San Diego, CA
Family Health Centers of San Diego (FHCSD) is a Federally Qualified Health Center providing comprehensive health services including HIV care at over 24 clinic locations. FHCSD implemented the Coordinated Services Integration (CSI) intervention from May 2018 to September 2020 as part of a Ryan White HIV/AIDS Program (RWHAP) Special Projects of National Significance (SPNS) initiative. This intervention integrates healthcare, housing, and employment services to enhance health outcomes related to HIV. FHCSD provided health care services; Townspeople, a HOPWA-funded housing program, and the National Alliance on Mental Illness (NAMI) were responsible for offering housing services; and San Diego Workforce Partnership (SDWP) and San Diego Employment Solutions (SDES) provided employment services. Clients participating in the intervention had improvements in retention in care, viral suppression, housing status, and employment status.
Limited affordable housing and lack of coordination among service providers have exacerbated the housing crisis in San Diego County. In 2016, shortly before FHCSD implemented the CSI intervention, about 15,000 people living in San Diego were HIV positive, with more than half identifying as racial and ethnic minority groups.1 Almost 30% of FHCSD’s clients with HIV experienced unstable housing and 56% experienced unemployment in 2018 and 2019. People with HIV encounter many barriers to housing and employment such as discrimination and stigma, lack of transportation, and health-related obstacles; and lack of stable housing and/or underemployment contributes to poor HIV-related health outcomes.
“Unfortunately, while housing remains the most prevalent need among racial/ethnic minority people with HIV, San Diego County lacks sufficient affordable housing units and coordination among providers.”
A full-time linkage coordinator, who was recruited internally from within FHCSD, met regularly with clients to determine which support services were needed, and to link clients to them. During regular monthly meetings, the linkage coordinator offered advice and positive reinforcement to help clients gain confidence to seek employment, and facilitated referrals to the partner organizations offering employment support and housing services. The linkage coordinator followed up with clients after meetings, maintaining communication with clients until they secured consistent HIV care, stable housing, and employment. The linkage coordinator was supported by an administrative management team and a data management team, and collaborated with FHCSD’s RWHAP case managers to identify clients to enroll in CSI.
SDWP assisted FHCSD in offering employment support activities, such as interview preparation, professional advice, employment skills workshops, and resume support. FHCSD also partnered with San Diego Employment Solutions (SDES) to offer additional assistance and customized support, including mental health services, for clients throughout the employment application process. After a client secured employment, SDES offered an additional nine months of support.
Clients met with a housing navigator at Townspeople to complete their initial housing application. Townspeople served as a landlord, collaborating directly with the San Diego Housing Commission to provide housing units to clients and implement the Commission’s housing program. Afterwards, NAMI provided clients with payment assistance as needed, budgeting training, and help in the management of applications.
Standard activities for patients at FHCSD include an automated call for missed appointments, automated reminders prior to the appointment, follow-up to determine medication adherence, and reengagement in care activities (i.e., telephone calls, prompts on the electronic health record system) focused on patients who needed medication refills or were due for a viral load test.
FHCSD enrolled 121 people in the intervention; eligibility criteria included individuals with HIV aged 18 and above, experiencing unstable housing, and/or currently unemployed. An evaluation of the CSI intervention, conducted by the Institute for Public Health at San Diego State University, compared viral suppression rates, retention in care rates, housing status, and employment status pre-intervention and post-intervention.
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Source: The HIV Housing and Employment Project. The San Diego Coordinated Services Integration Intervention Implementation Manual.
Collaboration with partner organizations. FHCSD established formal partnership agreements with Townspeople, NAMI, SDWP, and SDES detailing the services each would provide as part of CSI. Interagency team meetings were held regularly with all the partners, initially to design and plan the intervention, and later to address implementation challenges and find solutions.
Intervention promotion. FHCSD publicized the intervention model during regional community service provider meetings, such as the RWHAP People of Color Case Management meetings and the Transitional Case Management Annual Meeting. FHCSD staff also promoted the intervention in each of its 24 clinic locations.
Staffing. The CSI staffing plan included three teams: Program Management (associate director, intervention manager), Client Services (linkage coordinator who collaborated with RWHAP case managers), and Data Management (data manager, software engineer). All staff received training on housing and employment needs and resources. The linkage coordinator received additional training, such as strength-based case management, trauma-informed care practices, and employment assessment techniques.
Electronic health record enhancements. Multiple upgrades were made to FHCSD’s electronic health record system to help facilitate the CSI intervention, including enabling the collection of data on the housing and employment needs of all clients, and improved sharing of information on referrals and referral completion.
CSI was funded as part of a RWHAP Part F SPNS initiative, the HIV, Housing, and Employment Project, and was conducted and evaluated within a RWHAP-funded site. FHCSD’s partnerships with Townspeople, NAMI, SDWP, SDES, and other community organizations extended beyond the initial three-year intervention period to help sustain integrated healthcare, housing, and employment services.
- The readiness of clients to use housing and employment services varied greatly; substance use and low self-esteem often acted as barriers to engaging clients in the intervention. It is important that linkage coordinators provide positive reinforcement and emotional support to enhance client self-esteem and improve retention in the program. Linkage coordinators should also be prepared to refer clients who need them to substance use treatment and support.
- During the intervention period, fewer housing units were available than initially forecasted, delaying housing placement for many clients, and adding to the workload of the linkage coordinators supporting clients who were unstably housed.
- Undocumented persons faced extremely high barriers to obtaining permanent housing, which necessitated FHCSD to partner with additional housing programs with more flexible eligibility requirements and service providers focused on supporting undocumented persons.