Whitman-Walker Health provides medical care and enhanced social support to people outside of clinical settings through the Mobile Outreach Prevention and Engagement (MORE) program. MORE focuses on people who are not virally suppressed and/or who have not attended an HIV medical appointment in six months. Participants can choose from one of three MORE programs, depending on the intensity of services they want. Those at the highest level can receive medical care, social support, and lab draws in their homes or other community-based settings. Based on initial evaluation findings, participants who received more intensive MORE services were more likely to be virally suppressed and less likely to be lost to follow-up than those who received less intensive services. MORE is supported by funding from the Washington AIDS Partnership, the DC Department of Health, and various foundations.
Washington, DC
Regular attendance at HIV medical appointments promotes antiretroviral therapy (ART) adherence and viral suppression. However, research has found that many clients do not stay engaged in care;1 age, race/ethnicity, socioeconomic status, and substance use are all factors associated with lack of engagement.2 MORE was developed to make medical care more accessible, building off evidence of the positive impact nurse-led home visits can have on retention-in-care rates.3
“[MORE] services are provided outside the four walls of Whitman-Walker’s health centers to meet patients in their homes, community, or wherever is most convenient for them.”
People who are not virally suppressed and/or have not attended an HIV medical appointment in six months are eligible for MORE. These eligible clients meet with a mobile care navigator to discuss their HIV medical care and supportive service needs. The mobile care navigator introduces the client to MORE’s three programs (Low, Medium, or Full MORE), and the client selects which is the best fit.
Low MORE participants receive their medical visits at a Whitman-Walker Health medical center and labs during standard hours. They also have access to food cards, referrals for mental health services, and transportation support through bus tokens, Metro cards, and the coordination of insurance-sponsored transportation. Medium MORE participants receive care navigation at a Whitman-Walker Health medical center in addition to these services.
Full MORE participants can access mobile services. A mobile advanced practice practitioner provides medical care at the client’s home or location of choice. The mobile advanced practice practitioner can also serve participants at the Whitman-Walker Health medical center outside of standard hours. Clinical care consists of lab draws, identifying and treating urgent needs, making referrals to specialists or behavioral health care, monitoring vitals, and filling prescriptions. Clients can also receive visits from the mobile care navigator at their homes or locations of choice. The mobile care navigator schedules home visits, assesses and addresses medication adherence issues, uses motivational interviewing to encourage harm reduction techniques, and provides health education.
Through a MORE evaluation supported by the Center for Innovation and Engagement’s (CIE) Equity in Evaluation Project, 370 participants self-selected into one of three groups: Low, Medium, or Full MORE. Participants were followed for four years while receiving MORE services and one follow-up year. All three groups experienced an increase in viral suppression, but the Full and Medium MORE participants benefited the most from the program. The three groups shared similar baseline viral load suppression rates and demographic characteristics such as race/ethnicity, gender, and health coverage status.
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Source: NASTAD. Mobile Outreach, Retention, and Engagement (MORE) Intervention. [SPNS Equity in Evaluation Intervention Guide.] July 2022.
Referrals. Clients are referred to MORE in three ways:
- Clinic staff refer clients.
- A quality improvement team reviews medical charts twice a year to identify clients clinically eligible for MORE.
- Through the regional “Recapture Blitz” initiative, the DC Department of Health also identifies clients who are out of care and refers them to Whitman-Walker Health for MORE engagement.
A mobile care navigator reviews information to confirm eligibility and determines which MORE program the client would like to participate in.
Stakeholder input. Whitman-Walker Health met with various external and internal stakeholders to share the goals of MORE and obtain input on its design. Whitman-Walker Health leadership was provided information on the need for care in non-clinical settings and participant feedback on the value of the services.
Staffing. MORE is supported by three staff types. The mobile advanced practice practitioner provides clinical care in homes and the community. The mobile care navigator coordinates home visits and provides social support. Depending on the size of the program, multiple mobile advanced practice practitioners and mobile care navigators may be needed. Finally, a MORE program manager informs retention and engagement activities by sharing evidence-based practices and providing support to other staff members.
Training. These staff members receive training on social determinants of health, effective client engagement strategies, motivational interviewing, and navigating the electronic health record system. The mobile advanced practice practitioner is also trained on conducting blood draws in the community.
MORE is implemented in partnership with Washington AIDS Partnership, the DC Department of Health (Ryan White HIV/AIDS Program Part B funding), and various other funders, including Bristol Myers Squibb Foundation, MAC AIDS Fund, and ViiV Healthcare. Funding covers two mobile care navigators, two mobile advanced practice practitioners, and client costs related to transportation and food vouchers. It also contributes to the time of a social worker and a medical director.
- Mobile advanced practice practitioners and mobile care navigators need special traits to do their work effectively. Mobile advanced practice practitioners should have a strong willingness to conduct clinical care in community settings as well as experience working with diverse populations, including those with substance use or mental health issues. obile care navigators must be flexible and responsive to client needs and also organized to manage referrals and appointment scheduling.
- Caseloads were carefully considered, and clients with high needs were often assigned multiple team members to reduce staff burnout.
- Clients who want to stay with their current clinicians can still enroll in MORE, using mobile advanced practice practitioners only as needed. Mobile care navigators can support coordination with existing clinicians.
- While it only takes a mobile advanced practice practitioner an average of 20 minutes to travel to a client’s home, it might take another provider longer. Agencies should account for travel time when making decisions about how many clients to enroll in MORE and assign to a mobile advanced practice practitioner’s/mobile care navigator’s caseload.
- Staff should work together to agree on expectations around communication, dress code, and work schedule related to home visits.
- Providers should consider the best way to improve access to psychiatric care, whether through mental health staff on the MORE team or through internal or external referrals.
“The intervention team worked with [Whitman-Walker Health] WWH leadership to reduce the number of assigned patients to make caseloads more manageable for staff.”
Implementation Resources
Additional Resources
- Marks G, Gardner LI, Craw J, Crepaz N. Entry and retention in medical care among HIV-diagnosed persons: a meta-analysis. AIDS. 2010;24(17):2665–2678. doi:10.1097/QAD.0b013e32833f4b1b
- Retention in Care | Treatment, Care, and Prevention for People with HIV | Clinicians | HIV | CDC.
- Wood EM, Zani B, Esterhuizen TM, Young T. Nurse led home-based care for people with HIV/AIDS. BMC Health Services Research. 2018;18(1):219. doi:10.1186/s12913-018-3002-4
