The Max Clinic, located within the University of Washington’s Harborview Medical Center complex in Seattle, offers walk-in services and incentives to clients reengaging in HIV care, especially those who have not been well served by the traditional health care model—including clients who are experiencing homelessness, or who have mental health and substance use issues. The Max Clinic offers rapid antiretroviral therapy (ART), incentives, a flexible clinical model, and access to comprehensive support services. A University of Washington study demonstrated that Max Clinic clients were significantly more likely to reach viral suppression after 12 months than a comparable control group.
Obstacles such as limited appointment availability, the need for advance scheduling, and appointment start times with limited flexibility require patients to be organized and familiar with the healthcare system to navigate care successfully. These obstacles may be more difficult to overcome when trying to engage people with psychosocial barriers into HIV care. For example, people who are unstably housed and/or with substance use disorder and/or with HIV attributed to injection drug use are less likely to be virally suppressed than the overall population with HIV.1 The clinicians who started the Max Clinic felt that for many clients who were not engaged in care, they had not been well served by the traditional health care model and needed greater flexibility, additional supports, and incentives related to their care.
The Max Clinic is housed within an existing public health STI clinic, which operates on a walk-in basis. Clients can access case management (medical and non-medical) and medical services five full days a week, allowing walk-in flexibility for approximately 250 Max Clinic clients. Clients re-engaging in care at the Max Clinic are offered same-day medications at the time of their first appointment, and typically leave their first appointment with medications in hand. The state AIDS Drug Assistance Program (ADAP) and Medicaid program have rapid enrollment to cover the cost of treatment immediately.
Engaging in medical care and adhering to medications are not always top priorities for the Max Clinic clients. As reported by a social worker, “their priority is surviving.” Therefore, the Max Clinic offers clients financial incentives, funded through state dollars. Clients receive $25 every two months with a lab draw and $50 when they reach viral suppression. Clients also receive bus passes, gift cards to local fast-food restaurants, and snacks at the clinic.
Social workers conduct mental health and substance use assessments and refer clients to intensive services offered through Harborview Medical Center. Clients also have access to specialty care and other clinical services at Harborview. Max Clinic Disease Research and Intervention Specialists (DRIS) support these referrals, while social workers support health care coverage eligibility and connection to housing and food assistance.
A DRIS team member works with local jails, hospitals, and homeless shelters to identify people eligible for Max Clinic services. Service providers can also refer clients to the Max Clinic by completing a referral form with medical history and considerations related to housing, substance use, and mental health diagnoses. A DRIS team member, clinician, and social worker then determine whether the client meets the Max Clinic eligibility criteria, including not being virally suppressed or not taking ART, poor engagement in medical care, failure to reengage after previous attempts, and/or recommendation by a case manager or clinician. The team accepts one to two referrals per week.
Providing services to clients with complex medical and social needs who have not been engaged in conventional medical care requires flexibility and a willingness to partner with clients to determine a realistic care plan. Some clients may only be able or willing to engage in conversation for a short period during clinic visits. Providers may need to expand their scope of practice or develop creative care plans for clients who are not able to complete specialty appointments or are unwilling to go to the emergency room or stay in the hospital. Principles of harm reduction are central to the low-barrier care approach.
Many Max Clinic clients interface with several other organizations, such as supportive housing facilities, substance use treatment programs, and jail release planners. Coordinating case management and care plans between these organizations helps support patients and avoids duplicating or conflicting care plans. The case managers and DRIS at the Max Clinic have a weekly case conference with the local jail health and release planning team which also includes a day support program and shelter for people with HIV. Sharing information across organizations is required for effective coordination.
The Max Clinic has made many changes to their care model and approach over time. Starting a new program required the team to recognize when things were not working and rapidly change them. The team needed to grow and change as the clinic patient population grew. A commitment to rapid learning and ongoing improvement helped the Max Clinic improve their approaches to effectively engage people with complex needs in treatment.
“When you ask the patients about what are the things that work in Max Clinic, the three things [are] walk-in care, incentives, and relationships. Those are the things that the patient identifies that matter. And those relationships are with the entire staff of the clinic, not just the doctors.”
The original evaluation study was conducted in 2015–2016. Max Clinic clients (n=50) were randomly matched to Madison Clinic clients, who received usual care (n=100) in a 2:1 ratio. While viral suppression improved for both groups after 12 months, the study found that Max Clinic clients were significantly more likely to reach viral suppression than Madison Clinic clients.
* statistically significant
Source: Dombrowski JC, Galagan SR, Ramchandani M, Dhanireddy S, Harrington RD, Moore A, Hara K, Eastment M, Golden MR. HIV care for patients with complex needs: a controlled evaluation of a walk-in, incentivized care model. Open Forum Infect Dis. 2019;6(7):ofz294. doi:10.1093/ofid/ofz294
Cross-agency collaboration. The Max Clinic model stemmed from a collaboration across multiple agencies: Harborview Medical Center and its affiliated HIV clinic, Madison Clinic, the Public Health Sexual Health Clinic, Seattle & King County Public Health Department, and the Washington State Department of Health. Many Max Clinic clinicians also serve clients at the Madison Clinic and Public Health Sexual Health Clinic, facilitating collaboration. The state and county public health departments have played a key role in funding.
Community referral network. Relationships with community partners including local jails, hospitals, and homeless shelters, facilitate referrals into the program. The agencies meet regularly to discuss shared clients, especially related to post-incarceration linkage to care.
Expansion of services as needed. The Max Clinic was started with limited hours and staff. Services were added and expanded as staff learned more about the needs of their clients and the demand for the program increased. Staff worked with the county and state to secure additional funding for more clinicians and longer clinic hours. The Max Clinic also recognized the need for additional support staff with tailored roles. Once again, county and state agencies provided funds to build more robust social support teams. As of 2022, four DRIS staff members conduct outreach to bring clients into the clinic, manage incentives, and make referrals to other clinical services. Three social workers conduct assessments, support enrollment into the Ryan White HIV/AIDS Program (RWHAP), and health care coverage, and refer clients to other support services.
Data exchange. Data sharing and analysis support the Max Clinic’s work. DRIS team members receive alerts from the Harborview hospital when clients are admitted. The Max Clinic also created a report in its electronic health record to track key clinical measures and screenings for clients so staff can fill gaps in treatment.
Health care coverage plays a key role in funding the cost of care and medication. Washington State was an early adopter of Medicaid expansion. In addition, both Medicaid and ADAP have expedited enrollment processes, so care can be covered immediately. Social workers help clients complete paperwork for health care coverage applications. The Max Clinic also receives RWHAP Part B funding from the Washington State Department of Health and Ending the HIV Epidemic funding from the Seattle & King County Public Health Department. Given the state’s and county’s demonstrated funding commitments, the Max Clinic is confident its model is sustainable over time.
In addition, the Max Clinic model is currently being replicated and evaluated as part of the RWHAP Part F Special Projects of National Significance (SPNS) Using Innovative Intervention Strategies to Improve Health Outcomes among People with HIV (2iS) initiative.2
- Clinicians prioritize medications for the first visit. While clinicians prefer to spend an hour with the client to better understand their medical history, needs, and strengths, clients may be unable to stay that long. Therefore, clinicians first perform the activities needed for the ART prescription and coordinate with the pharmacy to dispense medications.
- Max Clinic staff acknowledge that their comprehensive model might not be feasible for many providers. Therefore, they suggest starting small and building on processes based on lessons learned and additional access to resources.
- Communication across staff is essential for addressing client needs. One staff member mentioned that the team “over-communicates” when a client comes into the clinic, so everyone is aware of whether the client has a medical issue, needs to be connected to social services, or is due for incentives.
- Personal relationships and small acts of kindness matter. A staff member mentioned that when a client received a card and small gift during the holidays, he said, “This is the only card I will receive.” Clients and staff alike acknowledge that these relationships keep clients coming back.
“We pretty much [have been] putting everybody on ART right away for years and years at this point. Our pharmacists are so good that [if there are issues, it’s] more about how much medicine they give you the first day, not whether we are going to give you the medicine.”
Dombrowski JC, Ramchandani M, Dhanireddy S, Harrington RD, Moore A, Golden MR. The Max Clinic: Medical care designed to engage the hardest-to-reach persons living with HIV in Seattle and King County, Washington. AIDS Patient Care STDS. 2018; 32(4):149-156. doi: .1089/apc.2017.0313
Dombrowski JC, Galagan SR, Ramchandani M, Dhanireddy S, Harrington RD, Moore A, Hara K, Eastment M, Golden MR. HIV care for patients with complex needs: a controlled evaluation of a walk-in, incentivized care model. Open Forum Infect Dis. 2019; 6(7):ofz294. doi:10.1093/ofid/ofz294
Beima-Sofie K, Begnal ER, Golden MR, Moore A, Ramchandani M, Dombrowski JC. “It’s me as a person, not me the disease”: Patient perceptions of an HIV care model designed to engage persons with complex needs. AIDS Patient Care STDs. 2020; 34:267-274. PMCID: PMC7262637