The RWHAP Best Practices Compilation gathers and disseminates interventions that improve outcomes along the HIV care continuum. Explore the Compilation to find inspiration and new ideas for improving the care of people with HIV. Learn more about the Best Practices Compilation and submit your innovation today for possible inclusion.
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The intervention integrated supportive employment services, housing services, and HIV care for clients receiving case management services and with unmet housing and employment needs. Evaluation of the program showed improvements in employment rates, participant confidence in being able to hold onto a job, household median income, participants’ living situations, and self-perception of homelessness status.
Emerging Intervention
People who are unstably housed
Beyond the care continuum
Support service delivery model; Data utilization approach
Paterson, NJ
The Arizona Department of Health Services partnered with three clinics to identify people with a dual diagnosis of HIV and HCV, determine their care needs, and link them to HCV treatment.
Emerging Intervention
People with HCV
Beyond the care continuum
Data utilization approach; Outreach and reengagement activities
AZ
CoRECT was a data to care project to identify and reengage people with HIV who were newly out of care. It included a clinic and health department data reconciliation process to identify missed laboratory results or appointments and create the out-of-care list, case discussions via telephone to review the combined list, and field epidemiologist outreach to assist clients with making appointments, securing transportation, and arranging referrals. The intervention employed strengths-based case management techniques and motivational interviewing to contact identified people within 30 days, reengage them in care, and reduce time to viral suppression.
Evidence-Based Intervention
People with HIV who are not in care
Linkage to HIV medical care; Retention in HIV medical care
Outreach and reengagement activities; Data utilization approach
MA
CT
Philadelphia, PA
The goals of the Emergency Department and Hospital-Based Data Exchange for Real-Time Data to Care (ED Alert) intervention are to reengage people with HIV in care and to improve viral suppression rates. This is achieved using a real-time data exchange system that connects clients presenting to the emergency department with health department linkage specialists. ED Alert increased viral load testing and viral suppression over six months following a provider visit in the post-intervention period.
Evidence-Informed Intervention
People with HIV who are not in care
Linkage to HIV medical care; Viral suppression
Clinical service delivery model; Data utilization approach
Seattle, WA
The Bottom-Up Project is a multi-organizational initiative focused on leveraging health information exchange data and peer navigation. Using real-time clinical data, in combination with linkage to HIV care and social services, the Bottom-Up Project locates and reengages people with HIV who are not currently in medical care and are not virally suppressed. Through this collaboration, over half of patients on the lost-to-follow-up list were found and invited to enroll in the linkage to care/reengagement program.
Emerging Intervention
People with HIV who are not in care
Retention in HIV medical care
Data utilization approach; Outreach and reengagement activities
NY
The Utah Department of Health and Human Services collaborated with RWHAP Part B-funded medical case managers to improve care and outcomes for clients following Franklin Covey’s 4 Disciplines of Execution: 1) focus on the wildly important goal; 2) act on the lead measures; 3) keep a compelling scoreboard; and 4) create a cadence of accountability. Through intensive case management, regular monitoring, and feedback sessions, the state's RWHAP Part B program's overall viral suppression rate increased from 88.9% in 2020 to 90.4% by December 2021.
Emerging Intervention
All clients
Viral suppression
Data utilization approach; Outreach and reengagement activities
UT
The Louisiana Public Health Information Exchange is a bidirectional exchange that connects hospital system electronic health records with state surveillance data. Providers use the exchange to identify and relink people with HIV who are out of care to clinical and supportive services. Since LaPHIE was implemented in 2009, thousands of people with HIV who were out of care have been identified, with a significant number being successfully linked to care.
Evidence-Informed Intervention
People with HIV who are not in care
Linkage to HIV medical care
Data utilization approach
LA
Link-Up Rx is a pharmacy-data-based Data to Care program implemented by the Detroit Health Department in partnership with the Michigan Department of Health and Human Services and a specialty pharmacy. Using pharmacy data to identify clients in need of follow-up greatly reduced the amount of time for clients to appear on “not in care” lists compared to traditional D2C approaches. Protocols for a three-tiered outreach and reengagement approach were developed to connect clients back to antiretroviral therapy and HIV care following a missed pharmacy pick-up. Nearly half of identified clients were linked back to their pharmacy or other HIV medical services.
Emerging Intervention
People with HIV who are not in care
Retention in HIV medical care; Viral suppression
Data utilization approach; Outreach and reengagement activities
Detroit, MI
LA Links is a combined data-to-care and client navigation approach that cross-references routinely collected HIV surveillance data with other secondary data sources to identify and locate people with HIV who are not in care, as well as those who are in care, but with high viral loads. Originally implemented in 2013 as part of the Care and Prevention in the United States Demonstration Project, LA Links improved linkage to care, reengagement in care, and viral suppression. Louisiana expanded the program statewide in 2016.
Evidence-Informed Intervention
People with HIV who are not in care; People with a new diagnosis of HIV
Linkage to HIV medical care; Viral suppression
Data utilization approach; Outreach and reengagement activities
Baton Rouge, New Orleans, and Shreveport, LA
The Michigan Department of Health and Human Services was one of seven health departments funded by Leveraging a Data to Care Approach to Cure Hepatitis C Virus (HCV) Within the RWHAP Part F SPNS initiative implemented from 2020–2022. With the support of the Yale University School of Medicine, which served as the Technical Assistance Provider, MDHHS matched RWHAP and HIV and HCV surveillance data, calculated HCV viral clearance cascades for coinfected populations, and worked with three RWHAP clinics to generate clinic-based lists of coinfected clients and conduct outreach and linkage to HCV treatment.
Emerging Intervention
People with HCV
Beyond the care continuum
Data utilization approach; Outreach and reengagement activities
MI