New York City HIV Care Coordination Program

The New York City HIV Care Coordination Program (CCP) is a structural intervention that combines multiple strategies, including multidisciplinary care coordination, patient navigation, and personalized health education to address client medical and social needs. The CCP uses a medical home model to help people with a new HIV diagnosis, or who are experiencing barriers to reaching and sustaining viral suppression. The New York City Department of Health and Mental Hygiene (DOHMH) launched the CCP, funded through the Ryan White HIV/AIDS Program (RWHAP) Part A, in December 2009. Multiple evaluations of the program, which has evolved over the years, consistently show improvements in viral suppression and engagement in care, especially for people with a new diagnosis of HIV or who are out of care.

New York, NY

Implementation Guide
Evidence-Based Intervention
Icon for Intervention Type
Clinical service delivery model; Outreach and reengagement activities; Support service delivery model; Systems/structural interventions
Icon for HIV Care Continuum
Retention in HIV medical care; Viral suppression
Icon for Ending the HIV Epidemic in the U.S. Strategy
Icon for Focus Population
People with a new diagnosis of HIV; People with HIV who are not in care
Icon for Priority Funding
RWHAP Part A; Minority HIV/AIDS Fund (MHAF)
Icon for Setting
Community health center, including Federally Qualified Health Centers (FQHCs); Community-based organization/non-clinical setting; Hospital or hospital-based clinic
Need Addressed

Early diagnosis, early and uninterrupted access to antiretroviral therapy (ART), continuous engagement in medical care, and consistent adherence to ART are all essential to reducing mortality and morbidity among people with HIV. However, disparities in health outcomes for people with HIV still exist due to factors associated with social determinants of health and access to quality care, including housing instability, economic hardship, substance use disorders, mental health conditions, and justice system involvement. These factors increase the likelihood of being out of care and treatment, and delaying the initiation of care or treatment for HIV. To address these factors, DOHMH developed the CCP, designed for people with HIV experiencing or at risk for poor HIV outcomes.

Core Elements
Multidisciplinary care team case conferencing

Members of the care team, including a primary care provider, care coordinator, and patient navigator, discuss clients' diverse needs and ensure they are met. The primary care provider renders medical care and clinical guidance, the care coordinator conducts outreach and facilitates care team meetings, and the navigator follows through on the care plan directly with clients. The care team meets frequently and collaborates to ensure that client medical and non-medical records are updated regularly. When necessary and feasible, clients are invited to care team meetings.

Patient navigation

Client-centered patient navigation facilitates clients’ access to all needed services and addresses barriers to care. Navigators set up transportation, accompany clients to routine primary care appointments, and send appointment reminders. Additionally, navigators provide HIV self-management tools, health education, and ongoing support to clients via outreach calls, virtual meetings, and during field visits (meetings with clients in their homes or public spaces). Lastly, navigators attend regularly scheduled meetings with the care team to remain informed and responsive to client needs. Frequency of contact with clients ranges from daily to quarterly connections with CCP staff, depending upon the level of need.

Personalized health education curriculum

Navigators provide clients with HIV self-management tools to promote medication adherence. Using a structured curriculum, they also personalize the health education they provide to every client. These one-on-one coaching and/or counseling sessions address various topics, including treatment guidance, medication adherence support, social support, co-occurring conditions, sexual health, substance use, and harm reduction.

ART adherence support

Navigators are primarily responsible for providing modified Directly Observed Therapy (mDOT) to ensure clients take medications as prescribed. mDOT can be provided in the clinical setting, the client’s home, an agreed upon site in the community, or virtually by video chat. mDOT is offered to clients at enrollment when starting ART or a new ART regimen and when changing or starting medication regimens to treat mental illness, opportunistic infections, or hepatitis C. mDOT is provided to clients who need and accept this level of support.

Outreach to clients after missed appointments

If primary care providers deem clients to be lost to follow-up (i.e., no contact for more than nine months), care coordinators will attempt to reengage them in care. A client found through outreach is scheduled for a medical appointment, while a client who misses an appointment is called and/or texted daily for three days, after which the navigator visits the client’s home or other community locations the client is known to frequent weekly. If still unable to meet with the client after two weeks of failed outreach, a letter will be sent to the client.


Multiple evaluations of the program consistently show improvements in viral suppression and reengagement in care, especially for people with a new diagnosis of HIV, and those previously out of care or who had not reached viral suppression. In one recent evaluation of people with HIV who were out of care, defined as having no viral load test in the last 12 months, those enrolled in CCP had higher levels of reengagement in care and viral suppression after 12 months compared to matched controls who received usual care.

Category Information
Evaluation data
  • Retrospective data from the New York City HIV Surveillance Registry for those meeting criteria from December 2009 to March 2013 and follow-up data out to 12 months
  • Care reengagement, defined as having ≥ 2 laboratory events ≥ 90 days apart at 12-month follow-up
  • Viral suppression, defined as having HIV RNA ≤ 200 copies/mL on the most recent viral load test at 12-month follow-up
  • The proportion of out-of-care individuals reengaged in care was 88% in the CCP compared to 63% in the usual-care group*
  • The proportion reaching viral suppression was 66% in the CCP compared to 49% in the usual-care group*

* statistically significant

Source: Irvine MK, et al. HIV Care Coordination promotes care re-engagement and viral suppression among people who have been out of HIV medical care: An observational effectiveness study using a surveillance-based contemporaneous comparison group. AIDS Res Ther. 2021 Oct 12;18(1):70.

Planning & Implementation

Staffing. The CCP team consists of patient navigators, care coordinators, a program director, and primary care providers. 

  • Patient navigators provide client-facing services including outreach and reengagement; health promotion, education and coaching; mDOT; and follow-up on clients’ connections to and experience with services. They provide critical feedback to other members of the care team to inform the client’s care plan.
  • Care coordinators provide case management, assessment of clients’ needs, supervision of patient navigators, and coordination with the primary care provider and other care team members.
  • A program director provides oversight and administration, training and supervision of care coordination staff, communication and coordination with the health department, and management of program reporting and compliance with RWHAP Part A policies and requirements. 
  • Primary care providers provide medical care to clients participating in the program. They participate in referral and case conference activities and keep care team members informed about important clinical events.
  • Other care team members include anyone involved in the client’s medical care or social service needs, such as: specialty medical providers, behavioral health providers, substance use counselors, social workers, home health aides, and other ancillary service providers.

Staff training. All core staff participate in training from DOHMH on the CCP model. The comprehensive core training addresses medical case management, patient navigation, HIV self-management health education, home and field visits, mDOT and treatment adherence support, and developing care plans. Additionally, staff are trained on emerging HIV topics, harm reduction approaches, mental health, and cultural responsiveness. 

Partnerships of community, clinical, and support services settings. Programs based in non-clinical settings must have formal partnerships with HIV primary care providers to ensure integration of medical care and support services. Specifically, clients must receive their HIV primary care at the agency where they enroll in the CCP or at a partnering medical facility in the case of community-based organizations without in-house primary care. Programs are also expected to establish and maintain partnerships with support service providers to reduce barriers to care. These partners may provide housing benefits, financial assistance, food assistance, transportation, legal assistance, and child and elder care, among other services.

  • DOHMH uses RWHAP Part A and Minority AIDS Initiative (MAI) supplemental funding to support the CCP, which funds staff and some administrative costs.
  • DOHMH continues to provide core training for all new program staff and refresher trainings for staff previously trained on the CCP.
  • Through a CDC cooperative agreement with the Education Development Center and DOHMH, key components of the CCP were translated into an online toolkit, STEPS to Care, with the potential to support broader dissemination. The freely available, online toolkit includes resources such as tools, templates, and guidance to support replication by other organizations. 
  • In addition to the STEPS to Care toolkit, other materials including the New York City HIV Care Coordination Program Manual, health education workbook, and self-management assessment tools, support continued operation of the program within RWHAP Part A-funded agencies in New York City.
Lessons Learned
  • While the original CCP was successful, there were still challenges, including a rigid system of program enrollment tracks (which had set a fixed frequency of client contact with the program based on assessed need); a complex reimbursement model; and a requirement for weekly visits over a three-month “induction period.” These original program features were reported by service providers to impede enrollment of some clients in need and to contribute to client attrition.
  • In response to these challenges, the DOHMH and its community partner, the HIV Health and Human Services Planning Council of New York, outlined a set of CCP revisions which were implemented in 2018 to enhance intervention delivery, engagement and impact, and to reduce implementation barriers. The modifications included: 
    • Adding a client self‐management assessment, a video chat visit option, and the option to facilitate immediate initiation of ART following enrollment or diagnosis;
    • Changing guidance to promote the identification and recruitment of people with clinical need for care coordination;
    • Changing the payment structure from per‐client‐per‐day to fee‐for‐service; and
    • Increasing the program's flexibility to allow for more differentiated care based on clients’ needs.
Resources & Tools

Implementation Resources

  • STEPS to Care Toolkit
  • New York City Dept. of Health and Mental Hygiene. New York City HIV Care Coordination Program Manual. 2022. Available upon request. Please contact Gina Gambone at [email protected].

Additional Resources

Articles on the Intervention
New York City Department of Health and Mental Hygiene, Bureau of Hepatitis, HIV, and STIs
Gina Gambone, MPH
Director of Quality Management and Program Implementation in the HIV Care and Treatment Program
New York City Department of Health and Mental Hygiene, Bureau of Hepatitis, HIV, and STIs
Mary K. Irvine, DrPH, MPH
Health Department Principal Investigator on the PROMISE (R01MH117793) and CHORDS (R01MH101028) studies of HIV Care Coordination

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