Each year, more than 80 people are diagnosed with HIV in Toronto through immigration clinics. Newcomers to Canada may not know how health care systems work and may have limited health insurance and drug coverage. They may also be fearful about how this diagnosis could affect their immigration status and about disclosing this information to others. Fourteen percent of clients served by Ontario AIDS Service Organizations report care challenges related to recent immigration. Precariously insured newcomers such as visitors and foreign students are also being diagnosed at public health testing sites, with very restricted options for HIV care due to limited drug coverage and other affordability issues. The Toronto to Zero Linkage to Care working group identified the need for enhanced services to this community.
In response, the OHTN, Toronto Public Health, Hassle Free Clinic and the AIDS Bureau partnered to pilot the new role of a Linkage to Care Coordinator serving immigration clinics and newcomers. Simran Kaur was hired in the fall of 2018 to develop this service and provide support to this underserved population.
In the first few months, Simran consulted with public health nurses, community-based agencies, testing services, and immigration clinic physicians to adapt the pilot to the needs of potential clients and the participating clinics. It was vital to create procedures that:
- offered a simple referral process for immigration physicians to complete
- respected the confidentiality of clients
- linked clients to the coordinator quickly after diagnosis.
Following extensive outreach, six of 13 possible immigration clinics agreed to be part of the pilot. A formal process for referrals was launched in January 2019, and the pilot has steadily gained visibility and support since then. In addition, the consultation process highlighted the number of vulnerable newcomers that needed to be re-engaged in care – due to challenges navigating medical and drug coverage or a history of other issues (housing instability, mental health challenges, and problematic substance use), which had diverted them from treatment.
With the client’s verbal consent, clinics or agencies contact the linkage to care coordinator to provide support, including referring the client to HIV care. Simran calls clients within 24-48 hours of referral, and schedules an intake appointment in a place convenient for them. She introduces newly diagnosed clients to needed providers often accompanying them to service visits. Simran can also provide one-on-one counselling and short-term case management services, ultimately linking clients to AIDS service organizations and settlement services for ongoing help related to housing, employment, legal needs, mental health and crisis services and other ethno-specific support services.
Simran can also provide one-on-one counselling and short-term case management services, ultimately linking clients to AIDS service organizations and settlement services for ongoing help related to housing, employment, legal needs, mental health and crisis services and other ethno-specific support services.
In the first eight months of operation, the linkage to care coordinator pilot has supported 42 clients – including 25 who required initial linkage to HIV care. The coordinator has supported newcomers with a range of immigration statuses – most commonly refugee claimants and those with temporary immigration status (students or visitors). These individuals are particularly vulnerable to being lost to follow-up due to the limited services available to them and the costs often associated with their medical services.
The average time from initial contact to a client’s first medical appointment is 18.8 days, but the range is broad – from 5 to 77 days. The client’s path to care may be derailed by a lack of drug coverage as well as wait lists for affordable services. In addition to medical care referrals, Simran often helps people access housing, immigration services, and legal supports.
Building a Service Network
As this two-year pilot continues, the coordinator will work to build a more effective referral network particularly for under-insured clients. Care providers at Maple Leaf Medical and the Church Wellesley Medical Clinic have been generous in providing services in the downtown area, but challenges remain for clients attending newcomer clinics in Toronto, but who reside outside the downtown area.
Precariously insured clients need a range of services and the coordinator has also begun to facilitate links to other forms of support working within the new Blue Door clinic – another Toronto to Zero initiative – which was recently established at the Regent Park Community Health Centre to provide care to precariously insured newcomers living with HIV in Toronto.
A comprehensive evaluation of this pilot will be conducted over the coming year, now that the terms and scope of the linkage to care coordinator’s role has been defined and formalized. In the summer of 2019, a partnership agreement was signed with LOFT’s Positive Services Coordination to allow for coordination of care and referrals between these programs; similar agreements will be explored with other key partner agencies. If the efficacy of this initiative can be demonstrated, the partners hope that an ongoing linkage to care coordinator position will anchor a more effective network of HIV care and services for vulnerable newcomers.