Medical Home for Multiply Diagnosed HIV-Positive Homeless Populations

The Ryan White HIV/AIDS Program (RWHAP) Part F Special Projects of National Significance (SPNS) program funded the Building a Medical Home for Multiply Diagnosed HIV-Positive Homeless Populations initiative from 2012–2017, to provide coordinated housing supports and HIV, behavioral and mental health care to people experiencing homelessness. Nine funded demonstration sites created partnerships with housing providers, integrated behavioral health and HIV care, and provided intensive patient navigator services. A multi-demonstration site evaluation found that, compared to baseline, participants were more likely to be virally suppressed after 12 months in the intervention.

Pasadena, San Diego County, San Francisco, CA

New Haven, CT

Jacksonville, FL

Cumberland, Hoke, Harnett, Johnston, and Sampson Counties, NC

Multnomah County, OR

Dallas and Harris Counties, TX

Implementation Guide
Evidence-Based Intervention
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Support service delivery model
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Retention in HIV medical care; Prescription of antiretroviral therapy; Viral suppression; Beyond the care continuum
Icon for Ending the HIV Epidemic in the U.S. Strategy
Icon for Focus Population
People who are unstably housed
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RWHAP-funded clinic or organization
Need Addressed

People who experience homelessness or are unstably housed are disproportionately impacted by HIV and have worse health outcomes.1 Mental and behavioral health issues exacerbate clients’ existing challenges such as maintaining consistent health care coverage and engaging with complex health care systems. Stigma, food insecurity, lack of transportation, and encounters with the justice system are also barriers to HIV care. While case managers can help clients access resources, many are not trained to deal with the complex social-emotional issues that people who experience homelessness often face.

Core Elements
Navigators providing client-centered care

With a typical caseload of 25–30 clients, navigators accompanied clients to appointments, helped them connect with housing supports, provided access to transportation, and educated them on HIV care and treatment. On average, they connected with clients three times a month. About a third of encounters occurred in community settings, such as shelters or support service agencies. Navigators also served as an important intermediary across members of the larger care team, coordinating the services of medical, substance use disorder treatment, mental health, and housing providers. Upon client enrollment, a navigator conducted a needs assessment that generated an acuity score and informed a care plan developed in collaboration with the care team. All clients enrolled in the program typically received navigator support for 12–18 months. Once clients met criteria (e.g., viral suppression) established by the demonstration site, they transitioned to a case manager for long-term support.

Expedited linkage to HIV medical services

Health care providers were key members of the care team. They prescribed antiretroviral therapy (ART), conducted physical examinations, addressed client complaints, and coordinated with specialists and members of the care team. Demonstration sites used various methods to improve access to medical care, such as adding HIV health care services to satellite clinics and including clinical staff on mobile teams (e.g., in vans or walking the streets).

Mental and behavioral health care

Mental and behavioral health services were often co-located with HIV care delivery. Other demonstration sites formed partnerships with mental and behavioral health agencies to ensure smooth access to services. Supports included harm reduction services, medication-assisted therapy, substance use counseling, mental health counseling by a licensed professional, and prescription of psychiatric medications. Navigators played a key role in facilitating behavioral health service access whether co-located or provided by an external agency.

Housing supports

Demonstration sites formed partnerships with organizations that provided housing services. Navigators often worked with these agencies to connect clients to emergency housing or to more long-term housing solutions through relationships with private landlords. Some demonstration sites relied on navigators that coordinated all medical, behavioral health, and housing services, while others had navigators that focused exclusively on housing. 


Across the nine sites, the program enrolled 700 people with HIV who were 18 and older, experiencing homelessness, and with diagnoses of behavioral and/or mental health conditions. Participants were identified through existing RWHAP case management programs, clinic screenings, emergency departments, and referrals from housing organizations and law enforcement. The study used a pre-post research design, comparing housing status and health outcomes at baseline and 6 and 12 months after the intervention.

Category Information
Evaluation data

Client survey and medical record data collected at baseline and 6 and 12 months after the intervention

  • Percent of clients retained in care, defined as having two medication appointments at least 90 days apart during the 12-month study period
  • Percent of clients who were virally suppressed, defined as having at least one viral load <200 copies/mL 
  • Percent of clients who were prescribed ART within the last six months
  • Percent of clients with perceived HIV external stigma (summary score based on whether respondents feel that people they know would treat someone with HIV as an outcast, feel uncomfortable around someone with HIV, etc.)

Participants who stabilized their housing (n=417) were more likely than those that became or remained unstably housed (n=283) to:

  • Be retained in care (86% vs 79%)*
  • Be prescribed ART (84% vs 72%)*
  • Have higher rates of viral suppression (77% vs 66%)*

* statistically significant

Source: Rajabiun S, Tryon J, Feaster M, et al. The influence of housing status on the HIV continuum of care: Results from a multisite study of patient navigation models to build a medical home for people living with HIV experiencing homelessness. Am J Public Health. 2018; 108, S539–S545.

Planning & Implementation
  • Navigator training. Navigators received 60 hours of training on motivational interviewing, harm reduction, trauma-informed care, de-escalation, and advocating for clients who may be difficult to house. They came from a range of backgrounds; some were licensed clinical social workers, while other navigators were able to draw from lived experience (e.g., experienced homelessness, were HIV-positive). A project coordinator often oversaw navigator activities, helping to manage caseloads and providing self-care support. 
  • Use of Patient-Centered Medical Home (PCMH) and Housing First models. The project leveraged two important models to guide care delivery. The PCMH model uses multidisciplinary teams to provide comprehensive and coordinated services, while the Housing First model prioritizes housing over treatment and connects clients to housing services without pre-conditions, such as sobriety.
  • Cross training of staff. Clients often do not disclose their housing status to medical providers. Therefore, demonstration sites trained staff so they could better identify people who were unstably housed. Similarly, HIV care providers trained staff experienced in housing issues on HIV and care delivery.  
  • Partnership building. Demonstration sites often built housing coalitions. Regular meetings across agencies served as an opportunity to establish relationships, educate existing housing initiatives on the project, and identify opportunities for client referrals.
  • Referrals into the program. Demonstration sites accepted referrals to the project from medical providers, housing providers, and law enforcement. To support these efforts, they developed and implemented outreach strategies and clear processes to receive and manage referrals.  

The average annual cost per client was $2,713 in 2016 across the nine demonstration sites. SPNS funding covered staff salaries, transportation for staff and clients, prepaid cell phones to facilitate communication, and agency overhead. Medical and behavioral health care costs were not included in this calculation because they were typically not covered by the SPNS initiative funding. For example, RWHAP and health care coverage programs, such as Medicaid, usually covered the cost of these services.

Lessons Learned
  • Assigning a project champion to communicate project goals and navigator activities to staff and other stakeholders can help the project get off to a good start. Communication should emphasize that navigators do not replace existing case managers; instead, they provide extra support to a population with high needs.

“Any time you introduce a new intervention and a new classification of staff, you need to realize that it can have an impact on your overall operation. Introducing navigators affects the jobs of everybody else in the clinic. You need to look at each role and say what is this role vis-à-vis the navigator.”

  • The SPNS initiative highlighted that private landlords are often willing to provide housing to people with a history of incarceration or substance misuse if they are supported by a formal program.  
  • Projects that provide intensive services, such as patient navigation and housing supports, may generate additional walk-in traffic, which providers can accommodate by building out triage rooms, training staff on how to best direct clients to medical care or navigation support, and rearranging waiting rooms. 
  • Navigators may feel unsafe serving clients in community settings. Full access to project leadership, regular check-ins, self-care techniques, and safety procedures can help navigators feel supported and keep them safe. For example, when navigators met clients in the community, they typically informed other staff members and carried a cell phone.

“Senior leaders were asked to make themselves totally available to navigators and to help problem-solve. That is what made it successful.”

  • Some clients may not be ready to engage with the project at the first contact. Navigators who continue to communicate with clients and create a positive rapport may eventually be successful. For example, though hesitant initially, a client enrolled in the project after a navigator visited him in the hospital. The navigator had received an alert from the city’s coordinated referral system that the client was admitted to the hospital. 
  • Clients may not see themselves as “unstably housed” if they have a place to stay (e.g., parent’s or friend’s house) even if the location changes periodically. Navigators can play a crucial role in understanding clients’ living situations and advocating for them to find more permanent housing.
Serena Rajabiun, PhD, MA, MPH

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