The St Vincent’s HIV and Related Programs service was one of only 4 services throughout Victoria that commenced in 2009 with pilot funding from Department of Health. The program now delivers services under the HIV and Related Programs and is fully funded as a mainstream service. The Infectious Diseases service provides assertive outreach, disease management, care coordination, allied health intervention and medical specialist services to people living with HIV with complex care needs. Clients do not have to reside in the Health Independence Program catchment area to be eligible for our program, nor must they be treated at St Vincent’s for their HIV. Our program ensures that each individual receives a tailored care plan to optimise their HIV treatment and address issues with medical conditions, physical function, and psychosocial status and improve self-management of their health and wellbeing.
Model of Care
People living with HIV are living longer and provide new challenges in healthcare which require a care-coordination approach to self-management of chronic and complex care needs. Our model of care provides a collaborative approach of specialist medical and nursing management and allied health intervention.
The HIV team works across the continuum of health care by spanning acute, subacute and community sectors. Direct client input and care planning occurs in the emergency department, inpatient units, sub-acute care settings and at the clients home and within their local community. Streamlining discharge and offering best practice HIV medical care in the acute care setting is a significant role played by the clinical nurse consultant, as is the social and emotional support of the HIV Social Worker during a hospital admission. Planning for transition home, post-discharge supports, and medical follow-up and community services is often better received from the staff of the HIV team, who knows the clients well, and can actively assist in discharge planning with clients who are hard to engage and private about their health and wellbeing.
The majority of intervention is conducted in clients’ homes and communities in an assertive outreach model. Phone calls are common as a form of monitoring and to sustain engagement.
Clients are actively recruited from our hospital’s Emergency Department, Inpatient Units, Infectious Disease Outpatient Clinics, Royal District Nursing Service and North Richmond Community Health. The HIV and Related Programs service has approximately 45 clients at any one time. The total number of people living with HIV accessing specialist medical treatment through the ID outpatient clinics at our hospital is over 100.
St Vincent’s HIV clients are more likely to be older, more likely to be female, more likely to be from a culturally and linguistically diverse background, less likely to identify with being homosexual and usually present with AIDS defining illnesses when compared to the mainstream HIV population accessing other Melbourne metropolitan health care services. Our clients do not access many of the HIV community based services, are often poorly supported by family and friends and in the vast majority of cases, have not disclosed their diagnosis to any other person. They are often medically complex, require salvage antiretroviral therapy necessitating careful medication management to ensure that ART drug resistance is minimised.
Our program ensures that each individual receives a tailored care plan to optimise their HIV treatment and address issues with medical conditions, physical function, and psychosocial status and improve self-management of their health and wellbeing.