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PLHIV SUPPORT AND CASE COORDINATION

A service guide to the delivery of support, case coordination and ‘inreach’ services for people living with HIV.

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Table of Contents Introduction – USAID CAP-3D.................................................................................................... 4 The Increased HIV Case Finding & Retention in Treatment & Care Initiative ........................... 4 Background to the Manual’s development ............................................................................... 5 About this Manual ..................................................................................................................... 5 A Note on Language .................................................................................................................. 6 Acronyms and Abbreviations .................................................................................................... 7

SECTION ONE: PROJECT OVERVIEW ....................................................................... 9 1. 2. 3.

Mission Statement ............................................................................................................ 9 Philosophy of Service ........................................................................................................ 9 Core Peer Support Services ............................................................................................ 11 3.1 ‘In-reach’ service provision..................................................................................... 12 3.1.1 Establishing service partnerships with health facilities.......................................... 13 3.1.2 Maintaining service partnerships with health facilities ......................................... 14 3.2 One-to-one counseling ........................................................................................... 14 3.3 Case Coordination .................................................................................................. 15 3.3.1 Client service pathway ........................................................................................... 15 3.3.2 Case allocation and caseload management .......................................................... 16 3.3.3 Algorithm of caseload management and service delivery ..................................... 17 4. Potential Funding Sources .............................................................................................. 18

SECTION TWO: SERVICE MANAGEMENT .............................................................. 20 5.

6. 7. 8.

9.

Structure and roles ......................................................................................................... 20 5.1 Support Cells........................................................................................................... 20 5.2 Team Coordinators................................................................................................. 21 5.3 Caseworkers ........................................................................................................... 21 Staff and volunteer rights and responsibilities ............................................................... 22 Ethical behavior for staff and volunteers ....................................................................... 23 Supervision, support and case meetings ........................................................................ 23 8.1 Staff and volunteer supervision.............................................................................. 23 8.2 Staff and volunteer support ................................................................................... 24 8.3 Case Meetings ........................................................................................................ 25 Management of Targets for reaching new clients .......................................................... 25 9.1 Team Targets ......................................................................................................... 25 9.2 Individual caseworker targets ................................................................................ 26 9.3 Team Incentives ..................................................................................................... 27

SECTION THREE: SERVICE DELIVERY ..................................................................... 29 10. The Client Service Pathway ........................................................................................ 29 10.1 The four-step service pathway explained .................................................................. 30 10.2 The four-step system – list of forms, actions and outcomes ..................................... 31 11. GUIDANCE ON USE OF FORMS, INFORMATION AND POLICY .................................... 32 11.1 Client Information Form ............................................................................................. 32 11.2 The Client Consent Form ............................................................................................ 39 11.3 The HIV Resilience Scale ............................................................................................. 40 11.3.1 About the HIV Resilience Questionnaire ............................................................ 41 11.3.2 Comparative Analysis of Resilience Scale Responses......................................... 42 11.4 The Client Information Pack ....................................................................................... 43 11.5 Client Satisfaction Survey ........................................................................................... 44 12. Guidance on online, internet-based support to clients ............................................. 44

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SECTION FOUR: APPENDICES ............................................................................... 46 INITIAL INFORMATION LETTER for service provider teams..................................................... 46 DIRECTOR/ADMINISTRATOR Request Letter .......................................................................... 47 CODE OF CONDUCT for Staff and Volunteers ......................................................................... 48 CONFIDENTIALITY/WORK PRACTICE AGREEMENT .................................................................. 49 JOB STATEMENT –COORDINATOR, SUPPORT CELL ................................................................. 50 JOB STATEMENT –CASEWORKER ............................................................................................ 53 CLIENT INFORMATION FORM .................................................................................................. 56 CLIENT CONSENT FORM .......................................................................................................... 61 HIV RESILIENCE SCALE ............................................................................................................. 62 INFORMATION FOR CLIENTS #1 Charter of Client Rights & Responsibilities .......................... 64 INFORMATION FOR CLIENTS #2 Our Privacy and Confidentiality Policy ................................. 65 INFORMATION FOR CLIENT #3 Complaints Resolution Policy................................................. 68 CLIENT SATISFACTION SURVEY ................................................................................................ 72

Publication: PLHIV Support and Case Coordination Manual This manual was developed by APMGlobal Health (APMG) and The HIV Foundation. Author: Scott Berry

Editors and Technical Advisors: Dave Burrows, Lou McCallum

Edition Date: 15 November 2013

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Introduction – USAID CAP-3D The USAID CAP-3D Project is a five year project to improve the health status of people in the Mekong sub-region by strengthening health systems that respond to HIV, tuberculosis and malaria. In 2003, USAID CAP-3D supported the establishment of the Increased HIV Case Finding and Retention in Treatment and Care Initiative. The Initiative responds specifically to HIV among men who have sex with men (MSM) and transgender people in Thailand in response to rising rates of HIV infection among these sub-populations.

The Increased HIV Case Finding & Retention in Treatment & Care Initiative The Increased HIV Case Finding and Retention in Treatment and Care Initiative (henceforth ‘the Initiative’) is implemented by APMGlobal Health (APMG) in partnership with The HIV Foundation Thailand. The Initiative works collaboratively with local USAID CAP-3D partners in Thailand to develop new models of HIV community service delivery to respond to the need to reverse HIV rates among MSM and TG people in Bangkok, Chiang Mai and selected cities in Southern Thailand. The goal of the Initiative is to strengthen the capacity of local MSM and TG people’s community organizations and HIV service systems to increase HIV case finding and retention in HIV care and treatment among MSM and TG people. USAID Forward shifts the focus of USG aid directly on to the support and strengthening of sustainable local organizations. It emphasizes the need for new partnerships, bold innovation and a focus on results over the coming years in order to impact upon the major development challenges facing the globe. The Initiative aligns with this shift in focus by innovating to develop new models of community HIV service delivery and working closely with local organizations to transform their service models and supporting them to sustainably integrate new approaches into their programming. The technical assistance mechanism Technical engagement with local developed by The Increased HIV Case partners Finding and Retention in Treatment and Care Initiative has involved establishing The Good Life Project in Bangkok during 2013. The Good Life Project acts as a resource hub for piloting new ideas for community-based HIV service delivery in Thailand. Once tested through The Good Life Project these models become the basis for technical engagement with local USAID CAP3D-funded Technical engagement with local organizations. In partnership with PSI Thailand and CAP3D consortium partners partners, the models are adapted to fit local organizational cultures and sustainable implementation within local organizations. Technical management of new organizations entering the MSM and TG people’s HIV service space is an ongoing part of the work of the Initiative, in partnership with PSI Thailand.

Good Life Projec

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Background to the Manual’s development The PLHIV Support and Case Coordination Service guide has been produced by The HIv Foundation for use by community-based HIV organizations working with PLHIV, including Key Populations for HIV, across Asia. This manual provides the technical framework for high quality service delivery of support and case coordination by and for people with HIV in local places. The manual has been developed from experiences with service delivery to newly HIV diagnosed MSM and transgender people in Thailand by APMGlobal Health (APMG) and The HIV Foundation. It has also been developed through experiences with the delivery of peer support, case management and peer counseling in Central Asia, South East Asia and the Pacific. The manual has been written in a general way so that it is specific enough to be useful but general enough that it can be applied easily to any Key Population for HIV. The manual will be helpful to those delivering peer support – i.e. where the service provider is themselves a person living with HIV and/or identifies as coming from a Key Population for HIV. The manual will be helpful to those delivering non-peer based services including professional social workers or welfare practitioners who may or may not be living with HIV or identify with a Key Population for HIV. The manual procedures and policies have been developed from contexts in which both peers and non-peers deliver the support services. The core aim of the manual is to strengthen cross-sector collaboration between the medical, welfare and community sectors and to facilitate multiple entry points to care for people with HIV from Key Populations. New cost-effective models that increase reach and coverage as well as loss-to-follow-up among PLHIV are urgently needed and this manual aims to contribute to this challenge in Thailand and the Asia region.

About this Manual The PLHIV Support and Case Coordination Service guide is a resource for grassroots organizations seeking the management and technical tools needed to run a support and case coordination service for people living with HIV. The manual provides the basic information and resources needed to deliver services to people with HIV. The core aim of the PLHIV Support and Case Coordination Services is to support people living with HIV to live successful and independent lives. The service achieves this by assisting people living with HIV to access the services they need. The PLHIV Support and Case Management Manual assists caseworkers to provide ‘inreach’ services. In-reach is a specialized form of service delivery in which caseworkers deliver services at hospitals and clinics and cooperate with clinical teams at these sites. The aim of the approach is to minimize loss to follow-up among people with HIV accessing the health system. Caseworkers also provide case coordination. Case coordination is a specialized form of support in which the range of health and welfare needs of an individual are identified and decisions made together with the individual about how best to meet those needs. In order to ensure that people with HIV are well supported, 5


Caseworkers accompany them to health and welfare services. Caseworkers help people with HIV solve the problems they experience within health and welfare service systems so they can live successful and independent lives with HIV. The service is a health promotion project that aims to a) Build knowledge and skills in people with HIV so they can make informed choices about their health, b) Work cooperatively with HIV service agencies to ensure service access with little difficulty as possible and c) Influence and change health service policy and implementation so that it better meets the needs of people with HIV over time.

A Note on Language This Service guide is designed to be generic enough to fit any host organization that is planning to deliver a PLHIV Support and Case Coordination Service. The manual provides a general project overview, advice on service management and advice on service delivery. This approach means that language is used throughout the manual to reflect the general nature of the advice given. Host Organization: A host organization is one that has decided to deliver a PLHIV Support and Case Coordination Service and is using this manual to establish and manage the project. A note on Staff and Volunteers: The manual uses the terms staff and volunteers interchangeably. It also refers to ‘caseworkers’. This is in acknowledgement that host organizations will have varying human resources systems for managing service delivery. Some organizations use paid staff exclusively, others use volunteers exclusively. Still others employ a mix of paid staff and unpaid or subsidized volunteers for the delivery of services. The manual does have a view about any of these human resource systems and seeks to support the existing structures of host organizations and allow them to decide for themselves how to manage human resources.

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Acronyms and Abbreviations AIDS ARV BCC CBO CCM DIFD GFATM HIV ICT IEC ILO KAP MARP MSM MOH NSP PEPFAR PLHIV STI UNAIDS UNDP UNESCO UNFPA UNICEF UNODC USAID VCT WHO

Acquired Immune Deficiency Syndrome Antiretroviral treatment Behavior Change Communication Community-Based Organization Country Coordinating Mechanism Department for International Development (UK) Global Fund to Fight AIDS, Tuberculosis and Malaria Human Immunodeficiency Virus Information and Communication Technology Information, Education and Communication International Labor Organization Key Affected Population Most-At-Risk Population Men who have Sex with Men Ministry of Health National HIV and AIDS Strategic Plan President’s Emergency Fund for AIDS Relief People living with HIV Sexually Transmitted Infection Joint United Nations Programme on HIV/AIDS United Nations Development Programme United Nations Educational, Scientific and Cultural Organization United Nations Population Funds United Nations Children’s Fund United Nations Office on Drugs and Crime United States Agency for International Development Voluntary Counseling and Testing World Health Organization

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SECTION ONE – PROJECT OVERVIEW

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SECTION ONE: PROJECT OVERVIEW The PLHIV Support and Case Coordination Service guide provides the resources needed to deliver support and case coordination services to people with HIV to help them access the services they need to live healthy and independent lives with HIV. This section of the manual describes  Mission Statement  Philosophy of Service  Core Services in PLHIV Support and Case Coordination  Potential funding sources

1. Mission Statement PLHIV Support and Case Coordination service assists people living with HIV to live well by supporting timely access to health services and by reducing the social isolation that can be associated with living with HIV. It works to achieve this goal by cooperating with local HIV partners to deliver counseling and case coordination services to people with HIV experiencing difficulties or crises in their lives. The HIV partners include local hospitals and clinics providing HIV services to people with HIV as well as local community-based organizations. The difficulties experienced by people with HIV mostly relate to being newly diagnosed, being diagnosed with HIV-related illness, and problems accessing or understanding how to access treatment or health care services when in need. The objective is to work with people with HIV and their health care providers to maximize health and support PLHIV living independently. The staff and volunteers who deliver PLHIV Support and Case Coordination services are trained and receive ongoing support and supervision. PLHIV Support and Case Coordination strives to achieve service excellence through regular reflection, evaluation and by inviting feedback from both clients and service partners that results in improvement of services over time.

2. Philosophy of Service The philosophy of service emphasizes the right of individual people with HIV to make their own decisions and to live successfully and independently. The view of the person with HIV People with HIV are capable of living healthy and independent lives when they have the support and health service access they need. Even in the midst of crisis, illness or other difficulties, people with HIV can make their own choices about how to solve problems when they have a supportive environment for doing so.

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Health Promotion To best facilitate a supportive environment for healthy and independent living, PLHIV Support and Case Coordination Services operate within a health promotion framework by (a) Seeking to increase the knowledge and skills of our clients and support them to support each other in groups and communities; (b) Working closely and cooperatively with other service agencies and (c) Influencing health service policy and implementation at local levels. No discrimination Services are offered to people with HIV regardless of mode of transmission, ethnicity, and religious or other beliefs, their backgrounds or their sexual or gender orientation. Everyone with HIV is welcome. A role as family or friend Some people with HIV have little access to family or friends to whom they can disclose their HIV status. PLHIV Support and Case Coordination plays a valuable role as substitute family or friends to people with HIV in some circumstances. Caseworkers are not medical experts The first and most important aspect of case coordination through the service is that caseworkers are not medical experts. They defer to both clients and their service providers for guidance on health, medication and monitoring. They do not diagnose illnesses and nor give medical advice of any kind to clients. Client-centered practice The primary focus of service delivery is on the client’s needs. Even in the crisis of initial HIV diagnosis, the client can assist in tailoring an individualized program of services and supports that can meet their unique and particular needs. The client and the caseworker should use sessions to jointly identify needs, how needs should be responded to and how everyone will know that each need has been addressed. However, client-centered practice is more than just focusing on clients. The core principles behind client-centered practice are  Unconditional positive regard – valuing clients unconditionally and offering them high quality service no matter who they are,  Empathy – “walking a mile in the client’s shoes”, trying to understand the world from the client’s perspective and  A non-judgmental attitude –making no judgments about the client’s life, opinions or behaviors. PLHIV Support and Case Coordination services are led by the client. This can be difficult because caseworkers won’t always agree with clients about what might be best for them. Also, when service involves others in meeting the client’s needs, these others may disagree with the client and ask us to side with them. Caseworkers focus on solving problems through supportive and diplomatic negotiation. Ultimately, attention is focused on the client and their needs with a desire to help them to best meet these. 10


The important belief here is that individual PLHIV are people who bring skills and life experience to their situation and who are capable of solving their own problems with assistance from Caseworkers and other service partners. Clients are involved and considered as experts, as equal partners in the process of assessing and resolving their own situations. Early Intervention and Prevention Staff and volunteers have a duty of care to ask questions about issues and problems that lie outside the experience of HIV. Early intervention in, or prevention of serious health problems can make a real difference to the lives of clients. Therefore, staff and volunteers should look to identify other needs beyond the client’s presenting issues and to agree with clients on some action about those issues, where they are identified. For example, this could include identifying a client’s drug or alcohol issues or that a client is in a violent relationship. Supporters are not experts on the various health and other issues, which might affect someone. Therefore, they should refer to their team leaders and to the clinical staff at the clinics and hospitals where they provide service when they have concerns and before taking further action. Duty of care There are some times when presenting issues are of such a serious nature that caseworkers have a ‘duty of care’ to respond. Caseworkers are not experts on duty of care issues and should always seek urgent advice from team leaders and clinical staff at the clinics and hospitals where they provide service in these cases. Some issues that might indicate the need for advice might include (but aren’t restricted to):  Mental health issues (e.g. the client or others claim to hear voices or have visions or appear to be bipolar or severely depressed)  Statements indicating a risk of suicide or self-harm  Threats to harm others  Suspicions of violence or abuse (e.g. the client has unusual bruising, appears frightened and/or states they are being hurt or threatened) Caseworkers are obligated to act in these and other circumstances to ensure the safety of individuals and may be held accountable in law if they fail to act where a duty of care exists.

3. Core Peer Support Services The PLHIV Support and Case Coordination Service provides the following core services:  ‘In-reach’ – Caseworkers who facilitate linkages between services by working at hospitals and clinics so that no person with HIV is lost to follow-up or ‘falls through the gaps’ of service provision.  Basic one-to-one counseling – Caseworkers whose goal is to listen to and support an individual client in relation to their emotional needs.

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Case Coordination – Caseworkers who facilitate access to local health and welfare services, accompany clients to medical appointments, support clients who are hospitalized or at home sick through hospital and home visits.

3.1 ‘In-reach’ service provision PLHIV Support and Case Coordination involves the delivery of support and case coordination in hospital and clinic settings, in partnership with clinical teams. This kind of service partnership is sometimes called ‘in-reach’ and where people with HIV deliver the service is sometimes called ‘Expert Patient Services’. ‘In-reach’ is based on the same management structures and systems used in community outreach projects for HIV prevention, but focuses instead on support for people living with HIV. Volunteer or staff teams work together to deliver services to people outside their organizations. However, instead of these teams working at venues and public places to distribute condoms, needles and other paraphernalia (as is done in outreach education), ‘in-reach’ teams attend clinics and hospitals and provide support and counseling to people with HIV in partnership with clinical teams at those sites. ‘In-reach’ to clinics and hospitals may involve caseworkers taking the role of a greeter or intake assistant. In these roles, caseworkers direct patients to where they need to go for further help and may accompany them to different sections of the hospital or clinic. In other cases, caseworkers take blood pressure, weight and temperature of patients to alleviate the pressure on nursing teams. Their role depends on the clinic or hospital with which the team is working. Whatever the role taken, caseworkers aim to take the opportunity to make a strong connection with each patient and to let them know they are available to help them with ongoing support should they need it. When the relationship between casework teams and clinical teams is working well in the setting, nurses and doctors will refer patients that need follow up support to caseworkers. They may invite caseworkers into a consultation with a patient who needs case coordination help beyond the capacity of the nurse or doctor. The main objectives of in-reach include:  

Develop cooperative relationships with hospitals, clinics, women’s services, drug support services and other health welfare services to facilitate the shared service provision and referral of clients/patients. Develop supportive relationships with newly-diagnosed people with HIV so they are not lost to follow-up by the health system and are not isolated and alone. This means that clinics providing voluntary counseling and testing (VCT) are a primary target of the service. Develop supportive relationships with patients who present with HIV-related symptoms at hospitals and clinics, and with people with HIV-related illness in their homes and in the community, so they can access the range of health and welfare services they need in a timely manner. Develop supportive relationships with patients being hospitalized with symptoms of HIV illness, so that support and assistance can be arranged for them while they are an inpatient and so that the transition from hospital-to12


home can be managed smoothly. This means that clinics and hospitals providing care to people living with HIV are a primary target of the work of PLHIV Support and Case Coordination services. 3.1.1 Establishing service partnerships with health facilities This section of the manual provides information for host organizations and their staff who are establishing the PLHIV Support and Case Coordination services for the first time. The goal of this establishment period is to ensure the capacity to deliver regular services within hospitals and clinics in the local area on a daily or weekly basis. Five general points of advice are offered here: 1. Identify relevant health facilities: VCT clinics, HIV clinics and hospitals, women’s Projects, drug treatment Clinic 1 facilities, community-based services. 2. Approach clinical staff at those health facilities: Approach staff you already know or find someone who has a PLHIV Clinic 4 Clinic 2 Support relationship with staff at each facility. Project Explain the concept and how it can assist both medical staff and their patients. Provide written information about the idea so that medical teams Clinic 3 can discuss together. Seek support for the proposal to establish in-reach services at the facility. An example information letter is provided here. 3. Determine with staff the best way to support clinical staff at each site: This means understanding the way the clinical team works in each site and agreeing together how the PLHIV Support and Case Coordination team can best support their work. Some organizations act as greeters during intake, others take temperature, weight and blood pressure for the clinical team, still others wait to be referred patients once the clinical team has seen the patient. 4. Formally approach facility administration: Seek approval for the provision of a shared service partnership. This will usually mean the Director of your organization writing to the Administrator of the clinic or hospital and an exchange of letters approving the delivery of ‘in-reach’ in each setting. An example letter is provided here. 5. Establish a “Medical Link Worker” at each facility – this is someone, usually a nurse, who will act as a liaison for the partnership and help to solve problems in the settings if and as they emerge. 6. Trial a pilot period (3-6 months) of shared service delivery so that initial problems are anticipated and can be resolved quickly and easily.

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3.1.2 Maintaining service partnerships with health facilities This section of the manual provides information on maintaining cooperative relationships with health facilities. 1. Resolve problems in the partnership quickly and cooperatively. 2. Write to the Administrators of each clinic and hospital every three months to update them on the services you have been providing and to thank them for their cooperation. 3. Include service delivery data in your communication with clinic and hospital Administrators so they can see their role in the success and share in your achievements. 4. Whenever staff present to forums or conferences they should acknowledge the partnerships and name each facility that is working with the project. 3.2 One-to-one counseling One-to-one counseling involves creating the space and making time to listen to a person with HIV. It involves being a ‘friend who listens’ to a person with HIV. The person with HIV should feel they have time to explore their feelings and thoughts about what is happening in their life right now. Counseling is about establishing a relationship where the individual being supported understands they have the opportunity to talk openly and that it is safe to express feelings without the fear of being judged by their Caseworker. Listen more than you talk The easiest way to establish a counseling-based relationship with a person with HIV is for the caseworker to focus on listening more than talking. When a caseworker is in a counseling session with a person with HIV, their goal is to keep the attention on the person with HIV and not on himself or herself. This can be hard to do - especially when the client keeps asking questions or is asking for the caseworker’s own experiences. A couple of strategies can help a lot:  If you are talking more than your client most of the time then this is a signal that you are taking too much attention away from the client.  Answer questions clearly and directly – taking the time you need to do so – but always be sure that if you are speaking about yourself, it is only so that you can clearly answering a direct question or need of the client.  Allow for silence. This can be uncomfortable but it helps to signal to the client that you are giving them the space and time to talk about themselves – leaving some silences in the conversation sometimes leaves room for the client to say what is really on their mind.

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3.3 Case Coordination The case coordination approach within PLHIV Support and Case Coordination services aims to assist people with HIV to make the transition to living well with HIV and identify and resolve problems and barriers that prevent them living with the highest possible quality of life. This is done by developing a supportive, nonjudgmental relationship with the client and by working with them to develop an Action Plan in which the client and the caseworker have tasks to complete. In case coordination, the caseworker will accompany clients to medical and other service appointments and be available to help to solve problems in the service delivery as they arise. In this way the caseworker becomes a central part of the support available to the person with HIV as they strive to adjust their lives to living well with HIV. A key feature of this case coordination approach is that it promotes cooperative connection between people with HIV and their service providers, partners, families, friends and communities. PLHIV Support and Case Coordination attempts to work with all parties where possible to increase the support available to people living with HIV. 3.3.1 Client service pathway The service pathway involves four steps of service delivery with the client. The diagram below demonstrates the client service pathway:  Step 1 - the point of first contact with a PLHIV Support and Case Coordination service– initiated either by a client themselves or their service provider.  Step 2 - service delivery to the client includes meeting and talking regularly and acting on the plan of action agreed together (usually around 10 weeks).  Step 3 - review of services provided and whether the goals have been met.  Step 4 exit of the client from the service and referrals to other services as needed.

Step One: first contact

Step Two: ongoing coordination and support

Client referred or self referred. Staff Action: Intake and Assessment

Staff Action: meet with client, follow up actions in the Assessment Plan

Step Four: Exit Staff Action: refer the client to other services where agreed client marked as 'inactive' but follow up with the client after six weeks to check on status.

Step Three: Evaulation

Staff Action: assess progress and decide to continue service or end the service relationship.

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3.3.2 Case allocation and caseload management Each caseworker may manage a caseload of up to 20 clients. The number of clients managed per caseworker depends upon a number of factors:  The capacity and experience of the caseworker - a caseworker with less experience should have fewer clients until they gain experience.  The skills and preferences of the caseworker – one caseworker may have skills and/or prefer to work with newly-diagnosed PLHIV while another may have skills and/or prefer to work with people with HIV-related symptoms. This can affect where caseworkers and deployed.  The number of very high needs clients in a caseworker’s caseload - for those with very high need clients the number of clients they hold in their caseload should be fewer because they have to devote more time to these high need clients. Case allocation refers to the methods used by the project for assigning a particular client to a particular caseworker. Clients can be allocated in a number of ways:  ‘Automatic’ allocation is when a caseworker meets a new client for the first time and that client automatically becomes part of this caseworker’s caseload. This is perhaps the easiest way to allocate clients.  ‘Determined’ allocation – means that a caseworker meets a new client for the first time, undertakes intake with the client but informs the client that they will be assigned another caseworker who will call them later. It is then determined in a case meeting who is the best ‘fit’ for that client and their particular needs. This is perhaps the harder way to allocate clients because it means a delay to direct service provision and can make the client feel they are not in control of the decision. However, sometimes this approach is necessary, especially when a client has highly complex needs. The client’s own preference for a caseworker must always be considered. For example, a woman with HIV may prefer a female caseworker, a transgender person with HIV may prefer a transgender caseworker, or a man with HIV may prefer a male caseworker. Moving clients between caseworkers may be necessary when a caseworker stops working for the project or to readjust and balance caseworker’s caseloads. In some circumstances, where a relationship between the client and a caseworker is not working well then another caseworker may need to be allocated that client. Passing the client to a new caseworker needs careful consideration and discussion and should involve a shared meeting between the client and both caseworkers. The team coordinator facilitates the allocation and reallocation process. The diagram below provides a visual description of the steps in the case allocation and caseload management process.

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3.3.3 Algorithm of caseload management and service delivery 1. Caseworkers work together to deliver peer support to people living with HIV coordination for the entire support cell provided by team coordinator… Team Coordinator

Peer Supporte r (Team 1)

Peer Supporte r (Team 1)

Peer Supporte r (Team 2)

Peer Supporte r (Team 2)

Peer Supporte r (Team 3)

Peer Supporte r (Team 3)

2. Each Caseworker carries a caseload and maintains client file notes on each client…

3. Clients can be transferred between Caseworkers with care when needed…

4. A client’s case can be ‘closed’ or placed on ‘maintenance’ (decided at case meetings only) with intermittent contact maintained between the project and the client once the client’s core needs have been met.

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4. Potential Funding Sources Host organizations interested in establishing PLHIV Support and Case Coordination may need to seek funding. Seeking new funding might involve considering resources from:      

City government. National government. Country Coordinating Mechanism (CCM) for GFATM Projects. Regional and international opportunities sometimes provided the UN or WHO. Bilateral and multilateral funding opportunities through USAID, DFID or other agencies. In-country, private or organizational donors.

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SECTION TWO SERVICE MANAGEMENT

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SECTION TWO: SERVICE MANAGEMENT An organization that provides PLHIV Support and Case Coordination Services will have its own management and supervision arrangements in place for its staff and volunteers. One internal service management structure for PLHIV Support and Case Coordination uses ‘support cells’ composed of caseworkers with a team coordinator. An organization, dependent on its capacity and funding, may have just one support cell delivering services in a local place or it may have many support cells that work together to deliver a unique set of services locally. This section of the manual describes:  Structure and roles  Ethical behavior for staff and volunteers  Supervision, support and case meetings

5. Structure and roles 5.1 Support Cells A ‘support cell’ is a team of up to seven people that is made up of one team coordinator and up to six Caseworkers. The coordinator is responsible for managing all aspects of their support cell from recruitment to supervision to resolving emergencies and dealing with difficult clients. The Caseworkers deliver services in teams of two. The work of the coordinator and their team depends on what the team is responsible for delivering. This might be ‘in-reach’ to some clinics and hospitals or it may be providing support at the premises of the local hosting organization. The cell may be responsible only for the delivery of group peer support services. The diagram below provides a visual description of a support cell.

Team Coordinator

Case worker (Team 1)

Case worker (Team 1)

Team 1 Responsible for services at one site.

Case worker (Team 2)

Case worker (Team 2)

Team 2 Responsible for services at one site.

Case worker (Team 3)

Case worker (Team 3)

Team 3 Responsible for services at one site.

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5.2 Team Coordinators Team Coordinators need to have experience in counseling, social work or education. They may have formal qualifications in these areas, but that is not essential. They should be good with people, able to work independently and be able to resolve problems quickly and easily. The Coordinator manages a team of 6 people, in three teams that service three local service sites. The Coordinator moves between these three sites liaising with the clinical teams and ensuring that caseworkers are attending and providing services appropriately. The coordinator will resolve any siterelated problems as they occur, including emergency situations. The coordinator, if they are highly experienced, will often support clients with the most complex issues themselves, or work closely with experienced caseworkers to work with these clients. Weekly or fortnightly case coordination meetings are facilitated by the coordinator and involve talking with the team case-by-case and deciding together how to best support each client. General Job Description for the Team Coordinator:  Ongoing recruitment of caseworkers to their cell as needed.  Ongoing training, supervision and support to caseworkers in the cell.  Managing case coordination of clients by caseworkers in the cell.  Ensuring service data is collected and reported on.  Liaison with medical staff at hospitals and clinics where the cell is doing this sort of ‘in-reach’ work.  Meeting with other cell coordinators (where they exist) to coordinate support to people with HIV. A detailed job description is provided in the Appendices or click here. 5.3 Caseworkers Caseworkers do not need experience in counseling, social work or education. They do need to either be people living with HIV, and/or people from Key Populations for HIV. They should have experience in mutual support provided between people with HIV and/or Key Populations for HIV. They should have experiences within networks or groups of people with HIV and/or Key Populations for HIV. Caseworkers work in teams of two to deliver ‘in-reach’ services at local hospitals and clinics, and/or to deliver support services at the host organization, and/or to facilitate groups or other kinds of support in the community. General Job Description for the Caseworkers:  Providing ‘in-reach’ services at hospitals and clinics or counseling services at local organizational premises.  Providing active case coordination and support for up to 20 clients including initial intake and assessment, counseling sessions, accompanying to hospital, clinic and other appointments, actively resolving service and related problems as requested by the client, referral of client to other services as needed.  Completing and submitting client forms and service statistics related to service delivery and case coordination. 21


 

Participating in case coordination meetings and other meetings as required. Participating in support and clinical supervision sessions as required.

A detailed job description for Ccaseworkers is provided in the Appendices or here.

6. Staff and volunteer rights and responsibilities Staff and volunteers of the PLHIV Support and Case Coordination Service have both rights and responsibilities. The rights and responsibilities described here will be read out and discussed during orientation with all new staff and volunteers. Rights The organization commits to:  Maintain the privacy and confidentiality of its staff and volunteers, especially in relation to sensitive, personal information.  Value and respect staff and volunteers equally and treat all staff and volunteers as important co-workers.  Provide orientation to all new staff and volunteers in the project.  Provide a supportive environment with regular one-to-one supervision, team meetings, and support and case meetings.  Inform staff and volunteers about what is happening with the project.  Provide input into planning and evaluation of the project.  Be clear about the roles of all staff and volunteers, including providing written job descriptions for all roles.  Provide a work environment free of intimidation, bullying or discrimination.  Respond to complaints by staff and volunteers in a timely, sensitive and respectful way.  Inform staff and volunteers clearly and respectfully when there are concerns about work performance and provide a ‘right of reply’. Responsibilities Staff and volunteers are responsible to:        

Commit to 6 months of service to the project (for volunteers only). Attend supervision, support and case meetings. Abide by the Code of Conduct and Confidentiality and Work Practices Agreement. Keep the coordinator and other relevant staff informed about what is happening with clients. Be reliable, honest and considerate in all dealings with clients, their friends and families, service providers and staff and volunteers of this project. Keep the project informed about changes in address or phone numbers. Be punctual when attending work shifts. Deliver services according to the guidance provided in the PLHIV Support and Case Coordination Service guides.

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7. Ethical behavior for staff and volunteers All staff and volunteers delivering PLHIV Support and Case Coordination services, including Coordinators, must comply with confidentiality and other ethical work practices to ensure that services they provide to people with HIV will do no harm. Ethical conduct is particularly important because professional conduct will help to maintain a good reputation for the service with local service providers. Unethical conduct will undermine the trust and respect needed to ensure that local service providers can cooperate with the service and refer their patients/clients. These set of behaviors are particularly important:     

No sex with clients under any circumstances. No gossiping about clients during or after service provision. No drug taking with clients under any circumstances. No financial transactions, lending to or borrowing money from clients. No engagement in illegal activity of any kind during service provision or with clients during or after service provision.

Engaging in these behaviors must result in dismissal of staff or volunteers in every case, as this is an important way to ensure cooperative and trustful relationships with other service providers. At the start of a new staff member or volunteer’s time with the service, an orientation must be undertaken. In this orientation the team coordinator should read out loud the Code of Conduct for staff and volunteers and the Confidentiality and Work Practices Agreement for staff and volunteers. At the end of reading each document, the coordinator should engage in discussion about the document and allow for questions and concerns to be raised. At the end of this process each new staff member or volunteer must sign:  

The Code of Conduct – click here to see the Code of Conduct. The Confidentiality and Work Practices Agreement – click here to read the agreement.

8. Supervision, support and case meetings Regular supervision, regular support sessions and case meetings provide the foundation for a supportive internal environment for the provision of high quality support services to people with HIV. Regular supervision ensures that team coordinators are up-to-date with the experiences of caseworkers. Regular support ensures that the host organization is meeting a duty of care to staff and volunteers. Regular case meetings ensure that all active clients are discussed in a timely manner and allows for caseworkers to share their knowledge and experiences with each other about client case coordination. 8.1 Staff and volunteer supervision The Team Coordinator provides individual supervision to staff and volunteers in their support cell. Supervision is a supportive space for caseworkers to talk about their experiences, successes and difficulties in delivering services to people with HIV. Supervision with caseworkers should occur every two weeks. The supervision session 23


can last from 30 minutes to one hour depending on the number of issues needing to be discussed and/or the support needs of the caseworkers. The supervision session should provide time for the caseworker to:  Talk about their recent experiences delivering services.  Raise problems and seek solutions in the delivery of services.  Talk about their personal responses and feelings about doing the support work with the supervisor, if appropriate. 8.2 Staff and volunteer support Burnout is a common phenomenon among caseworkers engaged in this type of service delivery. Burnout happens when caseworkers become emotionally exhausted by the support work. Symptoms can include increased irritability or sadness in a caseworker that is uncharacteristic. Increased non-attendance at work can also be a symptom, as can a dramatic slowdown in performing key activities and deliverables without a reasonable excuse. Burnout occurs for many reasons, but it can be delayed and even avoided if a supportive work environment is maintained. The provision of emotional support for caseworkers themselves is viewed as a key method for delaying or avoiding burnout. In providing emotional support to caseworkers, the host organization can avoid the increased financial and human resource expenses caused by high staff and volunteer turnover. The service will meet its duty of care to staff and volunteers by providing an external psychologist or counselor for the provision of clinical support to the caseworker team on a monthly basis. The psychologist or counselor should be an individual with no ties to the project. They should have no personal relationships with any people in the project. The person should not be someone intimately involved in the work of the service. The support relationship established between the external practitioner and the support team members should allow for discussion about their personal feelings and responses to undertaking the support service delivery. Support of this kind can be provided in a group counseling session for the caseworkers. However, it is recommended that one-to-one sessions for caseworkers are the main mechanism of support. Using a practitioner external to the project aims to ensure that the discussion of personal feelings by caseworkers has no negative consequences. The team coordinator or the host organization should not normally require report back from the external practitioner. However, there are some situations where report back is required. Where issues are raised in the support sessions that suggest  

A breach of the Code of Conduct or Work Practices Agreement. A caseworkers raises an issue that suggests the worker or a client is in danger, for example, where is a threat of to harm themselves or others, including children.

24


8.3 Case Meetings Case meetings should occur on a weekly or fortnightly basis. The goal of regular case meetings is to ensure that no client is ever lost to follow-up or forgotten by the project. All caseworkers need to participate in case meetings. The team coordinator usually leads case meetings. Basic guidance on case meetings includes:  All active case files must be brought in to the meeting room.  Each active case file must be opened, read and discussed.  The team coordinator should assess the standard of note taking in each file – do the file notes provide a comprehensive and accurate understanding of what has been done for this client?  Remember, case notes are the only way of knowing whether a caseworker is providing high quality services. If note taking is poor and inconsistent this suggests that service delivery is poor and inconsistent.  Decisions should be made about what to do next for each individual client and these decisions should be noted on the file.  The decision to close a client’s case is made at case meetings by the entire team. All active case files brought in to the case meeting.

All active cases discussed, standard of note taking critiqued, follow-up decided.

9. Management of Targets for reaching new clients A challenge for community-based organizations and their projects is ensuring that teams are focused on results. This section of the manual provides advice on target setting and team motivation strategies. The targets for the caseworkers will depend upon how the project is funded and on the targets set in service contract. 9.1 Team Targets Target setting is a helpful way to keep support cells focused on reaching new clients and meeting targets set in the service contract. Targets can help the host organization measure whether the project is getting the expected results or whether the project team needs more support to achieve results. Targets and then measuring against them can also be a useful way to encourage confidence in local partner organizations, donors and governments. Promoting the results of the work of the project can help to build a strong sense of achievement among staff, volunteers and also among your key service partners. 25


A poster, like the one below, can be placed on a wall in the host organization to help the team remember its targets. Regular team meetings should refer to this poster each week. In the diagram below, the team is aiming to reach 20 new clients per month between January and March.

Team targets for new clients Jan-Mar 60

40

20

Jan

Feb

Mar

9.2 Individual caseworker targets Once team targets are set, then individual caseworker targets for new clients per month need to be agreed upon. Each caseworker will be carrying a caseload of already-registered clients and will be supporting those clients. They will also be responsible to find new clients with HIV through ‘in-reach’ support and case coordination activities. In the diagram below a team of four is responsible to reach 20 new clients per month resulting in each caseworker aiming to find 5 new clients each per month. This sort of diagram can be placed upon a wall in the host organization and referred to on a weekly basis in team meetings. Caseworkers, on returning to the host organization after ‘in-reach’ activity can change their ‘actual reached’ to reflect increases in the number of new clients reached in real time. Meeting targets in this way can help build morale in the team and brings a sense of pride in shared achievements. It can also highlight when an extra push of activity is needed to reach monthly targets.

26


Individual targets - January Actual reached 2

Jane Paul

Target

5

1

5 4

John Mary

3

5 5

9.3 Team Incentives Some organizations use incentive-based strategies to motivate caseworkers to reach new clients and stay focused on results. Deciding to use incentives should usually involve a discussion with team members about the sorts of items they need in their daily lives that would genuinely assist them. Incentives can include:  Small items  Shopping vouchers  Phone or Internet credit In some cases, salaries and stipends are linked to results and increase as the caseworker achieves the agreed results. Other organizations do not use incentives at all. Instead they try to motivate their teams through discussion. The strategies outlined above for team and individual target setting and the use of team meetings and posters to motivate staff should assist.

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SECTION THREE: SERVICE DELIVERY

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SECTION THREE: SERVICE DELIVERY A host organization managing PLHIV Support and Case Coordination Services may already have its own service delivery systems. This section of the PLHIV Support and Case Coordination Service guides Manual provides information and resources needed to deliver support services specifically for PLHIV Support and Case Coordination. The service delivery pathway is described as a four-step process in which forms are required for each step and activities required to be completed at each step. This section of the manual includes:  An explanation of the Client Service Pathway  Forms, Information Sheets and Service Policies.  Advice on the provision of Ongoing Maintenance Support to clients.

10. The Client Service Pathway Four steps for service delivery to clients are proposed for PLHIV Support and Case Coordination. At each step, caseworkers are required to use a set of forms and engage in a series of service activities for and with the client. At the fourth step, which is the client’s exit from service, an ongoing maintenance support relationship is established using online social networking tools. This allows ongoing contact with clients and the opportunity to ensure that health concerns and questions can be followed up quickly and easily. The diagram below visually describes the four-step service delivery process:

Step One: first contact Step Two: ongoing service Step Three: review of service Step Four: exit from service

Ongoing maintenance support

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10.1

The four-step service pathway explained

Step One: First contact may occur at a Voluntary Counseling and Testing service site when a person has just received their diagnosis of HIV. First contact may occur at a hospital HIV clinic where a person with HIV is attending for a blood test and/or receiving HIV treatment. Alternatively, referrals of clients may be received by the host organization from a range of other services in the city or locality in which the service is being provided. At first contact, a caseworker mostly listens to the client and allows them to tell their story of being diagnosed with or living with HIV. Toward the end of this first meeting, the caseworker asks consent to provide the client with service and, if consent is given (see Client Consent Form), information about the client is collected in the Client Information Form. Step Two: Ongoing service usually lasts for a period of 3 to 6 months – mostly around 12 weeks of service provision. It involves accompanying a client to hospital and other appointments, connecting them to other services and meeting with them to discuss and resolve other issues of importance in their lives. An Activity Plan is provided in the Client Information Form to assist the service and the client to agree on the key activities needed to address problems in their lives. During this step, caseworkers attend weekly case discussion meetings with the team and present the issues and activities of the client in this case discussion meeting to receive guidance and support from others in the team. Step Three: Review of service involves a discussion with the client toward the end of Step Two. At this point the caseworker has been accompanying the client to appointments and actively engaged in resolving health and welfare concerns for the client. The goal of this step is to evaluate with the client whether significant issues have been resolved and if the client is connected to appropriate services and to a community of others living with HIV. If the client feels that most issues have been resolved, it is appropriate to close their case. If the client does not feel that issues have been resolved, then this should be brought to the case discussion meeting for discussion. Service can continue should there be significant outstanding issues unresolved for the client. Step Four: Exit from service is usually a final face-to-face meeting with the client in order to say goodbye and to finalize the service contract between the caseworker and the client. At this point, offering to connect the client to the caseworker through Facebook or other local social networking sites is helpful. This can help to ensure the client stays connected to the service and to others with HIV who are using the service. Ongoing maintenance support is a necessary component of PLHIV Support and Case Coordination. This ongoing contact is less costly and less time intensive. Contact is provided through online social networking sites such as Facebook or other local social networking sites used by the host organization. The caseworker should establish an online presence separate from any online presence they have with friends or family. This special online presence is established especially for this purpose of supporting peer support clients and the ‘friends’ of the caseworker online should only be clients of the HIV Support service. Ongoing maintenance allows for regular contact between the caseworker and also between clients. This 30


can include telephone contact between the caseworker and a client where an issue emerges that needs follow-up.

10.2

The four-step system – list of forms, actions and outcomes

The table below provides a quick and convenient way to understand the forms needed, actions to be completed and outcomes required for each of the four steps. SERVICE STEPS STEP ONE: First contact with the client.

STEP TWO: Ongoing delivery of service (approx. 6-10 weeks).

FORMS AND ACTIONS Client signs consent to have info about them recorded and used. 2. Complete the Client Information Form. Provide the client with: 3. Your name card. 4. The Client Info Pack. Ask the client to complete: 5. Client Resilience Scale (1) 1.

1. 2. 3.

STEP THREE: Review of service provided.

STEP FOUR: Exit the client\] from service and refer.

Accompany the client to hospital and other appointments. Complete Sessional Form for each session you have with the client. Continue to meet and communicate with client.

1. 2.

3. 4. 5.

1. 2.

3.

1. Discuss with client Ask the client to complete: 2. Client Resilience Scale (2) 3. Client completes the Client Satisfaction Form.

1.

1.

1.

2.

3.

Ensure the client is ready to complete service. Connect the client to a caseworker through Facebook or other social networking facility if they wish to. Ensure client is engaged with other services.

2. 3.

2. 3.

4.

OUTCOME Agreement to provide service given by the client. Information on how to get in contact with you and your organization if the client is having difficulties. Client Contact information. A picture of the presenting issues of the client. Agreement to meet again and date set for meeting. Agreement on actions to improve the client’s life. Act to meet the needs and improve circumstances by both the client and the Caseworkers. Connect the client with yours and other services. Comparison of client resilience scales. Client Satisfaction Form to your supervisor unopened. Agreement to end. Agreement to finish service Client is connected to services and able to access. Client is connected to a Caseworker for maintenance support through Facebook. Client knows how to reconnect with you.

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11. GUIDANCE ON USE OF FORMS, INFORMATION AND POLICY This section of the PLHIV Support and Case Coordination Manual provides guidance on use of forms, information sheets and policies associated with service delivery across the four-step service process. It includes:  Client Information Form – advice on use of the form and link to the form here.  Client Consent Form – advice on client consent process and a link here.  Resilience Scale– advice on the Resilience Scale and a link to the form here.  The Client Information Pack – advice on providing information about the service to clients and links to Information Sheets #1, #2 and #3.  The Client Satisfaction Survey – advice on the use of this form and a link.

11.1 Client Information Form The Client Information Form should be completed for every new client of PLHIV Support and Case Coordination. Keeping good notes on all client contact is essential. Note taking is an important discipline for caseworkers because it allows them to regularly reflect on what is happening in the interaction between themselves and a client. As well as this, note taking is important because (a) it allows others to easily understand what is happening with a particular client if for example a caseworker is absent or the client needs support when their caseworker is not available; (b) it assists the caseworker to remember important details affecting the client; (c) it helps with the collection of data that can inform donors, government and partners about the work of the project and (d) it is often the only way for the host organization to determine whether good, professional service is being provided to clients.

Client Name: ______________________ No: ______________ Section One: always collect contact info for every client.

Address: ___________________________________________ Mobile: ________________ Email: ________________

Section Two: ethnicity, age and sex of clients helps the team to determine how many men and women they are serving, of what age groups and ethnicity and can highlight gaps in service delivery to particular subpopulations. Again, host organization can report these facts to donors, government and partners.

Ethnicity:

□?

□?

□?

□?

□ Other _________ 32


Section Three: ensure collection of clinical information about the client as it becomes available. This includes CD4 count, viral load, AIDS-related conditions and any presenting symptoms of illness at first contact. This is important information that helps to decide how to respond to the client’s needs. It also allows for reporting to donors and government on clinical markers on entry in to the PLHIV Support and Case Coordination service system.

Age: Sex:

□ <18 □ 18-25 □ Female

□ 25-30 □ 31-40 □ 41-49 □ 50-65 □ Male □ Transgender

Clinical Information: CD4 count: ____

Date: / /

□ 66>

Viral load count: ____ Date: / /

Diagnosed AIDS-related conditions (if any):

Presenting symptoms of illness (if any):

Initial service received form clinic: □ VCT □ STI/ STI diagnosis and treatment □ CD4/ CD4 testing □ Viral load testing □ Other (specify):

Section Four: It is important to document a summary of the story each client tells about their experience with HIV at first contact. It is recommended that notes say something about (a) what was said (b) what was observed about the client (a) what was assessed about the client’s presenting needs and (d) what was planned to do in the future. The story of the client (Summaries the story of the client from first meeting) ___________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________

33


___________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________

Map of Clients Life Pathway Section Five: the diagram in this section of the Client Information Form aims to assist caseworkers focusing upon what they will do to improve the health of a client over a 12-week period. Along the dotted line (in the middle of the triangle below) the caseworker lists the presenting issues and concerns described by the client and assessed by the caseworker. Along the outside lines of the triangle list the support that will be provided to the client to address their concerns. An example scenario is provided below.

34


Week 12

Needs financial advice and support

No friends with HIV and no support system

Intensive support for treatment initiation and compliance as well as education for living well with HIV. Accompany client to hospital for CD4 result.

May need to start treatment

May not need to treat yet

Connect with local welfare agencies for food support and financial help.

Accompany to local support groups and facilitate support system development.

Education and information for living well with HIV.

Returns for CD4 result

Diagnosed with HIV today

Within two days telephone client and provide phone support. Then arrange face-toface meeting.

Plan of activity for and with the client

35


Section Six: the activities agreed upon with the client can now be listed as separate activities, with deadlines and responsibilities assigned. The majority of these will be the responsibility of the caseworker. However, it can be helpful to assign some of these activities to the client so they are taking responsibility for health seeking and managing their own support.

No.

Activity

Deadline

Who?

Details

1.

2.

3.

4.

5.

6.

36


Notes Section Seven: It is important to document a summary of each of the contacts you have with the client. This can help the caseworker to remember what has happened in the past but can also be a useful way to reflect on what has occurred and what else might need to be done to support the client. Again, it recommended that notes document (a) what was said (b) what you observed about the client (a) what you assessed about the clientâ&#x20AC;&#x2122;s presenting needs and (d) what you planned to do in the future.

Meeting 1 (Keep notes on what happened during the session) __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________

Meeting 2 (Keep notes on what happened during the session) __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________

37


The Client Information Form should be stored in the clientâ&#x20AC;&#x2122;s file.

38


11.2 The Client Consent Form The Client Consent Form should be completed at the end of first contact. The caseworker should talk through each paragraph of the form and ask whether the client understands and agrees. Should the client agree they tick  the ‘Yes’ column on the right hand side. Should the client disagree to any aspect of the consent they should tick  ‘No’ on the right hand side of the form. Where a client ticks ‘No’ the caseworker should discuss and seek agreement about how to manage information or provide more information. In order to provide you with service I need to ask for your permission to collect, store and use information about you. Caseworkers keep files on each client they supports. These files are kept in a locked storage cabinet in our office. Personal information about clients is not released to others without your permission. We are required to provide information to our funders and to government about the services we provide and the general profile of our client caseload. This is what is called ‘de-identified’ information in which information about you, your health and life situation cannot be determined by these funders or by government. In other words, no names, no addresses, no information that could identify you are provided. Giving your consent means we will be collecting and storing information about you and reporting on the health and support needs that you disclose to us. Yes No Do you agree? ☐ ☐ I have: - Been informed about why and how information is kept about me - Participated in determining the support that will be provided to me - Been informed where and how this information will be stored

Yes ☐ ☐ ☐

No ☐ ☐ ☐

It can be helpful to coordinate with other agencies in order to increase the support available to a client. The consent form ensures that the client is agreeing to this coordination and that the client can nominate the agencies a caseworker will talk to on the client’s behalf. Without this agreement caseworkers cannot talk to other agencies about the client. Sometimes it can be helpful to coordinate your support with other services such as hospitals and clinics or welfare agencies. After discussion with your caseworker, you can nominate here the agencies that you agree we can talk to on your behalf: Agencies nominated: ________________________________________ Signed: ______________________________ (Client’s Signature) Name: _______________________________ (Client’s Name)

Date: ____/____/____ Caseworker: _______ Initials

The Client Consent Form should be stored in the client’s file. 39


11.3 The HIV Resilience Scale The HIV Resilience Scale is a pre-and-post-service evaluation process that helps to assess the psychological and emotional impacts of the support services provided by in PLHIV Support and Case Coordination1. The same form is completed twice by the client. The form is first completed at Step One: First Contact with the client (see ❶ below). Service is provided to the client over several weeks through Steps Two and Three. The form is completed once again at Step Four: Exit from Service (see ❷ below). Responses are then compared between step one and step four (see ❸ below) to assess whether the psychological and emotional wellbeing of the clients has improved over the course of service delivery through the PLHIV Support and Case Coordination Service.

❶ Step One: First Contact Resilience Scale Form completed

❷ Steps Two and Three delivered.

Resilience Scale # 1

Step Four: Exit from Service Resilience Scale Form completed

Resilience Scale # 2

❸ Comparative Analysis of responses between Step One and Step Four 1 The HIV Resilience Scale has been developed from the Mental Adjustment to HIV

Scale which is a modified version of the Mental Adjustment to Cancer Scale produced by the University of Queensland and the New South Wales Department of Health in Australia. It was tested in a formal study in 2000 to assess its relevance to HIV among homosexual and bisexual men in three Australian Projects. That study applied the scale to 164 homosexual and bisexual men living with HIV. (Reference: Measuring Psychological Adjustment to HIV Infection, Authors: Kelly B, Raphael E, Burrows G, Judd F, Kemutt G, Burnett P, Perdices M and Dunne M. In The International Journal of Psychiatry in Medicine Vol 30, No. 1, 2000. 40


11.3.1 About the HIV Resilience Questionnaire The scale utilizes five sub-scales that focus on the level of hopelessness, fighting spirit, personal control, minimization and hopefulness in the client. A six-point Likert scale is used with ‘1’ representing a ‘definite no’ and ‘6’ representing a ‘definite yes’. 1

2

3

Definite No

1

At the moment I take one day at a time.

2

Problems with HIV prevent me planning ahead.

3

I suffer a great deal of anxiety about HIV.

4

I feel like giving up.

5

I am not very hopeful about the future.

6

I have plans for the future.

7

I feel that life is hopeless.

8

I feel I can’t do anything to cheer myself up.

9

I try to carry on my life as I have always done.

Definite No

I have been doing things that I believe will change my health. E.g. diet.

11

I firmly believe I will be OK.

12

I have been doing things that I believe will improve my health. E.g. exercise.

13

I believe that my positive attitude will help me.

HOPELESSNESS 5 6 Definite Yes

Hopelessness refers to the level of despondency of the individual about HIV and their lives. This sub-scale is comparative to the fighting spirit subscale and is predicted to return high scores in those with depressive and other psychological complications as well as those newly diagnosed or with HIV symptoms.

1

10

4

2

3

FIGHT SPIRIT/SELF-EFFICACY 4 5 6 Definite Yes

Fighting spirit refers to the capacity of the individual to feel they have personal agency over their own health and life. This sub-scale is in opposition to the hopelessness sub-scale.

41


14

I try to fight the illness.

15

I feel that there is nothing I can do to help myself.

1

2

3

4

PERSONAL CONTROL 5 6

Definite No

16

I avoid finding out more about HIV.

17

I want to make contact with others with HIV.

18

I am trying to get as much information as I can.

19

I’ve left it all to my doctors.

Personal control refers to the intention to take action and learn more about HIV both from others living with HIV and from medical services.

1 20

I’ve put myself in the hands of religion.

21

I count my blessings.

22

I keep busy so I don’t have time to think about it.

I try to keep a sense of humor about it.

24

Other people worry about it more than I do.

2

3

4

MINIMIZATION 5 6

Minimization refers to the capacity of the individual to develop strategies which minimize the negative psychological states associated with an HIV diagnosis.

1 23

Definite Yes

2

3

4

5

HOPEFULNESS 6

Hopefulness refers to the capacity of the individual to incorporate strategies that defend against negative psychological states associated with an HIV diagnosis.

11.3.2 Comparative Analysis of Resilience Scale Responses A Spreadsheet is provided separate to this Manual with instructions for use so that host organizations can produce reports using the data collected (see apmglobal.com.au). Care should be taken when drawing conclusions about the impact of services on clients’ psychological and emotional health. It will be hard to prove that PLHIV Support and Case Coordination has directly caused an improvement in psychological wellbeing, but it is possible to collect information 42


from clients that describes what the support has done for them. Where psychological and emotional health has not improved it can be argued that services provided need to be adjusted to address this. Where psychological and emotional health has improved, it is at best possible to conclude that the combination of time passing with service provided has contributed to this improvement. Responses by clients in the Client Satisfaction Form provided in Step Four: Exit from Service can help to substantiate such an argument.

11.4 The Client Information Pack It is important to ensure that all clients are fully informed of their rights and responsibilities. The Client Information Pack aims to facilitate this by providing information about rights, privacy and complaints at Step One: First Contact with a client. However, at first contact the client may be very emotional and in crisis. They may not be able to consider this information at that time and they may need a caseworker to simply listen to them and help to resolve urgent problems. In these situations it is easier to provide the pack and read through each information sheet at the second face-to-face contact with the client. The Client Information Pack includes three Information Sheets for Clients that cover Client Rights and Responsibilities, Privacy and Confidentiality and Making a Complaint about services provided by PLHIV Support and Case Coordination service. Summarizing or reading through the information pack is important because not all clients are literate and those who are literate may not always easily understand everything they read. Client Information Sheet #1 â&#x20AC;&#x201C; Charter of Client Rights and Responsibilities The caseworker reads through this charter or summarizes the key points of the charter with the client. The caseworker asks whether the client understands their rights and responsibilities once they have read through the charter. This can help the caseworker to keep rights and responsibilities in their mind and it helps the client feel they are informed and aware of both their rights and their obligations in the provision of services. Client Information Sheet #2 â&#x20AC;&#x201C; Our Privacy and Confidentiality Policy The caseworker reads through this policy on privacy and confidentiality or summarizes its key pints with the client. Again, the worker asks whether the client understands and whether they have any questions about the policy. Client Information Sheet #3 â&#x20AC;&#x201C; Complaints Resolution Policy The caseworker reads through this policy or summarizes its key points with the client. It can be helpful to explain that knowing how complaints are resolved and discussing potential reasons for complaints before there is a problem can help to prevent problems and/or to resolve problems easily should they occur.

43


At the end of this process, provide the client with the Client Information Pack so they can take it home and refer to it should they need to do so.

11.5 Client Satisfaction Survey Provide the survey at Step Four: Exit from Service along with an envelope that can be sealed by the client. Ask them to complete the survey, seal it in the envelope and return it to the caseworker. Explain to the client that the survey will not be opened or read by the caseworker. Only Coordinators see and read surveys.

12. Guidance on online, internet-based support to clients Establishing an online, internet-based system for the support of exited clients is a useful and inexpensive way to ensure ongoing maintenance support to people living with HIV. At any time in delivery of the four-step peer support service process, a caseworker can assist a client to ‘friend’ them on Facebook or connect via other social networking sites online.       

Caseworkers are encouraged to establish a new identity on Facebook specifically for clients of the PLHIV Support and Case Coordination Service. Caseworkers then facilitate clients connecting to them as friends using this Facebook identity. Caseworkers post pictures of themselves at the office, at clinics and hospitals. Caseworkers work with their casework team to develop standard, short messages about health and wellbeing, treatment adherence, connecting to others, seeking support when needed. Pictures posted should not include pictures of clients. Caseworkers encourage clients who use Facebook to ‘friend’ them. Caseworkers then carry a small, online caseload of people living with HIV connected to the caseworker through Facebook and can answer questions or engage directly with a client who messages them with a problem.

Online Privacy and Confidentiality Caseworkers always explain to clients that they are not required to engage with the caseworker through Facebook or any other internet-based networking system. This always remains the client’s own choice. It is important to ensure that the client understands how to protect their privacy online. Caseworkers can assist the client with this if needed.   

The client can set up their Facebook options to ensure that information about them is private and not automatically available to others. The client should be reminded that, should they post in the open stream, other clients connected to the caseworker will be aware of them and read the posts. Clients should be encouraged to reconfigure their Facebook privacy settings to ensure that others who are not friends cannot read their personal information or statistical information from their home page. 44


Supervision of online activity Coordinators should â&#x20AC;&#x2DC;friendâ&#x20AC;&#x2122; all caseworkers online and monitor the case worker and client activity online. Where necessary, the coordinator steps in to resolve difficulties or set boundaries if needed.

SECTION FOUR: APPENDICES

45


SECTION FOUR: APPENDICES INITIAL INFORMATION LETTER for service provider teams Dear [name], [name of your organization] is establishing a project designed to support your team in the important service work you do for people living with HIV. The PLHIV Support and Case Coordination Service is designed to support people living with HIV to live successful and independent lives. The project achieves this by assisting people living with HIV to access the services they need and by providing emotional and social support. This is a free service provided to your clients. It is a peer support service, which means that services are providing by people with HIV to other people with HIV. We are seeking your agreement to establish what is called ‘in-reach’ services in your facility. This letter aims to describe the key services of the PLHIV Support and Case Coordination Service so you can assess the value of the service to your day-to-day work with people living with HIV. The PLHIV Support and Case Coordination Service provides the following core services:  ‘In-reach’ – our caseworkers facilitate linkages between services by working with the teams at these services to help people with HIV. For example, we can be available in the waiting room of your service to help patients navigate the hospital or clinic site. We can be available when a doctor or nurse feels that a patient with HIV needs extra support to ensure their health. In this way, caseworkers develop relationships with people with HIV at your site and can work your clinical team when the team feels extra support might be needed. Our service aims to provide services so that no person with HIV is lost to follow-up or ‘falls through the gaps’ of service provision when clinical teams refer them elsewhere.  Basic one-to-one counseling – Caseworkers are also living with HIV and they are trained and supervised to listen to and support an individual client in relation to their emotional needs. This can be very helpful when a person is newly diagnosed with HIV, is suddenly hospitalized or is experiencing other personal crises in their lives.  Case Coordination – Caseworkers facilitate access to local health and welfare services, accompany clients to medical appointments, support clients who are hospitalized or at home sick by providing both hospital and home visits. We would like to request an initial meeting to come and speak with you and your team about this collaboration should you be interested. I look forward to hearing from you soon. Yours Sincerely,

46


[NAME]

DIRECTOR/ADMINISTRATOR Request Letter

Dear [name],

[name of your organization] is establishing a project designed to support your HIV team in the important service work they do for people living with HIV. The PLHIV Support and Case Coordination Service supports people living with HIV to live successful and independent lives. The project achieves this by assisting people living with HIV to access the services they need and by providing emotional and social support. This is a free service provided to your clients. It is a peer support service, which means that services are providing by people with HIV to other people with HIV. The project is funded and technically supported by [NAME OF DONOR(S)]. We are seeking your agreement to establish ‘in-reach’ services within your facility. Our project aims to ensure that no person with HIV is lost to follow-up or ‘falls through the gaps’ of service provision being coordinated across service sites. In-reach involves caseworkers coordinating linkages between services in the local area by working at local service sites and with the teams at these services to assist people with HIV. The support team can provide ‘task shifting’ support to your hospital or clinic by undertaking intake services with your supervision. The team can also be available when a clinical staff member assesses that extra support is needed for one of their patients. This can be particularly helpful when a patient appears to need more support that a practitioner at your site has time to provide. For example, when a patient is newly diagnosed with HIV, when they require hospitalization, when they are having ongoing trouble complying with HIV treatment or are experiencing other personal crises in their lives. In these situations a caseworker can provide the support and coordination needed to assist. I hope that you will agree this collaboration can assist your service. I would like to request your formal approval in writing to establish this collaboration in your HIV clinic with your HIV clinical team. Please don’t hesitate to contact me should you require further information and I look forward to hearing from you soon. Yours Sincerely,

[NAME]

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CODE OF CONDUCT for Staff and Volunteers Staff and volunteers at The PLHIV Support and Case Coordination Service have an obligation to work with care and skill and to act in a way that promotes The PLHIV Support and Case Coordination Service and protects our clients. You agree to: Personally:  Treat each other and other fairly, with respect, courtesy, compassion and sensitivity.  Not engage in verbal or physical bullying of any individual.  Not engage in sexual relationships with clients.  Not use illegal substances in the course of duty. Ethically:  Use The PLHIV Support and Case Coordination Service resources effectively, economically, appropriately and not for personal use.  Not accept money or gifts from clients or our partners.  Avoid or appropriately resolve any conflict of interest between your private interests and The PLHIV Support and Case Coordination Service.  Report immediately to management any unethical, corrupt or criminal conduct. Legally:  Follow lawful directions given by supervisors.  Comply with all policies and procedures of The PLHIV Support and Case Coordination Service.  Not disclose any confidential information during or after work conducted for The PLHIV Support and Case Coordination Service.  Not act illegally, unethically, unreasonably, unjustly or in a discriminatory way.  Comply with all privacy policies and requirements for collection notification. Professionally:  Be committed to team building principles.  Abide by program guidelines and principles.  Observe all The PLHIV Support and Case Coordination Service goals, rules and procedures as specified in the constitution, strategic and business plans and the Policy and Procedures manual.  Meet the standards and policies of The PLHIV Support and Case Coordination Service.  Represent The PLHIV Support and Case Coordination Service in a positive and professional way. NOT ADHERING TO THIS CODE CAN RESULT IN IMMEDIATE DISMISSAL. I, ____________________________________________ have read and understood this Code of Conduct and I agree to abide by the personal, ethical, legal and professional practices outlined above. Signed _______________________________________ Date

________________ 48


CONFIDENTIALITY/WORK PRACTICE AGREEMENT This agreement is for all caseworkers of the PLHIV Support and Case Coordination Service. Please complete this form and agree to the confidentiality and work practices requirements. I, ________________________________________________________________________ (FULL NAME) Accept that as an employee/volunteer of The PLHIV Support and Case Coordination Service, I may learn certain facts and have access to records that are of a personal, sensitive and confidential nature. I understand that information of a personal and confidential nature includes:  Medical conditions and treatments;  Relations with family members;  Sexual relations, HIV status of individuals and engagement in sex work or drug use by individuals;  Names and addresses of people with HIV;  Other personal and sensitive information;  Other records pertaining to volunteer workers, staff and clients. I undertake that I will not reveal to any other person any confidential information about:  The business of the PLHIV Support and Case Coordination Service;  The PLHIV Support and Case Coordination Service employees or volunteers; and  The PLHIV Support and Case Coordination Service clients who comes to my knowledge during the course of my employment or volunteering at the PLHIV Support and Case Coordination Service and has not been authorized by the Director of the PLHIV Support and Case Coordination Service for release and/or specifically authorized by the client to whom the information relates. I further understand that this obligation:  is subject to any legal obligation to disclose the information; and  Applies to me both while an employee/volunteer of the PLHIV Support and Case Coordination Service and after I cease to be an employee/volunteer of the PLHIV Support and Case Coordination Service. I understand that if I breach an individual’s confidentiality, that person is entitled to sue me for damages, and that the PLHIV Support and Case Coordination Service will not indemnify me for damages. I accept that a breach of these conditions may result in instant dismissal, and civil and/or criminal proceedings. I have read and accept the PLHIV Support and Case Coordination Service, Code of Conduct as the rules and guidelines by which I am required to work. I also accept that my colleagues are working to the same Code of Conduct. Signed __________________________________________ Date

__________

Note: more about your obligations re confidentiality can be provided by your supervisor. This document will be retained on your personnel file.

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JOB STATEMENT –COORDINATOR, SUPPORT CELL Office Use Only: Job Title: Coordinator, Support Cell Department: [add] Review date: [add]

Job Status: Full time Job Grade: Coordinator 1 Supervisor: Project Manager

Advertisement The PLHIV Support and Case Coordination Service is seeking a Coordinator to lead a team of caseworkers in the provision of counseling, case coordination and/or group work to people living with HIV. The successful applicant will be a local person with experience in the supervision of staff and/or volunteers, experience with clinics and hospitals that provide services to people living with HIV and an understanding and demonstrated commitment to people living with HIV. The successful applicant will be able to work independently, will be highly organized, outgoing and extremely good with people. The person may have qualifications in counseling or health, but this is not essential. You must have a high level of integrity, compassion and concern for others and a high degree of honesty. A starting salary of between [add salary range if applicable] per month is offered dependent upon experience. This is a one-year position with annual contracting up to five years dependent upon successful performance and continued funding. Applicants must provide a letter responding to the selection criteria, a CV and contact details to the Project Coordinator at [add email address]. Face-to-face interviews will be held with selected applicants. For more information and a copy of the job statement please contact [add name], on [add telephone number]. Recruitment for this position closes on [add date]. The PLHIV Support and Case Coordination Service offers a supportive workplace for people with HIV who are most welcome to apply.

Overview The Coordinator of a support cell is responsible for recruitment, administration, supervision and overall coordination of a team of caseworkers who deliver counseling and case coordination to people living with HIV. The Coordinator supervises up to six caseworkers at the places they provide services.

About The PLHIV Support and Case Coordination Service The PLHIV Support and Case Coordination Service provides support and case coordination services to people with HIV to help them access the services they need to live healthy and independent lives with HIV. The PLHIV Support and Case Coordination Service provides ‘in-reach’ services to hospitals and clinics in local places, project workers accompany people with HIV to medical appointments to help them solve problems they experience in the health system and they provide one-toone and group peer support and counseling to people with HIV. The Project is a health promotion service that aims to (a) build knowledge and skills in people with HIV so they can make informed choices about their health, (b) work cooperatively 50


with HIV service agencies to provide seamless services and (c) influence and change health service policy and implementation so that it better meets the needs of people with HIV over time.

Key responsibilities of this position The Coordinator of a support cell is responsible to supervise and coordinate a team of six caseworkers who travel across Bangkok working in clinics and hospitals delivering case coordination within HIV testing and counseling services provided by these hospitals and clinics. The Coordinator works from the host organization but travels to the clinic and hospital sites where the Centre delivers the service. The Coordinator is responsible to manage relationships with clinical staff at these sites and ensures the smooth running of service at these sites. The Coordinator also manages all logistical, administration, service, staff and financial needs of their support cell.

Salary and Conditions Salary: [add salary] per month dependent upon experience. Conditions: twelve month contract renewable for up to five years dependent upon successful performance and continuation of funding for the project. Probationary Period: 3 months. Hour of work: 40 hours per week. Expected times of work: Monday to Saturday from 7.00am – 6.00pm (flexible).

Roles and Responsibilities The Coordinator of a support cell is responsible for the recruitment, support and leadership of a support cell of Caseworkers. Supervision  Daily individual and group supervision with caseworkers.  Coordinate individual work planning and work plan review with the caseworker team.  Travel to all clinic and hospital sites and advise and guide caseworkers in relation to their day-to-day responsibilities.  Coordinate team building with caseworkers.  Coordinate individual annual performance review of caseworkers.  Explore and develop professional development opportunities for caseworkers. Administration  Coordinate and ensure that support staff has the forms they need and follow them.  Coordinate service data reporting.  Oversee management of petty cash, office space and equipment in all sites and with all caseworker teams.  Ensure that caseworkers follow protocols and procedures for office administration, rostering, etc. Leadership 51


  

Represent the PLHIV Support and Case Coordination Service at local clinic and hospital sites ensuring that the team has the office space and resources it needs to deliver a high quality service. Meet regularly and work cooperatively with the clinical teams at these sites to ensure smooth integration of services in to clinical teams. Explore and coordinate with mobile HIV testing and counseling services to offer this service if relevant.

Anti-discrimination  Work to ensure the workplace is free from bullying, harassment and all forms of discrimination.  Work to ensure that project is a welcoming service project for all marginalized people including ethnic minorities and migrants.  Ensure the workplace is a welcoming environment for people living with HIV, including women and girls, people who use drugs, men who have sex with men and transgender people.  Help to eliminate social and service barriers for clients. Organizational responsibilities  Participate in supervision with the Project Manager and/or Director and follow all reasonable instructions.  Read and utilize the host organization’s policies and procedures when representing the organization in service delivery.  Actively participate in team meetings and team building exercises conducted by the host organization.  Actively participate in individual annual performance review.  Engage in professional development to build your skills.

Selection Criteria         

Experience in the supervision of staff and/or volunteers. Experience providing support, counseling or welfare services to clients. Demonstrated experience working within or with clinics and hospitals. Demonstrated understanding and commitment to people living with HIV, and sensitivity to key populations for HIV. Demonstrated ability to work independently. Be highly organized with the ability to meet deadlines and organizational expectations on time and without prompting. Ability to communicate cooperatively and diplomatically with people at all levels. Capacity to write policy, evaluation reports and articles. A tertiary qualification in health, counseling or health management is desirable but not essential.

Review of this Job Statement This job statement will be reviewed annually. The next review of the position will occur on [add date]. 52


JOB STATEMENT –CASEWORKER Office Use Only: Job Title: Caseworker Department: [add] Review Date: [add date]

Job Status: Casual Job Grade: Casual 1 Supervisor: Coordinator

Advertisement The PLHIV Support and Case Coordination Service is seeking caseworkers to provide counseling and case coordination to people living with HIV. The successful applicants will be a local person with experience in the provision of support, education or care services to people living with HIV. Demonstrated skills in counseling are also required. Both personal and professional experience with clinics and hospitals is highly desirable as is an understanding of the issues affecting people living with HIV. The successful applicants will be able to work independently, will be highly organized, outgoing and extremely good with people. You must have a high level of integrity, compassion and concern for others and a high degree of honesty. This is a volunteer position OR a starting salary of between [add salary range if applicable] per month is offered dependent upon experience. This is a one-year position with annual contracting up to five years dependent upon successful performance and continued funding. Applicants must provide a letter expressing their interest to the Coordinator at [add email address]. Face-to-face interviews will be held with selected applicants. For more information and a copy of the job statement please contact [add name], on [add telephone number]. Recruitment for this position closes on [add date]. The PLHIV Support and Case Coordination Service offers a supportive workplace for people with HIV who are most welcome to apply.

Overview The Caseworker, PLHIV Support and Case Coordination Service is responsible for providing case coordination and peer support services to people living with HIV. Caseworkers operate in teams and travel across the city to provide case coordination and support services at clinic and hospital sites. Caseworkers usually carry a caseload of between 14-20 clients per month and engage in assessment, referral and shortterm peer support to these clients. Caseworkers are responsible for administration, evaluation of the service provided and liaison with local clinical teams where they provide services and are supported by a Coordinator.

About The PLHIV Support and Case Coordination Service The PLHIV Support and Case Coordination Service provides support and case coordination services to people with HIV to help them access the services they need to live healthy and independent lives with HIV. The PLHIV Support and Case Coordination Service provides ‘in-reach’ services to hospitals and clinics in local places, project workers accompany people with HIV to medical appointments to help 53


them solve problems they experience in the health system and they provide one-toone and group peer support and counseling to people with HIV. The Project is a health promotion service that aims to (a) build knowledge and skills in people with HIV so they can make informed choices about their health, (b) work cooperatively with HIV service agencies to provide seamless services and (c) influence and change health service policy and implementation so that it better meets the needs of people with HIV over time.

Key responsibilities of this position The Caseworker, PLHIV Support and Case Coordination Service is responsible to provide case coordination, referral and peer support to people living with HIV. Caseworkers work in teams of up to six caseworkers who travel across the city working in clinics and hospitals delivering case coordination. Caseworkers work from a host organization but travels to the clinic and hospital sites where the project delivers the service. Caseworkers may also engage in outreach- to places that people with HIV gather around these clinics and hospitals in order to encourage and accompany them to health services.

Conditions Stipend: _________ per day of work plus _________ per day for mobile phone costs. Hour of work: 8 hours per day up to a maximum of four days per week. Expected times of work: Monday to Saturday from 10.00am – 6.00pm.

Roles and Responsibilities The Peer Caseworker is responsible for case coordination, peer support, referral, promotion and liaison of the HIV Testing and Counseling Service at the PLHIV Support and Case Coordination Service. Case Coordination and Peer Counseling  Travel to clinic and hospital sites where service is delivered.  Engage in initial intake and assessment of people with HIV.  Basic counseling and support to people with HIV over a twelve-week period.  Referral and follow up of referrals to other services. Administration  Use the forms provided and complete them in delivering client services.  Collect service data and provide daily to the Coordinator.  Follow protocols and procedures for office administration, rostering, using the PLHIV Support and Case Coordination Service resources, etc. Liaison  Represent the PLHIV Support and Case Coordination Service at local clinic and hospital sites and work cooperatively with clinical teams at these sites.  Attending local places/events where people with HIV gather to promote the service at these sites. Anti-discrimination

54


   

Work to ensure the workplace is free from bullying, harassment and all forms of discrimination. Work to ensure that the PLHIV Support and Case Coordination Service is a welcoming environment for all marginalized people including ethnic minorities and migrants. Ensure the workplace is a welcoming environment for people living with HIV, men who have sex with men, transgender people and women. Help to eliminate social and service barriers for clients.

Organizational responsibilities  Participate in supervision with the Coordinator (or other members of the management team as directed) and follow all reasonable instructions.  Read and utilize the PLHIV Support and Case Coordination Service policies and procedures when representing the organization in service delivery.  Actively participation in team meetings and team building exercises conducted by the PLHIV Support and Case Coordination Service.  Actively participation in individual annual performance review conducted by the PLHIV Support and Case Coordination Service.  Engage in professional development to build your skills.

Selection Criteria       

Experience in the provision of support, education or care services to people living with HIV. Demonstrated skills and experience in counseling or peer support. Personal and/or professional experience with clinics and hospitals. Demonstrated understanding of and commitment to people living with HIV, especially key populations for HIV. Ability to work independently but cooperatively with others. Be highly organized, outgoing and extremely good with people. Demonstrate a high level of integrity, compassion for others and a high degree of honesty.

Review of this Job Statement This job statement will be reviewed annually. The next review of the position will occur on [add date].

55


CLIENT INFORMATION FORM Caseworker’s Name: _________________ (Initials) Client Name: ___________________________ No: ______________

Address: ________________________________________________ Mobile: ______________________________ Email: ___________________________ Ethnicity: Age: Sex:

□?

□?

□?

□ <18 □ 18-25 □ Female

□?

□ Other _________

□ 25-30 □ 31-40 □ 41-49 □ 50-65 □ Male □ Transgender

Clinical Information: CD4 count: ____

Date: / /

□ 66>

Viral load count: ____ Date: / /

Diagnosed AIDS-related conditions (if any):

Presenting symptoms of illness (if any):

Initial service received form clinic: □ VCT □ STI/ STI diagnosis and treatment □ CD4/ CD4 testing □ Viral load testing □ Other (specify):

The story of the client

(Summarize the story of the client as described in your first

meeting) ___________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________

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Map of Clients Life Pathway Week 12

Service to be provided ?

Service to be provided ?

Service to be provided ?

Service to be provided ?

57


First meeting

Plan of activity for and with the client No.

Activity

Deadline

Who?

Details

1.

2.

3.

4.

5.

6.

7.

8.

58


Notes Meeting 1 (Keep notes on what happened during the session) __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________

Meeting 2 (Keep notes on what happened during the session) __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________

Meeting 3 (Keep notes on what happened during the session) __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________

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Meeting 4 (Keep notes on what happened during the session) __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________

Meeting 5

(Keep notes on what happened during the session)

__________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________

Meeting 6 (Keep notes on what happened during the session) __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________

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CLIENT CONSENT FORM In order to provide you with service I need to ask for your permission to collect, store and use information about you. The PLHIV Support and Case Coordination Service keeps files on each client it supports. These files are kept in a locked storage cabinet in our office. Personal and contact information on clients is not released to others without your permission. We are required to provide information to our funders and to government about the services we provide and the general profile of our client caseload. This is what is called ‘de-identified’ information in which information about you, your health and life situation cannot be determined by these funders or by government. In other words, no names, no addresses, no information that could identify you are provided. Giving your consent means we’ll be collecting and storing information about you and reporting on the health and support needs that you disclose to us. Yes

No

Do you agree?

I have:

Yes

No

-

☐ ☐ ☐

☐ ☐ ☐

Been informed about why and how information is kept about me Participated in determining the support that will be provided to me Been informed where and how this information will be stored

Sometimes it can be helpful to coordinate your support with other services such as hospitals and clinics or welfare agencies. After discussion with your caseworker, you can nominate here the agencies that you agree we can talk to on your behalf: 1. ________________________________________ 2. ________________________________________ 3. ________________________________________ 4. ________________________________________ 5. ________________________________________

Signed: ______________________________ (Client’s Signature)

Date: ____/____/____

Name: _______________________________ (Client’s Name)

Caseworker: _______ Initials 61


HIV RESILIENCE SCALE Client No: __________ Step Completed: 1 | 4 (circle one) Date: ____/____/____

1

2

3

Definite No

1

At the moment I take one day at a time.

2

Problems with HIV prevent me planning ahead.

3

I suffer a great deal of anxiety about HIV.

4

I feel like giving up.

5

I am not very hopeful about the future.

6

I have plans for the future.

7

I feel that life is hopeless.

8

I feel I canâ&#x20AC;&#x2122;t do anything to cheer myself up.

9

I try to carry on my life as I have always done. 1 Definite No

10

I have been doing things that I believe will change my health. E.g. diet.

11

I firmly believe I will be OK.

12

I have been doing things that I believe will improve my health. E.g. exercise.

13

I believe that my positive attitude will help me.

14

I try to fight the illness.

15

I feel that there is nothing I can do to help myself.

4

HOPELESSNESS 5 6 Definite Yes

2

3

FIGHT SPIRIT/SELF-EFFICACY 4 5 6 Definite Yes

PERSONAL CONTROL

62


1

2

3

4

5

Definite No

16

I avoid finding out more about HIV.

17

I want to make contact with others with HIV.

18

I am trying to get as much information as I can.

19

I’ve left it all to my doctors.

6 Definite Yes

MINIMIZATION

1

20

I’ve put myself in the hands of religion.

21

I count my blessings.

22

I keep busy so I don’t have time to think about it.

2

3

4

5

6

HOPEFULNESS

1

23

2

3

4

5

6

I try to keep a sense of humor about it. Other people worry about it more than I do.

24

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INFORMATION FOR CLIENTS #1 Charter of Client Rights & Responsibilities At the PLHIV Support and Case Coordination Service we want you, as a new or potentially new client of our service, to understand your rights and responsibilities when you receive services from us. Below you’ll find a list of basic rights and responsibilities that we hope you’ll agree with. Your Rights As a person using the PLHIV Support and Case Coordination Service services you have a number of important rights that we want to inform you of. You have the right to:  Be treated with respect and courtesy  Have your needs assessed  Be informed and be part of decision making about the services we provide you  Receive quality services  Have the right to make a complaint without retribution – in other words, services will not refused to you or the quality reduced because you make a complaint about us  Have someone represent you (an advocate)  Have your privacy and confidentiality respected and to access all personal information kept about you by us  Accurate information about our Project and the services we can provide you  Non-discriminatory care – in other words, receive services which do not discriminate on the basis of age, race, religion, sexuality or gender  Ask for a different service provider and have that request met wherever it’s possible Your Responsibilities As a person using the PLHIV Support and Case Coordination Service services you have a number of important responsibilities that we want to inform you of. You have the responsibility to:  Treat staff, volunteers and other clients with respect and courtesy – for example, letting us know as soon as possible if you cannot keep an appointment  Provide a safe environment for staff, volunteers and clients and help us to provide you with services safely – for example, by not smoking while staff are present  Avoid placing our staff in situations that are illegal or that compromise our integrity and reputation  Inform us if you change your address or contact details  Inform us if you no longer require or desire our assistance  Take responsibility for the results of any decisions you make with us

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INFORMATION FOR CLIENTS #2 Our Privacy and Confidentiality Policy This information leaflet tells you about the steps that the PLHIV Support and Case Coordination Service takes to protect your privacy and confidentiality.

Our commitment to you At the PLHIV Support and Case Coordination Service we are strongly committed to protecting your personal information and to ensuring that information about you is not given or shared with others without permission. Our staff and volunteers have been trained in protecting your privacy and given clear instructions about how to do so. They have signed an agreement saying that they will protect your personal information carefully. We will do everything in our power to protect your personal and private information.

Aim of our privacy and confidentiality policy The aim of our privacy and confidentiality policy is to protect the personal and sensitive information of all our clients by providing clear and unequivocal direction to the PLHIV Support and Case Coordination Service staff and volunteers about their obligations to protect the personal and sensitive information of clients. Our client privacy and confidentiality policy aims to provide staff and volunteers with clear and practical guidance that assists them in their day-to-day work to ensure the highest quality standard of confidentiality and privacy protection possible. This policy applies to all paid staff, casuals and contractors of the PLHIV Support and Case Coordination Service.

Getting your consent At the first meeting between you and staff member or volunteer of the PLHIV Support and Case Coordination Service, you are asked to sign the Client Consent Form stating you are consenting to the collection and storage of information about you and that you consent to the sharing of information about your situation in an anonymous format to government, to our donors and in reports or journals. Any transmission of information outside this code is deemed to be a breach of your confidentiality. The boundaries of confidentiality are outlined in the PLHIV Support and Case Coordination Service Confidentiality and Privacy Agreement that all staff and volunteers sign when they first start working with us. All PLHIV Support and Case Coordination staff and contractors are under an obligation not to convey directly or indirectly, to any source, any private or personal information about a client that they are given or may obtain during the provision of their services. Breaches to this obligation shall be deemed to be a breach of confidentiality.

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How we store and transmit information about you We store information about our clients in a locked filing cabinet in an office that is staffed or locked when no one is present. We instruct our staff and volunteers that information about clients should be stored in a locked filing cabinet or on a computer with a saved password. Information about clients is not left unattended on desks or at photocopiers or other places in the office. As well, we provide clear advice and direction to our staff and volunteers about how information about clients should be stored and transmitted. This includes: 

Voice Mail and Fax: no detailed client information should be left on a voice message. If sending a fax, staff and volunteers should ensure first that the service provider will be standing at the send point to receive the fax immediately. Staff and volunteers are instructed that must NOT send a fax to a service provider without talking to them first and ensuring they’re available to receive it.

Email: client identifying details are NOT included in any email. Generally, the staff and volunteers talk to a service providers on the telephone or face-toface and then send an email about the client using the first two letters of a clients first and last name. For example,

Dear Sharon, In regard to our conversation regarding client: ScBe, I am emailing to confirm that he is available to meet with you on the 13th December at 10.00am in your offices and that he will attend then. Regards, John Smith.

Training and Demonstrations: the anonymity of clients will be maintained during training cases, presentations, case studies, seminars or conference presentations. This should include the name of the client and their personal details. Exceptions to this may occur where the client has given their written consent to be identified by name.

Conversations: the PLHIV Support and Case Coordination Service staff and volunteers DO NOT discuss clients in public areas such as corridors, waiting rooms, lifts or toilets under any circumstances.

Inquiries about clients: the PLHIV Support and Case Coordination Service will not confirm that an individual is or has been a client of the Project nor confirm a relationship nor divulge information about a client to third party other than appropriate service providers without the prior consent of the client. 66


Office access: visitors (e.g. clients and service providers) to the PLHIV Support and Case Coordination Service offices should be accompanied and supervised by a staff member at all times.

What to do if you believe your privacy has been breached Our staff and volunteers have been trained and are committed to preventing breaches of your confidentiality. Nevertheless, you may believe your privacy has been breached and, if so, we want to hear from you. Contact [NAME, POSITION, TELEHONE NUMBER, EMAIL ADDRESS]. When dealing with your complaint we will:   

Treat you with respect and take your complaint seriously. Investigate the complaint within one week and call to explain our findings. Provide you with a new staff member or volunteer.

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INFORMATION FOR CLIENT #3 Complaints Resolution Policy

About this policy The policy describes the resolution process that we follow where a complaint is received from a client or stakeholder regarding the behavior or service delivery provided by a staff member, volunteer or contractor of the PLHIV Support and Case Coordination Service. It outlines the steps to be taken in the event of a written complaint or grievance and who is responsible to lead and resolve these complaints.

Aim of this policy The aim of this policy is:  To foster an atmosphere within the PLHIV Support and Case Coordination Service in which complaints are viewed positively as a mechanism of quality service improvement and enhancing the reputation of the Project.  To provide for the resolution of complaints about staff, volunteers and contactors quickly and efficiently.  To provide transparent and accessible mechanisms for the resolution of complaints and review of the PLHIV Support and Case Coordination Service decisions in relation to grievances and complaints.

Scope of the policy The scope of this policy includes the activities, responsibilities and reporting relationships of staff, volunteers and contractors of the PLHIV Support and Case Coordination Service.

Promoting the policy All stakeholders of the PLHIV Support and Case Coordination Service are entitled to be informed of their right to resolve grievances that they may have from time-totime with staff, volunteers or contractors and with service delivery provided by the Project. In order to assist in promoting awareness of this right, the PLHIV Support and Case Coordination Service will ensure that: 1. All clients are provided with a Client Rights Information Pack at the point of initial assessment and an explanation of how to complain is provided by a staff member or volunteer. 2. The PLHIV Support and Case Coordination Service website will include information about how to complain on its website.

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Complaints Resolution General Principles 1. Genuine grievances are welcomed by the Project and its staff and volunteers as an opportunity to improve the processes and reputation of the Project. 2. The Project holds the view that all stakeholders of The PLHIV Support and Case Coordination Service have the right to seek resolution of grievances against staff, volunteers or services. 3. Complainants will therefore be treated with respect and care and there will be no recriminations by any other persons connected to the Project against any complainant.

Making a complaint 1. Enquiries about how to make a complaint about the service received can be directed to [NAME OF PERSON, TELEPHONE NUMBER, EMAIL ADDRESS]. 2. The Project will welcome verbal complaints and will document the details on the complainants’ behalf. 3. Complaints can be received by post, marked ‘confidential’ and directed to [NAME, POSITAL ADDRESS]. 4. Alternatively, email complaints can be forward to [NAME, EMAIL ADDRESS]. 5. Where the complaint relates to the Project Manager, those complaints can be received by post, marked ‘confidential’ and directed to the Director. 6. Alternatively, email complaints relating to the President can be forward to [NAME, EMAIL ADDRESS]. 7. Complaints can be anonymous. However, communication to the complainant about deliberations will not be possible.

Resolution of complaints 1. Complaints will be considered carefully by the Project. 2. The management team will consider and discuss the complaint, documenting the discussion and all decisions made in relation to the complaint. 3. Action to be taken:  Issue 1: the grievance relates to deficiencies in policy, procedure or systems 69


A resolution is made to alter policy, procedure and systems and monitor improvements. 

Issue 2: a grievance against an individual is found to be justified Provide support and counseling to the specific staff member or volunteer aimed to assist them understanding the deficiency and improving behavior and performance. The Project Manager must monitor performance improvements.

Issue 3: the individual’s behavior continues A clear directive to cease behavior in writing and dismissal of a particular staff member or volunteer where the grievance is serious, proven true and the behavior continues.

Issue 4: the behavior is illegal or dishonest This may be cause for instant dismissal of a particular staff member where they act dishonestly or illegally.

Issue 5: there is no grievance to answer from managements’ perspective The Director of the host organization may decide to take no action and make no agreements where they believe there is no grievance to answer.

Communicating the results 1. Communication in regard to the PLHIV Support and Case Coordination Service deliberations will occur by telephone or face-to-face in the first instance where possible. 2. A follow-up letter/email (where the complainant has identified themselves) will then occur. 3. Where resolution has resulted in Issue 5 above the host organization must outline its reasoning in the written reply.

Unresolved grievances In the event that a complainant remains dissatisfied with the PLHIV Support and Case Coordination Service decision about their concerns a further process of mediation can be established to assist resolution. In these instances 1. The complainant must indicate in writing (as outlined above) that they remain dissatisfied and request external mediation.

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2. The host organization enters in to an agreement with a third party to assist and mediate resolution. This third party may be a local service provider at a clinic or hospital familiar to the client.

Vexatious Complainants In some cases where the above processes have been exhausted it may be necessary for the PLHIV Support and Case Coordination Service to decide a particular individual is a vexatious complainant. A vexatious complainant would be someone where there is evidence of a previous relationship with a staff member and the complainant is using the resolution process to abuse and psychologically injure that individual. In these cases, the PLHIV Support and Case Coordination Service has an obligation to protect the individual being victimized. In other circumstances, a vexatious complainant may have complained repeatedly about the same or differing issues; The PLHIV Support and Case Coordination Service may have completed the above processes only to receive further complaints. In this case the Project is entitled to determine the complainant a vexatious complainant and no longer consider complaints received by this individual. The Project will write to an individual determined to be a vexatious complainant informing them of their decision and that they will no longer consider complaints received by them in future.

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CLIENT SATISFACTION SURVEY Thank you for participating in the Client Satisfaction Survey. Your feedback is important. It will help us learn more about what is good and what we can improve about our services. Please complete and then enclose it in the envelope provided.

ABOUT YOU a.

Where do you live? __________________________________________________________ (SUBURB/POSTCODE ONLY PLEASE)

b.

What is your gender?

Male

c.

What’s your country of birth?

?

d.

Do you speak a language other than?

No

Female

Transgender

Other _______________ (SPECIFY)

Yes _______________ (SPECIFY)

FIRST CONTACT WITH THE PROJECT During your first or second contact with a caseworker did they inform you of: e.

Your rights and responsibilities as a client?

Yes

No

f.

How to make a complaint?

Yes

No

g.

How information about you would be stored?

Yes

No

h.

Your rights to privacy?

Yes

No

Is there anything else you’d like to add about your first contact with us?

CONTACT WITH OUR OFFICE & OTHER STAFF a.

Were office staff polite when you called?

Yes

Sometimes

No

b.

Did your caseworker always call you back quickly?

Yes

Sometimes

No

c.

Did they do what they said they would do?

Yes

Sometimes

No

d.

Did they review your case with you?

Yes

Sometimes

No

e.

Did your caseworker attend meetings as agreed?

Yes

Sometimes

No

Is there anything else you’d like to add about contact with staff?

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RESULTS FROM OUR SERVICE TO YOU f.

Were you satisfied with the results of our service to you?

Yes

Somewhat

No

g.

Do you feel better able to manage now than before our service to you?

No

Somewhat

Yes

Do you feel better able to achieve your hopes for the future now than before our service to you?

Yes

Somewhat

No

i.

Do you have more contact with other PLHIV now?

No

Somewhat

No

j.

Do you have easier access to local services now?

Yes

Sometimes

No

k.

Are you more confident about your future?

No

Somewhat

No

h.

Is there anything else youâ&#x20AC;&#x2122;d like to add about the results of our service to you?

Thank you again for taking the time to complete and return this survey.

73

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