STEPS to Care: Strategies
STEPS to Care (STEPS) is an online toolkit designed to support diverse agencies in the uptake and implementation of three evidence-informed strategies to improve retention in HIV care and reduce viral loads: Patient Navigation, Care Team Coordination, and HIV Self-Management.
Introduction Video
Watch the video to see how Patient Navigation, Care Team Coordination, and HIV Self-Management work together to make up the STEPS to Care program. This video also appears on the STEPS to Care homepage.
How the Strategies Work Together
In the Patient Navigation sessions, navigators build a strong relationship with their clients and teach HIV Self-Management skills through educational information and counseling. Regularly scheduled Care Team Coordination meetings ensure the interdisciplinary team—including navigators, care coordinators, program directors, physicians, and nurses—remains informed and responsive to the client’s changing needs.
Patient Navigation
The Patient Navigation Strategy is focused on providing whole-patient care through intensive case management. Patient navigators work one-on-one with clients to encourage continued commitment and adherence to medical treatment, access to social services, improved communication, and prompt re-engagement in care.
Visit the Patient Navigation topic page to learn more and access essential forms.
Care Team Coordination
Care team coordination allows STEPS staff to establish and assess care plans to meet client needs across the care continuum and improve adherence and retention outcomes. Regular care team meetings ensure the team remains updated and responsive to the client’s changing needs and circumstances. The care team is usually comprised of a patient navigator, care coordinator, primary care provider, and other important medical and service providers. The core of Care Team Coordination is open and constant communication and collaboration between care providers with the goal of improving client outcomes.
Visit the Care Team Coordination topic page to learn more and access essential forms.
HIV Self-Management
Building a strong relationship with your clients is the foundation for the HIV Self-Management strategy, a process through which Patient Navigators empower their clients to take control of their HIV and manage their overall health. Patient Navigators work one-on-one with clients in patient navigation sessions using educational information and tools found in the HIV Self-Management website and workbook. The goal of the HIV Self-Management sessions is to help clients work towards managing their own health and increasing adherence to their treatment plan through coaching, counseling, and accessible content.
Visit the HIV Self-Management topic page to learn more and access essential forms.
This chart provides an overview of the client experience and shows how the three strategies work together to create the STEPS to Care program.
The chart also shows which staff member is responsible for each step along the path, and lists the forms and protocols needed to deliver HIV services.
This checklist contains an overview of agency practices involved in implementing each of the three STEPS to Care strategies and the tools that are designed to support them. Program Directors can use this checklist to determine if and how these activities align with what their agency is already doing and which tools they can use or adapt.
As the agency prepares for implementation, the checklist can be used to create a “training curriculum” for individual staff members. For example, Program Directors can place a checkmark next to the tools that a Patient Navigator should complete or read prior to meeting with clients, as well as a targeted completion date for each. Program Directors should meet at least once a month (more frequently at first) to discuss staff progress in using these tools.
