May 8, 2008

I supervise a three-person case management team that works with the doctors of NY Presbyterian Hospital, Division of Infectious Disease. My team does everything in our power to help HIV patients at the hospital get engaged in medical care and stabilize their situations so they can get better and go on with their lives.

Many of our clients are so sick and have been in and out of the hospital so much, they feel completely hopeless. We help them see that thing can get better, and we try to support and motivate them to get their medical care, stick with their meds, and start to reclaim their lives.

For many patients, the "leap" from in-patient hospital care to getting medical services in an out-patient clinic is overwhelming—there are so many different appointments, so much paperwork, and so much information to absorb. For patients who are already unwell and stressed, it can be too much to handle and they end up falling out of care.

That's where ASC's case management services come in. We start by meeting patients while they're still in the hospital. Once they're discharged, we're there for them every step of the way through the whole medical experience, until they're able to handle things on their own.

Our work is intensive, with a goal toward stabilization, in terms of housing, food and other basic needs. We work closely with their doctors to help coordinate their care. We take them to appointments, help them talk to their doctors, educate them about their medications, and help them resolve the barriers that stop them from taking their meds or keeping their appointments.

A few months ago, we had a gentleman who was at the lowest point in his life—he had 2 T-cells, weighed 90 pounds, and could hardly walk. We advocated for him, calmed him down when he was overwhelmed, escorted him to his doctor's appointments, and encouraged him to take his HIV meds. Now, he has an undetectable viral load, has returned to his normal weight, and feels like himself again. All the services he needs are in place for him. Stories like his make this work totally worthwhile—seeing the difference we can help make in people's lives is amazing.

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