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Building a Medical Home for Multiply Diagnosed HIV-positive Homeless Populations 

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The Special Projects of National Significance Building a Medical Home for Multiply Diagnosed HIV-positive Homeless Populations Initiative is a multi-site demonstration project initiative expected to provide funding during federal fiscal years 2012 - 2016 to support organizations that will design, implement and evaluate innovative interventions to improve timely entry, engagement and retention in HIV care and supportive services for HIV positive homeless and unstably housed people living with HIV and co-occurring mental illness and substance use disorders.  The interventions are expected to implement models of care that build and maintain sustainable linkages to mental health, substance abuse treatment and HIV/AIDS primary care services to HIV positive individuals who are homeless or unstably housed.  The purpose of all Ryan White HIV/AIDS Program funds is to ensure that eligible HIV-infected persons and families gain or maintain access to medical care. Given the transient and unstable lives of HIV infected homeless with co-occurring mental health or substance use disorders, it is important to strategically coordinate efforts to engage and retain individuals in care that meet their complex service needs and ensure adherence to treatment.

The HIV/AIDS Bureau (HAB) has recommended the adoption of a set of organizational structures characterized as having integrated or co-located strategies for service provision by each demonstration site funded under this initiative.  In addition, demonstration site organizations will be expected to provide intensive coordination of care and service needs to ensure retention and adherence to care.  For the purposes of this initiative, integrated services will be broadly defined to include the management and delivery of HIV primary care, substance abuse and mental health treatment that assure homeless and unstably housed people living HIV receive a continuum of care according to their specific needs.  In addition, awardees will be expected to include access to housing resources and services for their target population. This may be achieved through the co-location of services within an HIV primary care clinic; within a public housing facility that serves the target population or building a network of providers through the execution of memoranda of understanding or contracts.



Grants for this initiative are awarded to the organizations listed below. The abstracts provide a brief description of their project. Funding is anticipated for five years 2012-2017.


AIDS Arms, Inc., Dallas, TX 

Medical Home Path to Health, Hope, Recovery 

The MHPHHR project will refine a model of care coordination individualized to three priority cohorts of HIV+ individuals with co-occurring mental or substance use disorders: 1) literally homeless; 2) unstably housed; and 3) fleeing domestic violence without housing resources.All three will be created within the framework of AIDS Arms Inc’s HIV medical care and case management programs in Dallas, TX. AAI provides comprehensive outreach, testing, case-finding, risk-reduction, HIV/AIDS medical care and case management for a 12 county area in North Texas. To further optimize care, AAI is actively developing an HIV Primary Care Medical Home to provide comprehensive wrap-around care. The proposed project will further build this medical home by providing integrated services for PLWHA with co-occurring MI/SA disorders and who are homeless or at risk for homelessness.

The project will create a System of Networked Services with a Dedicated Continuity of Care/ Network Navigator approach with a significantly-enhanced care system strategically linked with other services to provide comprehensive, integrated services to the priority population. The care coordination component will augment and not duplicate AAI’s robust medical and non-medical case management services to achieve a high degree of intensity of support that will result in improved treatment engagement, retention, health and quality of life, and reduced cost. The key anticipated outcome for project clients is improved health status evidenced by decreased viral loads and improved immune system function. Other priority client outcomes are: 1) Self-sufficiency(combination of stable earnings and/or economic benefit programs sufficient to meet basic living expenses); 2) Stability (HIV/AIDS, psychiatric and physical illness/symptoms stable through regular treatment and appropriate self-management), 3) Shelter (permanent housing with supports or other stable housing), 4) Sobriety(substance use no longer interferes with daily functioning), 5) Social support (adequate network of social support to provide buffers for crises and losses); and 6) Safety (low vulnerability to abuse or exploitation).


City and County of San Francisco, San Francisco, CA 

HIV Homeless Outreach Mobile Engagement (HOME) Project 

The HIV Homeless Outreach Mobile Engagement (HOME) Project is a mobile, multidisciplinary team-based intervention designed to engage and retain in care the most severely impacted and hardest-to-serve homeless persons living with HIV in San Francisco. The HOME Project will differ from prior mobile team models in that it will explicitly target those homeless individuals who are the most difficult to engage and retain in care - individuals facing complex, multiple co-morbidities and barriers who have thus far resisted attempts to engage them in housing and/or HIV treatment. The project will deploy a mobile multidisciplinary team that will serve a caseload of 20 - 25 of the hardest to serve HIV-infected homeless individuals in San Francisco at any one time. The team will consist of two Medical Social Workers, a part-time Psychiatric Registered Nurse, a Homeless Peer Navigator, and a Homeless Outreach Worker. Mobile team members will continually meet together to coordinate care and participate in weekly case conferences. The mobile team will also seek to form intense, one-on-one relationships with their client population, and will maintain almost daily contact with the individuals they serve, including serving as proxy deliverers of HIV medications and conducting in-the-field medication observations to assess the degree to which clients are adhering to HIV treatment regimens.

At minimum, each client enrolled in the program will: 1) Have received a previous positive HIV test result; 2) Be living on the street or in HRSA-defined unstable housing situations; 3) Have identified psychiatric disorders and/or mental health conditions; 4) Have active substance abuse and/or chemical dependency issues; 5) Be an individual who is not currently engaged in HIV treatment or therapy; and 6) Be an individual who is not currently linked to an identified medical home. Clients will be continually assessed by the mobile team and will be actively linked and engaged to the widest possible range of programs and services to achieve stabilization and successfully link clients to long-term medical care, housing, and behavioral health services. Key outcomes of the project include: a) linking at least 90%of project clients to a patient-centered, culturally competent HIV medical home within one month of engagement in the program; b) transitioning at least 65% of project clients to long-term and supportive housing over the course of the program; c) ensuring that at least 75% of clients with a psychiatric diagnosis will have seen a psychiatrist and will be on a monitored psychotropic regimen within three months of engagement with the multidisciplinary team; and d) ensuring that at least 50% of chronic substance users will be enrolled in a medical substance abuse treatment plan within three months of engagement with the multidisciplinary team.


City of Pasadena, Pasadena, CA 

Operation Link 

Operation Link, a community-based demonstration program, will provide vital care navigation to approximately 100 HIV+ homeless individuals annually who are multiply diagnosed with mental illness and substance use addiction living in what is called the San Gabriel Valley. Operation Link has two simple, yet extremely important, components: 1) utilize a Mobile Care Unit that takes project services into the community, and 2) utilize care navigators who will conduct a customized Client-level needs assessment and work across a system of coordinated Network Providers to connect the client to appropriate services. The intervention and models of care are based on three evidence-based methods: 1) Critical Time Intervention; 2) Seeking Safety; and 3) Illness Management and Recovery. While each of these models have been studied and shown to be effective in their own right, Operation Link will bring these three approaches together as part of a new innovative Medical Home approach.

Operation Link is utilizing a System of Networked Services with a Dedicated Network Navigator as its organizational structure and has commitments from eight organizations ready to participate by providing appropriate care and services. More organizations will be added as the program progresses. Roughly 83 percent of the requested grant funds will be used for direct personnel costs that will be providing day-to-day care navigation to the target population. The staffing structure is unique and includes peer-to-peer counseling, which is viewed as essential to long-term success, and the program will use the latest in data collection technology to streamline both internal and external evaluations.  Operation Link has formal endorsements from the Los Angeles County Department of Public Health and the City of Los Angeles. Operation Link was developed to be the “Southern California” demonstration program and strengths and lessons learned will be shared among a vast system of network providers. Operation Link will positively impact multiply diagnosed, homeless and HIV+ individuals who reside among the largest homeless and second largest HIV+ populations in the nation..


County of Multnomah, Portland, OR 

Integrating Network Navigators into Medical Homes for Multiply Diagnosed Homeless PLWH/A 

The Multnomah County Health Department HIV Health Services Center (HHSC) was created in 1990 with Ryan White Part C funds. HHSC is the largest provider of HIV-specific medical care in the state of Oregon, serving 1,043 patients in 2011; recognized as a center of excellence; a designated AIDS Education Training Center; and certified as the highest level medical home by the State of Oregon. For the proposed project, the HHSC will continue its partnership with Cascade AIDS Project (CAP), the largest HIV support services organization in the state, to enhance its medical home model through the addition of Network Navigators. HHSC and CAP will achieve five project goals: 1) To expand and support a comprehensive, coordinated, culturally competent continuum of care that is able to identify and care for HIV positive homeless and unstably housed individuals with co-morbid mental health and substance use disorders; 2) To identify HIV positive homeless individuals with co-occurring substance abuse or mental health diagnoses and engage them in care; 3) To improve medical outcomes for PLWH/A with co-morbid mental health and substance use disorders who are homeless or at-risk for homelessness by providing them a medical home with comprehensive primary care and links to support services; 4) To assess the efficacy of the model through a local and a multi-site evaluation plan; and 5) To implement a long-term sustainability plan.

The proposed project plan will consist of: 1) network navigation; 2) outreach and identification; 3) enrollment; 4) intensive care coordination; 5) quality HIV primary care; 6) retention in care; 7) access to stable/permanent housing; 8) building sustainable partnerships; and 9) project administration and quality improvement.  The proposed intervention is firmly grounded within the theory of the Medical Home Model, and is supplemented with additional components of work based on the theories of Housing First, Community Health Workers, and the need to create sustainable, community-wide change through system and policy work. The intervention also uses innovative strategies based in specific best practice models such as Critical Time Intervention and the Continuous Relationship Model.


Family Health Centers of San Diego, Inc., San Diego, CA 

PCMH Connections for Multiply Diagnosed HIV+ San Diegans 

Family Health Centers of San Diego (FHCSD) is the second-largest federally qualified health center (FQHC) in the U.S. (measured by unique clients served per year). In 2011, it became the 2nd FQHC in the country to be designated a Primary Care Medical Home (PCMH) by The Joint Commission. As the regional lead agency for HRSA's Health Care for the Homeless Program (HCHP), the clinic has a long history of innovation designed to meet the needs of homeless San Diegans—20% of whom are military veterans (a rate higher than even Los Angeles). Among our past innovations are the use of three Mobile Medical Units (MMUs) to serve homeless clients in places where they congregate—and then connect them with a medical home clinic. Among FHCSD’s Ryan White-supported HIV+ clients who are in HIV care, over 50% meet the definition of homelessness used in this RFP. Last year, FHCSD served 22,421 unduplicated homeless clients through its HCH program.

FHCSD, People Assisting The Homeless, and the Institute for Public Health (IPH) at San Diego State University will collaborate to pilot and evaluate a program designed to connect 12 dual-diagnosed HIV + homeless San Diegans per quarter (48 per year) with a PCMH, HIV care, alcohol and other drug (AOD) abuse treatment, psychiatric medication if indicated, behavioral health care, three months of transitional housing at Connections to help stabilize the client—leading to a permanent housing placement with ongoing PCMH and social service supports upon graduation. The project has been designed to cost-effectively leverage the Health Care for the Homeless & Ryan White Care Act infrastructure of San Diego. IPH will conduct a local evaluation and FHCSD will coordinate reporting with the federal ETAC overseeing this demonstration project.


Harris Health System, Houston, TX 

Hi-5 Program 

Harris Health System located in Harris County, Texas is the nation’s fourth largest public health care system, encompassing two large general hospitals, 12 community health centers, nine school-based clinics, a dental program, a Healthcare for the Homeless Program (HCHP), and a multi-site HIV Services program based at the Thomas Street Health Center (TSHC). In 2011, HCHP provided care to 6,049 of Houston’s 13,000 homeless patients at 11 shelter based clinics and 33 outreach sites served by two mobile vans. The TSHC cared for more than 5,000 HIV-infected patients, of whom approximately three percent were homeless.  At TSHC, which achieved Medical Home status for HIV care in 2011, patients receive a full range of primary care, specialty, and supporting services.  The Hi-5 Program will utilize the expertise and resources available at TSHC to provide care at a variety of locations where homeless HIV+ patients are accustomed to receiving health care, either HCHP’s shelter-based clinics or its mobile van clinics. Patients who wish to receive care at TSHC may do so as well. The program will expand the care offered at the HCHP program to include HIV care, establish referral and navigation services for persons needing episodic care at TSHC, and expand pharmacy services to include HIV drugs at the HCHP pharmacies, allowing the HIV-infected homeless population to have a medical home at their shelters rather than forcing them to attend TSHC for comprehensive care.


Tri-County Community Health Council, Newton Grove, NC 

CommWell Health Medical Home Works 

The main goal of the CWMH project is to promote and improve timely entry, engagement and retention in quality HIV primary care, psychosocial and supporting services for medically underserved HIV positive homeless and unstably housed populations in rural Southeast North Carolina. The specific objectives are to: 1) Improve the experience of care for target populations; 2) Improve patient health outcomes; 3) Improve patient’s involvement in their own care; 4) Advance knowledge and understanding of cost containment strategies in the provision of health care; and 5) Evaluate the project. Through its 13 practice facilities in its service area, CommWell Health will be designated medical home of the “health team” providing in-house a large percentage of medical home services, including: 1) Primary and specialty medical care; 2) Comprehensive care management; 3) Intensive network navigation through the use of patient navigators; 4) Residential and outpatient substance abuse treatment; 4) Individual and family support; 5) Housing and transportation services coordination and follow-up; and 6) Information technology to link services, as appropriate. In addition, the CWMH model will build and maintain sustainable linkages to mental health, substance abuse treatment, and HIV/AIDS primary care services that meet the complex service needs and ensure adherence to treatment of HIV positive homeless or unstably housed individuals.

CWMH is an innovative community based previously untested model of care containing specific strategies to integrate mental health services and substance abuse treatment in the context of Ryan White primary care for the target populations. The CWMH will adopt the System of Networked Services structure for the implementation of the intervention. The Core Components of the proposed model are: 1) Personal primary care physician; 2) Patient-centered orientation; 3) Team-directed medical practice; 4) Intensive care coordination; 5) Building sustainable partnerships; 6) Quality and Safety; and 7) Consumer Involvement. The target population of this project is comprised of homeless and unstably housed medically underserved HIV positive African-American, Native American, and Latino/Hispanic individuals, migrant farm workers in rural Southeast North Carolina. A large number of participants would be chronically ill with complex needs and co-occurring mental health and substance abuse disorders and that would require intensive care in multiple settings. A rigorous process and outcome evaluation of the proposed medical home demonstration model will conducted to assess the extent to which the program objectives have been met and the extent to which these can be attributed to the project activities.  CommWell Health will promote sustainability during the implementation of the project through a variety of strategies including third party payers and other sources of revenue. The proposed model may have significant implications for replicating the model with other rural medically underserved HIV positive homeless or unstably housed multiply diagnosed populations nationwide.


University of Florida, Gainesville, FL 

The Partnership for Access to Treatment and Housing (PATH Home) Project 

The UF CARES Program is a comprehensive family-centered HIV/AIDS provider in North Florida, where there are a disproportionate number of homeless, women, and African Americans living with HIV/AIDS. UF CARES has provided direct medical HIV/AIDS care for over 20 years and has implemented Ryan White Program Parts A,C, and D goals since funded in 1998, serving 1,500 in 2011. UC CARES will work in partnership with River Region Human Services, a mental health, substance abuse treatment and housing provider to enhance and expand systems of care for HIV+ Multiply Diagnosed Homeless, to improve quality of life for this population and the health of the community. The UFCARES Program is recognized by the NCQA as a Level 3 Medical Home. River Region Human Services, founded in 1972, provides housing, substance abuse and mental health treatment to People Living with HIV/AIDS (PLWHAs), and has the oldest supportive housing program in NE Florida for PLWHAs. In our combined 50-plus years of service, we have both seen the impact of homelessness and HIV/AIDS, with mental health/substance abuse needs. This mosaic of needs combine to make Homeless PLWHAs some of the most difficult to serve, calling for the need to innovate and unite resources.

The PATH Home Project will work to improve health and stability for HIV+ homeless/unstably housed in our community through establishing a Peer Navigation system using empirically based models. The peers will work intensively to coordinate and link to needed services, engage, and retain clients in care. Through the use of the Permanent Supportive Housing Model (PSH KIT) we will house and promote healthier behaviors. PATH will engage the Homeless Coalition as well as Ryan White providers to better coordinate services, and will improve data collection through the use of CAREware and Electronic Records. We will work to “Open the Doors” to the medical home, by improving communication and patient retention through innovative strategies. Lastly, UF CARES will expand our clinic location to a Housing Complex to serve unstably housed, homeless HIV+ individuals in need of a medical home services. Through this effort, we will serve 60 HIV+ Homeless, multiply diagnosed individuals a year and 300 over the five year demonstration project.


Yale University, New Haven, CT 

mHEALTH: Medical Home Engagement and Aligning Lifestyles and Transition from Homelessness 

The target population for this demonstration project is homeless PLWHA who are primarily transitioning from the criminal justice system (CJS) and those that are not retained in HIV care in New Haven, CT – the 4th poorest city in the U.S. for its size and with disproportionate levels of HIV/AIDS, substance abuse, mental illness, homelessness and poverty. The mHEALTH intervention seeks to expand and enhance the existing New Haven Ryan White Continuum (NHRWC) to ensure the creation of a patient-centered medical home for homeless PLWHA by adding increased coordination and referral between the CJS and the Early Intervention Services (EIS) provided through an innovative mobile health program and the city’s largest housing provider for PLWHA. The EIS program will medically stabilize CJS clients through screening and provision of onsite HIV care (including directly administered antiretroviral therapy), substance abuse treatment (including buprenorphine or extended release naltrexone and  counseling) and psychiatric services (including medications and counseling). Moreover, the city-wide database of PLWHA (CareWare) that is operated by the NHRWC will be reconfigured to create an Early Alert System (EAS) that will identify anyone who has been lost to HIV care and invoke the EIS program to deploy community outreach to stabilize and re-engage them. Thus, homeless PLWHA from the CJS and the community will be served.

The EIS program will be enhanced through the provision of a Network and Peer Navigator that will deploy intensive case management (ICM) strategies based on evidence-based Assertive Community Treatment (ACT) and ACCESS programs used to retain individuals with mental illness and chronic homelessness, respectively, in care and to actively transition clients to urgent, transitional and ultimately stable housing through coordination with the EIS program and the patient-centered medical home created in New Haven as part of mHEALTH’s proposed expanded NHRWC. The likelihood of success is based on 10 years of previous SPNS activities, strong community support, the use of evidence-based interventions, a skilled group of collaborators who have a track record of evaluation and dissemination of finding and an extensive and long-standing history working with and providing innovative services for the target population.


Boston University School of Public Health, Boston, MA 

MEDHEART (Medical Home Evaluation And Research Team) 

The Health and Disability Working Group (HDWG) of the Boston University School of Public Health has over a decade of experience in training and technical assistance to implement and evaluate programs to identify, engage and retain people living with HIV (PLWHA) in HIV care. The BU SPH’s HDWG will work in partnership with Boston Health Care for the Homeless Program (BHCHP) as MEDHEART (Medical Home Evaluation And Research Team) which will serve as the Evaluation and Technical Assistance Center for this initiative.  MEDHEART will work with the demonstration sites in implementing and evaluating innovative and replicable comprehensive HIV service delivery models that integrate high quality HIV primary care with behavioral health, housing, and other supportive services, to improve the engagement and retention in care for homeless/unstably housed PLWHA. This work is in direct accordance with two of the three primary goals outlined in the National AIDS Strategy: 1) to increase access to care and optimize health outcomes for people living with HIV; and 2) to reduce HIV-related health disparities.

MEDHEART’s activities will address methods to evaluate and provide technical assistance to the demonstration sites in implementing their proposed programs to build medical homes for homeless/unstably housed PLWHA with co-occurring substance use and mental health disorders. These activities will include: 1) training and technical assistance (TA) to the demonstration sites in building medical homes including sustaining housing partnerships, developing integrated networks of care, and care coordination strategies; 2) providing clinical consultation on the delivery of clinical and behavioral health services; 3) designing and implementing multisite evaluation of the outcomes of the engagement and retention interventions and the effectiveness, cost, and sustainability of these interventions; 4) establish a web-based data collection system for a multisite evaluation; and 5) disseminate outcomes and best practices on engaging and retaining homeless/unstably housed PLWHA in integrated HIV care through intervention manuals, peer–reviewed publications, webinars, national workshops and conferences.


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