Improving Reengagement in Care: A Community Health Worker Model

In 2021, the City of New Orleans employed five community health workers (CHWs) to work with Ryan White HIV/AIDS Program (RWHAP) Part A-funded agencies on reengaging eligible clients back into care. CHWs contacted clients identified as out-of-care and helped them overcome barriers to attending primary care appointments. They also conducted HIV testing and prevention-focused community outreach, and administered patient experience questionnaires following appointments. From February 2021 through April 2022, CHWs attempted to contact 1,215 clients disconnected from care; 207 of these attended a primary care appointment and re-entered care, a 17% success rate at reengaging clients back into care.

New Orleans , LA

Implementation Guide
Evidence-informed intervention
Evidence-informed intervention
Icon for Intervention Type
Outreach and reengagement activities
Icon for HIV Care Continuum
Linkage to HIV medical care
Icon for Focus Population
People with HIV who are not in care
Icon for Priority Funding
RWHAP Part A; Ending the HIV Epidemic in the U.S. (EHE)
Icon for Setting
RWHAP-funded clinic or organization
Need Addressed

People with HIV who are engaged in care have better health outcomes, such as higher rates of viral suppression.1 Data showed that 33% of all people with HIV in the New Orleans Eligible Metropolitan Area (EMA) were not virally suppressed compared to 12% of RWHAP Part A clients in New Orleans, indicating that those engaged in care were more likely to be virally suppressed.2 However, many individuals disconnect from care due to a variety of barriers, lack of resources, or experiences with providers. Reengaging clients into care is often difficult because clients may not present themselves at service delivery entry points for support. Outreach is necessary to engage out-of-care clients, and CHWs are a proven resource for improving access to health services, increasing knowledge, improving trust with clients, and promoting health behavior change.

“[CHWs] have been very helpful in creating one-on-one relationships with our patients.”

Core Elements
Provider site flexibility in developing criteria for out-of-care clients

Client needs and barriers varied across participating RWHAP provider sites. Therefore, sites developed their own criteria for identifying out-of-care clients for CHW outreach, addressing each site’s specific needs. These lists included clients that providers were not able to reach, clients with identified barriers to care, or clients who were part of a population of focus (e.g., Black women). By having flexibility in who they could concentrate on for outreach, participating sites more effectively reached their intended populations of focus. 

CHW outreach and reengagement activities

CHWs, hired by the City of New Orleans, were assigned to work with more than one RWHAP provider site on reengaging the clients from their out-of-care lists. CHWs contacted clients via phone calls, texts, and video chat services (e.g., Zoom) to connect them to care. CHWs would help clients create a plan to address their barriers either by providing information on assistance programs (e.g., employment, transportation, counseling), providing vouchers for services such as transportation, or identifying alternative times to attend appointments. They would then set up the appointments or make referrals to services needed by the client, informing the client of the appointment dates and then following up with reminder calls/texts as well as affirmation and support for the clients. After appointments, CHWs would follow up with the client to assess for further needs. If the CHW was unable to contact the client via various methods, they would alert the RWHAP case manager who would then refer the client to a state linkage program.

Patient experience questionnaires

As part of their retention in care efforts, CHWs conducted patient experience questionnaires with clients after their appointments. These short questionnaires were designed to highlight in real time concerns that clients faced and bring them to the attention of the provider. Many clients reported feeling more comfortable discussing their experiences and concerns about services with a CHW than with other staff. Highlighting and addressing these issues is helpful in retaining more people in care.

Community outreach and education

As part of their outreach, CHWs regularly attended community events or community venues to distribute prevention information and resources (e.g., referrals for PrEP, information on at-home HIV testing). Additionally, they regularly engaged in stigma reducing activities, such as promoting the message of “U=U” (Undetectable=Untransmittable) and handing out “Stop HIV Stigma” pledge cards. These activities served to increase both connection with the community and awareness of the available services.


Between February 2021 and April 2022, 1,215 clients were identified and contacted; 207 (17%) were reengaged in care. 

Evaluation data

Out-of-care client lists developed by each provider site and logs CHWs used to track outreach.

  • Number of out-of-care clients contacted.
  • Number and % of clients who had a primary care appointment scheduled after contact with CHW.
  • Number and % of clients with a primary care appointment scheduled who attended that appointment.
  • 1,215 clients were contacted.
  • 455 clients had a primary care appointment scheduled (37.5%).
  • 207 clients with a primary care appointment scheduled attended it and re-entered care (17%).

Source: Murdock, D, Chanthala V, Lawless F. Improving reengagement in care using a community health worker model: Evidence from New Orleans. National Ryan White Conference on HIV Care & Treatment 2022.

Planning & Implementation

Learning collaborative. The idea for a CHW intervention to reengage clients in care was conceived as part of a learning collaborative with the University of California San Francisco in 2020. A root cause analysis was conducted around the goal of engaging people with HIV who disconnected from care in New Orleans during the COVID-19 pandemic. After identifying the major drivers, the City of New Orleans Office of Health Policy and AIDS Funding decided the CHW model of engagement was the best way to address the drivers and ultimately reengage people back into care.  

CHW staff recruitment and training. There were five CHWs hired by the City of New Orleans Office of Health Policy and AIDS Funding in collaboration with the Louisiana Department of Health to work with the 10 RWHAP-funded provider sites. Each CHW split their time across two sites. Training and supervision for the CHWs was provided in collaboration with the Louisiana Department of Health.

Range of participating sites. The 10 RWHAP-funded agencies were a range of community health centers, housing and support services providers, and healthcare education organizations, highlighting the adaptability of the intervention across a variety of settings, implementation locations, and service populations.

“From day one, [the CHW] has fit in with our staff with ease and has been a great asset to our department.”


The City of New Orleans Office of Health Policy & AIDS Funding used Ending the HIV Epidemic in the U.S. funds to hire the five CHWs. 

Lessons Learned
  • The flexibility permitted for provider sites in developing their own out-of-care lists meant that the CHWs were integrated into their existing workflows and were able to address that site’s specific needs.
  • Community outreach is essential for CHWs to build trust with the community and reaffirm their ‘insider status’ as community members.
  • Providers found that clients felt more comfortable speaking to CHWs about their concerns than with other provider staff. CHWs identified opportunities for quality improvement at the site that may have been overlooked, as well as eliciting concerns from clients that would have otherwise gone unaddressed.
  • CHWs and provider staff needed better communication and data tracking systems to ensure clients were not lost to follow-up, to prevent duplication of efforts, and to improve coordination between case managers and CHWs.
  • Many of the CHWs accepted positions at provider locations or with the Louisiana Department of Health. This outcome was viewed positively because it meant CHWs could continue their outreach and engagement activities within providers’ existing systems.

The CHW intervention is actually giving workers new skills that will enable them to strengthen the HIV care workforce.”

City of New Orleans Office of Health Policy and AIDS Funding
Daniel Murdock
EHE Manager

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