Best Practices Highlight: New York City Medical Home Model


A New York City HIV medical home model, established in 2009, has documented significant improvements in care outcomes, including:

  • 88% of the Community Care Program (CCP) clients who were out-of-care individuals were reengaged in services, compared to 63% for those getting care from the "usual-care" group.
  • 66% of CCP clients reached viral suppression, compared to 49% in the "usual-care" group.

The model, first launchd with funding from New York City's Ryan White Part A program, is described in detail in the RWHAP Best Practices Compilation, a growing collection of interventions with documented efficacy on improving HIV care outcomes. Among the core elements of CCP are:

  • Multidisciplinary care team case conferencing.
  • Patient navigation.
  • Personalized health education curriculum.
  • ART adherence support.
  • Outreach to clients after missed appointments.

Learn more about the New York City's CCP, including the STEPS to Care Toolkit, comprised of patient navigation, care team coordination, and HIV self-management.