Implementing a Locator Protocol to Support People Living with Human Immunodeficiency

Abstract

This quality improvement (QI) project implemented and evaluated a locator protocol in an urban hospital to community transitional care program for persons living with HIV to minimize the number of people lost to follow-up. Background: In the United States over 50% of people living with HIV (PLWH) are not engaged in HIV care. Individuals not engaged in HIV care do not have access to combination antiretroviral therapy, prophylactic medications or medical services which increases their risk of morbidity, mortality, and HIV transmission to others. Local Problem: The HIV population in Baltimore is highly transitory with high rates of substance use and mental health disorders, and homelessness. An urban HIV organization in Baltimore, Maryland connects PLWH who are newly diagnosed or out of care to medical care. Clients are enrolled in the transitional care program during hospitalization and staff initiate individualized care plans to address barriers to care and provide support services. After discharge from the hospital clients receive 90 days of intensive case management including home visits, transportation to medical visits and connection to resources. During enrollment in this program, up to 50% of clients may be lost to follow-up at various time points because phone numbers are disconnected, or client transience. Intervention: A locator protocol tool was developed and initiated to collect detailed social and personal information from clients in the transitional care program to minimize the number of clients lost to follow up. Inclusion criteria included consented clients age 18 or older who were newly diagnosed or out of care for HIV for at least six months and had 1 of the following: unstable housing, substance use and/or a mental health disorder. Questions in the locator protocol included local hang outs, identifying a person of trust who could be contacted in case the client was not found, programs, agencies or businesses frequented, and dwelling locations including shelters. Community health workers (CHW) completed the form with clients at the bedside before discharge from the hospital. The locator protocol was initiated if a client missed a medical appointment or when the CHW could not locate a client via phone or address. Results: Twenty clients were enrolled in LTC+ from September 10 to December 17, 2018. Outcomes: 1) Seventeen (85%) clients completed the locator protocol. 2) Clients were frequently lost and then found again with the locator protocol. 3) Thirteen (76%) were actively retained in care. Conclusions: People who have unstable housing, substance use or mental health disorders struggle to maintain their health in traditional medical care models. The locator protocol centralizes client information and standardizes internal protocols which results in more consistent communication between staff and clients. The more detailed social and personal information collected, the longer and more likely staff stayed in touch with clients and got them to appointments and engaged in HIV care.