The Maricopa Jail Project was implemented by five jails to decrease the wait time between incarceration and/or diagnosis to the start of treatment, and to better support clients to reach viral suppression. Maricopa hired a nurse practitioner to manage access and case manage across the jail system. The initiative was successful in increasing the number of clients who were virally suppressed.
People who are incarcerated; People with HIV
Clinical service delivery model
Gay Men’s Health Crisis updated its data management process to better document housing and employment service outcomes. Enhancements to the Electronic Health Record contributed to positive housing, employment, and viral suppression outcomes for clients.
Data utilization approach
Ryan Health, a Federally Qualified Health Center, and Alliance for Positive Change, a community-based organization, created a medical-community partnership to link clients to care and decrease missed appointments. The Linkage to Care program, utilizing peer navigators, was successful in reengaging clients who had fallen out of care.
People with HIV; People with multiple chronic conditions
Linkage to HIV medical care
Clinical service delivery model
Lehigh Valley Health Network Comprehensive Health Services implemented a trauma-informed approach to care delivery, including training staff on how trauma can affect people’s health and how microaggressions in healthcare environments can potentially trigger trauma responses. This approach positively impacted care delivery and the program’s retention in care rate.
Retention in HIV medical care
Clinical service delivery model
San Joaquin County Public Health Services Department partnered with the California Department of Public Health, Office of AIDS to help clients get to medical appointments via ridesharing. Representing the first partnership between a jurisdiction and a ridesharing company, this program addresses transportation barriers, promotes engagement in medical care, and leads to cost savings.
Retention in HIV medical care
Support service delivery model
MacGregor Infectious Diseases, a hospital-based clinic affiliated with the Hospital of the University of Pennsylvania, implemented a multidisciplinary approach to strengthen outreach to clients and improve care retention. As compared to clients in standard care, clients served with the multidisciplinary approach had higher rates of retention in care, particularly among clients who were not virally suppressed.
Retention in HIV medical care; Viral suppression
Clinical service delivery model
The Broward County Ryan White Part A Program identified a need to integrate primary care with behavioral health services, including linking clients to mental health and substance use services. Broward County trained providers on trauma-informed care, and modified contracts and standards of care to require that medical providers conduct mental health screening. The intervention seeks to increase the percent of clients who are linked to mental health treatment, retained in care, and virally suppressed.
Linkage to HIV medical care; Retention in HIV medical care; Prescription of antiretroviral therapy; Viral suppression
Clinical service delivery model
Caracole, an AIDS Service Organization, uses three interconnected approaches to improve retention in HIV care: housing first, harm reduction, and motivational interviewing. Clients in permanent supportive housing had high rates of viral suppression, exceeding Caracole's goal of 75%.
People who are unstably housed
Retention in HIV medical care
Support service delivery model
AIDS Healthcare Foundation Upland Healthcare Center helped gay, bisexual, and other men who have sex with men (MSM) of color reach viral suppression through intensive case management by applying tools and lessons learned in the Center for Quality Improvement Innovation (CQII) end+disparities ECHO Collaborative.
Black gay and bisexual men; Gay and bisexual men of color
Retention in HIV medical care
Outreach and reengagement activities
At The Rutgers School of Dental Medicine three extramural dental clinics began implementing the medical home model, with integrated trauma-informed care, to expand oral health care services for people with HIV, and improve outcomes along the HIV care continuum. After instituting the model, the dental clinics saw increases in referrals from partner organizations and in the numbers of new clients.
Retention in HIV medical care
Clinical service delivery model
Galloway, Northfield, and Somerdale, NJ