Module 6: Innovative Models of Care: In-reach


30 to 40 minutes

PLAN module


This module provides an overview and fosters discussion about the in-reach model of care. Participants will discuss the pros and cons of this model of care in targeting the marginalized and underserved PLWHA they wish to serve.

Materials Needed

  • Computer and compatible LCD projector to play the PowerPoint presentation
  • Notes created during previous modules
  • Paper and easel(s)
  • Colorful markers
  • Tape for affixing paper to the wall as necessary
  • A bowl or hat for the group activity
  • A printout of the Module 6 Case Study Profiles cut into individual strips and folded for selection from bowl
  • Copies of the Module 6 handouts to distribute
  • Invited guest speaker(s), as needed.

Module 6 features teaching material, guided group discussion, and a group activity.

The Facilitator or other appointed person should write key thoughts voiced by participants throughout the presentation and subsequent discussions on the paper.

Before beginning the presentation, distribute the Module 6 handouts: In-reach Script and Log and In-reach Logic Model.

The Facilitator should refresh participants about the previous models of care discussed, referring to the paper notes as necessary. The Facilitator should introduce the first slide, which serves as a refresher about the last session.

Slide #49: Training Refresher

Before we begin, let’s review the pros and cons of the previous model we reviewed.

Slide #50: In-Reach (Reconnecting Past Patients Lost to Care)

In-reach involves reaching out to former patients of the clinic and reengaging them in care. Some things to consider about this intervention:

  • It is extremely cost-effective.
  • Both medical personnel and other clinic staff can facilitate this model with little training. They must be versed in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) before accessing records and contacting patients. Staff also must be able to quickly identify patients lost to care in the clinic’s database and/or paper patient records.
  • Contact with patients should be guided by a script, such as that described in the In-reach Script and Log Handout.
  • Other methods of in-reach might involve concepts borrowed from other models of care: – Conducting traditional street/social outreach efforts where you know many PLWHA who have fallen out of care may be, such as bars, clubs, and drug treatment and syringe programs. – Leveraging social marketing techniques, such as printed flyers and advertisements in public transportation areas, to encourage patients to return to the clinic. – Sending out general messages through social networking outlets via platforms commonly used by patients, such as Facebook and Twitter.
  • Reconnecting with patients offers them a lifeline back to care. They often require the assistance of an HSN and/or MI counselor to work out issues that drove them from care in the first place. Though time-limited, this intensified support may yield greater results than other models of care, depending on the stability of the PLWHA’s personal situation.
  • Administrative limitations such as out-of-date client records can hinder implementation of this model, although current patients with connections to those out of care may be able to provide support and connection to targeted PLWHA by referring them back to the clinic. Providers that have electronic medical records (EMRs) equipped with analytical tools can benefit particularly from this model.

Slide #51: In-reach (Reconnecting Past Patients Lost to Care) Logic Model


Here we have the in-reach logic model.

We follow a patient from initial encounter to engagement in care.

In-reach borrows from other models of care, but is still a unique approach to engaging PLWHA.

It is focused on developing a relationship with the lost
patient and bringing him/her back into care.

The Facilitator should invite participants who have conducted in-reach to respond to the material covered in this training and offer their thoughts.

Slide #52: Module 6 Activity: In-reach Role Playing

The individual scenarios below should be copied, cut out, and folded for selection from the bowl.

To test whether this model of care may work for the clinic, we are going to break into pairs and engage in a role-playing exercise using the In-reach Script and Log Handout as a guide.

Everyone is going to pick a scenario from the bowl and take turns playing the “Clinic Employee” and “The Patient.”

Before beginning a dialog, the “Clinic Employee” describes how he/she identified “The Patient” for this in-reach effort, answering the following questions:

  • Did you find this person in paper files or the clinic’s EMR system?
  • How are you logging the information collected during and after your interaction? How are you contacting this person? By telephone?

Case Study Profiles

  • The Clinic Employee is speaking to Bea, a 60-year-old African- American woman who has four adult children. She was diagnosed with HIV and AIDS 5 years ago. She was engaged in care until becoming the legal guardian of her grandchildren 1 year ago. Her EMR indicates that she has missed several laboratory tests and did not fill her last prescription. When contacted by telephone, she says she does not have time to go to appointments.
  • The Counselor meets with Brian, a 45-year-old White man who has a long history of SUDs and has been sporadic to care since learning his serostatus 6 years ago. He is resistant to several HIV medications due to a history of treatment-adherence issues. Brian also frequently experiences food insecurity and shelter instability, and engages in sex work to survive.
  • Dwayne, a 22-year-old African-American gay man had a reactive oral swab HIV test in a mobile van. He came to the clinic several times after that initial encounter to have his results confirmed and other lab work done. He returned for his results but has not been seen at the clinic for the past 9 months. Several friends have come to the clinic and shared with staff that Dwayne broke up with his much older boyfriend and is now living on the street.
  • Mary is a 45-year-old transwoman living with HIV and hepatitis C. She has struggled to stay clean. For a while, she came to the clinic regularly and even began training to be a peer counselor. When she started using heroin again, however, she disappeared. The only contact information the clinic has is her e-mail address, since her phone has been turned off.
  • Guy is a 42-year-old Native American man who lives in the city. He and his wife have been married 10 years and have 2 children. They often experience food insecurity and shelter instability since Guy lost his job in 2007. After learning his HIV status 2 years ago, Guy has come to the clinic sporadically. He often misses appointments and is not treatment-adherent. He seems depressed but refuses to see a counselor. He is extremely concerned that his family, especially his wife, will learn he has HIV.

Lead the group evaluation discussion on whether this model of care will work for the clinic. Have participants refer to the Model of Care Evaluation Handout from Module 3.

Tape several pieces of paper with the model of care’s title on each.

Slide #53: Group Module Evaluation

Read each question/statement and then write down everyone’s thoughts, questions, suggestions, etc. on the paper.

  • Can this model of care be readily integrated within the clinic’s current operations and help it reach targeted populations of PLWHA?
  • Does the clinic already use this model of care, perhaps in a slightly different form?
  • Can the clinic satisfy all the requirements for this model of care?
  • What funding streams, staffing, materials, and other resources are necessary to implement this model of care? Does the clinic have access to these? If not, how will it access them?
  • How will buy-in be secured within the clinic?
  • Will the implemented model of care be promoted to potential patients? If so, how? Online through social networks? Word of mouth?
  • Does this model of care help the clinic identify and engage targeted PLWHA populations into care?
  • Compare the pros and cons of this initiative with those of the modules.

If more than 10 people are present, the Facilitator may split participants into two or three groups to discuss the questions above and write their thoughts on the paper. After a few minutes, the Facilitator should reconvene participants. Representatives from each group will explain their colleagues’ thoughts.

Save the paper from this and previous modules for reference in future sessions.