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Description:LINCS uses data-to-care (D2C) strategies to identify PWH who are NIC and patient navigation services to re-engage them in HIV care. LINCS uses three D2C referral strategies – referrals from (1) health care providers, (2) HIV surveillance epidemiologists, and (3) LINCS navigators using a clinical electronic medical record (EMR) registry matched to surveillance. All referrals are identified via the absence of viral load or CD4 test results or the presence of a recent high viral load (VL) value (VL >1500 copies/mL within last 4 months or no VL in >15 months). HIV surveillance epidemiologists use the viral load or CD4 criteria to identify patients in the Enhanced HIV/AIDS Reporting System (eHARS) for referral. Provider referrals also include patients with no evidence of care post-diagnosis, who have not accessed care over many months, or who are not adherent to medication. The clinical EMR match uses a registry developed through Health Resources and Services Administration HIV Ryan White quality improvement activities and includes all PWH receiving care in the public health clinics where LINCS navigators serve. The eHARS and clinical EMR are matched, and lists are sent to LINCS to determine current NIC status for referrals from all three sources prior to beginning outreach. Navigators attempt to locate individuals within 30 days of assignment using multiple electronic systems including the local STD surveillance database, the public health hospital EMR, and other disease intervention searching tools. PWH who are enrolled in LINCS are required to attend a relinkage appointment with an HIV care provider and receive short-term case management for up to 90 days; navigators provide a range of field-based services such as benefits navigation, appointment reminders, clinic accompaniment, motivational interviewing, and modified Anti-Retroviral Treatment and Access to Services (ARTAS) strengths-based case management.
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