Introduction
Frontline organizations play a critical role in providing programs and services that support people living with or at risk for HIV, hepatitis C and other sexually transmitted infections (STIs). To do this effectively, services need to be organized and delivered in a way that best meets our clients' complex and evolving needs.
Creating comprehensive programs and services, based on clients' needs, is one way to ensure that programs offer the best combination of interventions to most effectively improve health outcomes and reduce new infections.
This article profiles some of the different approaches Canadian organizations have taken to map services as a way to move toward more comprehensive and integrated services.
The right services in the right places at the right time
We need to deliver the right services in the right places at the right time to improve client health outcomes and reduce new infections. But how do we do this?
First, we need to understand what “package” of services the community needs. This means having a good understanding of who our target audience is. We must also understand the complex and interconnected needs of clients, what health and social services are currently available to them, and how accessible and linked those services are.
Having a better knowledge of the services and programs clients use, need and want, allows service providers to see where existing programs are succeeding and where they are falling short.
How do we provide the right services in the right places at the right time?
Integrating prevention, testing, treatment and support services is one important way to provide the right services, in the right places at the right time. Client-centred care is the overall goal of an integrated approach.
Integrated services address a client’s comprehensive engagement and linkage needs across the full continuum of prevention, testing, treatment, and care and support services, rather than working in “silos,” which has traditionally been the case in many communities.
What are integrated services?
Service integration allows clients to access a combination of programs and services that addresses their underlying health and social issues that are contributing to poorer health outcomes or ongoing risk for HIV, hepatitis and other STIs. Integrated approaches are a client-centred approach to program development through which multiple health and social issues are addressed in a coordinated way.
There are two broad approaches to integration – service integration and program collaboration.
Service integration is an approach that provides clients with seamless access to programs and services within a single organization through a one-stop-shop approach. This approach aims to make it easier for clients to access services by providing a single point of entry. Most service integration models include some degree of health navigation, case management and referrals.
Program collaboration is an approach based on partnerships and collaboration across existing programs, services and organizations. Program collaboration can reduce duplication of services and increase participation in service delivery from a variety of programs and organizations. Strong integrated programs are collaborative and link to other service providers, such as those who specialize in mental health, substance use, housing, income assistance and food security. Such collaboration may be most useful in settings with limited resources, where community organizations develop strong linkages with other community-based and medical programs and services to provide navigation across the continuum of care.
Service mapping: A first step to developing integrated services
Service mapping is one strategy to develop integrated client-centred programs and services. It provides service providers a way to situate the frontline services they offer in the broader landscape of the HIV, hepatitis C and STI work taking place in the community.
Through service mapping, you can examine what services and programs you offer; the services and programs that other agencies in your community offer; the links between these services; the services and programs your clients use, need or want; and identify any service gaps that may exist in the community that may need to be filled.
There is no one approach to service mapping; some Canadian examples are highlighted later in this article. However, service mapping should try to
- include participation from community members, other services providers and program planners
- evaluate whether current services are appropriate for the population being served (for example, LGBTQ friendly, culturally safe for Indigenous people, women, ethnoracial communities, and people of all abilities)
- assess whether services are underused, overused or simply don’t exist.
Service mapping can be a launching point for a discussion about how to better collaborate with available services in your community. It may also help you determine which organization is best positioned to fill any service gaps.
What does service mapping look like?
Different communities and organizations have approached service mapping in a variety of ways. Here are some Canadian examples of how this has been done.
Peel HIV/AIDS Network maps services for people living with HIV
Peel HIV/AIDS Network (PHAN) undertook a community mapping project in 2015 to find out more about how people living with HIV in the region accessed the services necessary to maintain their health and well-being. The goal of the project was to find out what services people living with HIV in Peel Region were using, how services were linked and what services were missing. The final data from the mapping project will influence the way HIV services are offered at PHAN and in the wider Peel Region.
Five people living with HIV, known as consultants, were contracted to facilitate mapping sessions after undergoing training from Universities Without Walls, the education and training arm of the Ontario HIV Treatment Network. These individuals were trained in community-based research, data analysis and facilitation techniques.
Over three 90-minute sessions, 20 people living with HIV from Peel Region drew maps of their community under the guidance of the five facilitators. On the map, participants were encouraged to illustrate what health and social services and support they accessed and then highlight links between them. The map was a tool of engagement to help participants think about the services they access, the services they need, and whether those services could better link to each other.
The final report on the community mapping exercise is expected in January 2016.
Projet Mobilise! asks gay men and other men who have sex with men about HIV prevention
Projet Mobilise! is a community-based research project designed to increase access to, and use of, HIV prevention services among gay men and other men who have sex with men (MSM) in Montreal. The project has 31 partners, including researchers, service providers, community organizations and community members and will run from 2015 to 2017.
The goals of this project are to:
- create better access to a combination of prevention services
- increase demand for services by improving the knowledge and capacity of gay men
- improve service delivery through the development of intersectoral collaboration and improved approachability, acceptability and appropriateness of services.
This project was informed by a 2012 ethnographic study that mapped programs, services and care in Montreal. This was done by enlisting four gay men to access services and report back on their experiences. This real-life research found that the system was not accessible, approachable, available, affordable or appropriate to gay men. These preliminary results informed what was needed: intersectorial collaboration, community mobilization and systemic change.
City of Winnipeg: Mapping HIV prevention and education services
In 2015, Nine Circles Community Health Centre convened an advisory body (comprised of seven different organizations) to assess HIV and STI prevention and education services in Winnipeg.
The goals of the project were to:
- find out if service providers offer the right services in the right places to the right people
- determine if services are being duplicated
- identify any gaps in services
- Assess the readiness for organizations to begin to look at the collective impact of services
The map of services was developed by a consultant who interviewed organizational representatives from any agencies offering HIV/STI prevention and/or education in Winnipeg. It is expected that the map will help Nine Circles as well as their partners to strategically plan their prevention and education services and better refer schools, youth groups and community groups that serve people at risk for HIV and other STIs to the right service provider.
The advisory team has also asked the consultant to conduct a review of Canadian collective impact initiatives. Collective impact looks at a system (in this case HIV prevention and education) and determines what measures are required to create a shared voice for change in that system.
This initiative has encouraged the committee members to move forward with a goal of better coordinating services.
Vancouver Coastal Health takes a look at the HIV system of care
Vancouver Coastal Health Authority (VCH) used a service mapping approach to pinpoint gaps in their system of care to improve the delivery of HIV services in the city. This approach allowed VCH to:
- prioritize the needs of the client or populations over the needs of the provider or system
- look at how parts of the system of care were working and whether they were working together
- look at how the system was functioning for a variety of populations and from a variety of perspectives.
VCH examined all services they delivered and funded in the health region and conducted community consultations with service providers to build their service map.
VCH used a number of strategies to map services in the city. VCH mapped a client’s journey through the continuum of care from prevention, through testing, diagnosis, public health follow-up to treatment and care. This was done by locating every service the health authority delivered directly, services contracted with NGOs to provide on its behalf, and services provided by other organizations. These services were laid out on a client journey framework. The framework followed the HIV service continuum from primary prevention, through HIV testing, HIV diagnosis, linkage to care, treatment supports and to end of life. When located on this framework, and organized by population of focus or neighbouhood, VCH then ran several client profiles through the service map to identify where the system worked well and where there were gaps in services or difficulties with connections, transitions and collaborations. These gaps became important priorities in the development of Vancouver’s new service-delivery models for HIV services.
The health authority also used geo-mapping to find out the number of HIV tests conducted per 10,000 people by local health area The geo-mapping was able to show VCH which neighbourhoods and municiipalities had inadequate access to HIV testing. Once established, targetted efforts were made to increase access to HIV testing by connecting with primary care physicians and acute care facilities and implementing other testing strategies.
Finally, VCH created an inventory of the HIV services available in First Nations communities in the Vancouver Coastal Health Authority. This was done by developing an inventory of all HIV prevention and testing activities identified by UNAIDS as best practice. The health directors in each of the 15 First Nations communities in the region completed the assessment with their staff, indicating whether access to services was good or needed improvement, and whether the services needed improvement or were not provided. This inventory supported the development of an HIV strategy for First Nations communities in the VCH region.
Service mapping in the health authority allowed VCH to plan HIV services accordingly and to target resources where they were most needed. Through service mapping, VCH was able to identify a need for and establish specific programs and resources. This included establishing a health promotion case management program to support resilience among people who are at high risk for HIV but who are HIV negative; establishing a nurse practitioner position for HIV-negative gay, bisexual and other MSM; and increasing access to HIV testing in particular communities through pharmacy-based point-of-care HIV testing.
About the author(s)
Laurel Challacombe holds a Masters degree in Epidemiology and is currently Associate Director, Research/Evaluation and Prevention Science at CATIE. Laurel has worked in the field of HIV for more than 10 years and has held various positions in both provincial and regional organizations, working in research and knowledge transfer and exchange.
Logan Broeckaert holds a Master’s degree in History and is currently a researcher/writer at CATIE. Before joining CATIE, Logan worked on provincial and national research and knowledge exchange projects for the Canadian AIDS Society and the Ontario Public Health Association.