Homeless Health Outreach Mobile Engagement (HHOME) offers mobile HIV primary care, behavioral health care, and connection to housing services to people with HIV experiencing homelessness in San Francisco, CA. This is an important alternative approach to care for clients who are not well served by traditional care options. It is primarily a collaboration between four agencies who provide low-barrier care to people experiencing homelessness. A centralized HHOME team acts as a hub to meet clients where they are, refer them to housing and support services, and provide ongoing case management and HIV primary care services. Clients participating in HHOME experienced increased retention in care, viral suppression, and connection to stable housing.
San Francisco, CA
San Francisco, CA has high rates of HIV and homelessness, and only 20 percent of homeless people with HIV were virally suppressed.1 Over half of homeless people reported a comorbid mental health condition and nearly two-thirds had an alcohol or substance use disorder.2 Numerous studies have shown that homelessness is associated with poorer HIV and overall health outcomes.3,4 Though multiple teams in San Francisco help to connect homeless people with HIV to care, some clients may not be ready to access typical healthcare settings but may be willing to engage in mobile care options.
The HHOME team consists of a project manager, medical doctor, registered nurse, medical social worker, peer navigator, and housing case manager. This team provides mobile care to clients referred into the program, and collaborates to ensure that clients have access to HIV primary care, behavioral health, and case management services. The mobile team seeks to form strong one-on-one relationships with their clients and maintain almost daily contact with the individuals they serve, providing health monitoring, linkage to needed services, housing assistance, mobile behavioral health care and addiction medicine, benefits acquisition, appointment escorts, and HIV medication adherence counseling. Staff engage in frequent case conferencing; they huddle as a team multiple times throughout the week.
Clients are referred to the program from various community and hospital settings across the city. HHOME staff travel to meet with the client where they are as quickly as possible, whether on the street or at other community locations such as shelters or food assistance programs. If they cannot meet immediately, the client is flagged in the system so that the provider is notified if the client is seen at another hospital or emergency room in the city. The team conducts an initial assessment and works with the client to identify goals and provide education on available resources.
The housing case manager develops a care plan based on the goals identified in partnership with the client and assigns an acuity level to indicate intensity of services needed; other members of the team add to the care plan and assign roles as needed. Staff coordinate using a group chat for real-time feedback and decision making. High acuity clients generally have care plans that include substantial care coordination services. Clients receive case management services until the HHOME team cannot meet client needs, or they have become self-sufficient.
Clients are connected to housing through one of the HHOME team’s partner housing resource programs. This may range from emergency and short-term housing to connection to permanent stable housing. Clients may need assistance from the HHOME team to obtain documentation necessary to secure housing.
The HHOME intervention enrolled and served 106 clients; 61 of these clients were part of an evaluation study of the intervention from 2014 to 2017. Clients participating in HHOME experienced increased retention in care, viral suppression, and connection to stable housing.
At 12 months post enrollment:
Source: Borne D, Tyron J, Rajabium, et al. HHOME: Mobile multidisciplinary care for hard-to-reach homeless in San Francisco. Am J Public Health. 2018 Dec;108(S7):S528-S530.
Community assessment. First, HHOME conducted a community assessment to identify the needs, infrastructure, and resources to provide care and services to people experiencing homelessness. Partners were identified who could provide drop-in medical services, mobile case management and outreach services, behavioral health services, and low-barrier HIV care.
Common client assessment tool. Next, HHOME selected an acuity scale to guide care plan development. This was approved by all partners and referral agencies to keep protocols standardized.
Participant recruitment. HHOME then conducted mobile outreach in areas with high levels of homelessness and received referrals from identified partners. Potential clients were screened for eligibility, received information on the intervention, and were enrolled if appropriate.
- This project was initially funded as a demonstration site for the Ryan White HIV/AIDS Program (RWHAP) Part F Special Project of National Significance (SPNS) Building a Medical Home for Multiply Diagnosed HIV-positive Homeless Populations initiative.
- This project is now being replicated in multiple other programs and additional partnerships across San Francisco. HHOME trainings are provided to new students, residents, and fellows at San Francisco General Hospital.
- A local Health Care for the Homeless program or a recommendation from the National Health Care for the Homeless organization can help identify key partners. Organizations are likely already working with clients who could benefit from the intervention, especially at transitions such as exiting the jail system.
- Trauma-informed care is essential to engage this population in care, and staff should be trained on trauma-informed care and harm reduction. Clients noted the importance of having a peer navigator with lived experience on the team, and all team members need good interpersonal skills to meaningfully connect with clients.
- Incentives such as food can help to engage clients and create a welcoming atmosphere. The project found that clients experiencing homelessness also appreciated receiving tarps, which helped to build trust.
- People experiencing homelessness often benefit from life skills education in key areas such as food and nutrition; money management; safe community participation; and home and self-care. HHOME adopted a Life Skills Assessment Checklist to work with clients.
- San Francisco Department of Public Health (SFDPH). HIV Epidemiology Annual Report, 2020.
- Applied Survey Research (ASR). San Francisco 2019 Homeless Count & Survey.
- Aidala AA, Wilson MG, Shubert V, Gogolishvili D, Globerman J, Rueda S, Bozack AK, Caban M, Rourke SB. Housing status, medical care, and health outcomes among people living with HIV/AIDS: a systematic review. AJPH. 2016 Jan;106(1):e1–23.
- Stanic A, Rybin D, Cannata F, Hohl C, Brody J, Gaeta J, Bharel M. The impact of the housing status on clinical outcomes and health care utilization among individuals living with HIV. AIDS Care. 2021 Jan;33(1):1-9. doi: 10.1080/09540121.2019.1695728. Epub 2019 Nov 25. PMID: 31766866.