PARTNERSHIP IN ACTION

A local example of community care for PLWHIV

Nalla Burk

HIV Clinical Nurse Consultant, RDNS Campbell Smith

Team Leader, VAC/GMHC Support

RDNS and VAC/GMHC catchment areas

• Nurses work from 21 sites across Greater Melbourne, about 5,000 square miles

• VAC/GMHC covers similar area and has 4 sites, plus some regional services

• Speciality HIV/AIDS nursing integrated within generalist nursing structure

• 3 HIV Clinical Nurse Consultants link RDNS expertise to HIV sector

• Hospital HIV liaison nurse • 4 HIV Resource Nurses • 1200 Registered Nurses

RDNS HIV model of care

VAC/GMHC Support

• Community-based support for PLHIV since 1984

• Volunteer teams provide social and practical support

• Attendant care and case management • Medical transport

RDNS, VAC/GMHC partnership

• 1985 – Informal partnership initiated • 1987 – Pilot project, evaluated in 1989 • 1990 – Formalised via Memorandum of

Understanding • 2006 – MOU revised, Partnership Agreement

established • 2010 – Revised and renewed

The partnership in practice

• Regular contact about client issues

• Shared role in HIV training for Support volunteers and RDNS nurses

• Joint projects (eg Tucker bag Meals)

What does it mean for clients

The partnership promotes engagement with services, which leads to:

• Better medication adherence

• Improved health outcomes

• Client independence

Treatment as prevention

• Engagement in care is critical to medication

adherence

• Clients required coordinated care

• Remove barriers in accessing care

Challenges

• Engaging with clients

• Behaviour management and boundary setting

• Sense of entitlement

• Capacity: managing entry and exit from services

Case study 1

MR R Mornington Peninsula, 60 After 20 years of poor health outcomes, care

coordination and partnership has achieved • Undectable viral load • Approx 100% medication adherence • Engaged in care • Boundary setting • Transport to medical appointments • Socialisation

Case study 2

Timorese woman, 30 • Resistant virus • Co infected with TB • Referred to RDNS • Daily visits initially • Assessed and referred to Support for women’s

afternoon tea. • Barrier to care identified

Case study 3

• 47 year old man • Living in caravan park • He was spending all money available to him on alcohol and

cigarettes. • Referred CVSP - Tuckerbag Meals and transport to medical

appointments • Initially Daily visits by RDNS • Introduction of 7 day dosette box. • Mr J was a RDNS client for a period of 12 months.. • At Discharge Mr J was able to identify strategies to engage in safe sex

and injecting practices. • 100% medication adherence • He had an undetectable viral load and CD4 of 550 • He is now employed working full time driving heavy vehicles.

Conclusion

• By working in partnership RDNS and CVSP are able to provide care which promotes; – Community model of care – Engagement in services – Coordinated care – Improved medication adherence – Education and health promotion – Treatment as prevention – Independence where ever possible.

Contacts Nalla Burk HIV CNC SE region 0416860878 nburk@rdns.com.au

Campbell Smith Team Leader VAC/GMHC Support 0413 886 867 campbell.smith@vicaids.asn.au