To identify historic and current refugees screened at Touhy that are HIV infected and assure linkage to care.
A list will be provided for health promotor (HP) of their case load (10-15 patients). The HP will reach out to all of them and assure they are obtaining health services (often via a phone interpreter).
If the patient is out side the Sinai system:
The patient identifies active treatment with a follow up date of service this is documented and case closed.
If the patient is lost to follow up from their provider, the HP will offer to connect them with services at Sinai. If this is declined, a follow-up call will be made to the patient to assure they are connected with care. Once this is verified (outside the system) case closed. If pt chooses to connect in our system they follow pathway below.
Sinai Health System Connect with patient to assure adherence with meds and appointments. Identify gaps and aggressively manage them. E.g. transportation, misunderstanding of medications/adherence, social issues (connect patient to public aid [may escort], housing etc).
If the patient previously in our system but lost to follow up. HP will reach out and assist in getting pt back in system. HP will assist with transportation (via uber account) and may escort the patient to and INTO the office with the doctor then provide follow up support (private meetings/phone contact to assure the doctor’s message is understood/reinforced).
Any reasonable activities to assure the patient gains understanding, self-reliance, and improved adherence to medications/appointments all reasonable under this grant.
Documentation: CRITICAL –this is a state grant. Weekly reports of HP activities (name of patient, time spent, and activity) are required with the expectation of 40 of time/week for patient care. These will be submitted to Dr. Kaufman and subsequently submitted with our grant.
Commitment: this is a 40h/week grant from 1/1/18 to 6/30/18. Times are generally 9-5 M-F but are flexible to assure there is time to assist patients. E.g. pt cannot navigate public transportation and has an evening appointment time spent assisting patient will count toward the 40h/week.
Training –on line programs certifications will be required (as by state mandate). Other questions will be directed to Dr. Kaufman and the Sinai infectious disease team.
*As there will be periods where there is less activity, the health promoters will be trained by the staff to act as medical assistants (take vitals, draw blood, give vaccines). This will serve to validate the health promoters a part of the Touhy health care team.
Schwab Rehabilitation Hospital is a freestanding, not-for-profit, 102-licensed bed facility onChicago’s West and Southwest Side that offers comprehensive inpatient and outpatient programs foradults and children. Schwab is a proud member of Sinai Health System and the first fully licensed andaccredited rehabilitation hospital in the Midwest.Our therapists see patients through the entire continuum o...f care, from acute inpatient admissions atMount Sinai Hospital, to inpatient rehabilitation and outpatient therapy services at Schwab. We alsohave a hospital-based rehabilitation-focused short-term sub-acute unit at Schwab that provides boththerapy and nursing services with exceptional outcomes.Our rehabilitation team takes a holistic, interdisciplinary approach to address the physical, cognitiveand psychosocial needs of each patient. Each patient is assessed and provided with a personalized careplan tailored to help achieve maximal independence and function. Schwab offers seven treatmentgyms featuring private treatment rooms, a warm-water indoor therapy pool, and an award-winningtherapeutic roof top garden.