A. Recruitment

Much of what we know about recruitment comes through having learned from other CRCS providers and their experiences with obtaining referrals to their programs and recruiting clients through their outreach activities.

CRCS programs may be more successful when they are fully integrated into multi-service organizations and the greater HIV prevention community, although single-service agencies with strong collaborative relationships in the service community are also good CRCS service providers.

Lessons from the field

Client recruitment is time and labor intensive. It may take several months of relationship building with colleagues and prospective clients in order to obtain a full case load. To reach individuals at high risk for HIV/STD acquisition or transmission, your agency needs to determine eligibility criteria before recruitment begins. Please see Part 2 in this Section (Screening, enrolling, and assessing clients, page 32) for a description of eligibility criteria for CRCS. Know the particular risk and psychosocial needs of the population you serve and tailor your program to meet those needs. Describe the program to prospective clients as improving health and quality of life, in addition to reducing risk.

Do not underestimate the time you need for recruitment!

Programs use both active and passive recruitment methods – for example, a more active method would be recruitment of potential participants by outreach workers. A more passive method might be leaving program flyers at another agency. In between active and passive might be obtaining clients from internal or external referrals. In such cases, CRCS staff might be very active in developing a referral network (meeting with providers within and outside the agency), but ultimately, the referral usually depends on the action of the referral source.

Quick recruitment overview –

• The CRCS recruiter should clearly explain the CRCS program and help your potential client to understand what to expect from it.
• Clarify roles and expectations for the client and CRCS counselor.
• Distinguish CRCS from other case management and HIV prevention programs.
• Reiterate your agency’s policies on confidentiality.
• Meet where clients will feel comfortable discussing sensitive topics.
• Pay attention to your facial expressions and body language – avoid judgmental reactions when clients disclose risk behaviors or attitudes and values that differ from your own.
• Work on using appropriate language and terms that your clients can relate to.
• Point out that CRCS is an intensive but relatively time-limited program focused on risk reduction. However, clients can re-enroll if they need the support to maintain risk reduction goals.

Remember that risk behavior may be episodic or sporadic

Lessons from the field

During an initial session, a CRCS counselor in a multi-service center found out that a CRCS client wanted to go back to school for his degree. In the course of developing their relationship, the counselor and client discussed how the client’s substance abuse was keeping him from achieving his goal of going back to school. This discussion was a key part of motivating the client to enter drug treatment and reduce his risk behaviors.   At another CBO, a CRCS counselor asks clients at their first meeting to write notes or key points about what they want from CRCS. The counselor then helps the clients connect their goals with the small steps that lead to risk reduction and other behavioral objectives they may have set.

Recruitment of clients into CRCS can be challenging –

• The characteristics or situations that make individuals eligible for CRCS – multiple psychosocial needs and high-risk behaviors – also make recruitment and engagement difficult.
• The highest risk people may not have or desire any contact with any systems of care or support, and therefore, they may be difficult to identify and recruit.
• CRCS may be a difficult program to describe and “sell” to clients. Tangible services may not be the primary outputs of the program, particularly for those who already have a case manager. In addition, behavior change or risk education may not be a priority, at least initially, for the potential CRCS client.
   

Lessons from the field

Reaching out to clients . . . Outreach through social networks of otherwise ‘hard to reach’, high-risk clients. Take recruitment and counseling services to clients, via vans, satellite offices, or other locally appropriate means. Locate PCM services close to other services used by persons at high risk for HIV transmission or acquisition. Provide PCM services during hours and at locations that are client-friendly. Adapt PCM linguistically and culturally, to meet the needs of specific ethnic and cultural groups. Work closely and collaboratively with providers of other services to high risk clients, to assist meeting client needs. Use the Internet to find out where high-risk sexual behavior occurs and recruit from those places.

1. Referrals

Referrals are a common source of CRCS clients and can come from inside and outside your agency.

a) Internal referrals

Many multiservice agencies find that most referrals to CRCS come from within the agency. Referrals to single service agencies – that is, agencies that provide only CRCS – depend upon developing good relationships with external partners

Lessons from the Field

Referrals from within agencies work well when the different parts of the organization understand the eligibility requirements for CRCS; that is, the type of client the intervention is intended to serve. Including CRCS counselors in case conferences or regular meetings at which clients are discussed will build staff relationships and allow CRCS counselors to make recommendations for CRCS when challenging clients are discussed. Regular meetings between CRCS counselors and other staff increase referrals by keeping CRCS in the minds of those who may need to refer their high-risk clients. Demonstrating what CRCS has done for clients also helps build relationships with other staff who are concerned about their clients. Case conferences, other staff meetings, are useful venues for sharing CRCS successes. CRCS clients may refer their friends to the program if they find the service beneficial.

b) External referrals

While internal referrals are the major source of client recruitment for CRCS in multi-service agencies, particularly for HIV-positive clients, your agency can use other strategies to find clients.

Referrals from outside your agency – by case managers, medical staff, or others – may also be productive. This type of referral requires the cultivation of collaborative relationships between agencies and their respective staff to support clients who are particularly challenged by life circumstances. The CRCS counselor or program manager can make presentations about CRCS to staff at other agencies (hospitals, jails, clinics, private medical providers, etc…) in order to increase awareness about CRCS and develop relationships with potential referral sources. You also may want to leave a CRCS brochure with the staff of other agencies for future reference.

Interagency relationships have to be frequently nurtured in order to foster collaboration. Previous demonstration projects have shown that steady referrals depend on ongoing or regular communication with staff of other agencies. One strategy that your agency might consider is co-locating your CRCS program in medical clinics and in other agencies with potential CRCS clients. This would provide an added service in the host agency and strengthen your agency’s ties within the HIV/AIDS service community and your ability to recruit and serve clients.

Don’t forget – your agency needs to have current Memoranda of Understanding (MOU) with other service providers, which are important for establishing and supporting protocols for interagency communication and collaboration.

Lessons from the field

A 2005 UCLA report on PCM programs found that agencies that had early development of implementation protocols and “clear program designs” had fewer problems interfacing with other agencies or case management services, recruiting clients, and referring clients to other agencies.

2. Outreach

One specific and active recruitment source can be through outreach workers at your agency or from other agencies.

CRCS counselors or outreach workers can recruit clients through such venues as

• Support groups
• HIV counseling and testing sites
• Social marketing campaigns or handing out brochures to potential clients or displaying posters describing CRCS and the kinds of services that CRCS provides
• Medical providers
• Prevention activities at venues where high risk individuals are likely to be encountered
  • Crack houses and shooting galleries
  • Bath houses and sex clubs
  • STD clinics
  • Commercial sex worker venues
  • 12-step programs

Outreach workers may have a relationship with and therefore access to a particular community.

• They are often from or are a part of the community
• They know the population
• They are familiar with the venues frequented by high risk clients
• They have an ability to quickly form bonds with community members

With training and practice, outreach workers will be able to describe CRCS to people who otherwise may not be involved with HIV programs or other health-related services.

Lessons from the field

In multi-service agencies, outreach workers also can serve as a bridge between the prevention and care services of the agency and thereby assist with retaining clients. In one PCM project, outreach workers conducted recruitment & eligibility screening while discussing risk issues and risk reduction needs with potential clients. They have great rapport with their target population and use terms and references the clients are sure to understand.

3) What Recruitment Strategy Works Best?

Use multiple approaches for recruitment & engagement.

Lessons from the field

A Program example- A program located in the northeast collaborates internally with its agency’s short-term transitional housing program for HIV-positive persons to provide CRCS to those clients who are about to lose their housing due to substance abuse and other issues. CRCS helps the client identify underlying issues that may be contributing to substance use or non-adherence and helps them gain skills to live independently. In addition, the program works externally with the Department of Corrections in order to provide CRCS to inmates with a history of high-risk behaviors who will be released within the next two to six months. Finally, the program also has a CRCS counselor who sees clients in a local drug treatment facility, and this relationship continues once the person leaves treatment. Develop your recruitment plan with staff who are familiar with the client base and with the risks that clients face. You might also check with potential clients about the best ways to recruit. Be careful to document your recruitment successes and failures in order to systematically learn from them and share them with other providers.

PEMS NOTE: To keep track of how long you work with clients in outreach, recruitment, or engagement before you enroll clients in CRCS and to get credit for this activity in PEMS: Select ‘CRCS’ as your Program Model in Table E. Then in Table F, select ‘CRCS’ and ‘Outreach’ as the interventions that are a part of the CRCS program model.

Go to section 2 part 1B