Launching partnership with AIDS Foundation of Chicago to expand program to other hospitals

The Ruth M. Rothstein CORE Center‘s Project CONNECT today hosted a stakeholders meeting, “The Past, Present, and Future of the HIV Inpatient Service & the Role of Care Coordination,” to highlight the project’s achievements and announce the launch of a partnership with the AIDS Foundation of Chicago to expand CORE’s transitional care coordination model to other hospital settings.

The partnership will focus on the creation of wrap around services, including case management, housing, transportation and clinical care for patients. It will feature the development of best practices for peer training and access to patient-centered medical home providers, such as the CORE Center. Partners also will ensure that HIV/AIDS patients who are not eligible for insurance coverage will continue to be linked to care.

Project CONNECT, a transitional care coordination program, was implemented in 2012 to help patients with HIV/AIDS access outpatient services at the CORE Center, where they receive primary & specialty care, social services, education and training, and opportunities to participate in research projects.

Since Project CONNECT’s inception, over 450 patients have been linked to care at the CORE Center. Project CONNECT has increased the percentage of patients who show up for follow-up appointments by 27 percent, which indicates successful retention. Clinical outcomes for participants show an increase in their T-cell count and a decrease in viral suppression, both of which correlate to the reduced likelihood of HIV transmission.

“Project CONNECT allows us to provide a personal connection between the medical staff and the patient,” said Dr. Ron Lubelchek, the associate medical director at CORE. “This relationship allows us to improve the patient care experience at the hospital, transition individuals to outpatient care at the CORE Center and decrease the need for hospital readmissions. We are here to serve our patients and make them feel as comfortable as possible throughout their stages of care.”

Project CONNECT is funded through the generous support of The Chicago Community Trust, Polk Bros Foundation, The Crown Family and the Dr. Scholl Foundation.

Project CONNECT staff works with the HIV inpatient team at the John H. Stroger, Jr. Hospital of Cook County to identify patients who are either:

• Newly diagnosed
• Lost care for at least 12 months
• Never engaged in care
• Experienced a 30-day unplanned readmission

Patients meeting these criteria are assessed within 24 hours or the next business day after being admitted. They are matched with a peer navigator who provides emotional support during their hospital stay and works closely with the inpatient team to successfully engage and transition them to their first CORE Center outpatient appointment.