Practice Transformation Project at the Native American Community Clinic

The Native American Community Clinic (NACC), with support from the Midwest AIDS Education and Training Center (MAETC), provides HIV services and resources with the goal of improving HIV outcomes through “practice transformation,” defined by the Centers for Medicare and Medicaid (CMS) as a “process that results in observable and measurable changes to practice behavior.”1 Starting in 2019, NACC and MAETC responded to HIV outbreaks in Minnesota’s metropolitan areas and their disproportionate impact on the American Indian/Alaska Native population. Through the Practice Transformation Project, NACC and MAETC developed strategies to increase testing and linkage to care within this population and for those who inject drugs and are experiencing homelessness. These ongoing efforts have increased HIV testing rates by 10 percentage points through harm reduction, community outreach, and culturally sensitive strategies.

Minneapolis, MN

Implementation Guide
Emerging Intervention
Emerging Intervention
Icon for Intervention Type
Clinical service delivery model
Icon for HIV Care Continuum
HIV diagnosis; Linkage to HIV medical care
Icon for Focus Population
American Indian/Alaska Native people; People who inject drugs (PWID); People who are unstably housed
Icon for Priority Funding
State funding; RWHAP Part F - AETC
Icon for Setting
Community health center, including Federally Qualified Health Centers (FQHCs)
Need Addressed

High rates of HIV prevalence and incidence in Duluth and the Twin Cities (St. Paul and Minneapolis), Minnesota disproportionately impact the American Indian/Alaska Native population.2,3 Social factors create significant barriers to care, as 13% of Minnesota’s homeless population is American Indian/Alaska Native, while only representing 1% of Minnesota’s total population.4 In addition, American Indian Minnesotans were ten times more likely to die of a drug overdose compared to their white counterparts.5 Other factors contributing to health disparities include food insecurity, lack of transportation and health care coverage, increased complications of chronic diseases, and increased risk of experiencing violence and sexual exploitation.

Core Elements
NACC clinical care

NACC is a primary care Federally Qualified Health Center that provides comprehensive services, including prenatal care, dental care, chronic disease management, behavioral health services, medication-assisted treatment (Suboxone and Vivitrol) for substance use disorders, as well as intensive outpatient services and traditional healing services. The HIV team includes a physician, nurse practitioner, nurse care coordinator, case manager, and outreach workers. The HIV team is integrated with NACC’s harm reduction team.

Harm reduction services

NACC provides culturally tailored harm reduction services to address the needs of the American Indian/Alaska Native community. These services include provision of safer use supplies (such as new syringes and smoking supplies) and naloxone distribution and education. Clients also have access to medication-assisted treatment services. Staff members provide education and safer use supplies within the community to build connections and encourage community members to visit the clinic when they are ready.

Outreach to disproportionately impacted communities

NACC reaches out to people living in encampments near the clinic. Outreach workers conduct rapid HIV testing once a week in the clinic and through pop-up events at local organizations (such as churches and shelters) and in encampment spaces, offering a range of resources, including safer use supplies, vaccines, wound care kits, hygiene kits, food, clothing, gift cards, and traditional medicines such as sage and cedar.

Telehealth appointments in the community

Telehealth appointments are also available to clients in the community. Outreach workers help clients find a private place for the virtual visit, connect with the clinician via an iPad, and coordinate post-visit care needs.

Linkage to care and support services

The clinic uses multiple strategies to engage clients in clinic-based care. Clients receive gift card incentives for attending HIV appointments, and walk-in appointments are available for client convenience. NACC also provides antiretroviral therapy (ART) starter packs for people with a new diagnosis, and pre-exposure prophylaxis (PrEP) for clients as needed, as well as cell phones, transportation to the clinic, and health care coverage assistance. Spiritual care, traditional medicines, and cultural teachings are also available through consults with American Indian/Alaska Native elders.

“Harm reduction is a lot more than providing education and tips. It’s also about making trusting connections in the community, which is so important as that trust can allow better engagement and we are there if they want to address some of their concerns.”


Within two years of implementing the Practice Transformation Project, NACC’s HIV testing rate increased by 10 percentage points compared to baseline. This increase can be attributed to staff education, clearer testing protocols, and NACC’s general efforts to create an accessible testing culture in the community and encourage clients to get tested for HIV regardless of their reason for visiting. In the same 2-year period NACC successfully linked 14 clients to HIV care within their own clinic, and more to other infectious disease clinics in the Twin Cities.

Evaluation dataTesting and linkage to care data collected by NACC
  • Percent of people served by the clinic who have received an HIV test before and after the Practice Transformation Project was implemented
  • Number of people linked to care from a testing event
  • 14% of clients received an HIV test prior to Practice Transformation Project, compared to 24% after 
  • 14 people were linked to care at NACC after a testing event since the beginning of the Practice Transformation Project

Source: Data provided from Native American Community Clinic

Planning & Implementation

Staff training and protocol development. To prepare for project implementation, NACC trained staff on addressing client barriers to care, safer use strategies, and issues related to sex work and human trafficking. NACC also developed protocols for HIV screening and testing, delivery of positive confirmatory HIV test results, PrEP, post-exposure prophylaxis (PEP), ART initiation (including Rapid ART), initial linkage to HIV care, and telehealth. 

Weekly clinical team meetings. The clinical team meets weekly and invites guest speakers ranging from clinicians to community workers to gain expertise and develop relationships for clinic referrals. NACC also meets with national experts from other successful HIV interventions to identify and adopt best practices. 

Regular quality improvement meetings. NACC and the MAETC meet regularly with the care team and consultants to strategize on improving NACC services. These meetings include sharing policy examples, troubleshooting program barriers, assessing data and outcomes, and discussing clinical questions.


Early intervention services are sustained through funding from the Minnesota Department of Health for HIV testing and syringe services. NACC receives Ryan White HIV/AIDS Program funding for a non-medical care manager who helps to link clients to care. Protocols, staff training, and devoted staff time for outreach are all important factors that lead to sustainability of this approach.

Lessons Learned
  • NACC is aware of trauma-induced stressors that may inhibit clients from seeking care in the clinic. Reaching out to the community through outreach and pop-up events can build relationships and encourage clients to enter NACC’s clinical environment on their own terms. 
  • Linkage to care is more successful when the clinic meets client needs in a non-judgmental manner and supports clients consistently through food distribution, safer use supplies, and other resources. 
  • Building relationships with other organizations—such as area syringe exchanges, HIV testing organizations, mobile medicine organizations, and housing organizations—is essential for expanding services and identifying creative strategies to address client barriers to care. 
  • Outreach that leads to linkage to care is more successful when it is based on strategic planning ahead of time. This includes understanding clinic capacity, identifying liaisons between NACC and community organizations, and developing a plan for linkage to care during non-business hours.
Midwest AIDS Training & Education Center
Emily Petran

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