LINKING AND RETAINING HIV
POSITIVE INDIVIDUALS IN MEDICAL
AND SUPPORTIVE CARE
Katie Horstmann
Wake County Human Services
HIV/AIDS Case Management
Supervisor
BACKGROUND
Wake County Human Services is the consolidation of programs and
services including social services, public health, mental health, job
training, child support, housing and transportation.
Under One Roof
Under One Roof is a collaborative
effort between Wake County
Human Services Case
Management/Bridge Counselors
and Alliance of AIDS ServicesCarolina (AAS-C).
Bridge Counselors History
• In 2001 the Did Not Keep
Appointment (DNKA) Rate among
HIV + clients attending WCHS
Clinic was the highest rate in
eleven years.
DNKA Rate
100
75
55
37
50
25
DNKA %
0
2003
2004
Source: WCHS CareWare
• In 2002 we applied for Ryan
White Part C funding to expand
clinical services that included the
creation of Bridge Counselor.
• In 2004 – Hired 1st Bridge
Counselor (RWC Funds) who
focused on getting new clients
into care.
• In 2005 initiated “Lost to Care”
(LTC) strategy.
Bridge Counselors History
• In 2006 a second RWB
Bridge Counselor was
added.
• In 2007 first full year
with two Bridge
Counselors.
• In 2008 gained 3rd
Bridge Counselor with 1
year grant from Hospital
Alliance funding.
60
DNKA Rate
50
40
30
20
10
0
Source: WCHS CareWare
Bridge Counselor Role
• Primary resource for newly diagnosed individuals, HIV
positive individuals transitioning care, and HIV positive
individuals new to Wake County in need of care.
• Coordinate medical and support services for newly
diagnosed individuals and those HIV positive individuals
not connected to either.
• Provides initial HIV education, social work assessment,
ADAP paperwork, and needed support service referrals.
• Track individuals who miss appointments and those lost
to follow up at WCHS HIV Clinic.
• Acquire and maintain a working knowledge of
community resources.
• Educate Medical Providers of BC Services and
Resources
BC PROCESSES
Under One Roof
1812 Tillery Place Suite 105
Raleigh, NC 27604
Criteria





Newly diagnosed HIV
positive
HIV positive moving
into Wake County
HIV positive individual
wanting to transition
care to another HIV
provider
Wake County Resident
Completed Bridge
Counseling
Agreement/Consent
You are eligible to receive the free services of a Bridge Counselor with Wake County Human Services. A
Bridge Counselor is a short-term case manager for clients who are newly diagnosed with HIV. The Bridge
Counselor will be available to discuss your feelings, questions, and concerns about HIV, as well as to
inform you about disease progression and treatment options. Part of this process may be assisting you to
find a suitable HIV health care provider.
The Bridge Counselor will also arrange transportation for your first clinic appointment and accompany you
to the appointment if requested. In addition, the Bridge Counselor can assist you with other needs you may
have, such as obtaining housing, food, disability, etc. Once you have accessed medical services with your
HIV health care provider, the Bridge Counselor will discharge your case, or if needed, refer you to longterm case management.
The Bridge Counselors and their phone numbers are listed below:
Andrew Farr, 919-856-5318
Betsy Santiago-Lane (Bilingual-English/Spanish) 919-856-5278
By signing below you acknowledge that you have read or been informed of the Bridge Counselor services
available to you. If you accept these services, you also give permission for the Bridge Counselor to obtain
your lab tests and inpatient or outpatient medical records, as these are needed for referrals to HIV health
care providers. This release of medical records will expire one year from the date of signature. Please
sign and date whether you accept or decline these services.
 I, ___________________________________, decline the services of the Bridge Counselor.
I, _________________________________, agree to accept the Bridge Counselor services. I also give
permission for either of the above Bridge Counselors to obtain my lab tests and medical records. I
understand that one of the Bridge Counselors will contact me within 48 business hours.
Date of Birth::______________________
Telephone Number(s)::____________________________________________________
Address::____________________________________________________
Client Signature
_________________________ Date _____________________
Referral source Name/Agency/Telephone:_______________________________________________
BC PROCESS
Once BC’s consent is received a Bridge Counselor will
contact client within 24- 48 hours.
To begin:
• Coordinating medical and support services for newly
diagnosed individuals and those HIV positive
individuals not connected to either.
• Initial HIV education
• Social work assessment
• ADAP paperwork
• Connecting to needed support services and referrals
2012 BC REFERRALS
Healing Place, 1
NCSU Hlth Ctr, 0
Lincoln/Durham, 0
Other/Unsure, 3
NCDPS/WCJ, 6
DOC, 12
WCHS - Other, 5
Self, 35
Clinic A, 7
Current
Client, 0
Friend/Family, 9
DIS - State, 24
ADAP, 3
DHHS
,1
WakeMed Raleigh, 14
Duke ID, 0
UNC, 1
Raleigh
Holly
ID, 1
Hill, 0
Duke
Raleigh, 2
AAS-C, 20
DIS - WCHS, 5
Rex Hospital, 1
WakeMed Cary, 2
2012 WCHS BC Data
BENEFITS OF BRIDGE COUNSELING
Bridge Counselors has been adopted by the
State of North Carolina as a Best Practice

Key strategic piece to engage
clients for life in medical
care

Higher percentage engaged
in treatment

Lowered Community Viral
Load

No show rate declined

Improved communication
among agencies

Services provided in both
English and Spanish
LEVEL OF INTEGRATION
HIV Acuity Scale: is a tool that helps identify
individuals level of need and standardize provision
of services.
 Helps providers identify referrals needed and
how best to work with other providers serving the
individual
 Helps identify social determinants that obstruct
individuals from achieving optimal health and
personal outcomes
 Helps prioritize staff workload base on clients
total points
 Helps program manage limited resources
WCHS HIV/AIDS ACUITY SCALE
1
4
2
5
3
1
2
3
4
5
Points
Disclosure
Client has no
issues with
disclosing
status to
anyone
Client has
disclosed status
to mostly
everyone in
support system
Client has
disclosed status
to some of their
support system
Client has
disclosed status to
one or two people
in support system
Client has disclosed
status to no one
Total Points
BRIDGE COUNSELORS AND HIV/AIDS CASE
MANAGERS
Wake County Human Services
THANK YOU