On a typical day, visitors to the inner-city Saskatoon Community Clinic – Westside pass through a small crowd hanging out on the street-front to get to the door.  There’s a “meeting-place” atmosphere around the clinic, as kids play on the sidewalk, and moms guide strollers up the ramp. The waiting room is always full, the elevators and stairways always busy.

Della, a nurse practitioner who has been with the clinic for seven years, is in her office early every day. Her patients generally come from the clinic’s surrounding neighbourhoods.

“When I first started here, I might have seen one or two people with HIV,” she told me. “Now on any given day I’ll see three, four, five people with HIV.”

RR-2014-11-26-Coordinated-HIV-CareStaff at the Westside clinic try to see as many people in a day as possible. It’s part of the team approach that means everyone, from the receptionist to the infectious disease specialist, works together to meet their clients’ most immediate needs.

The staff at the clinic understand the challenges their clients face daily, and it guides their work.

“Everyone is treated like an equal and that keeps everyone linked together,” Della said.

They take every opportunity to interact with clients, to make sure they are accessing the care they need. For instance, if the receptionist recognizes someone in the waiting room Della has been looking for, she’ll ensure that Della gets a moment to speak with them.

Della credits this “opportunistic style” with the clinic’s success in engaging patients.

“If somebody comes in and says, ‘I’m pregnant but I’m using and I’m HIV positive,’ I will bring them in right away,” she said. “I can knock on a door and get a doctor or a social worker to come right away. We can bring that patient into the circle of care and talk about what that patient needs right now.”

The focus at the Westside clinic is on building trust. For clients with a history of physical, sexual or emotional abuse, building trust with a medical provider is key to becoming engaged in their own care.

“Having continuity of care is very important. A lot of people in the community will say they are tired of telling their story over and over,” said Della. “It’s tough when you have to build up trust again and again.”

One of the biggest challenges Della sees with respect to HIV care is the shortage of low cost housing in the city. “If you have HIV, but you have no home, you have nowhere to store your medication. Housing is absolutely key to any of the health issues that we deal with. The amount of money people get from Social Services just doesn’t cover it when you have to have money for food and other expenses.”

Many of their patients don’t have background references needed to secure rental housing.

“In many cases, those who are coming out of jail or hospital are going straight to detox beds to addiction service beds and back to hospital because they have nowhere else to go,” Della said. “We do all this work to make things better and they’re ready for discharge, but they have no home to go to.”

Without transitional housing for people discharged from hospital, IV therapy and other types of home care can be problematic.

“We’ve had patients meet Home Care here at the clinic to do a dressing, and things like that,” Della said.

Finding appropriate housing for individuals with HIV-related dementia or organic brain disorder can be especially problematic.

“It’s hard work to keep people from falling back into addictions when they don’t have their own place,” Della noted, adding that the housing in Saskatoon isn’t getting any better.

But Della has seen progress in some areas.

“I work with moms with HIV who have their children, and seven years ago when I started it was unheard of, really, for a mom who was addicted and had HIV to come home with her baby,” said Della.

There have been no babies born with HIV for a few years now in Saskatoon Health Region, and she acknowledged that success has been achieved by the work of many disciplines, as well as by the women themselves.

“It starts with initiating people into care, whether they’re pregnant or not, and engaging them, adding outreach they can trust,” she said.

The work doesn’t end when a healthy baby is delivered. As the children get older, their needs change to those of active toddlers, and subsequently the stress upon mothers increase and old challenges begin to resurface. A peer mentorship program, where mothers could be with other mothers, would be very helpful in Della’s view.

“Mothers need to learn skills like how to mix formula, how long it’s good for after mixing, how often should you bathe your baby, what to do if your baby gets a temperature, when to start adding solid foods,” she said.

Many of the children who have successfully remained with their HIV positive mother will be starting school soon, and Della asked, “How do we keep them in school so they can be educated? How do we ensure moms can be moms that support their kids in school?”

Tomorrow’s generation is very much in the forefront of her mind. Della has photos in her office of the babies born to moms who visit the clinic. They remind her of the goal to make things better for the next generation.

“It’s certainly something we all work for,” she said.

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