LINCS

National statistics indicate that many HIV treatment programs experience a greater than 30 percent rate of clients lost-to-follow-up each year. This not only compromises individual’s health status, but also has impact on overall community and public health. In an effort to address these issues, reduce the health disparities, and improve health outcomes for out of care HIV positive African American and Latino women and youth in Alameda County, WORLD, in collaboration with the Family Care Network (FCN – have a link to FCN here), developed the LINCs program. LINCs (Linkage Improvement for Network Clients) works to establish and reinforce linkages with newly diagnosed women/youth and those who struggle getting the medical care and support services that they need and deserve.

The goal of the project is to improve health outcomes for hard-to-reach HIV positive women, and youth in Alameda County. LINCs provides client navigators (link to Client Navigator bios here) to bridge the gap between clients and health providers, and focuses on the following objectives: 1) to enhance access and utilization of primary care services, 2) to improve participation in continuum care services, and 3) to promote HIV/health knowledge and healthy behaviors.

In order to reach the clients, the LINCs program interfaces with primary care sites to illicit referrals of clients who have fallen-out-of-care or are at high risk. These include Highland Hospital Adult Immunology Clinic, East Bay AIDS Center, Downtown Youth Clinic, Children’s Hospital, Magic Johnson Community Clinic, and Kaiser Permanente – Oakland. Client Navigators outreach to these clients in order to establish rapport, assess needs and capacities, identify barriers and gaps in care and knowledge, and to establish a plan for overcoming these obstacles. Activities include addressing immediate life and health care needs, life/health goals and plans, health education, and life/health skills development. Navigators assist clients in setting appointments and accompany clients to appointments. They provide a link between positive women and providers assisting them in accessing the care and support that they need to improve their health by coordinating with Peer Advocates (link to WORLD Peer Advocacy Program), Case Managers, Nurses, Nurse Practitioners, and Doctors to ensure that clients’ needs are being met, and that barriers to care are being addressed.

Client Navigators also collaborate with other local CBOs by targeting drop-in centers, methadone clinics, needle exchange sites, medical marijuana dispensaries, and other agencies that provide services to clients, as well as doing street and prison outreach when and where necessary. Local testing sites are also targeted to identify newly diagnosed women and youth.