By Julia Hidalgo, ScD, MSW, MPH, National Program Office Director, Research Professor, George Washington University, Merck Foundation HIV Care Collaborative

State and local health departments (LHDs) face daunting challenges to improving the quality of care for low income, uninsured populations living with communicable and chronic diseases. Despite these challenges, many LHDs are piloting innovative new strategies that serve individuals in need. The Merck Foundation HIV Care Collaborative (HCC) is partnering with NACCHO to share strategies piloted in three LHDs in Houston, Philadelphia, and Fulton County. These strategies are effective not only to identify individuals in need of care, but to ensure that they remain connected to care. While HCC efforts have proven effective for working with HIV positive (+) populations, we believe they are widely applicable in LHDs serving patients with communicable and chronic diseases.

The workshop convened at the July 2015 NACCHO annual meeting, “State of the Art Public Health Practices to Identify and Link HIV Positive to High Quality Care in Health Departments,” brought together members of the public health community to learn from the experience of the HCC’s sites in Fulton County, GA, Houston, TX, and Philadelphia, PA.

The workshop detailed three effective strategies for identifying HIV+ individuals who have not initiated care or who were lost to care, linking or returning those individuals to care, and ensuring that they stay connected to care and benefit from highly-effective medications. Key strategies include:

• Data mining to locate individuals with communicable and chronic diseases who are not in care
• Integrating community health workers (CHWs) in multidisciplinary clinical teams to ensure linkage to and retention in care
• Continuous quality improvement to improve performance of CHWs in assessing and addressing personal and structural barriers to care

We kicked off the workshop by discussing the organizations’ role in connecting HIV+ patients to the care they need. The Merck Foundation HCC primarily works in underserved communities to identify HIV+ patients and assess their needs, establish an individualized service plan to meet these needs, and follow through with referrals and engagement in care. Representatives from each HCC site outlined ways in which they are implementing their linkage and retention strategies.

The City of Houston Department of Health and Human Services applied a unique epidemiologic data matching protocol to identify and locate HIV+ individuals who are out of care, allowing CHWs to offer direct client interventions. The City of Philadelphia CHWs participate in clinical ambulatory care teams to assess patient’s needs, identify and address barriers to care in coordination with team members, and address those obstacles to ensure retention in care. Fulton County Department of Health and Wellness CHWs collaborate with disease investigation specialists to ensure that HIV+ individuals served in sexually transmitted disease, tuberculosis, and HIV counseling and testing sites are rapidly engaged in linkage or re-linkage services.

Across all HCC sites, the quality of HIV linkage services has improved and more patients are remaining connected to care. Using the three key strategies helped the sites better assess what is working to provide high quality health care and to connect and keep patients connected to care.

For more information, please visit http://hivcarecollaborative.org/.