Nine Circles Community Health Centre

Outreach Program

Project Description

The objective of the Outreach Program is to provide support to clients living with HIV with complex needs in relation to adherence to treatment and engagement in primary care services in Winnipeg through Nine Circles Community Health Centre and the Health Sciences Centre HIV Program site.

The outreach team consists of four Outreach Workers who are front line team members working in the community.  The program has been in operation since 2007 and supports between 120-160 clients.

The Outreach Workers act as a liaison between the clients and care team.  The Outreach Team is supported by three Social Workers between the two sites.  They work in tandem with the Social Worker to support client to be empowered in addressing the impact of the social determinants of health in their lives and to have a voice in the various systems that affect them.  Overall supervision is provided by the Director of Allied Care and Health Promotion.

Outreach workers work with clients and care team members to identify barriers to treatment and care adherence.

Some of the activities include:

  • Transporting clients to medical appointments (internal MB HIV Program and external)
  • Join clients in their appointments where requested to assist in liaising with primary care personnel
  • Attending care team meetings with or without the clients to provide front line context
  • Medication and appointment reminders
  • Supportive listening
  • Assisting clients in navigating systems
  • Connecting client to Social Worker where appropriate and/or internal referrals to other care team members.
  • Maintain connection between client and program through regular phone and community check- ins to ensure linkage to care.
  • Work with Client on strategies to address barriers to treatment & engagement in primary care services ( social determinants of health) in partnership with social worker
  • Act as an agent in the care team when client is at risk of being lost to care by actively searching for them through community networks.