AFISE Home visits psychosocial program

Home visits psychosocial program – Does it help? Issues A signifi cant proportion of the social case management interventions are represented by home visits (36% of all patient encounters during 2011). Taking into consideration the time, eff ort and costs associated with this type of patient follow-up, it is important to describe the format and the impact of home visits program. Description BBSF patient care standards estab- lish some selection criteria for pa- tients that need to be prioritized for home visits (such as LTFU, CD4<200, adherence problems, etc). Objectives and most appro- priate interventions are further es- tablished by the team (monitoring, counseling, referral etc). During 2011, home pill count assessments showed that at least 34% of all cases visited had adherence problems; most home visit counseling topics focused on practical help related to legal rights (57%) or medical refer- rals (14%); a small number of patients needed to be represented or accompanied by the social worker to vari- ous institutions (7%). As most patients have been registered with the COE for many years, only 7% of all home visits had the goal of fi rst time evaluation. Lessons learned All patients selected for home visits are at some kind of risk and going through complications; there are multi- ple barriers and costs associated with home visits that complicate the interventions furthermore. However the home visits program is helping patients. Overall, the patients visited at home during 2011 had the following evolution: for 21% the overall functioning improved, for 59% of the visited patients the overall functioning and coping abilities have remained unchanged and for 20% the global functioning has altered signifi cantly. We have learned that the patients that actually improved were visited more than those that stayed the same. Next steps We plan to further review the home visits program, to critically analyze the criteria for home visits and the ob- jectives for the interventions and to establish a clear timeline for evaluating the individual impact of home vis- its. We need to further understand how best to adapt the home visits program in order to improve the lives of more patients. Authors: Ana-Maria Schweitzer, Luiza Vlahopol, Gabriela Bazaitu, Corina Pop, Emanoil Vasiliu, Niculaie Florica, Simona Vlase – Baylor Black Sea Foundation - BIPAI Romania