In 2010 the Saskatoon Health Region developed a strategy to address the high prevalence of HIV in the province. The strategy looked at HIV prevention, treatment and support to: • Increase efforts to prevent transmission of HIV; • Provide for the treatment and support needs of clients affected and infected with HIV; • Realign or redesign services that are accessible and acceptable throughout the continuum of care; • Address injection drug use and HIV related stigma and discrimination. Typically, Public Health personnel notify new HIV clients of their diagnosis, identify contacts and provide education. A referral is made to primary care for continued follow-up. In the spring of 2012, outreach workers in Street Health began to follow new cases to provide transportation and/or accompaniment to medical appointments and provide assistance with addressing social issues such as housing. Relationships were established and contributed to greater compliance by clients to attend appointments. This model of care mirrors that which is used successfully in other services such as Mental Health and Addictions. In the summer of 2012, a social case manager was hired to coordinate client care by drawing on the existing internal and community supports and to provide the following services to clients and families: (1) outreach, referral, client identification, and engagement; (2) a bio-psychosocial assessment of the client; (3) the development of a service plan; (4) implementation of the service plan; (5) coordination and monitoring of service delivery; (6) advocacy on behalf of the client including creating, obtaining, or brokering resources needed by the client; (7) reassessment of the client’s status; and (8) termination of the case when services are no longer warranted. The Population Public Health Social Case Manger follows the newly diagnosed HIV clients, and previously diagnosed clients with HIV who indicate a desire to be connected or re-connected to HIV medical care, for 16 months to monitor and ensure they are linked, engaged and retained to HIV medical care. Since the implementation of the new model of care, the number of new HIV cases linked to care has been consistently above the target goal of 70% for the evaluation period of April 2012 to May 2013. For May 2013 80% of clients were linked to care. From August 2012 to May 2013, the percentage of cases engaged has consistently been above the 30% baseline set in 2011.The number of clients engaged is 50%-80% in each measurement month. In May 2013, 53.8% of clients met the 6 month engagement criteria. The percent of clients retained has increased from just below 30% in August 2012 to a peak of 78.5% in April 2013. May 2013 reported that 66.7% of HIV clients had been retained to care. With review of the success of the Social Case Management the position has been made permanent and discussions have taken place with key stakeholders to ensure transition onto other supports happen at 16 months so new clients can be linked to care.

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