SCG - HART

HART WHY HART? hart HIV and Hepatitis C infection in Saskatchewan is an ongoing epidemic. Presently at Westside Community Clinic (WSCC), located adjacent to St Pauls Hospital, there are 502 HIV positive patients on file, of which 370 (73%) have had a clinic visit within the past year. The HIV population from WSCC generated approximately 300 ER visits and over 115 admissions in the past 18 months. Furthermore, over 70% of these patients are co-infected with HCV, and majority are intravenous drug users. That equates to a large burden of disease. As we face the HIV crisis in the Saskatoon, it was timely that a response team was put in place to link hospital care with continued care in the community. Having a central team to react to needs of this very special population enhances patient engagement, improves patient compliance with therapy, reduces re-admission rates and ultimately reduces viral transmission. The ER and acute care wards currently do not have the resources to deal with this population, addictions, mental health and homelessness. HART improves care by dealing with issues of addiction and mental illness on admission and works with the community to ensure successful completion of treatment while in hospital and ongoing support and coordination of services, so patients can manage the symptoms of their disease in an appropriate community setting instead of the hospital. PROGRAM HART consists of a specialized nurse, addictions worker, Peer Support worker and community support worker that have a HIV, HCV network of services and community support including access to HIV physician support, HCV physician support, Methadone physician support, Infectious Disease Specialists and Obstetrician Specialists and community resources to increase client capacity to manage the symptoms of their disease in a community setting. When an HIV and/or HCV patient presents to emergency or is admitted to hospital, HART would be alerted and a reaction cascade initiated (after hours, calls would be deferred until the next morning). Any available information on the status of the patients HIV or HCV therapy would be provided, and if there is an HIV or methadone physicians involved, the appropriate connections would be made. Any patient needing an Infectious Diseases specialist would with access to these services in a timely manner. During the patients hospital stay, HART would engage with the patient and staff to ensure appropriate and timely coordination of care occurs both within hospital and in transition to community. HART has the connections, clear lines of communication, resources and training needed for effective and efficient provision of care. Quick, responsive, and reactive care expedites and coordinates hospital stays and ensures continued care in the community. HIV NURSE Will lead the HART team and coordinate response to needs of patients Will work with the ER department in assessment of needs related to HIV and social determinants of health Will support the I.D specialist on the wards with assessment, treatment plans and discharge to community Will liaison with primary care physicians to ensure timely and appropriate care in the community ADDICTIONS COUNSELOR Will complete addictions assessments, referrals and triage to substitute therapy Will liaison and work with methadone physicians to ensure appropriate addictions care is being received in hospital Will provide addictions support to patients in the E.R and on the wards Will coordinate discharge and provide follow up and linkages with Methadone physicians in the community OUTREACH WORKER Will provide care coordination in the ER and on the ward Will work with patient on addressing needs in the community (housing, income assistance Est) Will coordinate and transport to medical and social appointments to reduce barriers to accessing care PEER SUPPORT WORKER Will support and mentor patients in the ER and on the wards Provide practical advice and encouragement to reduce chances of AMA

HIV and/or HCV patient

Call (306) 244-1200, email info@sanctumcaregroup.com, or use the website.

Phone

(306) 244-1200

Email

info@sanctumcaregroup.com

Website

https://www.sanctumcaregroup.com/programs/hart