STEPS to Care: Preview Guide and FAQs

The suite of STEPS to Care web pages contain information on the three strategies supported by STEPS to Care: Patient Navigation, Care Team Coordination, and HIV Self-Management, and how the strategies work together. The pages also include a video about the program, information about staff involved, an overview of the website and an agency readiness assessment.

• The STEPS website contains a comprehensive set of tools for Program Directors who want to start a STEPS to Care program at their agency.
• The online materials contain comprehensive guidance on establishing agency policies and procedures for a STEPS to Care program, assigning staff to specific roles, and budgeting. The tools include videos, downloadable forms, and templates that you can adapt to align with your own agency-specific policies and procedures.
• Project Directors may find it useful to review all materials and resources available and make strategic decisions about what will and will not be useful for your agency. For example, you may not need to use the STEPS intake form if you already have an intake form in place, but you may refer staff to the intake assessment training to help them develop their skills in building relationships and collecting personal information with new clients.

• Through STEPS to Care, your agency is providing services and activities related to Patient Navigation, Care Team Coordination, and patient education and health promotion (through the HIV Self-Management strategy).
• Reimbursement for HIV treatment services vary from state to state.

• STEPS to Care is comprised of three strategies—Patient Navigation, Care Team Coordination, and HIV Self-Management—that are derived from New York City’s effective HIV Care Coordination program. STEPS to Care and the online toolkit have been field-tested in various settings, from hospitals to community agencies, with multiple benefits as noted in the quotes below from participants in the field test.
• Through the Care Team Coordination strategy, STEPS to Care can improve how members of multidisciplinary care teams interact and communicate with each other. The tools developed for the program provide a process that considers the medical, behavioral health, and social support needs of clients.
• STEPS to Care is used to tailor care to client needs. Care team members collaboratively craft a Comprehensive Care Plan for each client. The plan is updated regularly and reflects client input.
• STEPS to Care provides intensive navigational support to clients so that clients who are newly diagnosed or have fallen out of care are engaged in care.
• Through STEPS to Care, clients gain access to a wide range of tools that enable them to learn about their condition, work with their navigator on strategies to improve medication adherence and overcome other barriers to care, and hear from other HIV-positive individuals. These tools are available online to be used by clients with their Patient Navigator and later their own time.
• “The draw of the patient self-management component is that it is private. A patient can access information at their convenience, in the privacy of their home or wherever they choose. No other person has to deliver the education, which can inadvertently violate a person’s privacy and/or confidentiality.” – Clinical Director, Hospital
• “…Primary Care Providers (PCPs) were more focused on medical treatment. Doctors see themselves as specialists rather than as involved in all aspects of care. S2C [STEPS] has caused me to see that we need to improve how our PCPs and our social services staff interact.” – Administrator, Hospital Primary Care Clinic

• Include staff in orientation webinars and planning meetings during the pre-implementation period. Staff need to feel a connection to the work that will take place.
• Help staff to see how the staff tools on this website and the client tools on MySTCTools will help keep clients engaged in care, improve communication with their care team, feel empowered to take charge of their care, and possibly improve outcomes like client retention and viral load suppression.
• Discuss with staff how STEPS to Care tools and trainings can facilitate their daily work and promote professional development.

• Share information about how the three strategies (Patient Navigation, Care Team Coordination, HIV Self-Management) are drawn from an effective model of care.
• Acknowledge that providers have limited time outside of providing clinical care and describe how STEPS to Care provides strategies and guidance for optimizing meeting time between care team members.
• Acknowledge that the strategies supported by STEPS to Care, such as Care Team Coordination, will improve the quality of communication between staff and PCPs and, in turn, the quality of care for clients; highlight how these strategies can enable PCPs and staff to develop as complete a picture as possible about the client and their care needs.

• The website contains concise and clear information summarizing the STEPS to Care program on the homepage, including an introductory video about the effectiveness of the three program strategies. This easy-to-access information can be used to introduce agency stakeholders to the program.
• Several tools and resources that are found on the website can be also printed or shared in group meetings to further clarify how STEPS to Care works. These include:
  • Client Pathway and Provider Tools Chart [PDF – 158 KB]
  • Care Team Coordination topic page and Care Team Communication Strategies Video
  • Patient Navigation topic page and video
  • HIV Self-Management topic page
  • The STEPS Strategies topic page
• We encourage you to explore the many resources on the website to determine which tools or topic pages may be most useful to share to gain buy-in from agency staff.

• The STEPS to Care strategies and tools can serve as a supplement to the HIV services your agency already provides. Even the most experienced Program Directors, Care Coordinators and Patient Navigators can benefit from new techniques and tools to enhance their services and outcomes.
• The tools and resources on the STEPS to Care website can help agencies either develop a coordinated care model from the ground up or, in many instances, enhance how care is being delivered to clients in order to improve client outcomes such as linkage, engagement/re-engagement, and viral load suppression.
• “The program tools are well written and can clearly guide an agency through the development of the STEPS model.” – Clinical Director, Hospital
• “The training tools are easily accessible, very concise, well written, and pertinent to the model. All level of staff could easily adopt this model and adapt to the structure of the model.” – Clinical Director, Hospital

• First, familiarize yourself with the STEPS to Care strategies and the various tools that are available on the website to support pre-implementation and implementation. It’s recommended that Program Directors review all the topic pages on the site.
• Once you are familiar with what is available on the site, work with staff to identify and prioritize trainings and topics based on their roles and responsibilities.
• Hold group trainings (where staff access the online tools together) covering topics that may need the most preparation, so staff can review materials together and ask questions.
• Provide staff with a clear mapping of which tools (e.g., forms, protocols) they should use to deliver the services that are part of their job function.
• Hold monthly supervision meetings using materials from the STEPS to Care website for ongoing professional development.

• Before answering these questions, familiarize yourself with the Staffing and Supervision topic page on the so you can describe the roles and responsibilities to staff.
• Explain that STEPS to Care roles can be fluid, and work with your staff to pick and choose from the tools based on what their responsibilities are.
• Do not let the staffing titles (e.g., Care Coordinator, Patient Navigator) limit which tools you and your staff use; explore all the topic pages and use what you need when you need it.
• Encourage staff to select tools that they need based on their job function vs. STEPS to Care staffing titles.

• Encourage staff to think of STEPS to Care as strategies that enhance what they are doing or help them do it in a slightly different way. The tools and protocols on the website provide templates and guidance for implementing the strategies in a way that has worked for other agencies. Many of these tools are provided for agencies who do not have these structures in place, and you may not need the STEPS specific tool. For example, if you are already using a client intake form that is tailored to your organization and your client needs, you do not have to use the STEPS Intake Assessment Form. Program Directors should review all available materials and assess which tools they will use.
• Clarify that STEPS to Care includes a set of three strategies that work in combination to improve client care and outcomes. Explain that, when used together, the tools on the site can help staff be more effective in helping clients to stay in care and achieve viral load suppression.

• Because STEPS to Care is comprised of three strategies that work in conjunction, consider those units of your agency that currently carry out or plan to engage in any or all of the following activities:
  • Patient Navigation – Identifying high-need clients and providing supportive case management.
  • Care Team Coordination – Supporting information-sharing and collaborative decision-making among care team members.
  • HIV Self-Management – Empowering clients with strategies to improve their care and health outcomes through easy-to-use client resources.
  • The unit should serve clients who could benefit from improved linkage to care, retention in care, re-engagement in care and viral load suppression.
  • It is recommended that the unit have a primary HIV medical care provider co-located or strongly affiliated with case management/care coordination services.

• While it is not a requirement, it is preferable to have medical providers at your agency. It is best to obtain buy-in from providers before implementation.
• If you do not have medical providers on-site, you can still implement STEPS to Care, if:
  • The agency provides medical care at the same site (and under the same organizational umbrella) as the case management/supportive services it offers at that site, or
  • Case management/social services clients receive HIV medical care from one (or from 2-3 maximum) medical care provider(s) with a formal business agreement or other legal relationship to provide primary medical care for your agency to facilitate information and records sharing.

It is not necessary. However, having an EMR or EHR greatly facilitates information sharing on medical visits, lab results, case management and Patient Navigation updates. In addition, evaluation of program success through review of client viral loads and other test results is much easier when an EMR or EHR is in place.

• Those at greatest risk for suboptimal HIV outcomes
• Those at greatest risk of poor HIV outcomes in the absence of enhanced support such as STEPS, including individuals who are:
  • newly diagnosed
  • previously lost to care (dropped out for >6 months) or never in care
  • irregularly in care (e.g., frequently missing appointments)
  • initiating a new ART regimen
  • demonstrating incomplete medication adherence or response to treatment (high viral load or low adherence as measured by self-report, pill count, etc.)
  • known to be facing a major care/treatment barrier (e.g., bereavement, relapse to substance abuse, interpersonal violence, homelessness or imminent risk of homelessness, fresh release from incarceration/ readjustment to community), requiring a period of more intensive support

The STEPS to Care site is designed to provide flexible and ongoing training for staff including:

• Onboarding/orientation training: All new patient navigators and care coordinators can be trained using the materials available on the STEPS to Care website. We recommend Program Directors create their own onboarding curriculum and share that list with staff as part of orientation. For instance, all new field staff could be instructed to view the STEPS to Care Intro and overview video on the homepage and complete all trainings on the “Working with Clients in the Field” page.
• On-demand individual training: The STEPS to Care training materials can be used to fill in gaps in staff knowledge, or to support staff who need more intensive guidance. For example, a Patient Navigator struggling with creating strong care plans could be directed to view the Care Plan topic page, which includes a training on working with clients to establish a care plan that uses client-generated SMART goals.
• Clinical supervision: STEPS to Care materials can be used in staff meetings to foster discussion and build skills for your entire staff. For example, staff could view the Care Team Communication video as a group and use it to discuss what is working and what could be improved in your agency Care Team Meetings.

• Program Directors should review all of the tools and resources available on the site during the pre-implementation phase so you can work with staff to identify the trainings most relevant to their jobs (see also question above about preparing staff for STEPS to Care).
• In some cases, it is helpful for program directors to develop a standard list of trainings that all Patient Navigators and Care Coordinators should complete before they start working with clients. These lists are often different for each role, depending on staff background and job responsibilities. Directors can choose which topics are especially relevant to their agencies, program, and staff to streamline the time it takes to complete the training process.

• All tools can be accessed through the Dashboard or the All Topics Page. Topics are arranged alphabetically on the All Topics Page and on the Dashboard; they are arranged by overall implementation steps.
• We recommend at start-up, Program Directors use the Key Components Checklist to create a “training” curriculum for staff based on their experience, roles, and responsibilities. This curriculum should include a clear list of tools to review and/or use, a schedule for completion, and ongoing meetings and supervision to discuss progress. An orientation may be helpful to show staff how to find each tool.

• No. You do not need to be connected to the STEPS to Care website to deliver services to clients. The STEPS to Care site contains trainings as well as other tools (videos, forms, protocols) to prepare staff to deliver services and for staff to use with clients during implementation—however, with preparation, it is not necessary to have access to the website at each client meeting.
• Some sites find it easiest to download a copy of the tools they will use regularly (e.g., Care Plans, Missed Appointment Protocol) to a shared folder. Program directors can customize and update the tools as needed and staff will always know where to access the most up-to-date version. Staff can then print a copy to complete with clients, and securely store the completed hard copy with the client’s medical records.
• Some of the tools are provided as PDF forms for convenience, but agencies are responsible for securely storing all client data in a secure location (such as a remote server for electronic records or locked file cabinet for hard copies).
• There is a separate client-facing website that should be used by Patient Navigators when delivering HIV Self-Management sessions: MySTCTools. This website is separate from the STEPS to Care provider site. No information is collected or stored.

No. The website does not store client data. Some PDFs are provided as fillable forms, but must be saved separately on the computer, as they will not be stored online. Be mindful if you use and save these forms, you should follow agency policy to protect client confidentiality.

Program Directors decide where STEPS to Care will be implemented within the agency and service structure. Sites that pilot tested STEPS to Care used various approaches to integrate STEPS into the agency’s HIV care continuum. In some instances, STEPS to Care was used early in the care continuum to engage newly diagnosed patients in care. In other instances, STEPS was used as an enhancement for patients who were prescribed ARTs but were sporadically in care and/or non-adherent. STEPS to Care was also used to re-engage clients who had fallen out of care.

Patient Navigation can help with navigation to medical and social services, active referrals to care providers, outreach to those out of care and care plan development focused on linkage to care goals. Care Team Coordination can help with sharing vital information between medical providers, navigators, clients and other care team members to ensure linkage to the most appropriate services for the client. Through HIV Self-Management, the patient navigator helps the clients learn strategies for staying healthy and, in turn, can encourage the client to seek those services he or she needs.

For client-level monitoring, the Services Tracking Log provides a list of services delivered to each client.

Used together, the STEPS to Care strategies address multiple stages on the HIV care continuum:

• Linkage/re-engagement (prompt connection or re-connection to primary care, for those either never in care or disconnected from HIV care for a period of over six months): Agencies can decide to pair clients at high risk for poor HIV outcomes to a patient navigator through STEPS to Care as soon as they test positive for HIV. Through the program, the navigator can help the client stay linked to medical care and other services he or she needs. The navigator can also use the outreach and missed appointment protocols to re-engage the client if he or she falls out of care.
• Retention (maintenance in HIV primary care, with at least one visit in each six-month period (or at least two visits at least 3 months apart, in a given year) The close relationship and frequent communication between the client and the patient navigator in STEPS to Care is intended to retain the client in care.
• Viral load suppression (achievement and maintenance of viral load levels ≤200 copies/mL. For those not yet achieving full suppression, significantly reduced viral loads over time and/or standardized self-report measures of treatment adherence may be considered as secondary outcome indicators.) The STEPS to Care program uses a multi-pronged approach to help clients achieve viral load suppression—through support to attend medical appointments, other social services, Care Team Coordination to fully understand client needs and barriers to care, and promotion of self-management skills to improve medication adherence and other healthy behaviors.

• MySTCTools is designed to be an anonymous site where clients can feel free to explore the tools and topics without being “watched.” Because of this, you will not be able to see when clients have accessed the site outside of an in-person meeting with them. However, once Patient Navigators has established a rapport with clients, self-report is a reliable way to determine if clients have used the site on their own.
• Many of the tools and worksheets on the site are designed for patient navigators to access with their clients during HIV Self-Management education sessions. Because some topics on the site address potentially sensitive issues (e.g., safety in relationships), it is important for Patient Navigators to introduce the topics with their clients during the sessions and complete any worksheets or tools together with them the first time. Patient Navigators should be very familiar with the MySTCTools website and workbook prior to starting HIV Self-Management sessions with their clients.
• At each session, Patient Navigators can check in with clients on their use of the site, tools, and information in between sessions.
• The Comprehensive Care Plan Form also includes a section for patient navigators and clients to determine goals for completion of various topics available on MySTCTools.