Data to Care Model Specification Date: _________ Health Department: _________________ Program Name (if applicable): ________________

Problem statement: To link or re-engage PLWH reported to eHARS as of _ _/_ _/_ _ (“index date”) who are alive as of the index date, and with no CD4 or VL test for __ months before the index date.

Data to Care Model Specification

Step 3

Data to Care Model Specification

Step 6

Data to Care Model Specification

Data to Care Model Specification – Providers

Yes Yes Yes

Yes

Or And/or

And/or

And/or

And

And

And

Navigation Program Flow Chart

Contacted! Patient Agreed

NAV contacts patient to

schedule initial appointment and

enroll in Navigation Program

Moderate (MI)

IN CONSISTENT CARE (Intervention Ends)

Yes

In care elsewhere, case closed Linked to care

(medical, case management)

Unable to find, case

closed

Yes

No

Case closed

Low (Resources)

Initial appointment with NAV:

-consent

-survey

-intervention intensity assignment (Low, Mod, ARTAS)

ARTAS

Intervention

Transitional Retention

- NAV follow-up for 6 months after linkage

- additional NAV visits as needed

Not Linked

Not Linked

Clinic staff updated info in Casewatch

Referral to navigator

(NAV)

Initial attempt to contact using

clinic contact info

Clinic/Surveillance list of out of care

individuals

Located?

1) Utilize HARS/ Casewatch to gather contact info/status

2) Coordinate with MCC & prioritize

3) Utilize MMP/PHI investigative methods to locate

No Confirm

eligibility with clinic staff

Example from Los Angeles County, in+care Campaign presentation(available at: http://www.incarecampaign.org/files/85133/Linkage%20and%20Reengagement%20Programs%2003052014.pptx )