What is the Program?
The Health Promotion Case Management (HCPM) program provides short-term (less than six months), outreach-based case management to individuals at ongoing high risk for HIV infection who could use support to remain HIV negative. The program works with clients to decrease their vulnerability to HIV by providing case management to clients to help them develop the self-efficacy and personal skills that strengthen their resiliency. Case managers support clients to make the changes they want to their behaviour, lifestyle, relationships, and emotional and mental health. Case managers also address structural barriers to wellness that impact people at ongoing high risk for HIV, including support to access social assistance, housing, and healthcare, and referrals to community, immigration and legal services.
The program provides support to at-risk individuals from the following groups:
- Indigenous peoples
- HIV-negative partners in serodiscordant couples
- Women
- Newcomers, immigrants and refugees
- Gay, bisexual and other men who have sex with men (MSM)
The objective of HPCM is to improve clients’ self-management skills and, through a care plan, to develop a web of service providers that helps clients remain HIV negative in the long term. Through strong community partnerships, HPCM reduces silos and improves integrated healthcare for people at ongoing high risk for HIV infection.
The program, based at AIDS Vancouver, serves Vancouver and surrounding areas. It employs six case managers, three of whom are hosted at AIDS Vancouver. Another case manager is hosted by Settlement Orientation Services, which works with immigrants, refugees and newcomers. Finally, two case managers are hosted at Inner City Women’s Initiatives Society, an expert community organization working with women in Vancouver’s Downtown Eastside.
This case study has been paired with two program elements, also on the health promotion case management program. For more information about the work of case managers with specific populations, see the HPCM program elements on working in the Fraser Health Authority with gay, bi and other MSM, and on working with Indigenous peoples in Vancouver.
Why Was the Program Developed?
The STOP HIV/AIDS Pilot Project (2010–2013) re-organized the HIV system of care for people living with HIV in Vancouver Coastal Health Authority (VCH) and Prince George. As part of this pilot project, and after it received ongoing funding, VCH hosted a series of community consultations. The goal of the consultation process was to find ways to provide the necessary and appropriate HIV services sustainably. Service providers and members of affected communities were invited to participate. During the consultations, services for people living with HIV and for people at ongoing risk for HIV were discussed. One of the suggestions that emerged from those consultations was the need for an intensive case management program for HIV-negative people. A similar program, the STOP Outreach Team, already existed for people living with HIV who were not well-engaged in their treatment and care.
As a result of the consultation process and based on similar programs in the United States, the Health Promotion Case Management (HPCM) program was established in 2014 to provide intensive case management services in Vancouver and surrounding areas for people who were at high risk for HIV infection but who were known to be HIV negative or did not know their HIV status.
How Does the Program Work?
The Health Promotion Case Management (HCPM) program provides short-term, outreach-based case management to individuals from specific communities who are at high risk for HIV infection and who could use support to remain HIV-negative. The program is managed by a clinical supervisor at AIDS Vancouver. The work of case managers includes outreach, meeting clients, accompanying them to appointments, or staffing drop-in hours in community spaces around the city.
Three case managers work at AIDS Vancouver, while three others work in community-specific organizations around the city. One case manager is hosted by Settlement and Orientation Services and works with newcomers, and two are hosted by Inner City Women’s Initiatives Society and work with women. The diffused model of service is beneficial to clients because it means they can access case management in agencies that are already familiar to them.
Case managers work with clients to decrease vulnerability to HIV by focusing on their strengths and resiliency. Case managers support the development of self-efficacy and personal skills that can strengthen resiliency by supporting them to make the changes they want to make to their behaviour, lifestyle, relationships, and emotional and mental health. The program also addresses structural barriers to wellness that can impact people at ongoing high risk for HIV, including support to access social assistance, housing and healthcare, and referrals to community, immigration and legal services.
Referrals come from HIV testing nurses, healthcare providers who see people living with HIV whose partners are HIV negative, and other primary care providers. In addition, referrals also come from population-specific service providers such as immigration consultants, staff at Indigenous agencies, and service providers that work with gay, bisexual and other men who have sex with men. Completed referral forms are faxed to AIDS Vancouver.
There are also a significant number of self-referrals to the program. HPCM is widely advertised in community spaces (clinics, drop-ins, bathhouses, etc.) and individuals are encouraged to call the clinical supervisor directly for more information. In this instance, intake is done over the phone or in person, rather than through a referral form.
HCPM case managers are often present at HIV and sexually transmitted infection (STI) testing events around the city. Clients attending these drop-in testing events can talk to a case manager and be assessed to determine if HPCM is the right support service for them. The presence of case managers at testing events means that clients can have immediate linkage to support services if they want them.
Services
HPCM case managers typically work at both the individual and structural level with clients to reduce their risk of acquiring HIV. At the individual level, case managers work with clients to identify the strengths, values and behaviours that have been useful to them in reducing their risk for HIV. Case managers help clients identify specific health and wellness goals and work with clients to make positive changes to behaviour, lifestyle, relationships, and emotional and mental health that help them achieve those goals. Positive change shows clients that they have self-efficacy and the ability to manage their own health and wellness.
At the same time, case managers work to reduce structural barriers clients may face to health and wellness. They provide support to access forms of identification, social assistance, housing, and substance use and mental health services. Case managers also make referrals to community, immigration and legal services when necessary.
In addition to one-on-one support, HPCM has also hosted a support group for clients of the program and members of the community who may be interested in joining the program. The drop-in support group ran for eight weeks. Each week a new topic was discussed and participants had the opportunity to draw on the experience of their peers and the expertise of the case managers. The group was a good way for participants to be introduced to the program and its case managers in a safe, low-threshold space. The challenge for case managers has been finding the time to run subsequent support groups.
Tools
Although services are adapted to the needs of clients and reflect the needs of the wider population served, HPCM ensures that all clients receive quality, equitable services by providing each case manager with standardized tools to do their work. Tools such as intake forms, assessment forms and care-planning templates help case managers provide similar services. Case managers are also required to keep the same documentation standards, regardless of the community they serve or the agency that hosts them.
HPCM uses a client database to compile all client documentation. All clients’ files can be accessed and consulted by the clinical supervisor and all six case managers. This allows all case managers and the clinical supervisor to provide services to any client, if the need arises. For example, when a case manager is unavailable and one of their clients needs support, the clinical supervisor or another case manager can access the client file and quickly understand the client’s broad goals, strengths and challenges and offer them support.
Transitioning from the program
HPCM is an intensive, short-term (about six months) program. When clients have achieved their short-term goals, case managers start to plan for a transition to a more sustainable network of support for clients. Although some clients may not want or need a transition plan, case managers spend a significant amount of time with clients identifying the supports they have available to them and creating contingency plans if the client feels they need extra support. Typically, clients are followed for three to six months after they transition out of the program to ensure they maintain the positive health and wellness changes they made working with their case manager. Client files are never closed. Instead, the files of clients who do not need intensive suppport become inactive. Clients can return to the program at any time, if they need to.
Many clients need more long-term support to achieve their goals and be able to sustainably reduce their risk of HIV acquisition. These clients tend to stay with their case managers longer than six months. Most clients who need long-term support face complex life circumstances. Structural barriers pose a significant challenge as there is an inadequate number of housing suites, and spots in susbstance use and mental health treatment programs are limited. Many clients also live with histories of trauma, violence, residential schools, homophobia and transphobia. Many have a deep mistrust of health and social service providers that can take months to break down.
Relationships with other service providers
Through an existing partnership between AIDS Vancouver and Vancouver Coastal Health, HPCM clients have access to clinical services through clinics run by the health authority. This has built relationships between HPCM case managers and physicians and nurses. In addition to healthcare providers, case managers build networks of other service providers to which clients can be referred for needed services in housing, substance use, mental health, immigration and legal services. Appropriate population-specific service providers are identified by recommendations from other community workers, and client reports of positive experiences. Because the case managers work with different populations, the relationships they form are sometimes different from case manager to case manager. Over time, these service and medical providers become client referral sources for the HPCM program.
One of the goals of the HPCM program is to transition clients out of the program into a network of other service and medical providers who can work with clients sustainably to maintain positive health and wellness and reduce their risk for HIV acquisition. Relationships with other providers who can provide the supports clients need is a crucial component of ensuring the program’s clients are successful over the long term.
Supervision and support
The HPCM program is overseen by a clinical supervisor at AIDS Vancouver. The supervisor is responsible for overall management of the program, and increasing awareness about the program among healthcare and service providers.
The clinical supervisor is in daily contact with case managers, either over the phone or in-person. In addition to informal daily contact, the clinical supervisor has a bi-weekly meeting with each case manager to debrief on clients and brainstorm potential ways to better support them. Bi-weekly supervision meetings happen in person for all case managers, including those who are hosted at agencies other than AIDS Vancouver. This face-to-face supervision gives case managers an opportunity to talk about successes and challenges with clients, and allows the clinical supervisor to offer guidance.
The clinical supervisor and all the case managers also meet monthly for group supervision where operational and administrative information is shared. Specific client cases may also be discussed as a way for case managers to support each other. Quarterly, the group supervision meeting is given over to educational sessions led by the clinical supervisor or an outside expert on a timely topic relevant to clients and/or the work of case managers. Topics are identified by the case managers and are determined by local emerging trends. In January 2017, for example, the case managers received training on fentanyl and the overdose prevention sites set up to address the growing overdose crisis in Vancouver. Educational sessions deepen the case managers’ knowledge and skills which help them respond to the evolving needs of their clients.
Developing new or adapting existing policies
HPCM was a new program model for AIDS Vancouver. Most of the work is outreach-based and AIDS Vancouver is not the home agency of three of the six case managers . AIDS Vancouver had to adopt new or adapt existing policies related to outreach, communication and documentation.
AIDS Vancouver adapted its outreach policy to reflect the needs of the HPCM program. Before the program was established, AIDS Vancouver’s outreach policy stipulated that staff could only conduct outreach during the agency’s operating hours, and they should start and end their work days at the office. The policy was updated to reflect the work of HCPM case managers, which can require them to conduct outreach in the evening or spend the whole day offsite.
The agency’s communications policy was also adapted to meet the needs of HPCM case managers. Other staff at AIDS Vancouver typically work in the office and can communicate with their supervisors face-to-face as needed. Because this is not the case for the HPCM case managers, they are expected to check in at the beginning of the day and check out at the end. They are expected to keep their calendars up-to-date and to communicate changes in their calendar to their clinical supervisor when they arise. Each case manager has a dedicated mobile phone and laptop to help them stay in touch.
Required Resources
- Strong community partners with an interest in collaboration and hosting a case manager.
- Engaged case managers with strong ties to their community.
- Clinical supervisor with the ability to provide clinical supervision and to coordinate the program.
Challenges
- Complex client needs. Originally, the program was meant to be a short-term intervention to bridge clients at risk for HIV infection to a long-term network of supports. Case managers have found, however, that the needs of clients are more complex—housing, substance use and mental health treatment, among others—and require longer-term engagement.
- Increased use of stimulants. An increase in stimulant use among some populations has made the work of case managers more difficult. Stimulants, such as crystal meth, are highly addictive, treatments are inadequate, and as people become more active in their addiction it becomes more difficult to address their basic needs.
- Systemic factors. Lack of adequate resourcing for income-assistance, housing, transportation and food security programs impacts the ability of the program to best support clients. Ongoing shortages of both competent primary care providers and counselling spots for substance use treatment and mental health also make it difficult to support clients effectively.
- Working across multiple organizations. Although the HPCM program is coordinated by one organization, it is delivered across a number of organizations with different mandates. Open, mindful communication between administrators, managers and frontline services providers has been one way to overcome this challenge.
Evaluation
The HPCM program evaluation uses a mixed-method model that incorporates both quantitative and qualitative analysis. It assesses process, outcomes and impact:
- Process: The evaluation uses focus groups and surveys to assess fidelity to the model and leadership/partnership components. Case managers participated in a focus group to review the workflow, documentation and team functioning. The Lead Agency model, and communication and partnership strategies were assessed using components adapted from the validated Partnership Self-Assessment tool from the National Collaborating Centre for Methods and Tools.
- Outcome: Short-, medium- and long-term outcomes were identified in the program logic model and proxy measures were assigned for each outcome. To effectively evaluate change in client vulnerability, AIDS Vancouver adapted the Ryan White Acuity Measurement Scale (from the U.S.) which accounts for both behavioural and structural risk factors and is administered during intake and then at six-week intervals.
- Impact: To assess program impact, Vancouver Coastal Health’s Public Health Surveillance Unit will follow two cohorts to monitor HIV incidence. Cohort A will be clients who successfully complete the program and cohort B are those do not complete the program.
Lessons Learned
- Hire the right people. The program uses a hiring process that identifies strong case managers who can work independently and who can connect with the community they are serving. The clinical supervisor looks for specific skills and qualities, and the HPCM program hiring committee always includes one representative from an organization that specializes in the community in which the case manager will be working (Health Initiative for Men, for example, sits on hiring committees for case managers that work with gay, bi and other men who have sex with men).
- Strong champion. Each partner organization needs a strong champion of the program. Having a strong champion ensures that AIDS Vancouver and its partners are striving for the same goals and the work of individual case managers is not lost in an organization with competing priorities.
- Diverse ways of working. Although each case manager’s objective is to reduce the risk of HIV infection among clients, each case manager works according to the needs of their clients, offering different services and supports.
- Plan for client transition. When clients have achieved their short-term goals, case managers start to plan for a transition to a more sustainable network of support for clients.
Other Useful Materials
Resources
Outreach Planning Guide For Infectious Disease Practitioners who work with Vulnerable Populations
2012, National Collaborating Centre for Infectious Diseases (NCCID)
Guideline or manual
English, French
More information
Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: Recommendations for a public health approach - Second edition
2016, World Health Organization (WHO)
Guideline or manual
English
More information
Guidance on Couples HIV Testing and Counselling Including Antiretroviral Therapy for Treatment and Prevention in Serodiscordant Couples: Recommendations for a Public Health Approach
2012, World Health Organization (WHO)
Guideline or manual
English
More information
Contact Information
Ilm Kassam BSW, RSW
Program Manager and Clinical Supervisor
Direct Line: 604-696-4677
Confidential Fax: 604-893-2205
Email: ilmk@aidsvancouver.org