The City of Paterson, a Ryan White HIV/AIDS Program (RWHAP) Part A recipient in New Jersey, implemented the Coordination of Supportive Employment and Housing Services from 2017–2020, as part of a RWHAP Part F Special Projects of National Significance (SPNS) demonstration project. The intervention integrated supportive employment services, housing services, and HIV care for clients receiving case management services and with unmet housing and employment needs, in the Bergen-Passaic Transitional Grant Area (TGA). The intervention engaged people in HIV care, identified their social needs related to housing and employment, and created an effective referral process using a single data system, eCOMPAS®. 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.
Paterson, NJ
The intervention aimed to address needs related to housing and employment, including transportation, among people with HIV in the Bergen-Passaic TGA, a densely populated area of almost 1.5 million that is home to almost 4,500 people with HIV. Passaic County serves a lower-income and more diverse population than Bergen County. There are significant racial disparities in HIV incidence in the TGA, with higher rates of HIV incidence among Black and Hispanic/Latino populations. The City of Paterson, the RWHAP Part A recipient for the Bergen-Passaic TGA and a Housing Opportunities for People with AIDS (HOPWA) recipient, administered this SPNS intervention to better address housing, employment, and related needs for people with HIV in the area.
The intervention used Smart Care Management, a theory-based systems-driven approach, to engage people in HIV clinical care and connect them to integrated housing and employment services. This approach coordinated existing resources and drew on staff in different roles to conduct outreach to clients, track activities, assess gaps in services, and offer case management to meet all client needs. Effective case manager training in tracking and documenting referrals was considered an essential component of Smart Care Management. In addition, the approach focused on providing culturally and linguistically relevant care at all stages.
The intervention unified pre-existing housing, employment, and HIV clinical care resources to offer more coordinated services to people with HIV. The intervention used a “Housing First” approach, drawing on a theoretical framework establishing housing as a vital initial step for helping people with HIV establish care. Other key services in the unified model included a network of HIV care providers, medical and non-medical case management and patient navigation, and access to medication through various options (e.g., AIDS Drug Assistance Program, medication delivery).
Intervention staff partnered with the Bergen One-Stop Career Center, funded by the U.S. Department of Labor, and with local agencies to implement the intervention. Partners included the Paterson and Bergen housing authorities for housing assistance and the Paterson public library for computer access, job resources, and network referrals. Additional organizations (Bergen Family Center, Buddies of NJ, Team Management 2000, and Coalition on AIDS in Passaic County) offered additional intake services and referral support. Other organizations also contributed case management, research, linkage to services, and data system support.
The intervention used eCOMPAS®, a centralized data management system developed by RDE Systems for RWHAP and HOPWA case management and reporting, to identify eligible clients, assess gaps in services, facilitate referrals, and support quality improvement. Housing and income information were entered to establish a baseline, allowing for subsequent outcomes measurement. The eCOMPAS® system offered an HIV Care Continuum Report, a Referrals Module, dashboard functionality, and an Alerts Module (among others) to assist in intervention activities and monitor client progress. During the intervention, nine new housing and employment alerts were added that helped identify next steps for clients. The e2MYHealth Patient Portal within the eCOMPAS® framework offered clients access to health information, such as appointment reminders and lab results, in a user-friendly, plain language format. Nearly 200 patient accounts were created in this portal by the end of the intervention.
The three interventions goals were to: 1) reduce the number of out-of-care people with HIV; 2) reduce the number of people with HIV without stable housing; and 3) increase employment among people with HIV through effective referrals to education, training programs, and job placement. The project team conducted an evaluation beginning with 82 participants. Of these, 52 returned for a six-month follow-up interview and 22 for a 12-month follow-up interview. The evaluation observed 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.
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| Results | From the baseline interview to the 12-month follow-up interview (n=22):
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Source: HIV Housing & Employment Project, City of Paterson Intervention Manual
Staff onboarding and training. The intervention included robust staff preparation and training across the participating agencies. Training opportunities commenced with online modules from the U.S. Department of Housing and Urban Development (HUD) that provided valuable information about integrating employment services, HIV care, and housing assistance. Staff then participated in individualized training for their unique roles and received orientations to the participating programs, agencies, and services in the intervention.
Team communication. Intervention staff and partners participated in weekly meetings in a group setting with staff from different programs. Regular topics included services and support provided, updates on client status, and any challenges with the eCOMPAS® systems. In addition, monthly clinical supervision meetings expanded on themes addressed during the weekly meetings and provided advice on engaging with clients and meeting their needs.
Referral mapping. The intervention used referral maps to identify stakeholders, illustrate the project workflow, and highlight the major elements of the intervention. These visualizations helped track the flow of clients and opportunities to meet their needs.
Intervention promotion and public awareness campaign. The intervention was promoted through meetings with partners and external stakeholders, including the regional AIDS Education and Training Center. In addition, a public awareness campaign disseminated information about the intervention’s services through flyers, posters, and other materials in various partner and community locations.
The intervention was funded by SPNS for a three-year demonstration period. However, the eCOMPAS® system enhancements and Smart Care Management tools are permanent and will be used by the Paterson TGA in the future, since the eCOMPAS® system is supported by ongoing RWHAP Part A funding.
- The Smart Care Management system significantly streamlined referrals between programs and improved the process of shared case management through real-time updates and status reports. It ultimately contributed to the intervention identifying 28-plus new housing and employment referral partners in the area, improved data collection and reporting, resulted in quality management process improvements, and improved collaboration and information-sharing with all partners.
- The eCOMPAS® system and enhancements were found to greatly increase efficiency and reduce duplication among participating partners. The intervention estimated that the system eliminated about 270 hours per year spent on double data entry for services received and medical information for clients.
- Strong working relationships with local and regional housing authorities were essential for success. This included working with a large network of local and regional providers, planning for housing transitions for clients, conducting housing needs assessments, and using effective data systems to track housing vacancies.
- Coordinating with existing employment services helped ensure that education and job training that met the needs of the focus population were available. Services combined elements from formal education, soft and hard skills training, and on-the-job training to help new employees succeed in their roles.
- The City of Paterson had initially wanted to focus on clients who were not virally suppressed and faced housing and employment challenges. However, it was challenging to find clients who met these criteria, in part due to the Paterson TGA’s long history of providing HIV care and helping clients reach viral suppression. Many clients with housing and employment needs were already virally suppressed. This demonstrates that viral suppression is possible, even for clients living in unstable housing or employment situations. Other client challenges were contacting clients without cell phones, ensuring culturally appropriate services, and securing housing for clients with specific challenges (e.g., low credit score).
- Staffing turnover and hiring delays affected immediate service delivery, while leadership changes in the city government affected support for the intervention. The intervention director worked to overcome these challenges by collaborating closely with community partners.
“Another success story of the Paterson SPNS initiative was the father who, along with his daughter, was sleeping in his car. Through the SPNS initiative and with the assistance of the housing authorities, the City of Paterson was able to place the man and his child into stable housing.”
Implementation Resources
Presentations
- National Ryan White Conference on HIV Care & Treatment (NRWC) 2020: Housing, Employment and HIT Improve Access for Vulnerable Populations in Paterson, NJ and Puerto Rico
- City of Paterson Coordination of Supportive Employment and Housing Services Poster
Other Resources
