Systems Linkages and Access to Care Intriguing Improvement Strategies In Upper Manhattan October 31, 2012 TEMPLATE Systems Linkages and Access to Care for Populations at High Risk for HIV Infection in New York State

Agency Name Title: Name of your linkage or retention project Improvement Strategy: In one sentence, describe the most intriguing test of change or strategy that you have run & List the gap/barrier in linkage/retention that this strategy targets for improvement.

Agency Name What makes your Strategy “Intriguing”? How is your strategy new/unique in its design/concept relative to the care processes you usually provide? & What evidence/data can you share to demonstrate the positive impact of this strategy on linkage and retention?

Describe your next steps: (E.g.-Refine strategy and/or expand testing? Agency Name Next Steps Next Steps Describe your next steps: (E.g.-Refine strategy and/or expand testing? -Integrate into delivery care system? -Start over? -Seek technical assistance?)

Systems Linkages and Access to Care Intriguing Improvement Strategies In Upper Manhattan October 31, 2012 EXAMPLE Systems Linkages and Access to Care for Populations at High Risk for HIV Infection in New York State

Improvement Strategy: Heights Health Care + Community House Linking Young LGBT to HIV Primary Care Improvement Strategy: Involves--Primary Care Clinical Provider & CBO in a test of Linkage/Retention Collaboration Process—Use peer escorts to expedite the process of linking newly diagnosed Young LGBT patients to adolescent HIV primary care Barriers/Gaps Addressed: Discrimination and Alienation; Stigma; lack of trust/comfort in “traditional” services for homelessness/adults. Weak linkage/retention systems

Intriguing Design/Concept Heights Health Care + Community House What makes the Strategy “Intriguing” Intriguing Design/Concept One team across 2 very different agencies: Staff “move” with the clients across agencies Co-facilitated/supported activities “Maps” of expedited access/connection to care with clear roles/responsibilities

EXPEDITED Linkage to Care within 30 days Newly Diagnosed Young LGBT Heights Health Care + Community House Intriguing Results EXPEDITED Linkage to Care within 30 days Newly Diagnosed Young LGBT DECREASING No-Show Rate* *No-Show Rate = % of primary care visits where pts do not show Client and Staff Report: Increased support and coordination of care!! Next Steps Expand the peer escort strategy to include a second peer. Create a plan to sustain support group and measure impact.

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