keep Appointment (DNKA) Rate among HIV + clients attending WCHS Clinic was the highest rate in eleven years. In 2002 we applied for Ryan White Part C funding to expand clinical services that included the creation of Bridge Counselor. In 2004 – Hired 1 st Bridge Counselor (RWC Funds) who focused on getting new clients into care. In 2005 initiated “Lost to Care” (LTC) strategy. Source: WCHS CareWare

5. Bridge Counselors History In 2006 a second RWB Bridge Counselor was added. In 2007 first full year with two Bridge Counselors. In 2008 gained 3 rd Bridge Counselor with 1 year grant from Hospital Alliance funding. Source: WCHS CareWare

6. Bridge Counselor Role Primary resource for newly diagnosed individuals, HIV positive individuals transitioning care, and HIV positive individuals new to Wake County in need of care. Coordinate medical and support services for newly diagnosed individuals and those HIV positive individuals not connected to either. Provides initial HIV education, social work assessment, ADAP paperwork, and needed support service referrals. Track individuals who miss appointments and those lost to follow up at WCHS HIV Clinic. Acquire and maintain a working knowledge of community resources. Educate Medical Providers of BC Services and Resources

7. BC PROCESSES Criteria Newly diagnosed HIV positive HIV positive moving into Wake County HIV positive individual wanting to transition care to another HIV provider Wake County Resident Completed Bridge Counseling Agreement/Consent Under One Roof 1812 Tillery Place Suite 105 Raleigh, NC 27604 You are eligible to receive the free services of a Bridge Counselor with Wake County Human Services. A Bridge Counselor is a short-term case manager for clients who are newly diagnosed with HIV. The Bridge Counselor will be available to discuss your feelings, questions, and concerns about HIV, as well as to inform you about disease progression and treatment options. Part of this process may be assisting you to find a suitable HIV health care provider. The Bridge Counselor will also arrange transportation for your first clinic appointment and accompany you to the appointment if requested. In addition, the Bridge Counselor can assist you with other needs you may have, such as obtaining housing, food, disability, etc. Once you have accessed medical services with your HIV health care provider, the Bridge Counselor will discharge your case, or if needed, refer you to long- term case management. The Bridge Counselors and their phone numbers are listed below: Andrew Farr, 919-856-5318 Betsy Santiago-Lane (Bilingual-English/Spanish) 919-856-5278 By signing below you acknowledge that you have read or been informed of the Bridge Counselor services available to you. If you accept these services, you also give permission for the Bridge Counselor to obtain your lab tests and inpatient or outpatient medical records, as these are needed for referrals to HIV health care providers. This release of medical records will expire one year from the date of signature. Please sign and date whether you accept or decline these services.  I, ___________________________________, decline the services of the Bridge Counselor. I, _________________________________, agree to accept the Bridge Counselor services. I also give permission for either of the above Bridge Counselors to obtain my lab tests and medical records. I understand that one of the Bridge Counselors will contact me within 48 business hours. Date of Birth::______________________ Telephone Number(s)::____________________________________________________ Address::____________________________________________________ Client Signature_________________________ Date_____________________ Referral source Name/Agency/Telephone:_______________________________________________

8. BC PROCESS Once BC’s consent is received a Bridge Counselor will contact client within 24- 48 hours. To begin: Coordinating medical and support services for newly diagnosed individuals and those HIV positive individuals not connected to either. Initial HIV education Social work assessment ADAP paperwork Connecting to needed support services and referrals

9. 2012 BC REFERRALS 2012 WCHS BC Data

10. B ENEFITS O F B RIDGE C OUNSELING Key strategic piece to engage clients for life in medical care Higher percentage engaged in treatment Lowered Community Viral Load No show rate declined Improved communication among agencies Services provided in both English and Spanish Bridge Counselors has been adopted by the State of North Carolina as a Best Practice

11. L EVEL OF I NTEGRATION HIV Acuity Scale HIV Acuity Scale : is a tool that helps identify individuals level of need and standardize provision of services. Helps providers identify referrals needed and how best to work with other providers serving the individual Helps identify social determinants that obstruct individuals from achieving optimal health and personal outcomes Helps prioritize staff workload base on clients total points Helps program manage limited resources

12. WCHS HIV/AIDS A CUITY S CALE

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20. Points Disclosure Client has no issues with disclosing status to anyone Client has disclosed status to mostly everyone in support system Client has disclosed status to some of their support system Client has disclosed status to one or two people in support system Client has disclosed status to no one Total Points

21. B RIDGE C OUNSELORS AND HIV/AIDS C ASE M ANAGERS Wake County Human Services THANK YOU