Co-Locating Care Management Staff and Peers in Medical Clinics

Ryan Health, a Federally Qualified Health Center, and Alliance for Positive Change (Alliance), a community-based organization, created a medical-community partnership to link clients to care and decrease missed appointments. The Linkage to Care (LTC) program, utilizing peer navigators, was successful in reengaging clients who had fallen out of care.

New York, NY

Implementation Guide
Emerging Intervention
Emerging Intervention
Icon for Intervention Type
Clinical service delivery model
Icon for HIV Care Continuum
Linkage to HIV medical care; Retention in HIV medical care
Icon for Focus Population
People with HIV who are not in care; People with multiple chronic conditions
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Community health center, including Federally Qualified Health Centers (FQHCs)
Need Addressed

Clients with barriers to care often need additional support offered through peer navigators and Home Health Care Managers to help them stay engaged in care.

Core Elements
Utilizing data to identify clients for outreach

Ryan Health used their electronic health record (EHR) and population health database from a partner hospital to generate client lists for the Alliance LTC/peer navigator team. These clients had missed appointments, two or more emergency department visits in the past year, and/or fell out of care.

Re-engagement activities

Ryan Health leveraged Alliance’s capabilities to find and engage these individuals in medical care. Alliance staff participated in case conferencing as members of the Ryan Health patient care team, utilizing peer navigators, providing treatment adherence services, and connecting patients to Health Home Care Management services, a Medicaid reimbursable care coordination service available to people with certain chronic conditions. Through these services, Alliance helped Ryan Health patients reach “alignment” with medical providers (two or more consecutive visits in 12-month period).

Co-location of Alliance Care Manager at Ryan Health

Alliance co-located a Medicaid-funded Health Home Care Manager within Ryan Health, who served as a key facilitator in the success of the intervention. The Care Manager supervised two peer navigators, and the Alliance LTC team contacted patients at least monthly, in-person or virtually, with an average of three monthly outreach encounters per person to be re-engaged. Co-location allowed for real time data exchange, on-site case conferencing between care manager, peer navigators and medical providers, fast track access to medical appointments, and provision of wraparound services.

Funding through the Medical Health Homes project

Alliance leveraged Medicaid dollars through the Health Home Care Management initiative, which provides care management services for Medicaid enrollees who have two or more chronic medical conditions. The Health Home Care Manager coordinates medical care appointments, collaborates with the care team, develops service plans, conducts social determinants of health screenings, connects clients to wraparound services, and supervises peer navigators who assist with patient engagement and consistent connection to medical care.

“You've got to co-locate the care manager within the clinic and the peer navigators, but the clinic has to make a commitment by identifying a key liaison to the Care Management team. And Ryan [Health] was really willing and open to doing that, and I think that's a critical piece.”


Alliance reached out to a total of 104 clients from February–June 2019 and evaluated the pilot.

Evaluation dataAlliance utilized client demographic, service, and medical data.

The percentage of patients successfully reengaged in care, measured by attendance at one medical visit within two months of being located and enrolled in the LTC program. 

Of those who were successfully reengaged in care, Alliance also measured the percentage of those who were engaged in ongoing medical care, defined as a minimum of two medical visits a year at least four months apart.

  • 43% of clients were reengaged in care.
  • 98% of currently enrolled patients had at least two primary care physician appointments in the past 12 months.
  • 100% of currently enrolled patients were consistently engaged with the care management team every month.

Source: Alliance/Ryan Health Pilot Project: Care Management & Peer Navigation. National Ryan White Conference on HIV Care & Treatment 2020 presentation.

Planning & Implementation
  • Clinic and community-based organization partnership. Alliance and Ryan Health established a partnership where Ryan Health was able to leverage Alliance’s capabilities to provide peer navigation and Health Home Care Management services to find and engage hard to reach individuals. Clinic leadership was needed to establish the partnership, which took multiple years to be solidified. Clinic liaisons support communication between Alliance and Ryan Health.
  • Dedicated peer navigators. Each Alliance Health Home Care Manager has a dedicated peer navigator to provide the "boots on the ground" for the patients. Together, the Health Home Care Manager and peer navigators help patients work through any barriers that might prevent them from seeing their doctor or other medical care professional. Peer navigators, who have a shared lived experience culturally, linguistically, socially, and economically, help promote long-term engagement and guide patients toward health and stability. Potential peer navigators participated in a two-month training, completed an application, and if selected started with part-time employment.
  • Space at the clinic. Alliance care management staff needed appropriate space within the Ryan Health clinic and access to the EHR to work effectively.
  • Regular team meetings. Regular communication is essential. Periodic meetings, attended by stakeholders from each program, are conducted to support the evaluation and refine program protocols.

“I think in the beginning, especially when we were first identifying patients that would best benefit from the service, the peer navigators were a big part of reaching out to these members. Reaching them in person [and] going to their home to not only discuss with them the opportunity for additional services, but [also] really to reconnect them back to the clinic.”

  • A main challenge to sustainability is maintaining staff for the collaboration. However, Alliance was able to secure a steady funding source with Medicaid revenue.
  • Both Alliance and Ryan Health have been able to offset other costs by taking on aspects of the program “in-kind.” For example, Alliance does not pay rent to Ryan Health.
  • Peer navigators participate in ongoing trainings and weekly support groups. Trainings address "soft skills," including conflict resolution, time management, anger management, and communication skills.

Photo Source: HRSA Ryan White HIV/AIDS Program Photo Library

Lessons Learned
  • It is essential to get clinic buy-in and establish cooperation around data points and reporting metrics.
  • Teamwork and communication are important to ensuring all data teams are trained to properly document and utilize the EHR.
  • Both the medical facility and the community partner must identify supervisory-level staff to facilitate effective referrals of clinic patients to the care manager, as part of the patient flow at the clinic.

“The buy-in piece with the clinic is constant, always revisiting it with providers. I think everyone is so busy and when it is something new, sometimes it can be difficult to reinforce the message over. Having the care manager integrated and visiting those staff meetings, being part of those daily rounds and being really integrated within the clinic workflow helps to really keep the staff engaged with the collaboration and [helps them] understand that it's part of the clinic; this program is part of them and their team.”

Alliance for Positive Change
Cynthia Rossi
Director of Care Management and Treatment Support

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