No Wrong Door for High-Acuity Care

Fenway Health, Fenway AIDS Action Committee, and MassHire Downtown Boston provided housing and employment supports to clients who were unstably housed and were un- or under-employed, in order to improve health outcomes as part of the Ryan White HIV/AIDS Program (RWHAP) Part F Special Projects of National Significance (SPNS) initiative Improving HIV Health Outcomes through the Coordination of Supportive Employment and Housing Services. Almost 70 percent of clients who participated in this intervention and received medical care at Fenway Health were virally suppressed, despite facing considerable barriers to care.

Boston, MA

Emerging Intervention
Use of technology and mobile health
Retention in HIV medical care; Viral suppression
Treat
People who are unstably housed
RWHAP SPNS
Community health center, including Federally Qualified Health Centers (FQHCs); Community-based organization/non-clinical setting
Need Addressed

Stable housing and income can lead to better health outcomes for people with HIV. Boston, MA experiences high levels of income inequality and high housing costs. People of color face systemic racism historically embedded in housing and employment policies and practices. People born outside of the United States and people with substance use disorders also face barriers to stable housing and income. These challenges have led to persistent disparities in health outcomes.

"In Massachusetts, Black and Hispanic/Latinx people living with HIV are less likely to be engaged in medical care, to remain in care, and to be virally suppressed."

Core Elements
Tiered case management approach

Most clients received team-based case management that included linkages to both medical care and community resources. High-acuity case managers had smaller client caseloads in order to provide more intensive support; this included accompanying clients to housing and employment-related appointments. Using a Massachusetts Department of Public Health assessment tool, managers determined all clients to be high acuity.

Housing supports

Fenway AIDS Action Committee leveraged its long-standing experience providing housing supports to link clients to affordable housing, rental assistance, and supportive housing programs. The team’s knowledge of the complex system of housing supports in Boston, along with legal and case management expertise, helped meet clients’ comprehensive needs.

Employment supports

MassHire provided employment supports to individuals enrolled in the program. Specialists conducted detailed assessments of career-related strengths and goals, and helped individuals with job searches and referrals to training and adult education programs. MassHire staff provided services at a Fenway AIDS Action Committee location to reduce client access barriers.

“[Employment] services included access to daily free workshops; networking groups; job search strategy groups; information and referral to skills training programs; citizenship and green card advice and assistance; advice and assistance for ex-offenders and criminal background check advice; English classes, adult education, and other educational programs.”

No wrong door: client coordination and program integration

A dedicated program coordinator helped clients navigate through these case management, medical, housing, and employment services. The program coordinator sent referrals to MassHire and carefully tracked client housing and employment status to share with case management. The intervention also broke down silos of service delivery by creating opportunities for team meetings, cross-training, shadowing, and the co-location of services.   

Outcomes

From 2018–2019, the intervention team served 92 individuals and reported health outcomes for 57 receiving medical care at Fenway Health.

Category Information

Evaluation data

The evaluation was informed by data collected in REDCap,* ETO,† and Fenway’s electronic health record system.

Measures

Number of clients who:

  • obtained employment

  • received housing assistance

Percent of the 57 clients receiving medical care at Fenway Health who were:

  • retained in care

  • virally suppressed

Results

  • 23 clients obtained employment

  • 44 received housing supports

  • 64% of clients were retained in care

  • 68% of clients were virally suppressed

* Research and Evaluation Data Capture (REDCap) is a web-based, open-source database platform which allows for easy instrument and survey creation.
† Efforts to Outcomes (ETO) is a web-based, nonprofit Customer Relationship Management (CRM) database.

“While we redirected clients to the appropriate provider whenever possible, we also recognized that staff from each part of the intervention also needed to communicate those needs back as well. This entailed greater flexibility in our roles. We call this the ‘no wrong door’ approach.”

Planning & Implementation
  • A quality improvement (QI) expert led the development of protocols for service delivery. Protocols and guidelines included identifying high-acuity clients and setting caseloads, communicating the U.S. Department of Housing and Urban Development (HUD) definitions for living situation, defining the process of accompanying clients to employment services, and addressing incomplete referrals.
  • Fenway Health developed a REDCap database and updated its Efforts to Outcomes (ETO) database to support program eligibility determination, and tracking of referrals, client encounters, barriers, and outcomes. ETO allowed both evaluation and direct service providers (e.g., case managers) to run a data dashboard to track client progress and identify next steps.  
  • Fenway Health also created a flag in its electronic health record system to assign high-acuity clients correctly to team-based case management, as well as to facilitate tracking and follow-up.
  • Staff from the three locations were cross-trained on housing, employment, case management, and HIV care. In addition, they participated in a HUD training, Getting to Work, which included HIV-specific content, such as how to address disclosure in the workplace.
  • Fenway Health conducted focus groups with existing clients to understand the best strategy for delivering employment-related supports, a new service to the agency.
Sustainability

Fenway Health, Fenway AIDS Action Committee, and MassHire Downtown Boston aimed to remove program silos and maintain cross-agency collaboration and referrals to employment and housing services. Although RWHAP Part F SPNS funding has ended, many of the services provided through this intervention were funded through external sources, including RWHAP Parts A, B and C, HUD, and state and other local funding streams.  

Lessons Learned
  • The co-location of services (e.g., behavioral health, medical case management, housing, employment) helped ensure that all clients’ needs were met at one time. Clients struggled to attend scheduled employment-related appointments. Therefore, Fenway Health arranged for drop-in access to these appointments at a Fenway AIDS Action Committee location that clients and staff were more familiar with instead of at MassHire. Clients preferred to attend sessions in a familiar environment while receiving other services.
  • Fenway Health found that staff across divisions did not interact regularly. Existing relationships were often informal and a result of staff moving from one division to another. Therefore, the intervention adopted multiple strategies to improve communication both within Fenway Health and with external partners. Regular interaction through team meetings, cross-training, shadowing, and co-location of services helped remove silos and facilitate access to care.
  • Referrals relied on strong partnerships with external agencies. Fenway Health learned that leadership buy-in was essential for establishing these referral relationships. In addition, partner agency staff were much more likely to refer their clients when they saw that their clients were benefitting.
Contact
Fenway Health

We'd like your feedback

Was this page helpful?
I found this page helpful because the content on the page:
Check all that apply
I did not find this page helpful because the content on the page:
Check all that apply
Please include an email address if you would like a response
Please include an email address if you would like a response