EDs should determine their standard operating procedures (SOPs) for linking patients who test positive to care based on the needs of the ED, local health department (LHD), and/or referral clinics. SOPs (download example SOP here) should clarify roles and responsibilities. Assign staff titles to each step of the process so that everyone knows who is responsible for which parts of the linkage to care (LTC) process. LTC should occur for all patients who test positive for syphilis, HIV, and/or HCV.

In general, if positive results return while the patient is still in the ED, the ED provider should disclose the results and, when clinically appropriate, initiate empiric treatment. The provider should also consult the patient navigator to meet with the patient to begin the LTC process by assisting in scheduling follow-up appointments and making referrals before the patient is discharged.

If positive results return after the patient has been discharged from the ED, the patient navigator should reach out to all patients to disclose results and begin the LTC process by scheduling follow-up appointments for ongoing treatment & care.

The LHD may also support EDs in LTC and to ensure treatment. What this looks like will vary, so meeting with the LHD is a crucial component when developing LTC SOPs.

Please view the EDSP webinar ‘What Next? When Patients Test Positive’ for more key components of developing LTC systems and SOPs.

Collaboration with your LHD is critical as linkage to care and ensuring treatment is a shared responsibility between EDs and LHDs. And, there is oftentimes overlap between patients who test positive in the ED and priority patients for LHDs. Below are types of support that LHDs may provide. This collaboration will vary, so it is critical to meet with your LHD to learn about their current processes and what support they may be able to provide to your ED screening program.

 From there, you can begin to establish a LTC standard operating procedure (SOP) in collaboration with your LHD with delineation of who is responsible for which pieces of the process.

 Please reach out if you would like support connecting with your LHD. We can facilitate e-introductions or facilitate calls between the ED and your LHD, if helpful.

 Support from LHDs may include:

• Education & support in answering complex patient management questions.
• Historical diagnosis & treatment record searches to support treatment & partner services.
• Collaboration on linkage to care, ensuring treatment, & supporting partner services for patients who test positive.
• Field outreach to locate patients & ensure treatment and linkage to care (e.g., mobile vans, third-party application tools).
• Referrals to Doxypep (STI prevention) and HIV pre-exposure prophylaxis (PrEP) & other social services (e.g., syringe services programs, housing and food support).

EDs should develop a process (i.e., during intake) to confirm multiple methods of contacting patients to support linkage to care efforts. Up-to-date contact information is critical so patient navigators and/or local health department partners can follow-up with patients who test positive and link them to care.

Best Practices:

• Explain to patients that you will need to reach them in case of a positive result.
• Ask patients without a consistent address for:
  • Nicknames/aliases
  •  Email addresses and phone numbers
  • Addresses where they (1) receive mail, (2) commonly stay or spend time, (3) access services (e.g.,Where do you get your mail? Where do you stay? Where do you hang out? What services are you connected with?)
  • Contact information for people that typically know how to reach them (e.g., Is there someone who knows where you are or can get ahold of you if we need to reach you?)
  • Social media handles
• Review narrative parts of medical records for prior contact/location information, and check phone numbers listed from previous visits.
• Add storyboard flags in your electronic health record system or ad-hoc notes/addendums to support follow-up in case the patient returns to the ED.
• Work with your local health department for support locating patients who cannot otherwise be reached (e.g., through outreach, street teams and/or social media).

See EDSP Culturally Responsive and Trauma-Informed Care Resources, Working with people with significant barriers to care (e.g. homelessness, substance use)

Linkage to care and treatment is a shared responsibility between the ED doing the testing and initiating treatment, patient navigators, follow-up clinics, and the public health department. We recommend all EDs develop standard operating procedures (SOPs) to delineate responsible roles for disclosure, treatment, and linkage to care. Plans should include the processes when results return while the patient is still in the ED, and how/if that differs when results return outside of the ED.  We also recommend having these SOPs agreed upon and, if appropriate, signed by key leadership of the involved entities. Download the example SOP here.