Welcome to Sanctum Care Group

HART

HIV AIDS RESPONSE TEAM

A partnership between Sanctum, Aids Saskatoon, Westside Community Clinic and Infectious Disease Specialist

Why hart?

hart

HIV and Hepatitis C infection in Saskatchewan is an ongoing epidemic.  Presently at Westside Community Clinic (WSCC), located adjacent to St Paul’s 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 patient’s 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 patient’s 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 physician’s 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

 Hart Chart

background information

  • In 2009, the incidence rate of HIV infection in the Saskatoon Health Region was more than three times the national rate. Although the rate has decreased, the 2011 rate in the region was still double that seen nationally.
  • Saskatoon Health Region has some of the highest rates of HIV/AIDS related deaths in North America.
  • In 2009, the new cases were predominantly found to be IDU (77%); and of this group, 84% were of Aboriginal ethnicity (Saskatchewan HIV Strategy).
  • A large percentage of persons living with HIV in the region also suffer from mental illness, addictions, homelessness and poverty.
  • Research indicates that 75% of Homeless individuals living with HIV and without support will die within 5 years. (North American Housing and HIV research Summit, 2011)

Homeless persons face numerous barriers to receiving appropriate health care. Research has demonstrated homeless persons have high rates of physical illness, mental illness, substance abuse, and early mortality. They are more likely to be admitted to hospital, have increased length of hospitalization, and present a 

  • substantial burden on the resources of safety-net hospitals and clinics. (JAMA)
  • Among persons who use injection drugs and visit a hospital, those who are HIV-positive are admitted substantially more often than those who are HIV-negative, and those who are HIV-positive have longer lengths of stay than those who are HIV-negative. (CMHA)
  • Extended hospital stays are often a requirement for appropriate treatment for such diagnoses as endocarditis, but due to the environment and the complex issues faced by this patient population, treatment often is not completed. In many cases for persons living with HIV or other chronic illness who do have a place to stay, the location has been “red flagged” by the health region thereby prohibiting the provision of home health care services for that individual. There are currently 45 buildings and homes that have been “red flagged” by Home Care in Saskatoon.
© 2018 Sanctum Care Group. All Rights Reserved.