Staffing
Key Considerations
A comprehensive D2C program requires significant staff time investment. Results from NASTAD’s National HIV Prevention Inventory (NHPI) found that for jurisdictions implementing D2C, staff capacity was the number one program challenge (reported by 63% (n=27) of jurisdictions implementing D2C). As D2C continues to scale up nationally, health departments must navigate the right balance of staff to operate their programs – both in terms of staff capacity and skills. Most health departments will require personnel from different programs and with different skill sets to collaborate. As of 2017, D2C programs most often used Disease Intervention Specialists (DIS) to re-link individuals found to be not-in-care based on surveillance data (80% of jurisdictions implementing D2C, n=35). Other categories of staff members commonly used by health departments for D2C re-linkage are specialized D2C staff (60%, 21), case managers (54%, 19), care program staff (51%, 18), and local health department staff (51%, 18). Fewer health departments used other categories of staff or partner organizations to facilitate D2C re-linkage. These other categories include prevention program staff, community-based organization (CBO) staff, health care providers, patient navigators, peer workers, HIV surveillance staff, and community health workers. Many jurisdictions also use various combinations of staff in the above roles to perform D2C-related linkage work.
Health Department Recommended Skills for Linkage to Care Staff
When hiring and training new linkage staff for D2C who will be working in the field to locate and re-link people living with HIV (PLWH) to care, health departments should determine what experience and skills are needed for working with communities in their jurisdiction. Some feedback shared by health departments to find staff who are a good fit include:
- If mental health or substance use barriers are common for not-in-care individuals in your jurisdiction, consider hiring staff with a background in these areas so they can help linkage clients navigate additional services.
- When hiring, build in ways to assess how prospective hires would interact with clients on a personal level. For example, address how they would practice cultural responsiveness with individuals from backgrounds different from their own.
- If your health department has staff in leadership positions who were formerly DIS or linkage staff, their input can be helpful in interviewing and writing job descriptions.
- Training new staff in interventions such as Anti-Retroviral Treatment and Access to Services (ARTAS) can be beneficial to provide enhanced client-level linkage skills.
Program Coordination
Having a shared understanding of the goals and benefits of D2C across your jurisdiction’s surveillance, care, and prevention programs can go a long way in building a healthy working collaboration and helping your program run efficiently. Coordination between programs can be formal or informal in structure. Some examples of what program coordination for D2C staffing may look like include:
- The health department’s prevention program provides funding for additional staff in other areas of the HIV program. For example, using prevention funds to fund data informatics staff within the surveillance program or funding additional partner services staff to work on D2C activities.
- The Ryan White HIV/AIDS Program (RWHAP) could use funds to pay for a percentage of prevention program staff salaries for D2C-related linkage work they perform.
- The surveillance and prevention programs may collaborate to create the not-in-care list and perform initial investigation before providing the cleaned list to the RWHAP staff. Then, the RWHAP staff would perform client outreach and linkage and bill for client interactions.
- D2C activities may be added on as additional duties for program staff already working in related areas.
- Programs may have informal ongoing collaboration between programs. For example, standing monthly meetings between DIS and RWHAP case managers.
Differentiating overlapping staff tasks can be challenging. For example, clarifying the “scope” of the role of a specialized D2C outreach worker, as compared to a DIS, as compared to a RWHAP case manager. If one category of staff perceive others are overstepping their roles, relationships can become strained. Having clearly defined roles and timelines for various staff working with not-in-care individuals can avoid this issue and increase productivity. For example, a program flow could look like DIS/D2C outreach staff having responsibility for getting a re-engaged D2C client to their first appointment and then transferring the client’s care to a case manager for supporting ongoing engagement in care. Or, DIS/D2C outreach staff could be responsible for working on re-linkage with an individual for a set period (e.g., 90 days) before transferring to a case manager. Supervisors for linkage staff should make efforts to communicate and coordinate regularly. Having case managers attend periodic partner services/DIS staff meetings to explain their work and troubleshoot any potential overlap among roles may be a helpful strategy. Building in ongoing opportunities to develop friendly relationships between DIS and care staff can also help facilitate honest communication about perceived “stepping on toes.”
Enhancing Provider Capacity
In some jurisdictions, access to medical providers can present a barrier to re-linking individuals to care. In this case, the health department should consider how to enhance relationships with medical providers or expand the number of providers who can provide HIV care. For example, some health departments have their medical director visit “Centers of Excellence” within the jurisdiction to develop relationships and help facilitate a peer-based approach to educate other providers within their jurisdiction on issues related to HIV care. If your jurisdiction has few infectious disease specialists, health departments can also explore telemedicine opportunities or using a detailer to work with primary care physicians to enhance their comfort providing HIV care and medications.
See Data to Care in the Field: Frequently-Asked Questions (FAQs) for additional considerations for D2C field staff, including discussions about collaborations, methods for locating and re-linking individuals who are not-in-care, managing caseloads, and data and evaluation for D2C outreach. For an additional health department example of D2C linkage strategies, read the success story from Detroit’s D2C pilot, Link-Up Detroit.
Health Department Example
Tennessee's DIS Re-Engagement Specialists
The Tennessee D2C program uses specialized staff, called DIS Re-engagement Specialists (Specialists), to locate, contact, and re-engage individuals who appear to be not-in-care. These staff members differ from the partner-services-focused DIS in Tennessee because they only work with clients who have been out of care for 12 or more months. Specialists also receive training in additional interventions, such as ARTAS, to help address barriers and develop linkage to care skills. Although they differ from other DIS, the Specialists will work with the “traditional” DIS in their region to gather locating information on individuals if they had a recent interaction with DIS for partner services. The Specialists also meet on a quarterly basis with each other to discuss clients and challenges and try to meet with the traditional DIS on an annual basis to provide updates.
Tennessee’s Specialists locate not-in-care clients through initial data searches and phone calls to providers, followed by contacting clients through phone calls, field visits, letters, and social media (specifically, using Facebook to try and determine whether a client has relocated and sending messages from a health department account to the client). Partnerships with local health departments also help locate individuals on the not-in-care list.
The Specialists also assess reasons why individuals stopped receiving HIV medical care, and work to address or remove barriers. Common barriers reported by individuals needing relinkage services in Tennessee include: lack of transportation, lack of insurance, work schedules, provider mistrust, mental health, substance use, lack of housing, and childcare issues. To address these barriers, Specialists also provide additional services beyond re-linkage such as providing direct transportation assistance or transportation vouchers for medical visits, facilitating referrals to RWHAP for individuals without insurance, and assisting with transitioning individuals to medical case managers if clients are eligible for RWHAP services.
In addition to working with clients, the Specialists also work with other partners to help provide seamless linkage services. Specialists perform annual visits with partner health care facilities to build relationships with providers and their front desk staff. Specialists will also coordinate with the health department’s Corrections Navigators who coordinate transitional services and linkage for clients within three months of being released from the state prison system. For more information on Tennessee’s program, contact: Kimberly Truss (kimberly.truss@tn.gov).
